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PubMed2003

Replacement of physiologically autoinhaled nitric oxide in intubated patients.

Autoinhaled nitric oxide (NO) is produced mainly in the upper airways. Orotracheal intubation disrupts the natural autoinhalation of NO from the naso- and oropharynx. The effect of disrupting and then replacing autoinhaled NO on arterial oxygenation was investigated in intubated patients. Two groups of nine patients without lung disease were examined during anaesthesia using an inspired oxygen fraction of 0.50. In both groups, the individually produced NO of the whole respiratory tract and the upper airways was determined. The amount of NO normally autoinhaled from the upper airways was replaced for 5 min after orotracheal intubation in one group. The amount of NO from the upper respiratory tract was 47+/-19 parts per billion (ppb) in the test group and the replaced NO concentration was 48+/-20 ppb. No significant increase in arterial oxygen tension could be detected during the replacement of the autoinhaled NO. Haemodynamic parameters remained unchanged. In the control group, the NO from the upper airways was 34+/-16 ppb. In contrast to the test group, it was not replaced after intubation. These findings suggest that in healthy subjects the autoinhalation of nitric oxide does not play an important role in arterial oxygenation during anaesthesia.

Aged↗
PubMed2003

Underdosing of midazolam in emergency endotracheal intubation.

OBJECTIVES: To determine whether midazolam, when used as an induction agent for emergency department (ED) rapid-sequence intubation (RSI), is used in adequate and recommended induction doses (0.1 to 0.3 mg/kg), and to compare the accuracy of the dosing of midazolam for ED RSI with the accuracy of dosing of other agents. METHODS: The authors conducted a systematic query of a prospectively collected database of ED intubations using the National Emergency Airway Registry data, gathered in 11 participating EDs over a 16-month period. A data form completed at the time of emergency department intubation (EDI) enabled analysis of patients' ages, weights, and indications for EDI, as well as the techniques and drugs used to facilitate EDI. Data were analyzed to determine whether midazolam is used in recommended doses during RSI. Patients intubated with midazolam alone were compared with patients who received other induction agents for RSI. RESULTS: Of 1,288 patients entered in the study, 1,023 (79%) underwent RSI. Of the 888 RSI patients with an age recorded, midazolam was used as the sole induction agent in 140 (16%). The mean (+/-SD) dosages of midazolam used in RSI were 2.6 (+/-1.7) mg in children (age < or = 18) and 3.7 (+/-2.5) mg in adults (age > or =19); the mean (+/-SD) dosages by weight were 0.08 (+/-0.04) mg/kg in children and 0.05 (+/-0.03) mg/kg in adults. More than half (56%) of the children, and nearly all (92%) of the adults, received dosages lower than the minimum recommended dosage (0.1 mg/kg). Of patients who received barbiturates, only 21% of children and 21% of adults received a dose lower than the minimum recommended. When combined with another induction agent, midazolam was dosed similarly to when it was used alone: mean adult doses were 3.1 (+/-1.2) mg and 0.04 (+/-0.02) mg/kg. CONCLUSIONS: Underdosing of midazolam during ED RSI is frequent, and appears to be related to incorrect dosage selection, rather than to a deliberate intention to reduce the dose used.

Adolescent↗
PubMed2004

Emergency physician-verified out-of-hospital intubation: miss rates by paramedics.

