Indian Journal of Anaesthesia | Vol.

57| Issue 2 | Mar-Apr 2013 170

Address for correspondence:
Prof. Atul P Kulkarni,
Prof. & Head, Division of
Critical Care, Department
of Anaesthesiology, Critical
Care and Pain, Tata Memorial
Hospital, Mumbai - 400 012,
Maharashtra, India.
E-mail: [email protected]
INTRODUCTION
Airway management is the primary responsibility of
the anaesthesiologists: To secure, preserve and protect
it during induction, maintenance and recovery from
anaesthesia. Failure to manage airway can lead to
catastrophic results; death or worse; brain damage.
Most anaesthesia mishaps occur at the time of
induction of anaesthesia.
[1]
Orotracheal intubation
is the most common method used to secure and
maintain airway. A variety of methods are available
for intubation: Digital or tactile method, lighted stylet,
intubating LMA, fibre optic endoscopic intubation
and conventional direct laryngoscopy.
Glottic view during laryngoscopy can be classified
using Cormack Lehane grading
[2]
or percentage of
glottic opening (POGO Score).
[3]
Glottic view can be
improved by external manipulation of larynx using
either backward-upward-rightward pressure (BURP)
or Bimanual Laryngoscopy. The need for external
manipulation and the number of attempts are indicators
of difficulty encountered during laryngoscopy and
intubation.
Literature
[4]
suggests that glottis is viewed better with
the straight blades while tracheal intubation is easier
with the curved blades. We therefore, compared the
Macintosh, Miller, McCoy blades and the Trueview

laryngoscope (Truphatek International Ltd, Netanya,
Israel), which incorporates a prism in a straight blade,
for glottic visualisation and ease of tracheal intubation.
AtulPKulkarni,AmarSTirmanwar
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
Comparison ofglotticvisualisation and ease of
intubation withdifferentlaryngoscopeblades
ABSTRACT
Context: Literature suggests glottic view is better with straight blades while tracheal intubation is
easier with curved blades. Aims: To compare glottic view and ease of intubation with Macintosh,
Miller, McCoy blades and the Trueview

laryngoscope. Settings and Design: This prospective

randomised study was undertaken in operation theatres of a 550 bedded tertiary referral cancer
centre after approval from the Institutional Review Board. Methods: We compared the Macintosh,
Miller, McCoy blades and the Trueview

laryngoscope for glottic visualisation and ease of

tracheal intubation; in 120 patients undergoing elective cancer surgery; randomly divided into
four groups. After induction of anaesthesia laryngoscopy was performed and trachea intubated.
We recorded: Visualisation of glottis (Cormack Lehane grade), ease of intubation, number of
attempts; need to change the blade and need for external laryngeal manipulation. Statistical
Analysis: Demographic data, Mallampati classifcation were compared using the Chisquare
test. A P<0.05 was considered signifcant. Results: Grade 1 view was obtained most often (87%
patients) with Trueview

laryngoscope. Intubation was easier (Grade 1) with Trueview

and McCoy
blades (93% each). Seven patients needed two attempts; one patient in Miller group needed three
attempts. No patient in McCoy and Trueview

Groups required external laryngeal manipulation.

Conclusions: We found that in patients with normal airway glottis was best visualised with Miller
blade and Trueview

laryngoscope however, the trachea was more easily intubated with McCoy
and Macintosh blades and Trueview

laryngoscope.
Key words: Cormack lehane grade, external laryngeal manipulation, intubation, laryngoscopy
Access this article online
Website: www.ijaweb.org
DOI: 10.4103/0019-5049.111846
Quick response code
Clinical
Investigation
How to cite this article: Kulkarni AP, Tirmanwar AS. Comparison of glottic visualisation and ease of intubation with different laryngoscope
blades. Indian J Anaesth 2013;57:170-4.
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Kulkarni and Tirmanwar: Glottic visualisation and ease of intubation
171 Indian Journal of Anaesthesia | Vol. 57| Issue 2 | Mar-Apr 2013
METHODS
This prospective randomised study was conducted
after obtaining approval from the Institutional Review
board. One hundred and twenty adult patients,
based on convenience sampling, were included who
had given written informed consent. These patients
were ASA grade I or II, between 18 years and 70 years
of age, were undergoing elective cancer surgery under
general anaesthesia requiring endotracheal intubation.
Patients were excluded if they refused consent, were
pregnant, had potential difficult mask ventilation
and/or anticipated difficult intubation or had pathology
in neck, upper respiratory tract and upper alimentary
tract. A detailed routine pre-anaesthetic check-up was
performed in the pre-anaesthesia check-up clinic;
where airway was assessed using Mallampati Scale,
Inter-incisor gap, jaw slide and normalcy of neck
movements; and routine laboratory investigations
were obtained. As per random numbers generated by
computer the patients were divided in four groups
of 30 each: Group 1: Macintosh, Group 2: McCoy,
Group 3 Miller and Group 4: Trueview

