Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : UC05 - UC10 Full Version

Comparative Evaluation of King Vision Video Laryngoscope, McCoy and Macintosh Laryngoscopes in Patients Scheduled for Mucormycosis Surgery: A Randomised Clinical Trial


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53696.16070
Michell Gulabani, Vibhor Gupta, Richa Chauhan, Suman Choudhary, Ashok Kumar Saxena, Prerna Vasudev

1. Assistant Professor, Department of Anaesthesia, University College of Medical Sciences, New Delhi, India. 2. Assistant Professor, Department of Anaesthesia, University College of Medical Sciences, New Delhi, India. 3. Assistant Professor, Department of Anaesthesia, University College of Medical Sciences, New Delhi, India. 4. Senior Resident, Department of Anaesthesia, University College of Medical Sciences, New Delhi, India. 5. Professor, Department of Anaesthesia, University College of Medical Sciences, New Delhi, India. 6. Postgraduate Student, Department of Anaesthesia, University College of Medical Sciences, New Delhi, India.

Correspondence Address :
Dr. Richa Chauhan,
11012, Ats One Hamlet Apts, Noida, Uttar Pradesh, India.
E-mail: drrichsilverdust@gmail.com

Abstract

Introduction: Mucormycosis, an aggressive fungal infection may result in a difficult airway owing to its inflammation. King Vision Video Laryngoscope (KVVL) is a useful addition to a difficult airway armamentarium. McCoy laryngoscope with hinged tip is well-known equipment of difficult airway cart. Conventional Macintosh laryngoscope dominates in anaesthesia practice. Standard, existing and contemporary devices were compared in difficult airways resulting from mucormycosis.

Aim: To compare the relative performance of KVVL, McCoy, and Macintosh laryngoscopes based on the ease of intubation and haemodynamic response in patients with mucormycosis.

Materials and Methods: The present study was a randomised clinical trial, conducted in a tertiary care government hospital, during June-August 2021 on 90 consenting patients of 18-65 years age, belonging to either sex with microbiologically confirmed mucormycosis undergoing debridement surgery. Group A was intubated with a non channeled KVVL, while group B had McCoy and group C had Macintosh laryngoscope. Primary outcome parameters were Cormack Lehane (CL) grade, time from laryngoscopy to successful intubation, number of attempts, any adjuncts or optimisation maneuvers, and any mucosal injury. Secondary outcome parameters were Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Blood Pressure (MBP) measured on arrival, before induction, after induction, and at 1, 2, 3, 5, and 7 minutes after intubation. Comparison of quantitative variables not normally distributed were analysed using Kruskal-Wallis test. Post-hoc analysis by Dunn’s multiple pairwise comparison test. Friedman test followed by pairwise comparison was done to compare haemodynamic parameters within each group. Chi-square test was used for qualitative variables. The p-value ≤0.05 was considered to be statistically significant.

Results: The CL grade was lowest in group B (1.83±0.38) against group A (1.93±0.25), group C (2.13±0.35) with p-value of 0.029. Time from laryngoscopy to successful intubation was the least in group B (19.5±3.98 seconds) against group A (26.07±9.8 seconds), group C (21.33±3.74 seconds) with p-value of 0.002. No significant difference was there in the number of attempts, airway adjuncts/optimisation maneuvers, mucosal injury. Haemodynamic variables were comparable.

Conclusion: McCoy laryngoscope was found to perform best in difficult airways resulting from mucormycosis. It was most effective for glottic visualisation, with the shortest time to successful intubation and, haemodynamic parameters were comparable to KVVL and macintosh laryngoscopes.

Keywords

Airway, Anaesthesia, Glottis, Haemodynamics, Intratracheal

Mucormycosis is an aggressive angioinvasive infection of immunocompromised patients (1). The estimated prevalence of mucormycosis in India is nearly 70 times that of worldwide data, at a median of 0.2 cases per 100,000 persons (2). Rhino-Orbital Cerebral Mucormycosis (ROCM) is the frequently encountered variant, invading hard palate, paranasal sinuses, orbit and brain. An anaesthesiologist may encounter difficult mask ventilation and endotracheal intubation as a result of fungal debris in the oropharyngeal region, epiglottitis and supraglottic oedema (3).

