|Year : 2020 | Volume
| Issue : 1 | Page : 22-28
Comparative study between C-MAC, Air Traq laryngoscope, and Air Q in adult patients
Amany M Abdel Haliem1, Enas M Ashrey2, Soad S El gaby3
1 Department of Anesthesiology, ICU and Pain Management, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Anaesthesia, Intensive Care and Pain Management, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
3 Department of Anaesthesia and Intensive Care, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||09-Dec-2019|
|Date of Decision||18-Dec-2019|
|Date of Acceptance||24-Dec-2019|
|Date of Web Publication||20-Apr-2020|
MD Enas M Ashrey
Anaesthesia and Intensive Care, Department of Anaesthesia and Intensive Care, Faculty of Medicine for Girls, Al-Azhar University, (11517), Alzahraa University Hospital Abbasia, Cairo
Source of Support: None, Conflict of Interest: None
Introduction Airway management is one of the cornerstones of anesthesia. The role of airway assessment is very important for airway management. So many devices have been introduced to improve tracheal intubation such as C-MAC video laryngoscopes (C-MAC VL) and Air Traq. Also, some of supraglottic airway devices have been modified for endotracheal intubation like Air Q intubating laryngeal mask airway.
Aim The aim of the study was to compare C-MAC, Air Traq laryngoscopes, and Air Q in terms of hemodynamic changes such as primary outcome, and ease of intubation, success rate and intubation time, number of attempts, complications, and incidence of esophageal intubation such as secondary outcome, in patients who need tracheal intubation for elective surgeries.
Patients and methods A total of 60 adult patients aged 21–65 years, with the American Society of Anesthesiology I, II, Mallampati I, II scheduled for elective tracheal intubation, were divided into three equal groups in a randomized controlled manner: group CM (n=20) intubation was done with C-MAC VL; group AT (n=20) intubation was done with Air Traq; group AQ (n=20): intubation was done with Air Q.
Results There was statistically significant prolongation in the duration of intubation in the AQ group followed by AT group and then CM group. Ease of intubation, decrease in the number of attempts, and success rate were similar in CM, AT groups. In contrast, the AQ group showed difficulty in intubation and the failure rate was 15% (P=0.043). No complication or incidence of esophageal intubation occurred during intubation with the CM group or AT group, but AQ group showed increased incidence of esophageal intubation in 15% of patients.
Conclusion We concluded that C-MAC VL is a more superior, easier, and protective method of safe intubation followed by Air Traq optical laryngoscope proved by ease of intubation, shorter time of intubation, and number of intubation needed with no incidence of esophageal intubation than Air Q intubating laryngeal mask.
Keywords: Air Q, Air Traq, airway management, C-MAC video laryngoscope
|How to cite this article:|
Abdel Haliem AM, Ashrey EM, El gaby SS. Comparative study between C-MAC, Air Traq laryngoscope, and Air Q in adult patients. Sci J Al-Azhar Med Fac Girls 2020;4:22-8
|How to cite this URL:|
Abdel Haliem AM, Ashrey EM, El gaby SS. Comparative study between C-MAC, Air Traq laryngoscope, and Air Q in adult patients. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 May 30];4:22-8. Available from: http://www.sjamf.eg.net/text.asp?2020/4/1/22/282857
| Introduction|| |
Airway management is one of the cornerstones of anesthesia. Airway assessment has a role in the identification of problems during intubation and maintenance of oxygenation and ventilation . So many devices have introduced to improve tracheal intubation and decrease morbidity and mortality of patients. Devices like C-MAC and Air Traq laryngoscopes improve laryngeal view, ease of intubation difficulty, and success rate of intubation compared with direct laryngoscopy during routine and difficult airway management . Also, some of supraglottic airway devices have been modified to be used as conduits for endotracheal intubation like Air Q intubating laryngeal mask airway. It is used in many scenarios during airway management . The C-MAC video laryngoscope (VL) is a fourth-generation VL that was developed and manufactured by the Karl Storz (Tuttlingen, Germany) in 1999. It can be used as direct and indirect laryngoscopes. It has standard Macintosh blade with camera placed at its tip . It has been successfully used for visualization of the larynx especially in difficult airway patients . Using the Air Traq optical laryngoscope, used in patients with normal and difficult airways, best view of the glottis can be seen by Air Traq without aligning the oral with the pharyngeal and laryngeal axes . It has two separate channels: the optical channel contain the optical system and the guiding channel that hold the endotracheal tube. Tracheal intubation with the aid of a rigid laryngoscope is an invasive technique, so supraglottic airway devices is used as a superior alternative . And some of these devices have been modified to be used as conduits for endotracheal intubation like Air Q. It was introduced by Daniel Cook in 2005 as a conduit for tracheal intubation during general anesthesia . It also proved to be a lifesaving alternative as a rescue device in difficult airway .
