Ain-Shams Journal of Anaesthesiology

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 9  |  Issue : 1  |  Page : 34--38

Comparison of hemodynamic response to tracheal intubation with laryngoscope versus intubating laryngeal mask airway in elderly hypertensive patients


Mohamed M Abdel Fattah 
 Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Correspondence Address:
Mohamed M Abdel Fattah
Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura
Egypt

Abstract

Background Management of airways during intubation is a very stressful process that affects the hemodynamics, especially in elderly hypertensive patients. We aimed in this study to compare the hemodynamic response to tracheal intubation in elderly hypertensive patients using ILMA and Direct laryngoscopy. We aim in this study to prove that hemodynamic consequences with intubation using ILMA is that intubation with an ILMA has less hemodynamic consequences that last for a shorter period compared with DL in elderly hypertensive. Patients and methods A total of 70 patients of both sexes, ASA physical status II, above 60 years of age, undergoing elective abdominal surgery lasting less than 2 h were divided randomly using a regular sample method into two equal groups. Intubation was performed using a Macintosh laryngoscope in group (direct laryngoscopy), and in the second group [intubating laryngeal mask airway (ILMA)] intubation was performed with laryngeal mask airway. Hemodynamic data and oxygen saturation were recorded. Intraoperative adverse effects and postoperative complications such as sore throat, hoarseness of voice (during the first 24 h after surgery), and laryngospasm were recorded. Results There was a significant increase in heart rate and mean arterial blood pressure immediately after laryngoscopy and tracheal intubation until 3 min when compared with ILMA. Moreover, there was significant increase in heart rate, mean arterial blood pressure, and rate pressure product after tracheal extubation for 3 min, whereas it was for 1 min in the ILMA group. No significant difference was seen between the number of patients with or without symptoms after extubation in both groups. Conclusion Intubation with ILMA has less hemodynamic consequences for a shorter time compared with direct laryngoscopy in elderly hypertensive patients.



How to cite this article:
Abdel Fattah MM. Comparison of hemodynamic response to tracheal intubation with laryngoscope versus intubating laryngeal mask airway in elderly hypertensive patients .Ain-Shams J Anaesthesiol 2016;9:34-38


How to cite this URL:
Abdel Fattah MM. Comparison of hemodynamic response to tracheal intubation with laryngoscope versus intubating laryngeal mask airway in elderly hypertensive patients . Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2019 Jul 23 ];9:34-38
Available from: http://www.asja.eg.net/text.asp?2016/9/1/34/178877


Full Text

 Introduction



Airway management using direct laryngoscope (DL) and endotracheal intubation are known to induce hemodynamic changes [1] . The stress response to laryngoscope is well known to be centrally mediated sympathetic reflex [2] , presumed that stretching of the laryngeal and pharyngeal tissue during laryngoscopy was the major cause of the hemodynamic response.

DL produces marked short-term stress responses [3] , with determined effect on the coronary and cerebral circulations in high-risk patients, particularly in those with systemic hypertension [4] . Previous studies on circulatory effects of anesthesia in treated and untreated hypertensive patients observed that most of the patients experienced three periods of circulatory instability: during intubation, after tracheal intubation, and during the immediate period surrounding awakening [5] as the release of endogenous catecholamines increases myocardial oxygen demand [6] .

The problems might be reduced by using the alternative devices such as intubating laryngeal mask airway (ILMA), a device with high success rate that facilitates the tracheal intubation without laryngospasm [7] .

There are conflicting results [8],[9] on comparison of hemodynamic and stress response of endotracheal intubation using an ILMA with a DL.

This prospective randomized study was conducted to compare hemodynamic consequences [systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), and heart rate (HR)] between DL and ILMA and ease of maneuver in controlling hypertensive elderly patients subjected to operations under general anesthesia.

 Patients and methods



This study was approved by the International Ethics Committee at Mansoura University, and written informed consent was obtained from each patient. A total of 70 patients of ASA physical status II, both sexes, above 60 years of age, undergoing elective abdominal surgery lasting less than 2 h at Mansoura University Hospital, were enrolled in the study.

