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PubMed2001

Comparison of two video-assisted techniques for the difficult intubation.

BACKGROUND: Two recently developed video-optical intubation devices, the video-optical intubation stylet (VOIS) and the angled video intubation laryngoscope (AVIL) were compared for intubation times and success rate in a simulated difficult tracheal intubation setting. METHODS: Thirty anaesthetists were asked to perform 5 intubation attempts with both techniques. Intubation times were recorded and the subjective degree of difficulty and preference for each technique were requested. RESULTS: Intubation time with the VOIS was shorter (17.4+/-6.8 s) than with the AVIL (22.8+/-13.4 s; P=0.0001). Four of the 150 intubation attempts with the AVIL were scored as unsuccessful, due to prolonged intubation time (>60 s). The estimated degree of difficulty was not significantly different. CONCLUSION: In conclusion, both video-assisted intubation devices, the video-optical intubation stylet and the angled video intubation laryngoscope, can be considered to be simple and effective tools which facilitate tracheal intubation and which require only brief instruction and training.

Humans↗
PubMed1998

The intubating laryngeal mask. Results of a multicentre trial with experience of 500 cases.

A multicentre trial of the use of the intubating laryngeal mask was carried out at seven centres in the United Kingdom using the same agreed protocol. Lung ventilation followed by blind tracheal intubation through the intubating laryngeal mask was attempted on 500 ASA grade 1 and 2 patients. It was possible to insert the intubating laryngeal mask in all 500 cases. Ventilation via the intubating laryngeal mask was described as satisfactory in 475 (95%) cases, difficult in 20 (4%) cases and unsatisfactory in 5 (1%) cases. Blind tracheal intubation through the intubating laryngeal mask was possible in 481 (96.2%) cases within three attempts. Intubation was successful at the first attempt in 399 (79.8%) cases, at the second attempt in 62 (12.4%) cases and at the third attempt in 20 (4%) cases. The tracheas of 19 (3.8%) patients were not successfully intubated within the three attempts. Ventilation via the intubating laryngeal mask was described as unsatisfactory during two of these cases but oxygenation remained satisfactory in spite of this. Seventeen of the 19 failures occurred during the individual operator's first 20 attempts. The intubating laryngeal mask provides a successful method for blind tracheal intubation in a large proportion of cases and appears to be superior to the standard laryngeal mask airway for this purpose. The intubating laryngeal mask may be of use when tracheal intubation has failed using conventional methods.

Adolescent↗
PubMedDate not supplied

Etomidate as a sole agent for endotracheal intubation in the prehospital air medical setting.

INTRODUCTION: Etomidate is an anesthetic agent with rapid onset, short duration of action, a generally stable hemodynamic profile, and cerebroprotective effects. It is used in the hospital setting to facilitate emergency endotracheal intubation. This helicopter EMS used etomidate as an intubating agent without paralytics for 2 years. METHODS: Intubations performed by the helicopter crew using etomidate alone were reviewed. Intubation was classified as successful or unsuccessful. Successful intubations requiring three or more attempts or repeated doses of etomidate were interpreted as difficult. RESULTS: Fifty patients received etomidate to facilitate orotracheal intubation. Etomidate was the sole agent in 44 of these cases. Mean age was 31 years (range 4-79); 35 patients (80%) were men. Most patients (79%) were victims of blunt trauma. The mean dose of etomidate was 0.5 mg/kg (range 0.3-1.1). Hemodynamic parameters remained stable. Intubation was successful in 39 patients (89%). Intubation was difficult in seven patients (16%) and unsuccessful in five (11%). Masseter muscle spasm was noted in three of the five patients for whom intubation was unsuccessful. Other complications included emesis in eight patients and seizure-like activity in one patient. CONCLUSION: Etomidate can be used to facilitate emergency endotracheal intubation in the prehospital air medical setting, with a success rate of 89%. At the doses used in the study, hemodynamic parameters remained stable, but intubation was difficult or unsuccessful in 27% of patients. Masseter muscle spasm, which may represent orofacial myoclonus or inadequate relaxation, is common in patients who cannot be intubated with etomidate. Etomidate is recommended as a sole agent for facilitating intubation only when rapid sequence intubation with paralysis is contraindicated or otherwise undesirable.