laryngoscope.
In the operating room, pulse oximeter,
electrocardiograph, capnography and automated
non-invasive blood pressure were attached for
monitoring and intravenous access was secured.
Demographic data such as age, sex and weight of the
patient was noted. Airway assessment was once again
carried out using Samsung and Youngs modification
[5]

of the Mallampati classification. The patient was
asked to sit, open the mouth maximally, and protrude
the tongue but not phonate. Visibility of the oral
and pharyngeal structures was then classified by an
observer sitting at the same level as the patient.
Class I: Soft palate, fauces, uvula, pillars visible
Class II: Soft palate, fauces, portion of uvula, visible
Class III: Soft palate, base of uvula visible
Class IV: Only hard palate visible.
A Doughnut-shaped pillow and hard sponge square
pillow, was placed under the head of the patient
to obtain classical sniffing position. The patient
was pre-oxygenated with 100% oxygen for 3 min.
Anaesthesia was then induced with 1-3 mg/kg of
propofol or thiopentone sodium 5 mg/kg, fentanyl
2 g/kg. Feasibility of ventilation with a face mask
was checked prior to injection of non-depolarising
muscle relaxant. After ventilation was confirmed
vecuronium was administered and the patient was
ventilated with isoflurane 0.5-1% in 50:50 mixture
of O
2
and N
2
O for 3 min then ventilated for 1 min
with 100% O
2
. The laryngoscopy and intubation were
carried out in classical intubating position by a single
anaesthesiologist. This investigator had trained for
2 months with all laryngoscope blades until he had
obtained sufficient familiarity. We studied following
aspects during tracheal intubation.
Visualisation of laryngeal inlet: This was graded using
Cormack Lehane (CL) Grades:
Grade 1: Complete glottis visible
Grade 2: Anterior glottis not seen
Grade 3: Epiglottis seen but not glottis
Grade 4: Epiglottis not seen.
Ease of intubation: This was graded as follows:
[4]
Grade 1: Intubation easy
Grade 2: Intubation requiring an increased anterior
lifting force and assistance to pull the right
corner of the mouth upwards to increase space
Grade 3: Intubation requiring multiple attempts and a
curved stylet
Grade 4: Failure to intubate with the assigned
laryngoscope.
If the view after laryngoscopy was more
than CL Grade 2 external laryngeal manipulation
was carried out. The need for external manipulation
was classified as Grade 1: No requirement of external
laryngeal manipulations and Grade 2: Requirement of
external laryngeal manipulation.
Number of attempts was noted. After failure at first
attempt stylet was used. Patients were ventilated
with 100% oxygen between attempts at laryngoscopy
and intubation so that no patient was allowed to
desaturate below 95%. After 3 attempts at intubation
with assigned blade, patients were intubated using
Macintosh blade.
Statistical analysis
Demographic data, Mallampatti Classification and
other variables were compared using the Chi-square
test using SPSS version 16. A P<0.05 was taken to
assume statistical significance.
RESULTS
This study was carried out over a period of 8 months.
During the first 2 months, the anaesthesiologist
practiced with all laryngoscope blades until he was
proficient. The patients included in the study were
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172
Kulkarni and Tirmanwar: Glottic visualisation and ease of intubation
Indian Journal of Anaesthesia | Vol. 57| Issue 2 | Mar-Apr 2013
between 18 years and 70 years of age. The mean age,
weight and Mallampati scores were similar in patients
undergoing intubation with different laryngoscope
blades [Tables 1 and 2]. All patients were easy to
ventilate and there were no failed intubations.
Grade 1 view was obtained most often (87% patients)
using the Trueview

laryngoscope [Table 3]. This was

followed by Miller (83%), then McCoy (77%) and then
the Macintosh blade (63%). This was not statistically
significant and intubation was easier (Grade 1) with
Trueview