Hence, the aim of this study was to compare C-MAC VL, Air Traq, and Air Q in terms of hemodynamic changes such as primary outcome, and ease of intubation, success rate, duration of intubation, number of attempts, complications, and incidence of esophageal intubation as secondary outcome in patients who need electively tracheal intubation.
| Patients and methods|| |
This prospective randomized study was conducted at Al-Zahraa University Hospital on 60 adult patients scheduled for elective surgery under general anesthesia during the period that started from November 2018 to August 2019 after approval by the local ethics committee from the Research Ethics Committee (REC) of the Faculty of Medicine for Girls, Al-Azhar University under registration number N0 REC 201911233. Written informed consent was taken.
Inclusion criteria was patients aged 21 to 65 years, of both sexes, with American Society of Anesthesiology I, II, Mallampati I, II.
Exclusion criteria included patients with gastroesophageal reflux disease, thyromental distance less than 2.5 fingers, pregnant patients, and patients with susceptibility of difficult intubation mallampat III.
Patients were divided into three equal groups (20 patients in each group) by a computer-generated sequence using sealed opaque envelopes.
- Group I (CM group) (n=20): intubation was done with C-MAC VL.
- Group II (AT group) (n=20): intubation was done with Air Traq.
- Group III (AQ group) (n=20): intubation was done with Air Q.
Preoperative airway assessment was done the day before the surgery. After arrival to the operating room intravenous cannula was inserted. All patients were monitored by: noninvasive blood pressure, ECG, pulse oximetry for oxygen saturation (SpO2), and end-tidal CO2 (ETCO2) values by capnography.
All patients received general anesthesia, induction of anesthesia was done with the administration of 100% oxygen at 6 l/min for at least 3 min, followed by intravenous fentanyl (1–1.5 μg/kg), propofol (2–3 mg/kg), and cis-atracurium (0.15 mg/kg). Maintenance of anesthesia was achieved with a mixture of oxygen and air, isoflurane 0.8–1.2%, and cis-atracium 0.025 mg/kg that was given in incremental doses. Performance of intubation was done by one of the three devices according to each group.
Failure to intubate was defined as the inability to intubate the patient’s trachea within 120 s or unsuccessful two intubation attempts, or occurrence of desaturation (SpO2, 80%). In this case, the trachea was intubated using Macintosh laryngoscope. And instruments like bougie or stylet are used during intubation; after intubation the patient was connected to mechanical ventilation with adjustment of parameters to maintain hemodynamics.
Primary outcome is evaluation of the hemodynamic state. Secondary outcome is evaluation of success rate of intubation, time taken to intubate, ease of tracheal intubation, number of intubation attempts, use of bougie or stylet, complications during and after intubation, and incidence of esophageal intubation.
Sample size justification
MedCalc, version 126.96.36.199 program (Ostend, Belgium) was used for calculations of sample size; statistical calculator was based on 95%) confidence interval and power of the study (80%) with an α error of 5%. A previous study  has shown that the time taken to intubate patients with C-MAC VL was less than Air Traq. In another study  it has been shown that success rate was 100% for group VL, versus 80%for group LMA Fastrach (P=0.023) and there was higher successful intubation in the first attempt in group VL. So, it can be inferred from this study, based on this assumption, that the sample size calculated according to these values produced a minimal sample size of 57 cases enough to find such a difference. Assuming a dropout ratio of 5%, the sample size will be 60 cases, subdivided into three groups: group CM (n=20), group AT (n=20), and group AQ (n=20).
Recorded data were analyzed using the Statistical Package for Social Sciences, version 20 (SPSS Inc., Chicago, Illinois, USA). Normality of quantitative data distribution was tested using the Shapiro–Wilk test. Data were presented as mean (SD) and number as appropriate. The three groups were compared using the one-way analysis of variance when compared between more than two means. Post-hoc test: least significant difference was used for multiple comparisons between different variables. The repeated measures analysis of variance tests for whether there are any differences between related means. Pearson’s correlation coefficient (r) test was used for correlating data and the χ2 test (with Yates correction if needed) as appropriate. A P value of less than 0.05 was considered statistically significant.
| Results|| |
The three groups were comparable with respect to age, sex, weight, American Society of Anesthesiology grade, Mallampati, and there was no statistically significant difference between groups according to demographic data ([Table 1]).
