|Year : 2018 | Volume
| Issue : 1 | Page : 18-22
Comparison of flange slide pack technique using macintosh laryngoscope blade with conventional laryngoscopy-guided throat packing: A pilot study
Abhijit A Karmarkar, Deepak Dwivedi, Vidhu Bhatnagar, Vibhu P. S. Raghuvanshi, Ashish Chauhan, Shatabdi Chakraborty
Department of Anaesthesia and Critical Care, INHS Asvini, Mumbai, Maharashtra, India
|Date of Web Publication||9-Jul-2018|
Lt Col Deepak Dwivedi
Department of Anaesthesia and Critical Care, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: An analytical pilot study was conducted prospectively to ascertain the efficacy of a new method of throat packing “Flange Slide Pack Technique” (FSPT) in patients undergoing nasal, faciomaxillary, and oral surgeries.
Aim: To compare the conventional technique of throat packing guided by direct laryngoscopy with FSPT where the Macintosh laryngoscope blade is used as aid for throat packing.
Settings and Design: A comparative observational pilot study was conducted at a tertiary care hospital.
Subjects and Methods: Subjects were randomly allocated into two groups based on the technique for throat packing by computer-generated random numbers as Group A (conventional technique) and Group B (FSPT). Primary outcomes measured were total time duration taken for packing the throat with a standardized length of ribbon gauze and changes in heart rate and change in Mean Arterial Pressure (MAP) from baseline. Secondary outcomes measured were incidence of postoperative sore throat (POST) at 6 h postoperatively and ease of insertion of the throat packs.
Statistical Analysis: Parametric data were analyzed using “unpaired t-test.” Comparison of proportions and data were analyzed using Chi-square test. SPSS Version 17 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.
Results: The time taken to pack the throat was shorter in Group B; percentage increase of MAP from baseline was higher in Group A. Ease of insertion of throat pack was more in Group B. POST results were insignificant.
Conclusions: FSPT can prove to be an alternative technique to the conventional method of packing the throat by minimizing duration of laryngoscopy and thereby limiting the stress response.
Keywords: Laryngoscopy, oral cavity, physiological stress response, postoperative complications, sore throat
|How to cite this article:|
Karmarkar AA, Dwivedi D, Bhatnagar V, Raghuvanshi VP, Chauhan A, Chakraborty S. Comparison of flange slide pack technique using macintosh laryngoscope blade with conventional laryngoscopy-guided throat packing: A pilot study. J Mar Med Soc 2018;20:18-22
|How to cite this URL:|
Karmarkar AA, Dwivedi D, Bhatnagar V, Raghuvanshi VP, Chauhan A, Chakraborty S. Comparison of flange slide pack technique using macintosh laryngoscope blade with conventional laryngoscopy-guided throat packing: A pilot study. J Mar Med Soc [serial online] 2018 [cited 2018 Jul 19];20:18-22. Available from: http://www.marinemedicalsociety.in/text.asp?2018/20/1/18/236259
| Introduction|| |
Packing the throat after endotracheal intubation is a common practice in various oral, nasal, nasopharyngeal, and maxillofacial surgeries done under general anesthesia (GA).,, It is practiced to prevent the passage of surgical debris in to the trachea and esophagus.
It is commonly done by direct laryngoscopy-guided placement of the wet gauze or ribbon gauze in the throat using a Magill's forceps. While a lot of work has been done to make guidelines and protocols to prevent retention of throat pack inside the oral cavity and prevent postoperative sore throat (POST), there are no standard procedures or ways to place a throat pack so as to place it quickly, effectively with minimal stress response.,
This pilot study was conducted to compare the conventional method of packing the throat with a modified new method which is described as Flange Slide Pack Technique (FSPT). This method uses Macintosh laryngoscope blade as a conduit during insertion of throat pack. The primary outcomes compared were time in seconds taken to pack the throat after intubation with standardized length of ribbon gauze (150 cm) in both the groups and magnitude of stress response measured in terms of percentage change in heart rate (HR) and mean arterial pressure (MAP) at the end of the procedure when compared to baseline. Secondary outcomes compared were the evidence of POST and ease of insertion of throat pack between the two groups.