OBJECTIVES: To prospectively quantify the number of unrecognized missed out-of-hospital intubations by ground paramedics using emergency physician verification as the criterion standard for verification of endotracheal tube placement. METHODS: The authors performed an observational, prospective study of consecutive intubated patients arriving by ground emergency medical services to two urban teaching hospitals. Endotracheal tube placement was verified by emergency physicians and evaluated by using a combination of direct visualization, esophageal detector device (EDD), colorimetric end-tidal carbon dioxide (ETCO(2)), and physical examination. RESULTS: During the six-month study period, 208 out-of-hospital intubations by ground paramedics were enrolled, which included 160 (76.9%) medical patients and 48 (23.1%) trauma patients. A total of 12 (5.8%) endotracheal tubes were incorrectly placed outside the trachea. This comprised ten (6.3%) medical patients and two (4.2%) trauma patients. Of the 12 misplaced endotracheal tubes, a verification device (ETCO(2) or EDD) was used in three cases (25%) and not used in nine cases (75%). CONCLUSIONS: The rate of unrecognized, misplaced out-of-hospital intubations in this urban, midwestern setting was 5.8%. This is more consistent with results of prior out-of-hospital studies that used field verification and is discordant with the only other study to exclusively use emergency physician verification performed on arrival to the emergency department.

Allied Health Personnel↗
PubMedDate not supplied

Circulatory changes in patients with coronary artery disease following thiamylal-succinylcholine and tracheal intubation.

Circulatory responses after thiamylal (4 mg/kg) and succinylcholine (SCh) (2 mg/kg) administration followed by direct laryngoscopy and tracheal intubation were measured in 20 patients before elective aortocoronary vein bypass graft operations. Compared with awake measurements, the mean arterial pressure (MAP) decreased 19 +/- 3 torr (mean +/- SE) and heart rate (HR) increased 9 +/- 3 bpm 1 minute after thiamylal-SCh. MAP was increased 39 +/- 4 torr and HR 20 +/- 3 bpm above awake levels in response to laryngoscopy and tracheal intubation. Blood pressure and HR returned spontaneously to near awake levels without additional anesthesia within 5 minutes of anesthetic induction. Stroke volume index was decreased significantly after tracheal intubation but cardiac index was not altered. The authors conclude that thiamylal-SCh followed by tracheal intubation is an acceptable anesthetic induction sequence for patients without evidence of left ventricular heart failure who require anesthesia for elective coronary artery revascularization.

Anesthesia, Intravenous↗
PubMed1991

Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol?

Eighty patients, ASA physical status II-IV, scheduled for noncardiac surgery, were randomly assigned in a double-blind, placebo-controlled manner to receive a preintubation dose of either placebo, 200 mg lidocaine, 200 micrograms fentanyl, or 150 mg esmolol. Induction of anesthesia was accomplished with 4-6 mg/kg thiopental IV followed immediately by the study drug; 1-1.5 mg/kg succinylcholine was given at minute 1. Laryngoscopy and intubation were performed at minute 2 with anesthesia thereafter maintained with 1 MAC (+/- 10%) isoflurane in 60% nitrous oxide in oxygen at a 5 L/min flow for 10 min. Heart rate was recorded every 15 s and blood pressure every minute from induction until 10 min after intubation. Maximum percent increases in heart rate (mean +/- SE) during and after intubation were similar in the placebo (44% +/- 6%), lidocaine (51% +/- 10%), and fentanyl (37% +/- 5%) groups, but lower in the esmolol (18% +/- 5%) group (P less than 0.05). Maximum systolic blood pressure percent increases were lower in the lidocaine (20% +/- 6%), fentanyl (12% +/- 3%), and esmolol (19% +/- 4%) groups than in the placebo (36% +/- 5%) group (P less than 0.05), but not different from each other (P greater than 0.05). Only esmolol provided consistent and reliable protection against increases in both heart rate and systolic blood pressure accompanying laryngoscopy and intubation.

Adrenergic beta-Antagonists↗
PubMed1992

Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil.

