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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 252-258

Easy pediatric nasal intubation


Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission30-Sep-2017
Date of Acceptance17-Apr-2018
Date of Web Publication31-Aug-2018

Correspondence Address:
Ramy Mahrose
Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_82_17

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  Abstract 

Background Pediatric anesthesiologists during nasal intubation use Magill forceps frequently, but it is often difficult to push the tube into the trachea. Differences in the airway structure of children compared with adults may be the cause of the problem. Modified pediatric Magill forceps (modified by Farouk and his colleagues) added anteroposterior firm grasping of the nasotracheal tube which enables us for elevation and downward rotation of the nasotracheal tube, which makes the tube in line with the axis of the trachea facilitating its passage into the trachea.
Objectives The aim of this study was evaluation of the value of modified pediatric Magill forceps in facilitating nasal intubation.
Patients and methods The study included 100 American Society of Anesthesiologists physical status I–II patients (age range: 2–6 years) who were scheduled for tonsillectomy operation. The patients were divided randomly into two equal groups. Group A in which modified pediatric Magill forceps was used to assist nasotracheal intubation, while group B in which Magill forceps was used to assist nasotracheal intubation. For each patient, the following data were collected: age, body weight, intubation time, number of intubation attempts, hypoxia, pharyngeal trauma, and need for tube corkscrewing.
Results The results showed that there was a statistically significant decrease in intubation time in group A when compared with the corresponding values in group B. Also, group A showed a statistically significant decrease in the number of intubation attempts in comparison to group B denoting easier nasal intubation attempts in group A. Patients in group A showed a decrease in the number of patients who developed hypoxia during intubation attempts in comparison to group B. There were no statistically significant differences between both groups regarding pharyngeal trauma. Group A showed a decrease of numbers of the need to do corkscrewing in comparison to group B, and the difference between the two groups was significant statistically.
Conclusion The results of this study demonstrated that performing nasal intubation using the modified pediatric Magill forceps showed greater ease of nasotracheal intubation than the usage of conventional Magill forceps.

Keywords: easy, nasal intubation, pediatric


How to cite this article:
Mahrose R. Easy pediatric nasal intubation. Res Opin Anesth Intensive Care 2018;5:252-8

How to cite this URL:
Mahrose R. Easy pediatric nasal intubation. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2018 Oct 16];5:252-8. Available from: http://www.roaic.eg.net/text.asp?2018/5/3/252/240276


  Introduction Top


We commonly use Magill forceps during nasotracheal intubation for the pediatric population during a lot of surgeries such as dental operations and tonsillectomy operations, but we have difficulty advancing the nasotracheal tube into the trachea [1].

This is because the more cephalic larynx and the trachea is angled posteriorly relative to adults, in addition to the nasotracheal tube facing the anterior trachea once passed the vocal cord ([Figure 1]) all are thought to contribute to the problem [2].
Figure 1 Nasotracheal tube facing the anterior trachea while using Magill forceps.

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To overcome this problem, we need to redirect the tip of the nasotracheal tube caudodorsally for easy advancing the nasotracheal tube into the larynx [2].

Neck flexion and tube rotation on its axis have been successfully used to do this redirection, but it may lead to laryngeal trauma, prolonged intubation time, and the occurrence of hypoxia [3].

Modified pediatric Magill forceps (modified by Farrukh and his colleagues) has an added +45° tilt at the distal end in a direction away from the handle added anteroposterior support to the nasotracheal tube giving a firmer grasping of it which enables us to rotate the tip of the nasotracheal tube downward and posteriorly, which makes the tube in line with the axis of the trachea facilitating its passage into the trachea preventing it from getting caught on the anterior trachea ([Figure 2]) [4].
Figure 2 Modified (to the left) and conventional (to the right) Magill forceps.

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  Aim of the work Top


The purpose of the study is to compare between Magill forceps and modified pediatric Magill forceps for nasotracheal intubation (which method is easier and better?).


  Patients and methods Top


The study was conducted in the ENT operating room of Ain Shams University Hospitals during a period of 6 months. The study protocol was approved by the ‘research and ethics committee’ of the Anesthesia and Intensive Care Department, Ain Shams University. Informative consent was obtained from the parents before enrolling in the study.

Hundred patients were registered in the study. The patients were randomly allocated by a computer-generated random number list into two study groups of 50 patients each, with a range of age between 2 and 6 years. All patients were with the American Society of Anesthesiology physical status of 1 or 2 and were undergoing tonsillectomy operations.