| Subjects and Methods|| |
This comparative observational pilot study was conducted at the Department of Anaesthesia and Critical Care after obtaining clearance from the Institutional Ethics Committee. Patients undergoing nasal, faciomaxillary, facial reconstructive, and oral surgeries were enrolled in the study for the duration extending from January 2016 to August 2017. Written informed consent was obtained from all the patients. Patients were randomly allocated into two groups based on the technique for throat packing used by computer-generated random numbers. Group A included patients in whom the conventional technique of throat packing using direct laryngoscopy with Macintosh blade was utilized. Group B included patients in whom the modified technique FSPT was used for placing the throat pack with the aid of a Macintosh blade during direct laryngoscopy.
Inclusion criteria included patients slated for nasal, faciomaxillary, facial reconstructive, and oral surgeries requiring insertion of throat packs. All adult patients in American Society of Anesthesiologists (ASA) Physical Status I and II of either sex with Mallampati classification (MPCL) I and II in age group between 18 and 60 years were included. Exclusion criteria included patients of extremes of age, patients of ASA Physical Status more than III with comorbidities such as hypertension, coronary artery disease, and Chronic Kidney Disease, and patients with a history of difficult intubation with associated MPCL grade more than or equal to three.
Preanesthesia evaluation was done for all the patients. They were kept fasting overnight for 8 h for solids, and tablet alprazolam 0.25 mg was given night before surgery. On the day of surgery, the patients were allocated to either of two groups by opening of sealed envelopes.
On arrival in the operation theater (OT), the patient was connected to all the standard monitors (electrocardiography, pulse oximetry, noninvasive blood pressure, capnography) and baseline readings were taken followed by coinduction with the injection fentanyl 1.5 μg/kg and injection propofol 2 mg/kg intravenous (IV). Airway was secured with the appropriate-sized polyvinyl chloride endotracheal tube (ETT) following injection atracurium 0.5 mg/kg IV. ETT was fixed and secured at the right corner of the mouth. Maintenance of anesthesia was done with oxygen, air and sevoflurane targeting a minimum alveolar concentration of 1.2. Anesthesiologist trained in both the techniques packed the throat with either of the techniques as described later in the text. Standard length of saline-soaked wet and moist ribbon gauze (150 cm) was used in both the groups.
Total time for throat packing in seconds was calculated from the time the laryngoscope was inserted till the packing was complete. Stress response was assessed by measuring percentage increase in the MAP along with HR from the baseline till the end of throat packing and laryngoscopy. All observations were recorded by the paramedical staff that were blinded for the procedure. Postoperatively, evidence of sore throat was assessed at 6 h postsurgery and was graded as none – no throat pain or discomfort, mild – symptoms of throat irritation, moderate – mild throat pain and irritation, and severe – throat pain with difficulty in swallowing. Ease of packing by the anesthesiologist was graded as Grade 1 – very smooth with no attempts of maneuvering inside the oral cavity, Grade 2 – smooth and easy but requiring little maneuvering, and Grade 3 – not smooth which required multiple attempts of maneuvering inside the oral cavity.
Conventional technique of throat packing
Macintosh blade of direct laryngoscope of appropriate size is inserted in the oral cavity from the head end of the patient. This is followed by packing of throat using the Magill's forceps. Distal end of the ribbon gauze is held in the Magill's forceps for insertion and the proximal end of the ribbon gauze is held by the assistant who is positioned on right side [Figure 1]. The ribbon gauze is deposited around the ETT by repeated engaging and disengaging of the Magill's forceps with each attempt, thereby attaining a complete seal around the ETT. The proximal end is brought out of the oral cavity and secured. A tag with “throat pack in situ” is pasted on the patient's forehead.