Adolescent↗
PubMedDate not supplied

Intubation success rates by air ambulance personnel during 12-versus 24-hour shifts: does fatigue make a difference?

OBJECTIVES: To determine whether the skill performance and psychomotor agility, as measured by the endotracheal intubation success rate, of air ambulance medical personnel would be affected by the potential fatigue incurred when increasing the length of their shifts from 12 to 24 hours. METHODS: This was a retrospective review of all flight and intubation records from a large air medical transport system from 1997, when 24-hour shifts were in place, and six months (March-August) of 1996, during which 12-hour shifts were scheduled. Records of all intubation efforts during both periods, including multiple attempts per patient, and outcomes of all attempts, were recorded. Results of successes and failures were tabulated for both ultimate intubation outcome per patient and all attempts per patient for each calendar day and for the 12 hours between 19:00 and 07:00 when fatigue might play a role. Results from the two study periods were compared using Fisher's exact test. RESULTS: During the six months of 1996, 190 of 199 (95.5%) patients were ultimately successfully intubated. These patients required 237 attempts (80.1% successful). During 1997, 362 of 376 (96.3%) patients were successfully intubated, and required 438 attempts (82.6% successful). There was no statistically significant difference in the number of ultimately successful intubations (p = 0.66) or total intubation attempts (p = 0.37) between 1996 and 1997. Analysis of intubations between 19:00 and 07:00 revealed 81 of 84 (96.4%) patients successfully intubated in 1996, with 81 of 103 (78.6%) attempts successful. During 1997, 173 of 180 (96.1%) patients were ultimately successfully intubated, with 173 of 212 (81.6%) attempts successful. Again, there was no significant difference in the number of successful intubations (p = 0.99) or intubation attempts (p = 0.55) between 1996 and 1997. CONCLUSION: Psychomotor agility of air ambulance medical personnel, as measured by the success rate of endotracheal intubation, was not affected by the potential additional fatigue incurred as a result of increasing shift length from 12 to 24 hours.

Air Ambulances↗
PubMed1996

Fiberoptic intubation using anesthetized, paralyzed, apneic patients. Results of a resident training program.

BACKGROUND: There is no consensus about the best way to teach fiberoptic intubation. This study assesses the effectiveness of a training program in which novice anesthetic residents routinely were taught fiberoptic tracheal intubation of anesthetized, paralyzed, apneic patients. METHODS: Eight inexperienced anesthetic residents learned fiberoptic and conventional tracheal intubation simultaneously during their first 4 months of training. All intubations were performed using general anesthesia and muscle paralysis. Of these intubations, 223 (23%) were fiberoptic and 743 (77%) were laryngoscopic. Subsequently, their intubation skills with the two techniques were studied in a prospective, single-blind randomized trial involving 131 elective patients. Intubation times, SpO2, ETCO2, hemodynamic changes on intubation, and complications were recorded for 71 fiberoptic and 57 laryngoscopic intubations. RESULTS: There were two failures of the rigid and one failure of the fiberoptic technique due to inability to intubate within 180 s. In cases of failure, the tracheas were intubated successfully after mask ventilation by the alterative technique. No hypoxemia or hypercarbia occurred in any patient. There were no differences in hemodynamic indexes nor incidence of sore throat or hoarseness between the two groups. Mean intubation times were 56 +/- 24 s (mean +/- SD) for fiberoptic and 34 +/- 10 s (mean +/- SD) for laryngoscopic (P < 0.001). CONCLUSIONS: Novices taught fiberoptic intubation and rigid laryngoscopic intubation under similar conditions, with similar volumes of experience, learn both techniques well. The safety and effectiveness of this training regimen commend it for inclusion in any residency program.