We have noted that tracheal intubation can be accomplished in many patients after induction of anesthesia with propofol and alfentanil without the simultaneous use of muscle relaxants. This study was designed to evaluate airway and intubating conditions after administration of propofol and alfentanil in 75 ASA physical status I or II outpatients with Mallampati class I airways undergoing various surgical procedures. The patients were randomly assigned to one of five groups for induction of anesthesia. All patients received midazolam 1 mg IV before induction of anesthesia. Group I patients (n = 15) received d-tubocurarine 3 mg, thiamylal 4 mg/kg, and succinylcholine 1 mg/kg IV. Groups II-V patients (n = 15 each) received alfentanil 30, 40, 50, or 60 micrograms/kg followed by propofol 2 mg/kg IV. No muscle relaxants were given to patients in groups II-V. Airway management was performed by one of the authors who was blinded as to the dose of alfentanil administered. After loss of consciousness, patients' lungs were ventilated via face mask, and the ease of ventilation was recorded. Jaw mobility was also assessed. Ninety seconds after administration of the propofol or thiamylal, laryngoscopy was performed and exposure of the glottis and position of the vocal cords were noted. Intubation of the trachea was performed and patient response was noted. Heart rate and arterial blood pressure were also recorded before induction of anesthesia, after induction, and then again after intubation of the trachea. The lungs of all patients were easily ventilated via mask, and the jaw was judged to be relaxed in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Attenuation of the cardiovascular and catecholamine responses to tracheal intubation with oral guanabenz.

We conducted a randomized, placebo-controlled, and double-blind study to evaluate the efficacy of oral guanabenz, an alpha 2-adrenergic agonist, in attenuating the cardiovascular and catecholamine responses to laryngoscopy and tracheal intubation in 30 normotensive (ASA physical status 1) patients undergoing elective surgery. They were allocated to one of three groups (n = 10 for each): placebo, 4 mg, or 6 mg of guanabenz groups. These tablets were administered 2 h before the induction of anesthesia. Anesthesia was induced with thiopental 5.0 mg/kg intravenously (IV), and tracheal intubation was facilitated by the administration of vecuronium, 0.2 mg/kg IV. During anesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Laryngoscopy lasting 30 s was attempted 2 min after the administration of thiopental and vecuronium. Patients receiving placebo showed a significant increase in mean arterial blood pressure, heart rate, and plasma catecholamine concentrations in response to tracheal intubation. These changes were significantly smaller in patients receiving either dose of guanabenz (P < 0.05). Oral administration of guanabenz before induction of anesthesia is a simple and effective method for attenuating the pressor and tachycardic responses to laryngoscopy and tracheal intubation with the drug acting at least partly via inhibition of the increases in plasma catecholamines concentrations.

Administration, Oral↗
PubMed1993

Reevaluation of a maneuver to visualize the anterior larynx after intubation.

Confirmation of translaryngeal placement of the tracheal tube can be unexpectedly difficult. This study examined the usefulness of displacing the larynx posteriorly with the tracheal tube during laryngoscopy with a straight laryngoscope blade to confirm tracheal tube placement. One hundred ASA Classes I, II, or III patients presenting for elective surgery whose normal anesthetic care included placement of an orotracheal tube via direct laryngoscopy were enrolled in this institutionally approved study after giving their written, informed consent. The view of the larynx at laryngoscopy was graded, and the tracheal tube was then inserted. When the larynx was incompletely exposed, the tracheal tube was displaced posteriorly while the laryngoscope was maintained in the intubating position in an attempt to better visualize the larynx. The effect of the maneuver on Mallampati grade for laryngeal exposure was noted. During laryngoscopy with a Miller blade none of the glottis was initially visualized in 17 patients (Mallampati laryngeal Grades 3 and 4). Thus, the tracheal tube actually was not seen to pass between these patients' vocal cords. Use of the maneuver resulted in improved visualization of the intubated larynx in 12 of these patients, and confirmed tracheal intubation. This maneuver is recommended as an aid to the anesthesiologist in the confirmation of tracheal intubation.

Adult↗
PubMed2003

Electroencephalographic burst suppression versus loss of reflexes anesthesia with propofol or thiopental: differences of variance in the catecholamine and cardiovascular response to tracheal intubation.