Anaesthesiologists have many devices in their arsenal to manage a difficult airway, ranging from direct laryngoscopy with gum elastic bougie, lighted stylet, mcCoy laryngoscope, intubating laryngeal mask airway, fiber optic bronchoscope and various video laryngoscopes. There is an ongoing quest for new devices to facilitate optimal difficult airway management. McCoy improves glottic visualisation by virtue of its hinged tip which elevates epiglottis, requiring less neck movement and external laryngeal manipulation (4).

The KVVL with a light emitting diode and camera as part of the blade which may be a standard- non channeled requiring the use of a stylet to direct the tube, or a channeled, blade incorporating a guide channel for Endotracheal Tube (ETT) towards glottis (5). Conventional macintosh laryngoscope is the gold standard for endotracheal intubation. It is the most ubiquitously used device despite vast advances in anaesthesia.

There are similar researches in literature, pertaining to the aforementioned three devices, in predicted difficult, normal as well as simulated airway scenarios. Several studies observed that video laryngoscopes perform better than others (4),(6),(7),(8),(9),(10) in aiding endotracheal intubation. Studies that outline the management of airways that are made challenging due to various infective pathologies including mucormycosis have been published (3),(11). However, a comparison of intubation devices to evaluate their relative performance in this sub-group of patients has been lacking. Therefore, the present study aimed at comparing KVVL, mcCoy, macintosh in patients with ROCM undergoing surgical debridement at the study Institute, with the aim to ascertain the relative performance of one over the other. Primary outcome parameters measured were CL grade, time from laryngoscopy to successful intubation, number of attempts needed for intubation, any adjuncts or optimisation maneuvers required, and any resulting mucosal injury. Secondary outcome parameters were HR, SBP, DBP, Mean Blood Pressure (MBP), Oxygen Saturation (SpO2), and Electrocardiogram (ECG).

Material and Methods

The present study was a randomised clinical trial, conducted in a tertiary care government hospital, during June-August 2021. The Institutional Ethics Committee (IEC) approved the study (proposal number IECHR-2021-50-4-R1), and the CTRI number is CTRI/2021/08/035912.

Sample size calculation: The sample size estimation was done based on a pilot study (4),(6). The proportion of patients with CL grade 2a in group A was 46.67%, group B was 80% and in group, C was 13.33%. CL grade was used as one of the primary outcomes and grade 2a signifies ease of vocal cord visualisation, hence this measure was incorporated for sample size calculation. Taking these values as a reference, the minimum required sample size, with 80% power of the study, and 5% level of significance was 29 patients in each study group. To reduce the margin of error, the total sample size taken was 90 (30 patients per group).

The formula used was:

n>=((pc*(1-pc)+pe*(1-pe))*(Zα+Zβ)2)/(pc-pe)2

with pc=proportion of patients with CL grade 2a in one group, pe=proportion of patients with CL grade 2a in another group. Zα is the value of Z at the two-sided alpha error of 5% and Zβ is the value of Z at a power of 80%.

Inclusion criteria: American Society of Anaesthesiologists (ASA) classification I and II, aged 18-65 years of either sex, Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) negative for COVID- 19, and microbiologically confirmed mucormycosis.

Exclusion criteria: History of uncontrolled hypertension, cardiac or respiratory disease, pregnancy, morbid obesity, progressive neurological disease, and bleeding diathesis.

Patients were scheduled for various endonasal and external debridement procedures as well as orbital exenteration and decompression. A complete pre-anaesthetic checkup including predictors of difficult airway like mouth opening, inter-incisor distance, oropharyngeal space assessment, Mallampati Grade (MPG), Thyromental Distance (TMD), and neck mobility were performed.

Study Procedure

Patients were allocated to the three groups by a computer-generated random number table (Table/Fig 1). A structured questionnaire was used for recording the airway parameters and haemodynamic data both before and after induction of anaesthesia. Patients in group A were intubated with KVVL non channeled blade since this version was available at the study Institute. Patients in Group B were intubated with mcCoy, and those in Group C with macintosh laryngoscope after induction. All intubations were performed by an experienced anaesthesiologist.