Group A

Fifty patients for whom modified pediatric Magill forceps was used to assist nasotracheal intubation.

Group B

Fifty patients for whom Magill forceps was used to assist nasotracheal intubation.

Exclusion criteria for the study included

Parental refusal to consent (absolute contraindication), patients with aspiration risk, known upper airway abnormalities, and those having difficult airway were excluded.

Methodology

On arrival in the operating room, all patients were continuously monitored with ECG, noninvasive blood, pressure and pulse oximetry, then inhalational induction by halothane (Pharco Pharmaceutical, Cairo, Egypt) is started to avoid agitation of children and to be able to insert the intravenous cannula while they are sleeping, atropine (CID pharmaceutical, Giza, Egypt) 0.01 mg/kg is given to avoid bradycardia, fentanyl (Sunny Pharmaceutical, Badr City, Cairo, Egypt) 1 µg/kg is given for analgesia, and then muscle relaxant (atracurium, Sunny pharmaceutical, Badr City, Cairo, Egypt; intubating dose 0.5 mg/kg) is used.

Group A

Lubricating gel is used to lubricate the tube during passage through the nose until it reaches the pharynx, then we use the laryngoscopy to view the vocal cords, modified pediatric Magill forceps is used to help advancing the tube into the trachea by firm grasping of the tube, then elevation and downward rotation of the tube which makes the tube in line with the axis of the trachea facilitating its passage into the trachea preventing it from getting caught on the anterior trachea, capnography is used then to confirm the correct position of the tube inside the trachea. Pressure-controlled ventilation was used adjusting the airway pressure, tidal volume, and respiratory rate, according to patient age and weight.

Group B

Magill forceps is used to help advancing the tube into the trachea.

Capnography is used then to confirm the correct position of the tube inside the trachea. Pressure-controlled ventilation was used adjusting the airway pressure, tidal volume, and respiratory rate, according to patient age and weight.

In the two groups, the following data were collected: intubation time, number of intubation attempts, hypoxia (recognized when oxygen saturation decreases below 94% [5]), pharyngeal trauma, and need for corkscrewing.

Anesthesiologists shared in the study were given training on how to use the altered pediatric Magill forceps with the aid of a model pediatric airway, followed by four untimed trial attempts and four timed trial attempts.

Sample size estimation

To show the difference in intubation time and attempts with P value less than 0.05 and power 80%, we needed at least 50 patients per group to compare the modified pediatric Magill forceps group and the conventional Magill forceps group.

Statistical analysis

Analysis of data was done by IBM computer using Statistical Program for Social Sciences, version 16 (SPSS Inc., Chicago, Illinois, USA) as follows:
  1. Description of quantitative variables as mean±SD.
  2. Description of quantitative variables as n (%).


Statistical analysis was performed using statistical tests included Student’s t-test, χ2-test, and table analysis. A P value less than 0.05 is considered significant.


  Results Top


Demographic data

As regards age, sex, and body weight of patients, there were no significant differences statistically between both groups (P>0.05) ([Table 1]).
Table 1 Demographic data

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Regarding intubation time

Group A showed a decrease in intubation time in comparison to group B, and the difference between the two groups was statistically significant (P<0.05) ([Table 2] and [Figure 3]).
Table 2 Intubation time

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Figure 3 Intubation time.

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Regarding the number of intubation attempts

Group A showed a decrease in the number of intubation attempts as a larger number of patients were intubated from the first attempt (35 patients) in comparison to group B, where a lesser number of patients were intubated from the first attempt (21 patients), and the difference between the two groups was statistically significant (P<0.05) ([Table 3] and [Figure 4]).
Table 3 Comparison between group A and group B regarding the number of attempts of intubation

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Figure 4 Intubation attempts.

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Regarding the occurrence of hypoxia

Group A showed a decrease in the number of patients who developed hypoxia (12 patients) during intubation attempts in comparison to group B where 38 patients developed hypoxia during intubation attempts; the difference between the two groups was statistically significant (P<0.05) ([Table 4] and [Figure 5]).
Table 4 Comparison between both groups regarding the occurrence of hypoxia

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Figure 5 Occurrence of hypoxia.

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Regarding pharyngeal trauma

There were no significant differences statistically between both the groups ([Table 5] and [Figure 6]).
Table 5 Pharyngeal trauma

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Figure 6 Pharyngeal trauma.