UNLABELLED: The electroencephalographic burst suppression pattern (BSP) might indicate the brain's effect-site concentration of anesthetics more precisely than clinical signs and thus eliminate bias from studies on the reaction to tracheal intubation after different induction drugs. To test this hypothesis, we compared the catecholamine and cardiovascular responses and their variances to tracheal intubation when either BSP was induced by infusion of propofol (30 mg x kg(-1) x h(-1); n = 14) or thiopental (75 mg x kg(-1) x h(-1); n = 14) or anesthesia by repeated bolus doses until loss of reflexes (LR), initially of propofol 2.5 mg/kg (n = 15) or thiopental 5 mg/kg (n = 15). The standard deviations were more often smaller in the BSP than in the LR groups, but the results of Levene's test for differences of variance were insignificant. At the LR level, propofol attenuated catecholamine, arterial blood pressure, and heart rate responses to intubation better than thiopental, but at the BSP level, only the norepinephrine response was better attenuated. Cp50 concentrations of propofol and thiopental at the onset of BSP were 9.65 and 31.60 micro g/mL, respectively. IMPLICATIONS: Our results did not support the hypothesis that the responses to tracheal intubation can be more accurately predicted when unconsciousness is controlled with the aid of an electroencephalographic burst suppression pattern. Significant differences were found in the reactions between propofol and thiopental. At the burst suppression level, the catecholamine response was abolished with propofol.

Adult↗
PubMed2004

Rigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie.

UNLABELLED: We describe a technique by which a gum elastic bougie (GEB) is used to facilitate an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy. After placing the GEB through the lumen of the rigid bronchoscope, the GEB-suction catheter assembly was used to safely withdraw the bronchoscope in a manner mimicking the withdrawal of an intubating laryngeal mask airway (LMA) over the endotracheal tube using a stabilizer rod. The rationale for management and potential advantages of this approach versus use of an airway exchange catheter (including increased stability of an intubation guide) are discussed. IMPLICATIONS: We describe a technique of using a gum elastic bougie to facilitate an endotracheal intubation in a patient undergoing rigid bronchoscopy, which can be useful in a variety of clinical situations when the rigid bronchoscope is used in patients with abnormal airway.

Adult↗
PubMed2004

Failed obstetric tracheal intubation and postoperative respiratory support with the ProSeal laryngeal mask airway.

UNLABELLED: The ProSeal laryngeal mask airway (ProSeal LMA) provides a better seal and probably better airway protection than the classic laryngeal mask airway (classic LMA). We report the use of the ProSeal LMA in a 26-yr-old female with HELLP syndrome for failed obstetric intubation and postoperative respiratory support. Both laryngoscope-guided tracheal intubation and face mask ventilation failed, but a size 4 ProSeal LMA was easily inserted and high tidal volumes obtained. A gastric tube was inserted through the ProSeal LMA drain tube and 300 mL of clear fluid was removed from the stomach. There were no hemodynamic changes during ProSeal LMA insertion. Postoperatively, the patient was transferred to the intensive care unit, where she was ventilated via the ProSeal LMA for 8 h until the platelet count had increased and she was hemodynamically stable. Weaning and ProSeal LMA removal were uneventful. There is anecdotal evidence supporting the use of the LMA devices for failed obstetric intubation (19 cases) and for postoperative respiratory support (8 cases). In principle, the ProSeal LMA may offer some advantages over the classic LMA in both these situations. IMPLICATIONS: We report the successful use of the ProSeal laryngeal mask airway for failed obstetric intubation and postoperative respiratory support in a patient with HELLP syndrome.

Adult↗
PubMed2005

The effect-site concentration of remifentanil blunting cardiovascular responses to tracheal intubation and skin incision during bispectral index-guided propofol anesthesia.