All haemodynamic data were measured on arrival in operating theatre, before induction, after induction, and at 1, 2, 3, 5 and 7 minutes after intubation by an independent observer. Preoxygenation with 100% oxygen done and induction with injection fentanyl 2 μg/kg, propofol till the loss of response to verbal commands. After confirming adequate bag-mask ventilation, injection succinylcholine 2 mg/kg was administered. Laryngoscopes were used for intubation depending upon the group.

Primary outcome parameters were CL grade, time from laryngoscopy to successful intubation, number of attempts needed for intubation, any adjuncts or optimisation maneuvers required and any mucosal injury. Secondary outcome parameters were haemodynamic data (HR, SBP, DBP, MBP) which were measured on arrival, before induction, after induction, and at 1, 2, 3, 5 and 7 minutes after intubation. Successful intubation is defined as correct placement of the Endo Tracheal Tubes (ETT) in the trachea, as confirmed by end-tidal CO2 capnometry, pulse oximetry and chest auscultation.Time from laryngoscopy to confirmation of successful intubation is defined as time taken from insertion of a laryngoscope till confirmation of ETT placement in trachea by capnometry.

Statistical Analysis

The analysis was done with the use of a Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 21.0. The presentation of the categorical variables was done in the form of numbers and percentages (%). Quantitative data with normal distribution were presented as mean±SD and data with non normal distribution as median with 25th and 75th percentiles. Data normality was checked by using the Kolmogorov-Smirnov test. Non parametric tests were used for data not normal. The comparison of the variables which were quantitative and not normally distributed in nature analysed using the Kruskal-Wallis test and a post-hoc analysis by Dunn’s multiple pairwise comparison test was carried out. Friedman test followed by pairwise comparison was done to compare haemodynamic parameters within each group at different time intervals. The comparison of the qualitative variables were analysed using the Chi-square test. The p-value ≤0.05 considered statistically significant.

Results

Demographic parameters were comparable in the three groups (Table/Fig 2). Preoperative mouth opening was two fingers- 53.3% in group A, 50% in group B, 30.33% in group C (Table/Fig 3). The most frequently observed MPG was 3, 73.33% in group A (3.07±0.52), 83.33% in group B (2.97±0.41), 96.67% in group C (3.03±0.18). Neck mobility and TMD were normal in all patients (Table/Fig 3).

The CL grade obtained was lowest in group B (1.83±0.38) against group A (1.93±0.25), group C (2.13±0.35); p=0.029. Time from laryngoscopy to successful intubation was least in group B (19.5±3.98 seconds) against group A (26.07±9.8 seconds), group C (21.33±3.74 seconds); p=0.002. No significant difference was obtained in the number of attempts, airway adjuncts/optimisation maneuvers, and mucosal injury. No episode of desaturation or abnormal ECG occurred in any of the patients (Table/Fig 4).

HR measured at various time intervals including the preinduction period (p=0.836), postinduction period and at 1 (p=0.07), 2, 3, 5, 7 minutes time intervals after intubation, no significant difference was obtained (Table/Fig 5). Similarly, for MBP, on intergroup analysis done at the above-mentioned time intervals, no statistically significant difference was found, except at an isolated time interval of 2 minutes for group A vs C (Table/Fig 6). The p-value at pre-induction was 0.692, at 1 minute postintubation 0.192. Further, on intragroup analysis, a serial attenuation of HR and MBP was observed in all three groups (Table/Fig 5), (Table/Fig 6). On pairwise intragroup analysis of haemodynamic parameters at various time intervals of 1 to 7 minutes (Table/Fig 7), (Table/Fig 8), a uniform pattern of attenuation wasn’t seen with any one particular device.

Discussion

In the present study population, mcCoy emerged superior with regards to ease of glottic visualisation and shortest time to successful intubation, as compared to KVVL and macintosh laryngoscope. Haemodynamic response to laryngoscopy was comparable but not significant in the three groups.

The study achieved glottic visualisation best with mcCoy laryngoscope in patients of group B when compared to KVVL and macintosh (Table/Fig 4). Contrary to these findings, Ali QE et al., compared channeled KVVL, McCoy and Macintosh laryngoscopes in patients with immobilised cervical spine requiring manual inline stabilisation and, found better glottic visualisation with KVVL (6). The use of non channeled KVVL is comparable to the channeled version as per the recent ASA 2022 practice guidelines difficult airway (12).