|Figure 1: Direct laryngoscopic-guided conventional method of throat packing|
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Flange slide pack technique
In this modified technique, the anesthesiologist does laryngoscopy from the patient head end with the assistant positioned on the left side of the patient. The ribbon gauze is loaded over the flange or tongue of the blade acting as a conduit while the distal end at the tip of the blade held with the Magill's forceps. The proximal end of the gauze is held in tension by the assistant close to the heel of the laryngoscope blade. The packing is done by sliding the ribbon gauze over the flange of the blade with the help of the Magill's forceps and forming a uniform seal around the ETT [Figure 2]. The operator does not have to disengage the tip of the Magill's forceps repeatedly. The tip of the Magill's forceps engages the ribbon gauge initially, and with the help of FSPT, one side reposition of the throat pack is carried out; then, the tip of the Magill's forceps disengages and reengages the ribbon gauge so as to successfully attain the seal on the other side of the ETT.
|Figure 2: Flange Slide Pack Technique of throat packing demonstrating the ribbon gauze sliding over the flange of the Macintosh blade|
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Statistical analysis was done using unpaired t-test for the continuous variables. Categorical variables were analyzed using Fisher's exact test and Chi-square test. Data have been expressed as mean (standard deviation [SD]) values. Statistical Package for the Social Sciences (SPSS Inc., Chicago IL, USA version 17.0) software has been utilized for analysis, and P < 0.05 has been considered statistically significant.
| Results|| |
A total of 89 patients were enrolled in this study. 46 patients qualified after meeting the inclusion criteria. Patients were randomly allocated into two groups of 23 each [Figure 3]. Allocation included all ASA Physical Status I and II patients of either sex. Demographic data including age, weight, sex, ASA Physical Status, and MPCL grade, when compared between the two groups, were comparable [Table 1].
Type of surgeries included in both the groups was faciomaxillary surgeries which included zygomatic bone fractures in majority, followed by ear-nose-throat surgeries such as septoplasty and tonsillectomy. Other category of surgeries included was reconstructive nasal surgeries and oral surgeries such as carcinoma palate and carcinoma tongue [Table 2].
Total time taken in seconds to insert the wet moist ribbon gauze (150 cm) was much shorter in Group B with mean (SD) value of 76.52 (7.14) s as compared to Group A with mean (SD) value of 85.39 (5.13) s and the results were statistically significant with P = 0.0001. Comparison of percentage increase in MAP (mmHg) from the baseline value to the value at the end of laryngoscopy and procedure revealed statistically significant results (P = 0.041) in Group A with mean (SD) value of 14.1 (5.98) when compared with Group B 10.69 (4.96). However, percentage increase in HR (beats/min) were not statistically significant with P = 0.358 [Table 3].
Observations for the secondary outcome such as POST were noted 6 h postoperatively, and the results were not statistically significant with P = 0.17. However, 52% of patients in Group B experienced only mild grade of sore throat as compared to 43% of patients in Group A which experienced moderate degree of sore throat [Table 4]. Of the 52% of anaesthesiologists in Group B graded throat packing with FSPT as very smooth. This was in contrast to Group A where only 21% of respondents graded conventional technique of throat packing as very smooth, and the results were statistically significant with P = 0.024 [Table 4].
| Discussion|| |
Throat packing forms an integral part of the preparation in cases of nasal, faciomaxillary, and oral surgeries. The main objective of throat packing includes prevention of debris including blood from trickling alongside the ETT and soiling the airway and inadvertent passage to the stomach.,, The other indications include providing the seal around the uncuffed ETT in pediatric patients, thereby preventing the loss of tidal volume as well as OT contamination due to leakage of the gases.
Most work has been done regarding preventing POST and comparing the efficacy between different types of pharyngeal and throat packs, but none of the studies dwell upon the techniques of throat packing.,,, Guidelines are in place to prevent the retention of throat packs after the completion of the surgery.,, Lesser evidence exists about the technique. An “Evidence-informed Practice tool” has been brought out by the Winnipeg Regional Health Authority in September 2014 which provides “Clinical Guidelines for the management of throat packs during surgical procedures.” Their main area of concern was to provide guidelines regarding safe reposition of throat packs and reduce the risk of unintentional throat pack retention.