Adult↗
PubMed1994

Teaching fibreoptic intubation in anaesthetised patients.

One hundred ASA grade 1 and 2 patients requiring orotracheal intubation for various general surgical procedures were randomly assigned to receive either expert rigid laryngoscopic or novice fibreoptic orotracheal intubation under total intravenous anaesthesia. Five anaesthesia residents in the 4th year, with no prior experience in fibreoptic laryngoscopy, participated in a fibreoptic training course, viewing two instructional videos and practising on the intubation manikin. Each resident intubated 20 patients in a randomised fashion either as an expert laryngoscopist or as a fibreoptic novice. The time (SEM) to achieve successful intubation was statistically different for fibreoptic and rigid intubation (77.2 (5.1) s vs 17.7 (1.6) s, p < 0.01). The time to achieve successful rigid laryngoscopic intubation remained constant over the ten intubations, whereas time required for fibreoptic intubation decreases significantly (p < 0.01). The learning objectives (fibreoptic intubation times in 60 s or less and with 90% or greater success rate on the first intubation attempt) were met by all residents. The haemodynamic profile was similar for fibreoptically intubated and conventionally intubated patients and there was no difference between the first two or the last two fibreoptic or rigid intubations. The study was designed to detect a difference of 10% in means (assuming alpha = 0.05 and beta < or = 0.2). The incidence of postoperative sore throat, dysphagia or hoarseness was similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1996

Oral intubation using a lighted stylet vs direct laryngoscopy in older children with cervical immobilization.

OBJECTIVE: To compare the tracheal intubation success rates of blind oral intubation using a lighted stylet vs standard of direct laryngoscopy in anesthetized pediatric patients wearing rigid cervical collars. METHODS: Seventy-eight children were randomly assigned to method of intubation (lighted stylet or direct laryngoscopy) and intubator; five patients were excluded after randomization. After sedation and paralysis, the patients were placed in rigid cervical spine collars to simulate intubating conditions for trauma patients. Three attempts at intubation were allowed. An observer recorded the following parameters during the procedure: 1) number of intubation attempts, 2) duration of each intubation attempt, and 3) complications. The intubators had limited prior experience with the lighted stylet technique. RESULTS: Thirty-three patients were in the lighted stylet group and 40 were in the laryngoscopy group. The patients in the lighted stylet group required more attempts prior to successful intubation (2.2 vs 1.5, p < 0.01), and the success rate was higher for the laryngoscopy group (26/33 vs 39/40, p < 0.05). CONCLUSIONS: Blind oral intubation using a lighted stylet under controlled conditions took longer than direct laryngoscopy. However, among those successful on the first intubation attempt, the times to intubation were not significantly different between groups (44.5 vs 52.9 sec). The lighted stylet technique is a viable alternative technique for intubating children who have concurrent cervical spine immobilization.

Adolescent↗
PubMed2001

Magnetically guided orotracheal intubation.

OBJECTIVE: To describe a novel endotracheal intubation technique, magnetically guided intubation (MGI), and its rate of success in inexperienced medical students and interns using an airway mannequin model. METHODS: This was a prospective, descriptive study of 25 medical students and interns participating in an introductory course on emergency medicine without prior experience in human orotracheal intubation. Magnetically guided intubation consists of a strong external magnet placed over the cricothyroid membrane to guide the introduction of a standard endotracheal tube containing a stylet with a magnetized tip. An airway mannequin was placed in a rigid cervical spinal collar to increase the difficulty of the intubation, and each student performed two sequential intubation attempts using MGI. The proportions of successful intubations and the time to complete intubation were determined. Descriptive statistics were used to describe point estimates and 95% confidence intervals for means and proportions of continuous and categorical data, respectively. RESULTS: Of 25 participants, 19 were students and six were interns. Their mean age was 27 years, and 76% were male. The overall proportion of successful intubations using MGI was 80% (95% CI = 69% to 91%). Of 24 intubations, 48% were attempted without visualization of the vocal cords; 67% were successful (95% CI = 46% to 87%). The mean time required to complete intubation was 17.0 seconds (95% CI = 14.5 to 19.5 seconds). CONCLUSIONS: A novel method of orotracheal intubation using magnetic guidance is described as achieving a high rate of successful intubations when performed by inexperienced intubators.