Likewise, several other studies in the literature have compared glottic visualisation with various video laryngoscopes against direct laryngoscopes (8),(10),(13),(14), and have concluded video laryngoscopes to be superior. These studies had anticipated difficult airway resulting from a fixed anatomical cause either simulated or pathologically present. The disparity in the results can likely be explained by the difference in difficult airway scenarios wherein normal cervical mobility was present in all the patients in present study.

From authors clinical experience, an explanation is put forward for the disparity in present study findings with KVVL. It was observed that a longer handle, wider blade increased the difficulty, time of insertion, and manipulation, into the oral cavity to obtain an optimal glottic view. Furthermore, authors clinical experience with KVVL is lesser than with direct laryngoscopes. Difficult airway resulting from infective pathology affecting MPG and mouth opening while maintaining normal neck mobility may have greater ease at glottic visualisation with mcCoy laryngoscope.

Present study observed that time from laryngoscopy to successful intubation was significantly shorter with mcCoy laryngoscope when compared with KVVL and macintosh (Table/Fig 4). Concordantly, time from glottic visualisation to intubation was observed to be longer with KVVL by Erdivanli B et al., when comparing it with macintosh in normal airways (15). Conversely, shorter time to intubation was observed with KVVL when compared to macintosh in studies by Murphy LD et al., and Aleksandrowicz D et al., (7),(9).

Arshad Z et al., found mcCoy to have a significantly lower time to successful intubation against macintosh laryngoscope in the anticipated difficult as opposed to in normal airways (16). Similarly, the mcCoy group had the shortest time to successful intubation in present study subjects having anticipated difficult airway.

Nandakumar KP et al., concluded that glidescope took a longer time to intubate with no significant difference in CL grade against macintosh and mcCoy in morbidly obese patients (17). They ascribed it to the need for hand-eye coordination with video laryngoscopes and difficult negotiation of ETT due to its impingement on arytenoids despite better glottic visualisation. Authors experienced the same with KVVL. Furthermore, reduced space may be available for introducing ETT during laryngoscopy due to central tongue position, which may be amplified by the presence of a large tongue and, or airway oedema.

It is noteworthy that the patients in the present study had physiologically difficult airways, in addition, owing to the underlying co-morbidities causing physiologic derangements, compromising the oxygen reserve, and increased risk of cardiovascular collapse during airway management. Hence, safe apnoea time was a limiting factor in this subset, making time from laryngoscopy to successful intubation an important consideration.

Contrasting observations have been made in the current literature pertaining to the time from laryngoscopy to intubation, with no laryngoscope unanimously established as superior over others. The intubation device performance varies with the airway scenario and expertise of the user. Present study concluded that mcCoy laryngoscope had the shortest time to intubation in the subset of difficult airway patients affected by mucormycosis.

Pieters BMA et al., in a meta-analysis, concluded that video-laryngoscopes had better glottic visualisation compared with macintosh in difficult airways, but time to successful intubation was more, akin to our observation (18). In a study by Pieters BM et al., various video laryngoscopes were compared with macintosh in manikins by experienced anaesthetists, residents, and paramedics and it was concluded, that, no single device was best for all caregivers (19).

Different studies have used simulated immobilised cervical spine as the benchmark where oral, pharyngeal, and laryngeal axes alignment was required without neck motion (6),(7),(8),(9),(10),(13),(14),(15), whereas neck mobility was intact in present study participants who had restricted mouth opening and MPG 3 as the cause of anticipated difficult airway. Therefore, the present study was not comparable to those in the above-referenced studies, thereby possibly resulting in disparate observations.

In present study, on intergroup comparative analysis of the intra-operative HR and MBP, no statistically significant difference was found; further on intragroup analysis (Table/Fig 5), (Table/Fig 6), HR, MBP were serially attenuated from 1 to 7 minutes post-intubation in all. Although a uniform attenuation pattern was not observed with any one particular device. Thus, present study did not establish any particular device significant for response attenuation to laryngoscopy, though the haemodynamic parameters were uniformly preserved in all.