and McCoy blades (93% each). The ease of

intubation was similar with these two blades as with
Macintosh blade, i.e., 90% of patients had Grade 1
intubation. With the Miller blade, Grade 1 ease at
intubation was seen only in 57% patients [Table 4].
The difference between McCoy, Trueview

and Miller
groups was statistically significant (P=0.01). Most
patients were intubated at the first attempt with all
laryngoscopes [Table 5]. Only seven patients needed
2 attempts, while one patient in Miller group needed
3 attempts. Seven patients in Macintosh group
and three patients in Miller group [Table 6] required
external laryngeal manipulation. No patient in either
McCoy or Trueview

group required external laryngeal

manipulation.
DISCUSSION
We undertook this study to confirm the hypothesis
that glottic visualization is better with straight blade
however; intubation is easier with the curved blades.
Patients undergoing head and neck cancer surgery for
intraoral pathology were excluded as the presence of
disease in oral cavity itself may lead to difficulty in
glottic visualisation and intubation and our aim was to
compare use of the various laryngoscopes in patients
with normal anatomy. Inclusion of these patients
may have confounded the results of our study; as it
is difficult to match patients with equal degrees of
difficult intubation.
In two patients in the Miller Group, the glottis was
visible (CL Grade 2 view), but the trachea impossible
to intubate with that blade in 3 attempts, we had to
switch to Macintosh blade to intubate the trachea (CL
Grade 3 view, which improved to Grade 2 on BURP).
We found that the quality of glottic visualisation was
best with True-View laryngoscope and Miller blade.
Even with McCoy blade, a Grade I view was obtained
in 77% of patients. Macintosh blade performed the
worst (63% Grade I view). This difference was not
statistically significant, probably reflecting small
sample size. These findings are corroborated by
our other findings. We found external laryngeal
manipulation was more often needed with Macintosh
blade (23%) as compared to Miller blade (10%).
Benumof and Cooper
[6]
demonstrated that external
laryngeal manipulation improved glottic visualization.
Table 6: Need for external laryngeal manipulation
Group (n=30 each) Yes (%) No (%)
Macintosh 7 (23.3) 23 (76.7)
McCoy 0 30 (100)
Miller 3 (10) 27 (90.0)
Trueview

0 30 (100)
Table 1: Demographics
Group (n=30) Age (mean (SD)) Weight (mean (SD))
Macintosh 60.87 (9.15) 46.9 (11.98)
McCoy 59.63 (10.15) 43.68 (12.78)
Miller 59.70 (8.68) 46.9 (11.69)
Trueview

59.70 (8.68) 44.73 (10.20)

P value 0.77 0.67
SD Standard deviation
Table 2: MPC grading
Group (n=30) MPC grade n (%)
1 2 3
Macintosh 19 (63.3) 9 (30) 2 (6.7)
McCoy 19 (63.3) 9 (30) 2 (6.7)
Miller 23 (76.5) 6 (19.9) 1 (3.3)
Trueview

18 (60) 11 (36.3) 1 (3.3)
MPC Mallampati classifcation
Table 3: Glottic visualization
Group
(n=30 each)
Grade 1
(%)
Grade 2
(%)
Grade 3
(%)
Grade 4
Macintosh 19 (63) 10 (33) 1 (4) 0
McCoy 23 (77) 7 (23) 0 0
Miller 25 (83) 5 (17) 0 0
Trueview

26 (87) 4 (13) 0 0
Table 4: Ease of intubation
Group (n=30 each) Grade 1 (%) Grade 2 Grade 3 Grade 4
Macintosh 27 (90) 3 0 0
McCoy 28 (93) 0 2 0
Miller 17 (57) 8 3 2
Trueview

28 (93) 1 1 0
P=0.01 for McCoy and Trueview

versus Miller blade

Table 5: No. of attempts at intubation
Group (n=30 each) 1 attempt 2 attempts 3 attempts
Macintosh 30 0 0
McCoy 27 3 0
Miller 26 3 1
Trueview