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Regarding need for corkscrewing

Group A showed a decrease in numbers of who need to do corkscrewing (10 patients) in comparison to group B where 37 patients required corkscrewing of the endotracheal tube to facilitate intubation, and the difference between the two groups was statistically significant (P<0.05) ([Table 6] and [Figure 7]).
Table 6 Need for corkscrewing

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Figure 7 Need for corkscrewing.

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  Discussion Top


In the present study, we tried to overcome the difficulty of nasal intubation for pediatrics and to make it easy. The advantage of using modified pediatric Magill forceps is to facilitate intubation with the least number of intubation attempts, less occurrence of hypoxia, and less need for corkscrewing than in case of the usage of the conventional Magill forceps.

There have been previous modifications to the Magill forceps to help its use in foreign body removal and oral intubation of a difficult airway [6]. Liberman [7] modified the forceps to allow grasping of the nasotracheal tube in an anteroposterior fashion as opposed to side by side, allowing a firmer grasp and easier downward manipulation.

Ehrensperger et al. [8] modified the standard Magill forceps as the jaws of the forceps were modified to give curved nontraumatic parts without any serrations or sharp edges, reducing the risk of injuring the mucous membrane and perforating the cuff.

Boedeker et al. [9] showed that bending of the intubation podecker forceps (another modification of Magill forceps) makes it possible to simultaneously visualize the tip of the forceps and the glottic opening in the visual field during video laryngoscopy, making it easier to remove the glottic foreign bodies.

Farrukh and colleagues for their modification purpose, similar to Liberman’s modification, added +45° tilt at the distal tip. This gives the Magill forceps the ability to enter the side of the mouth, making visualization of pharyngeal structures better while maintaining the advantage of anteroposterior grasping with easy downward manipulation, but their study did not show a reduction of the number of intubation attempts, need for corkscrewing and occurrence of hypoxia in comparison to conventional Magill forceps. This is against our study which showed that modified pediatric Magill forceps facilitates intubation with the least number of intubation attempts, less occurrence of hypoxia, and less need for corkscrewing than in the case of usage of the conventional Magill forceps, the cause of this difference may be because of more additional training to anesthesiologists participated in our study with the use of the altered pediatric Magill forceps results in greater ease in nasotracheal intubation [4].


  Conclusion Top


The results of this study demonstrated that performing nasal intubation using the modified pediatric Magill forceps showed greater ease of pediatric nasotracheal intubation than the usage of conventional Magill forceps. This study opens the ground for intensive research to solve the problem of difficulty in advancing the endotracheal tube into the pediatric larynx during nasotracheal intubation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mahan R, Batra Y, Kumar S. Another use of Magill forceps to assist in nasotracheal intubation. Can J Anaesth 2007; 54:957–958.  Back to cited text no. 1
    
2.
Santillanes G, Gausche-Hill M. Pediatric airway management. Emerg Med Clin North Am 2008; 26:961–975.  Back to cited text no. 2
    
3.
Hall CE, Shut LE. Nasotracheal intubation for head and neck surgery. Anesthesia 2003; 58:249–256.  Back to cited text no. 3
    
4.
Munshey FN, Gamble JJ, McKay WP. Modified pediatric Magill forceps effect on nasal intubation time. Pediatric Anesth 2016; 26:221–222.  Back to cited text no. 4
    
5.
Daniel SM, Michael PWG. Precise control of arterial oxygenation. Critical Care Med 2013; 41:423–432.  Back to cited text no. 5
    
6.
Sim L, Patel A, Enderby D. Modified Magill’s forceps revisited. Anesthesia 2004; 59:97.  Back to cited text no. 6
    
7.
Liberman H. A new intubating forceps. Anaesth Intensive Care 1978; 6:162–163.  Back to cited text no. 7
    
8.
Ehrensperger C, Gross J, Hempel V, Henn-Beilharz A, Rau A. The modified Magill forceps. Anesthetist 1992; 41:218–220.  Back to cited text no. 8
    
9.
Boedeker BH, Bernhagen MA, Miller DJ, Doyle DJ. Comparison of the Magill forceps and the Boedeker (curved) intubation forceps for removal of a foreign body in a Manikin. J Clin Anesth 2012; 24:25–27.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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  In this article
Abstract
Introduction
Aim of the work
Patients and methods
Results
Discussion
Conclusion
References
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