The literature has contrasting evidence on attenuation of pressor response with video laryngoscopes when compared to direct laryngoscopes. Aggarwal H et al., in normal airways observed mcCoy laryngoscope to have a better haemodynamic response against C-mac and macintosh, being attributed to shorter laryngoscopy time and more experience with mcCoy, despite better glottic visualisation with C-mac (20). This neutralised the benefit of decreased airway tissue distortion on the pressor response by video laryngoscopes. Conversely, Devi NA et al., found KVVL to have a favorable haemodynamic response over macintosh (21).

Arshad Z et al., studied haemodynamic response in anticipated difficult and normal airways in ASA I, II patients. HR increase with laryngoscopy was significantly more with macintosh in the predicted difficult airway but more with mcCoy in the easy airway. MBP response to laryngoscopy with the two laryngoscopes was comparable in both the airway scenarios (16). In present study, HR, MBP responses were better with mcCoy though not statistically significant.

Nandakumar KP et al., comparing macintosh, mcCoy, and glidescope in morbidly obese found comparable haemodynamic response similar to present study (17). Buhari FS and Selvaraj V found increased pressor response with C-mac in comparison with mcCoy and macintosh where it was similar, amongst ASA I patients with normal airways (22). Han TS et al., and Haidry MA and Khan FA observed better attenuation of pressor response with mcCoy over macintosh in normal airways (23),(24). This was explained by the basic design of mcCoy blade requiring less lifting force during laryngoscopy, thus generating a less pressor response.

However, in present study patients mostly had anticipated difficult airways with co-morbidities. Additionally, difficult bag and mask ventilation with higher MPG grades may have resulted in an inadequate depth of anaesthesia during laryngoscopy, though this was not studied. The difference in anaesthetic depths may have resulted in the variable pressor response to laryngoscopy. Although, such patients were in comparable numbers in the three groups. In forgoing studies (20),(21),(22),(23),(24), the anticipated difficult airway was exclusion criterion which could have resulted in discordant observations.

Video laryngoscopes usually seen to have an edge over other laryngoscopes when primarily studied for attenuation of pressor response in patients having normal airways. While, in difficult airway scenarios including present study, an advantage in pressor response has not been shown with any particular laryngoscope.

Literature has diverse conclusions on the superiority of video laryngoscopes over direct laryngoscopes in different airway scenarios namely anticipated, unanticipated, and genuinely difficult airways. It is not easy to identify genuinely difficult airways as the diagnostic tests have low sensitivity and positive predictive value (23). In present study population, MPG was found to be the single major parameter anticipating difficult airways. It has poor inter-observer reliability and positive predictive value when used alone (24).

Video laryngoscopes are a far-reaching augmentation of the difficult airway cart. Proficiency with video laryngoscopes comes with a learning curve (25). Familiarity with direct laryngoscopes might unintentionally make the anaesthetists try to align oral, pharyngeal, and tracheal axes (26), paradoxically hindering intubation. The benefits of new devices might be outweighed by a lack of familiarity with them. The maximum benefit attained from any device needs to be assessed with its limitations and matched with the level and type of difficulty. Present study observed the ease of glottic visualisation and least duration to successful intubation using mcCoy laryngoscope in airways affected by mucormycosis.

Limitation(s)

Present study dealt with a small subset of patients, from a single centre, using only non channeled KVVL which may not have been the most appropriate choice of video laryngoscope. Furthermore, some study patients did not have an anticipated difficult airway.

Conclusion

McCoy laryngoscope was found to perform better with regards to ease of glottic visualisation and shortest time to intubation. The haemodynamic response was comparable with that of KVVL and macintosh laryngoscopes in patients of ROCM scheduled for debridement procedures. Further research is warranted in comparing the whole spectrum of video laryngoscopes with macintosh and mcCoy laryngoscopes to decide the best device for the patient while taking into account the patient’s airway and the expertise of the user.

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DOI and Others

DOI: 10.7860/JCDR/2022/53696.16070

Date of Submission: Jan 05, 2022
Date of Peer Review: Jan 14, 2022
Date of Acceptance: Feb 01, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 08, 2022
• Manual Googling: Jan 08, 2022
• iThenticate Software: Jan 28, 2022 (16%)

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