We sought to determine the effect-site concentration of remifentanil blunting sympathetic responses to tracheal intubation and skin incision during bispectral index (BIS)-guided propofol anesthesia. Forty-one ASA physical status I-II patients, aged 20-65 yr and undergoing major abdominal surgery, were randomly assigned to one of two groups: tracheal intubation (group TI, n = 20) or skin incision (group SI, n = 21). All patients received a target-controlled infusion of propofol of 4 microg/mL, which was then adjusted to maintain a BIS value ranging between 40 and 50. The effect-site concentration of remifentanil blocking the sympathetic responses to tracheal intubation and skin incision in 50% of cases (Ce50) was determined using an up-and-down sequential allocation method. The mean (95% confidence interval [CI]) Ce50 of remifentanil was 5.0 ng/mL for TI (95% CI, 4.7-5.4 ng/mL) and 2.1 ng/mL for SI (95% CI, 1.4-2.8 ng/mL). This study shows that effect-site concentrations of remifentanil of 5 ng/mL and 2 ng/mL are effective in blunting sympathetic responses to tracheal intubation and skin incision in 50% of patients when combined with a BIS-guided target controlled infusion of propofol.

Adult↗
PubMed2005

The influence of endotracheal tube tip design on nasal trauma during nasotracheal intubation: magill-tip versus murphy-tip.

UNLABELLED: We performed this study to assess the influence of endotracheal tube (ETT) tip design (Murphy-tip versus Magill-tip) on nasal trauma during nasotracheal intubation with a conventional polyvinyl chloride ETT. Patients were randomly allocated to one of four groups (n = 25 each): Magill-tipped ETT and Murphy-tipped ETT with or without thermosoftening. After preparation with a vasoconstrictor, the selected, well-lubricated ETT was advanced blindly into the nasopharynx, and intubation was completed under direct laryngoscopy. The severity of epistaxis was estimated based on the distance that blood had traveled up the suction catheter and tubing. Without thermosoftening, the Murphy-tipped ETT produced more severe epistaxis than the Magill-tipped ETT (P < 0.05). Thermosoftening effectively reduced the severity of epistaxis for both conventional types of ETT (P < 0.05). However, there was no difference in the severity of epistaxis and the incidence of nasal injury and pain between the Magill-tipped, non-thermosoftened ETT and Murphy-tipped, thermosoftened ETT. Thermosoftening is recommended because it decreases the trauma during nasotracheal intubation. However, if one chooses to use a normal ETT, the Magill-tipped ETT will cause fewer traumas than the Murphy-tipped ETT. IMPLICATIONS: During nasotracheal intubation with conventional endotracheal tubes, Magill-tipped, non-thermosoftened tubes seem to be comparable to Murphy-tipped, thermosoftened tubes with regard to trauma on the nasal mucosa.

Adult↗
PubMed2005

An evaluation of McCoy balloon laryngoscopy in patients with moderate-to-major endotracheal intubation difficulty.

UNLABELLED: We hypothesized that combined McCoy-balloon laryngoscopy may facilitate airway management relative to McCoy or balloon laryngoscopy. In 10 anesthetized/paralyzed patients with prior intubation difficulty scale scores of >5, McCoy-balloon laryngoscopy versus conventional/balloon/McCoy laryngoscopies resulted in greater laryngeal aperture exposure (2.3 +/- 0.6 versus 0.6 +/- 0.2/1.4 +/- 0.4/1.5 +/- 0.6 cm2, respectively), lower intubation difficulty scale score (0.00 (0.00-0.00) versus 6.00 (6.00-8.25)/1.50(0.00-4.00)/2.00(0.75-5.00), respectively, median [interquartile range]), and 9%-74% shorter time to intubation confirmation (P < 0.05-0.001 for all). Balloon and McCoy laryngoscopies improved laryngoscopic/intubating conditions relative to conventional laryngoscopy. In patients with moderate-to-major conventional airway management difficulty, McCoy-balloon laryngoscopy further improves laryngoscopic/intubating conditions. IMPLICATIONS: This study shows that, in patients with moderate-to-major conventional airway management difficulty, combined McCoy-balloon laryngoscopy results in improved laryngoscopic/intubating conditions when compared with the conventional, McCoy, and balloon laryngoscopic techniques. McCoy-balloon laryngoscopy combines the merits of McCoy and balloon laryngoscopy and can be recommended for patients with moderate-to-major intubation difficulty.