Hemodynamic changes (MAP, HR, SO2, and ETCO2) showed no statistically significant difference among the three studied groups at all operative times ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 2 Comparison between groups according to mean arterial blood pressure.|
Click here to view
There was no significant difference in the number of attempts between groups. The difference was statistically significant (P<0.001) in the time taken to intubate. Air Q showed longer time of intubation compared with C-MAC VL and Air Traq. The mean time for tracheal intubation was 45.75±10.67 s in the CM group and 60.75±8.63 s in the AT group as compared with 96.50±17.25 s in the AQ group.
Also, there was significant difference in the success rate of intubation between groups: CM group and AT group showed successful intubation (100%). In contrast, AQ group showed a success rate of intubation in 75% of patients and failure rate was 15%. There was significant difference in ease of intubation between groups. AQ group showed difficult intubation in three (15%) patients.
In the CM group, the use of stylet was required in 14 (70%) patients and bougie was used in one (5%) patient, whereas no stylet or bougie was required in five (25%) patients. In the AT group bougie was required in all patients intubated with AT while in the AQ group no stylet or bougie was required.
No significant complications were observed with the use of either of the devices except in three cases in the AQ group showing an incidence of esophageal intubation and use of Macintosh direct laryngoscope ([Table 2]).
| Discussion|| |
The present study was conducted to compare C-MAC, Air Traq laryngoscope, and Air Q in adult patients, and its effect on hemodynamic, success rate of intubation, time taken to intubate, ease of tracheal intubation, number of intubation attempts, use of bougie or stylet, complications during and after intubation, and incidence of esophageal intubation.
The results of the present study showed that there was no statistically significant difference found between the three groups as regards hemodynamics (P>0.05). In agreement with the results of the current study, the study done by McElwain and Laffey  who compare between C-MAC, Air Traq, and Macintosh laryngoscopes in patients with cervical spine immobilization undergoing tracheal intubation using manual in-line axial cervical spine stabilization showed that the heart rate increases in all groups after tracheal intubation, but within 5 min returned to baseline in all groups, with no differences between groups. Our findings are also in agreement with the results of the study performed by Ahmed et al.  who compared intubations with C-MAC and Air Traq laryngoscopes in neutral position. It has been concluded that the heart rate increases after tracheal intubation, but within 5 min returned to baseline. Also there was no statistically significant difference found between groups regarding MAP, group CM (P=0.565), and group AT (P=0.295).
Gümüş et al.  in their study comparing C-MAC VL and LMA in patients undergoing endotracheal intubation showed that no significant difference between the groups as regards end-tidal carbon dioxide concentrations after the intubation (P>0.05).
The current study showed that there was no statistically significant difference between groups according to the number of attempts. In group CM, AT 90% of patients were intubated at first attempt and only 10% of patients were intubated at second attempt. In the AQ group 15 patients were intubated at first attempt and only two patients were intubated at second attempt and failed intubation was observed in three patients after the second attempt. In agreement with the results of this study, the study done by Chugh et al.  compared the C-MAC, Air Traq, and MCcoy laryngoscopes in patients undergoing tracheal intubation with cervical spine immobilization showed that 100% of patients with C-MAC VL were intubated in the first attempt while 90%of patients in the Air Traq group were intubated in the first attempt and only 10% of patients required a second attempt.
Also Abdelgalel and Mowafy  who compared between Air Traq, Glidescope and Macintosh laryngoscopy for emergency intubation in the ICU showed that Air Traq has less number of attempts and higher first-attempt success rate than Macintosh laryngoscopy.
The present study showed that intubation with C-MAC VL required less time as compared with intubation with Air Traq and Air Q. Air Q showed the longest duration with minimal hemodynamic changes during intubation in all groups. The majority of patients required 30–65 s for intubation with C-MAC as compared with 50–80 s with the Air Traq, 80–120 s with Air Q.
In agreement with the results of the current study, Ahmed et al.  who proved that time taken with C-MAC is shorter than the Air Traq group CM=14±12.89 s, group AT=26.3±13.34 s (P=0.0014). Akbar and Ooi  concluded that C-MAC increases the first-time success rate and reduces intubation time than Macintosh direct laryngoscope. Also a previous study done by Gümüş et al. , Akbar and Ooi  showed that the time taken to intubate patients was significantly shorter in group VL than that of group LMA C Trach.