Adult↗
PubMed1992

Force applied during tracheal intubation.

This study quantitated the force applied during tracheal intubation to determine (a) whether the force differed among novice and experienced intubators, and (b) whether the force required differed when intubating patients' tracheas versus intubating the trachea of a commonly used training mannequin. We studied 27 tracheal intubations performed by 17 experienced (greater than 100 prior intubations) and 10 novice (less than 10 prior intubations) intubators. Each intubation was performed with a No. 3 Macintosh blade instrumented with strain gauges to determine force applied in the sagittal plane. The mean force applied was 24.6 +/- 2.9 N (mean +/- SEM) and the maximum force applied by each intubator was 47.6 +/- 3.8 N. There was no difference between groups in the mean force applied (28.8 +/- 6.1 N for the novice group vs 22.3 +/- 2.7 N for the experienced group, P = 0.27) nor in the maximum force applied (55.1 +/- 6.5 N for the novice group vs 43.2 +/- 4.7 N for the experienced group, P = 0.08). The only difference was in the impulse (force x duration), which was more for the novice group largely because of the longer average duration of intubation (40 +/- 12 s vs 19 +/- 4 s, P = 0.06). Among experienced intubators, we found that applied force correlated with patient weight and Mallampati class. Intubation of the Laerdal Airway Management Trainer required mean forces comparable to those required in patients (26.6 +/- 2.5 N vs 22.3 +/- 2.9 N), although the maximum force applied during the intubation effort was greater (58.3 +/- 4.7 N vs 43.2 +/- 4.7 N, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesiology↗
PubMed2003

Intubation after cervical spinal cord injury: to be done selectively or routinely?

Patients with cervical spinal cord injuries (CSCIs) often develop acute respiratory failure and require intubation. It is unknown if intubation should be offered preemptively in all CSCI patients or selectively based on signs of acute respiratory failure. The purpose of this study was to evaluate the role of routine early intubation in CSCI patients. The medical records of 68 patients with CSCI were reviewed. Univariate and multivariate analyses were used to identify independent risk factors for the need of intubation. Statistical significance was considered at P < 0.05. Fifty patients (74%) required intubation and 27 (40%) developed pneumonia. Of patients with CSCI above C5, 87.5 per cent required intubation compared with 61 per cent of patients with CSCI at C5-C8 (P = 0.026). Similarly, of patients with complete quadriplegia, 90 per cent required intubation compared to 48.5 per cent of patients with incomplete quadriplegia or paraplegia (P < 0.001). Of 31 patients not presenting with overt signs of acute respiratory failure on admission, 13 (42%) decompensated later and were eventually intubated up to 53 hours after admission. Six of these 13 patients had emergent intubation due to acute desaturation and developed pulmonary complications associated with emergent intubation. There were 3 independent risk factors for the need of intubation: Injury Severity Score > 16, CSCI higher than C5, and complete quadriplegia. The combination of the 2 latter risk factors resulted in intubation in 21 of 22 patients (95%). The majority of patients with CSCI require intubation. In patients with CSCI above C5 and complete quadriplegia, intubation should be offered routinely and early because delays may cause preventable morbidity.

Adult↗
PubMed1998

[Intubating laryngeal mask].