Adult↗
PubMed2006

Electroencephalographic mapping during routine clinical practice: cortical arousal during tracheal intubation?

We used quantitative analysis of the electroencephalogram (EEG) in 42 patients to assess the effect of tracheal intubation after induction of anesthesia with etomidate and sufentanil using standard clinical practice. The EEG was recorded from eight bipolar electrode derivations and Z-transformed relative to age expected normative data for relative power in the delta, theta, alpha, and beta frequency bands. Tracheal intubation resulted in classical cortical arousal, as indicated by acceleration of the EEG frequencies. Significant effects were seen in all frequency bands, most pronounced in the alpha frequency band, with the largest increase bilaterally in the fronto-temporal regions (F-values: Delta - 9.592, P < 0.001; theta - 1.691, P < 0.001; alpha - 18.439, P < 0.001; beta - 4.504, P < 0.001). Changes in alpha and delta power during induction of anesthesia were correlated with the dose of etomidate (P < 0.05). Changes in alpha after tracheal intubation were correlated at the parietooccipital brain regions to the dose of sufentanil (P < 0.05). Individual titration of the dose of etomidate and sufentanil, as during routine clinical practice, is not sufficient to block the strong noxious stimulation of tracheal intubation and results in cortical arousal. The clinical impact of this cortical wake-up phenomenon is undetermined.

Adult↗
PubMed2003

Video-assisted orotracheal intubation in mice.

Orotracheal intubation in mice is a complicated technique because of the peculiar oropharyngeal anatomy and the difficulty in visualizing the laryngis aditus. Here we report a new and simple method for rapid endotracheal intubation by using a small bore, straight fibre-optic arthroscope. Under endoscope-assisted visualization of the laryngis aditus, a polyethylene cannula, inserted on a guide-wire in order to facilitate the introduction of the tip across the vocal cords, was advanced in the trachea. The success rate of intubation was 100%. We were also able to re-intubate the mice 4 and 8 weeks later without any major complications. We conclude that this method can be easily and safely used for studies where controlled pulmonary ventilation is necessary.

Animals↗
PubMed1977

Glottic and subglottic stenosis from endotracheal intubation.

As a result of increased use of prolonged endotracheal intubation, complications of intubation are now being seen more often. Stenosis of the airway may develop at the level of the glottic or subglottic larynx, or in the trachea. Discussions of management do not always distinguish clearly between laryngeal stenosis and tracheal stenosis. Yet, these are two separate entities. Discussions of laryngeal stenosis usually deal with subglottic stenosis, with less emphasis on obstruction at the glottic level. Of 20 patients, 14 adults and six children, with stenosis of the larynx secondary to intubation, we were successful in establishing adequate airways in 16. An analysis of these 20 patients leads to the following conclusions: 1. Scarring in the glottic posterior commissure between the arytenoid cartilages is a frequent cause of laryngeal stenosis after intubation. 2. Endoscopic management can be successful in many cases if it is started early enough, and repeated as often as is necessary. The earlier it is begun, the better the results will be. 3. Indwelling stents which are extremely valuable in laryngeal stenosis from external trauma, may not be as useful in stenosis from endotracheal tube trauma.

Adolescent↗
PubMed1985

Untoward sequelae of prolonged intubation.

Laryngeal sequelae following prolonged endotracheal intubation are being observed with increasing frequency as this technique of airway management is being employed for extended periods of time. Many etiologic factors have been implicated in the development of these problems with the exact reasons being as yet unknown. After reviewing the records of 372 consecutive patients intubated over an 18-month period, we have observed an increased frequency of these complications in the diabetic female patient and suggest that early tracheostomy should be considered in these individuals when the use of prolonged intubation is anticipated. The possible pathophysiology of this problem in the diabetic, as well as the non-diabetic intubated patient, and its possible prevention will be discussed.

Adult↗

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