The patients enrolled were known to be hypertensive, receiving antihypertensive therapy. Exclusion criteria included patients with any anticipated difficult intubation, ischemic heart disease, diabetes, COPD, gastroesophageal reflux, renal or hepatic failure, and patients with Mallampati grade III or IV.

The selected patients were divided randomly (with regular sample method) into two equal groups of 35 patients.

On the night of the operation, psychological assurance was given for the patients and 5 mg diazepam tablet was administered.

On the morning of the operation and after insertion of intravenous line, midazolam 2 mg was given. On arrival to the operating room, cardiovascular monitoring was started before induction, and SBP and DBP, MAP, and HR were recorded as primary outcome measurements. Anesthesia was induced using fentanyl 2 mg/kg and propofol 2 mg/kg administered over 3 min, followed by intubating dose of atracurium 0.5 mg/kg intravenously. In group DL, intubation was performed using Macintosh laryngoscope; in the second group (ILMA) intubation was performed with a laryngeal mask airway.

An appropriate laryngoscope blade was selected on the basis of the body size for each patient in group I (DL), as well as in group II (ILMA). Intubating laryngeal mask was inserted using one handle rotation technique, with the head and neck in neutral position. No patient received topical or intravenous lidocaine before placement of ETT or ILMA.

Anesthesia was maintained in both groups with 50% oxygen in air and 1% isoflurane and top-up doses of atracurium when needed. Controlled mechanical ventilation of lung was adjusted to maintain end-tidal CO 2 between 30 and 35 mmHg as measured by capnogram.

The hemodynamic data and oxygen saturation were recorded at the following time intervals: baseline, before intubation, at 1, 3, and 5 min after intubation, at extubation, and at 1, 3, and 5 min after extubation.

Intraoperative adverse effects were also recorded as desaturation persisting for more than 3 or 5 min each (SpO 2 <90%) or hypercarbia greater than 3 min (ETCO 2 >45 mmHg).

Postoperative complications such as sore throat, hoarseness of voice (during the first 24 h after surgery), and laryngospasm were recorded.

Statistical analysis

All variables, including baseline, preintubation, 1, 3, and 5 min after intubation, at extubation, and 1, 3, and 5 min after extubation, were presented as mean with SD. Patient characteristics were compared using the χ2 -test or Student's t-test as appropriate, and rates of HR, SBP, DBP, and MAP were analyzed with analysis of variance test; values less than 0.05 were considered statistically significant. The sample size was calculated by comparing means of difference between groups using confidence interval 95% and study power 80%.

Sample size calculation was carried out from previous study results by assuming that an increase of 20% in the treated groups would be detectable using a sample size of 33 patients per group with 80% power. Thirty-five patients were included to replace any dropouts.

 Results



A total of 70 elderly patients of ASA physical status II, were enrolled in this study. There was no statistically significant difference between the two groups as regards age, sex, body weight, height, or duration of surgery [Table 1].{Table 1}

No significant difference was found between the two studied groups as regards measured hemodynamic indices at baseline [Table 2] [Table 3] [Table 4].{Table 2}{Table 3}{Table 4}

The MAP increased immediately after both tracheal intubation and ILMA (P < 0.05) in both groups, but it remained elevated for 3 min after tracheal intubation (group I), whereas it remained elevated only for 1 min after ILMA (group II) [Table 2].

Moreover, MAP increased significantly immediately after both tracheal extubation and ILMA removal (P < 0.05); it remained significantly high for 3 min in group I (ETT group), whereas it remained significantly high for only 1 min after ILMA removal (Table 11).

The HR increased significantly immediately after both tracheal intubation and ILMA insertion. HR was significantly higher during the first 3 min in group I compared with the first 1 min in group II (P < 0.05). The increase in HR was significant after tracheal extubation for 3 min, whereas the increase was significant for 1 min with ILMA [Table 2].

The rate pressure product (RPP) increased immediately after both tracheal intubation and ILMA insertion (P < 0.05) and remained higher for 3 min in group I compared with 1 min in group II [Table 4].

There was no significant change in arterial oxygen saturation throughout the period of study.