29 1 0
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Kulkarni and Tirmanwar: Glottic visualisation and ease of intubation
173 Indian Journal of Anaesthesia | Vol. 57| Issue 2 | Mar-Apr 2013
The difference in glottic visualisation can also be
explained by the mechanics of laryngoscopy with
different types of blades. With the Macintosh blade,
the curvature of the blade acts as a visual hill;
interrupting the line of sight, called the Crest of
the Hill effect.
[7]
Whereas with the Miller or any
other straight blade, the volume of tissue required
to be displaced to obtain the view is lower. While
using Macintosh blade to achieve the same glottic
view as with a straight blade, the tongue must be
displaced more into the submandibular space. With
Macintosh blade, the oral axis makes an angle with
the laryngeal axis, masking the glottis as it is covered
by the epiglottis and this interferes with glottic view.
When the McCoy blade is used, the epiglottis is lifted
out of the way improving glottic exposure. Thus, the
force required is reduced as the tongue only needs to
be displaced laterally. The TrueView

laryngoscope
incorporates a prism. Due to this prism, an optical
view is offered around the corner, without having to
align oral, pharyngeal and laryngeal axes.
Cinefluroscopic studies
[8,9]
suggest that with the
Macintosh blade, the hyoid and vallecula are pushed
anteriorly and caudally as compared with the Miller
blade. This also explains why the movement of
cervical vertebrae is less with the Miller blade. Achen
et al.
[10]
compared laryngeal view obtained by using
the Miller blade with paraglossal approach, to that
with the Macintosh blade. The Miller blade enabled
greater than 25% of the vocal cords to be seen in 95%
of the cases, whereas with Macintosh blade this was
achievable in only 80% cases. Uchida et al.
[11]
found
that when laryngoscopy was performed with neck in
neutral position the grade of glottic view improved with
use of McCoy blade from Grade 2 to 3 views obtained
with Macintosh blade. In a Japanese study
[12]
the views
obtained with McCoy blade were the best (82 Grade I
views) then with Miller blade (72 Grade I views)
while Grade I view was obtained in least number
of patients (47 Grade I views) with the Macintosh
blade. Arino et al.
[4]
found that laryngoscopic views
obtained with Belscope (98/100 Grade I views) and
Miller (96/100 Grade I views) blades were similar.
The levering tip of the McCoy blade laryngoscopes
significantly improved the laryngoscopic view (87/100
Grade I views) as compared to that without the use of
the levering tip (69/100 Grade I views). The Macintosh
blade fared the worst (72/100 grade views).
Cheung et al.
[13]
found that the glottic view was
significantly better with the Flexiblade, a type of levering
laryngoscope blade similar to the McCoy, than the
Macintosh laryngoscope. Another study
[14]
compared
Trueview

laryngoscope with Macintosh blade.

Trueview

laryngoscope produced better glottic view

with less maximum force applied during intubation
than when using Macintosh blade. Li et al.
[15]
found
better glottic view with Trueview

laryngoscope than
Macintosh blade in patients with Cormack-Lehane
grade <1. They suggested that Truview can be used
in patients with anticipated difficult intubation. In a
study in manikins
[16]
study Truview

laryngoscope
provided a better view of glottis.
In our study, intubation was easier with Trueview

and
McCoy blades (93% Grade 1 intubation in each group)
and almost as easy as with Macintosh blade. With the
Miller blade, Grade 1 ease at intubation was achieved
in 57% patients. The difference between McCoy (as
wells as Trueview

) and Miller was statistically

significant (P=0.01). The difference between Macintosh
and Miller did not reach statistical significance, it
suggested a trend towards easier intubation with
Macintosh (P=0.09), probably reflecting small sample
size. In a manikin study
[16]
20 anaesthetists (12 trainees
and eight consultants) compared the Truphatek
Truview EVO
2
with a conventional Macintosh size
3 blade. Though glottic view was better, Trueview

did not reduce the intubation time or the ease of
tracheal tube placement with respect to conventional
Macintosh blade.
Most of our patients were intubated at the first attempt.
All (30) patients in Macintosh group were intubated
at the first attempt, as compared to Miller blade (26
patients). Seven patients needed two attempts; three
each in McCoy and Miller groups and one patient in
Trueview

group; while one patient in Miller group

needed three attempts.
CONCLUSION
In this prospective randomised controlled study in
patients with normal airway, we found that glottis
visualisation is best achieved with straight blades
such as Miller blade and Trueview

laryngoscope.
Tracheal intubation however, is easier with McCoy
and Macintosh blades and Trueview

laryngoscope.
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Source of Support: Nil, Confict of Interest: None declared
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