In contrast, the result of the current study are against the result obtained by Sabry et al. . who found that compared between C-MAC D-blade and McCoy laryngoscopes patients with cervical spine immobilization undergoing tracheal intubation showed that the duration of successful intubation attempt was significantly shorter in the McCoy group than in the C-MAC group.
The present study showed that the incidence of successful intubation was 100% with C-MAC and Air Traq, but 85% with Air Q. Our result matched with Ahmed et al.  who showed that 100% successful intubations were observed in C-MAC and Air Traq groups. Most of the previous study conducted by McElwain and Laffey  and Chugh et al.  found the same result as regards the success rate of C-MAC VL and Air Traq.In disagreement with our study, the study done by Attarde et al.  showed that tracheal intubation using Air Q was successful in 76.7% patients only.
In the current study ease of intubation was statistically significant in C-MAC and Air Traq than Air Q. Chugh et al.  recorded the same result. With regard to the complications and incidence of esophageal intubation, there were no reported cases of such complication in group C-MAC, Air Traq, but the Air Q group showed increased incidence of esophageal intubation in three patients. The study done by Ozkan et al.  showed a similar result as in our study.
| Conclusion|| |
The authors conclude that C-MAC VL is a more superior, easier, and protective method of safe intubation followed by Air Traq optical laryngoscope proved by ease of intubation, shorter time of intubation, number of intubations needed with no incidence of esophageal intubation than Air Q intubating laryngeal mask.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yentis SM. Predicting difficult intubation − worthwhile exercise or pointless ritual? Anaesthesia
Teoh WH, Saxena S, Shah MK, Sia AT. Comparison of three videolaryngoscopes: Pentax Airway Scope, C-MAC, glidescope vs. the Macintosh laryngoscope for tracheal intubation. Anaesthesia
White P, Smith I. Laryngeal mask airway. In: Benumof JL, ed. Airway management principles and practice
. St Louis: Mosby 1995. 353–373
Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology
Kaki AM, Almarakbi WA, Fawzi HM, Boker AM. Use of Airtraq, C-MAC, and glidescope laryngoscope is better than Macintosh in novice medical students’ hands: a manikin study. Saudi J Anaesth
Maharaj CH, Costello J, Higgins BD, Harte BH, Laffey JG. Retention of tracheal intubation skills by novice personnel: A comparison of the Airtraq and Macintosh laryngoscopes. Anaesthesia
Abbas DN, Abdghaffar EM. Comparison of the air-Q intubating laryngeal airway versus the modified Williams intubating airway as aids for training in fiberoptic tracheal intubation. Ain Shams J Anaesthesiol
Bakker EJ, Valkenburg M, Galvin EM. Pilot study of the air-Q intubating laryngeal airway in clinical use. Anaesth Intensive Care
Ahmed SM, Doley K, Athar M, Raza N, Siddiqi OA, Ali S. Comparison of endotracheal intubation time in neutral position between C-Mac® and Airtraq® laryngoscopes: a prospective randomised study. Indian J Anaesth
Özkan S, Altınsoy M, Sayın H, Dolgun J, Ergil A. Dönmez comparison of cervical spine motion during intubation with a C‑MAC D‑Blade® and an LMA Fastrach. Anaesthesist
McElwain J, Laffey G. Comparison of the C-MAC®
, and Macintosh laryngoscopes in patients undergoing tracheal intubation with cervical spine immobilization. Br J Anaesth
Gümüş N, Dilek A, Ülger F, Köksal E, Çetinoğlu EC et al.
Comparison of LMA CTrach and video laryngoscope in endotracheal intubation. Turk J Anaesthesiol Reanim
Chugh V, Sehgal NP, Prakash A, Boro S. Comparison of the CMac, Airtraq and Mc Coy laryngoscopes in patients undergoing tracheal intubation with cervical spine immobilization − a prospective observational study. IOSR J Dent Med Sci
Abdelgalel EF, Mowafy MS. Comparison between Glidescope, Airtraq and Macintosh laryngoscopy for emergency endotracheal intubation in intensive care unit: randomized controlled trial Egyptian. J Anaesth
Akbar SH, Ooi JS. Comparison between C-MAC video-laryngoscope and Macintosh direct laryngoscope during cervical spine immobilization. Middle East J Anaesthesiol
Sabry LA, Shaarawy SS, Ellakany MH, Elmasry AA. Comparison between C-MAC D-blade and McCoy laryngoscopes in intubating patients during cervical immobilization. Anesthesiology
Attarde VB, Kotekar N, Shetty SM. Air-Q intubating laryngeal airway: study of the second generation supraglottic airway device. Indian J Anaesth
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]