To improve the success of blind intubation through a laryngeal mask, Dr. A.I.J. Brain constructed the intubating laryngeal mask airway (ILMA), marketed under the name Fastrach. The new construction allows blind intubation with highly flexible endotracheal tubes up to 8 mm ID with cuff (straight Woodbridge type), securing the airway around the intubation process and maintaining most of the characteristics of a standard laryngeal mask airway (SLMA), including contraindications. An additional contraindication is the existence of a Zenker diverticle. Up to now, eight working groups reported a success rate of blind intubation through the ILMA of more than 90% in about 1,200 patients, with a success rate of blind intubation of more than 50% for the first intubation attempt. Ten percent of the patients were difficult to intubate with the same success rate for blind intubation as in normal patients. Reduced mouth opening does not seem to hinder the use of the ILMA in spite of its increased outer diameter of 2 cm, as long as it is possible to enlarge the mouth opening to > 2 cm during anaesthesia. The new ILMA more than doubles the success of blind intubation compared to an SLMA, irrespective of a large variety of intubation difficulties. Correct judgement of endotracheal tube position is mandatory. The ILMA has the potential to be used in patients who are difficult to intubate and to substitute the SLMA in "cannot ventilate--cannot intubate" situations. The future will show if the ILMA also will improve emergency airway management by inexperienced personnel, including intubation, as has been shown for the standard laryngeal mask airway in cardiopulmonary resuscitation for ventilation only.

Contraindications↗
PubMed1991

Elective oral tracheal intubation in cervical spine-injured adults.

There is controversy regarding the optimal mode of elective tracheal intubation in the patient with an unstable cervical spine following trauma. A ten-year review of 150 patients with traumatic cervical spine injuries with well-preserved neurological function, presenting for operative stabilization, was conducted to compare neurological outcome with the mode of tracheal intubation. Preoperative neurological deficits were identified in 49 patients (33%); most were single-level radiculopathies. Intubation occurred after induction of general anaesthesia in 83 patients (55%) and in 67 patients (45%) the tracheas were intubated with the patient awake. One hundred and six patients (71%) underwent oral tracheal intubation and 44 underwent nasal tracheal intubation. Ten intubations were deemed to be difficult requiring more than one attempt to effect intubation. Cervical spine immobilization during intubation was documented in 86 patients (57%). Weighted traction or manual in-line traction were the two manoeuvres most commonly employed to maintain spinal alignment during intubation. After surgery, two patients had new neurological deficits. There were no differences in neurological outcome whether intubation was performed while the patient was awake or under general anaesthesia, or comparing oral tracheal intubation with all other techniques (P = 0.5, Fisher exact test). Also, in-line traction did not affect neurological outcome. Oral tracheal intubation with in-line stabilization, either performed after induction of general anaesthesia or with the patient awake, remains an excellent option for elective airway management in patients with cervical spine injuries.

Adolescent↗
PubMed1995

[Endotracheal intubation with propofol and fentanyl].