Pre-extubation laryngospasm, postextubation sore throat, hoarseness, and coughing during the first 24 h of the surgery were recorded at extubation time. There was no significant difference between the two groups as regards the number of patients with or without symptoms [Table 5].{Table 5}

 Discussion



Both DL and tracheal intubation induce the patient cardiovascular system reaction due to reflexive responses [10],[11] .

There are not many studies on ILMA to observe the hemodynamic response associated with intubation through this technique, as it was introduced as a relatively new technique facilitating tracheal intubation method, without the need for laryngoscopy [12],[13] .

The main findings of this study showed that in controlled hypertensive patients, HR, MAP, and RPP increased in both groups compared with the baseline values, with significantly higher and longer-lasting rise after tracheal intubation with laryngoscopy than with ILMA.

Hypertensive patients are prone to much greater hemodynamic changes after laryngoscopy and tracheal intubation compared with normotensive patients [5] , as manipulation of the airway, particularly with laryngoscopy, alters cardiovascular physiology by means of both reflex response and the physical presence of an endotracheal tube [11] . An increase in blood pressure associated with laryngoscopy and tracheal intubation is dangerous and may cause left ventricular failure, myocardial ischemia, or cerebral hemorrhage [14] . Therefore, the prevention of hypertension following intubation of the trachea is the major aspect in hypertensive patients.

Several investigations have studied and reached a conclusion that laryngoscopy is the main etiological factor for hemodynamic response associated with endotracheal intubation [15],[16] . Wilson et al. [17] also found significant increase in SBP after laryngoscopy between two studied groups (51.3% in tracheal intubation vs. 22.9% in ILMA).

In our study, a significant increase in HR and MAP was noted immediately after laryngoscopy and tracheal intubation until 3 min when compared with ILMA.

This finding was similar to that proved by Aziz and Bashir [18] , who found that the use of ILMA has been associated with fewer hemodynamic effects as compared with endotracheal intubation with laryngoscope.

Kihara et al. [13] conducted a study on 150 adult patients to observe the hemodynamic response to tracheal intubation with Macintosh laryngoscope versus ILMA and concluded that ILMA offered no advantage over DL as regards hemodynamic stress response, a finding that was not confirmed in our study.

Contradictory to our study results, Oczenski et al. [19] found that, after extubation, airway removal, the hemodynamic and plasma catecholamine concentration reached their highest level in the ILMA group and the endotracheal group, but there was no significant difference between the two groups. However, our results are in accordance with the finding of Fulii et al. [19] , who showed that removal of ILMA is associated with fewer cardiovascular changes compared with tracheal extubation in normotensive and hypertensive patients.

In our study, RPP after endotracheal intubation with laryngoscope showed significant increase (maximum 17 983) compared with ILMA (maximum 13 604). This finding was supported by the work by Fulii et al. [19] , who found that RPP after laryngoscopy was more than 20 000 in hypertensive patients, but with ILMA this critical increase in RPP was avoided, and the levels of RPP in excess of 20 000 are more commonly associated with angina and myocardial ischemia [20] .

In our study we selected hypertensive patients, as reflex circulatory response to laryngoscopy and tracheal intubation are serious in normotensive patients, but these changes are exaggerated in hypertensive patients. However, the present study showed that these changes in HR, MAP, and RPP in both groups were not associated with serious complication such as arrhythmias; the reason of this may be related to the preoperative oral antihypertensive medications prescribed.

Our study demonstrated that there was no significant difference between the numbers of patients in both groups in relation to the evaluation of complications, including sore throat, coughing, laryngospasm, and hoarseness, which confirms the results of Kihara et al. [6] .

There are some limitations in our study. First, although it was necessary to enroll more patients, because of high expenses of ILMA method and lack of preliminary evidences and restricted funding, we could not do so. Second, catecholamines as good markers for stress response were not measured at the time of the study because they were unavailable. Finally, there was no control group for evaluating the degree of stress response in normotensive patients in comparison with hypertensive patients.

We conclude that intubation with an ILMA has less hemodynamic consequences that last for a shorter period compared with DL in elderly hypertensive patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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