Therefore, our quest was to compare the conventional technique of throat packing using the Macintosh blade of laryngoscope as a guide to the modified technique of FSPT in which laryngoscope blade was used as an aid to pack the throat by sliding the ribbon gauze over it.
Total time to insert the standard size moist ribbon gauze compared between the two groups. The results showed that in Group B, the time duration mean (SD) was 76.52 (7.14) s as compared to 85.39 (5.13) s in Group A [Table 3]. On further discussion with fellow anesthesiologists who participated in the study, it was brought out that throat packing by conventional method was more time-consuming. The difficulty was increased primarily due to repeated engaging the distal end of ribbon gauze with the Magill's forceps inside the oral cavity, reposting it around the ETT, and then disengaging the tip of the Magill's forceps to release the ribbon gauze. Disengagement of the Magill's forceps in the limited space of the oral cavity and again engaging the ribbon gauze in the oral cavity in a sequential manner led to increased consumption of time due to the entangling of the gauze inside and loss of the previous seal. However, lesser time was consumed in the modified method of FSPT as the gauze was able to slide smoothly over the flange of the laryngoscope blade which was held in tension by an assistant at the heel of the laryngoscope blade which acted as a pulley. Therefore, repeated attempts of engaging and disengaging of the ribbon gauze with the tip of the Magill's forceps were limited in Group B facilitating early packing of the throat [Figure 2].
Hemodynamic response assessed in terms of percentage increase of the HR and MAP from the baseline value showed statistically significant increase of 13% in MAP from the baseline values in Group A perhaps due to prolonged laryngoscopy duration [Table 3]. Enough evidence exists in literature where the stress response to laryngoscopy is considered a well-defined fact. Among the various factors such as type of blades used, the duration of laryngoscopy is also considered a decisive factor in determining the stress response., The percentage increase in HR when compared was statistically insignificant between the two groups [Table 3] though it was more in Group A.
POST is a well-described entity following endotracheal intubation and the other etiological factors include female sex, mucosal injury during intubation, presence of nasogastric tube, increased cuff pressures, prolonged duration of anesthesia, and use of throat packs.,, The incidence varies between 50%–60% in the literature., Lee et al. prospectively analyzed patients who were intubated following GA and the results showed sore throat in about 57% of the patients. Rizvi et al. observed higher incidence of POST with the oropharyngeal packing when compared with nasopharyngeal packing. In our study, both the groups had sore throat, but Group A had a higher percentage of subjects with moderate sore throat (43%) as compared to Group B (17%), and this was basically attributed to the inadvertent trauma occurring during performing conventional way of throat packing where maneuvering and repeated opening and closing of the Magill's forceps tip resulted in shearing of the oral mucosa and caused trauma.
When the ease of insertion was questioned postinsertion of the throat packs, 52% of respondents of Group B graded the modified FSPT of throat packing as very smooth in contrast to Group A (21%). This could be attributed primarily due to the sliding of the ribbon gauze over the flange of the laryngoscope blade and consequently less handling of the ribbon gauze inside the oral cavity in contrast to the conventional technique.
Limitations of the study include the validation of the new technique which will require a prospective study with a larger sample size. Interobserver bias could not be completely ruled out. Inclusion of the heterogeneous group of surgeries could have resulted as a confounding factor in the assessment of POST as some variation in the incidence could have occurred depending on the tissue handling and duration of the anesthesia.
| Conclusions|| |
FSPT of throat packing can be used as an alternative to the conventional technique of throat packing. The advantages are an early and smoother placement of the throat pack. This can lessen the morbidities such as POST and the hemodynamic changes, resulting from the stress of prolonged laryngoscopy by conventional technique in patients having comorbidities such as hypertension and coronary artery disease.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]