The routine use of succinylcholine for endotracheal intubation is being increasingly questioned. Initial studies have suggested that a combination of propofol and alfentanil without a muscle relaxant can provide good intubating conditions. However, most of these initial studies either did not have a double-blind design or did not include a control group with muscle relaxants. In this study, intubation conditions using fentanyl/propofol without a muscle relaxant were compared with the combinations of fentanyl/propofol/succinylcholine and sodium thiopental/succinylcholine. MATERIAL AND METHODS. Following approval from the local ethics committee and written consent, 100 gynaecological patients (ASA I, II) were included in this study. The study was carried out in a double blind, randomized and prospective manner. Black perfusor syringes and extension sets were used, and the drugs administered were diluted to equal volumes. For induction, group 1 (n = 25) received 0.1 mg fentanyl, 1 mg vecuronium, sodium thiopental (demand-adapted) and succinylcholine 1 mg/kg; group 2 (n = 25) received 0.1 mg fentanyl and propofol (demand-adapted); group 3 (n = 25) received 0.2 mg fentanyl and propofol (demand-adapted); group 4 (n = 25) received 0.1 mg fentanyl, 1 mg vecuronium, propofol (demand-adapted) and succinylcholine 1 mg/kg. Each patient was assessed prior to induction with regard to visualization of the pharynx (grade I-IV). Following induction, jaw relaxation (grade I-IV) and the laryngoscopic visualization of the glottis (grade I-IV) were assessed. During the intubation, the position and movements of the vocal cords (grade I-IV) and patient movement during and 1 min following the intubation were assessed. The overall assessment of the intubation was graded (grade I-IV) by the anaesthetist and the anaesthetic nurse. Postoperatively the patients were questioned regarding muscle pain (grade I-IV). Before, during and after endotracheal intubation arterial haemoglobin oxygen saturation, heart rate and arterial blood pressure were monitored. RESULTS. There were no intergroup differences with regard to age, height, weight and preanaesthetic visualization of the pharynx. In group 1 an average of 5.5 +/- 1.2 mg/kg sodium thiopental was required. There were no significant differences in group 2, 3 and 4 with respect to the dose of propofol (2.4, 2.2 and 2.2 mg/kg). No intergroup differences were noted with regard to jaw relaxation, laryngoscopic visualization of the glottis and patients' movements during intubation. Statistically significant intergroup differences occurred with regard to the position and movements of vocal cords during intubation (group 3 worse than groups 1, 2, 4) and the patients' movements 1 min after intubation (group 2 worse than group 3). Significant intergroup differences also occurred with regard to the overall assessment of the intubation by the anaesthetist (group 3 worse than groups 2, 4) and the anaesthetic nurse (group 3 worse than group 4) and the postoperative muscle pain (group 1 worse than groups 2, 3). CONCLUSION. The use of 0.1 mg fentanyl/sodium thiopental/succinylcholine results in no better intubating conditions than 0.1 mg fentanyl plus propofol. Under these conditions, without the use of a muscle relaxant, it is possible to carry out safe endotracheal intubation in cases where no complications are anticipated.

Adult↗
PubMed1996

[Movement of the temporomandibular joint during tracheal intubation].

Laryngoscopy causes temporary postoperative dysfunction of the temporomandibular joint (TMJ): during iatrogenic TMJ manipulation in anaesthetised patients, the TMJs have lost the protection afforded by the tone of the surrounding muscles. Thus far, the exact type and extent of TMJ movements have not been known. The purpose of this study was to develop a method to visualise and assess TMJ movements during intubation by means of electronic axiography, a diagnostic monitor of TMJ movements used in dentistry: registration of the hinge axis (HA) as an equivalent of the condylar paths on extra-oral sagittaly mounted, parallel plates. The HA is individually defined in each patient by the pure, rotating TMJ movement during initial mouth opening (no farward gliding of the condyles, incisor distance up to 10 mm). The parallel plates are placed in the TMJ region in the skull-mounted plate bow: both registration tips ("drawing" the HA tracings on the electronic plates) are connected to the mandible by a face bow, paraocclusally fixed to the teeth. The face bow is individually shaped for each patient to allow mask ventilation and free movement of the laryngoscope during intubation. HA tracings are registered and calculated for both sides independently every 24 ms with the SAM/Klett system and presented on sagittal and frontal projections. In the operating theatre, the active mouth-opening traces (MOT) are registered first and the passive endotracheal intubation traces (EIT) after induction of anaesthesia (same head position). With informed consent and approval by the ethics committee of the Landesärztekammer Rheinland Pfalz. 40 male patients (ASA I. Mallampati I, limb surgery) were randomly allocated to four groups (n = 10 each). OS: Oral intubation, suxamethonium (1.5 mg/ kg); OV: Oral intubation, vecuronium (0.1 mg/kg); NS: Nasal intubation, suxamethonium (1.5 mg/kg); and NV: Nasal intubation, vecuronium (0.1 mg/kg). Intubation was performed 100 s after injection of the relaxant. Pre- and postoperatively (every 24 h over 3 days, in case of positive findings longer) recorded were: active movements of the mandible (maximal mouth opening/ max. laterotrusion); dysfunction of the TMJ; and pain sensation in the TMJ (Helkimo rating). MOTs and EITs were recorded and analysed with the system described and typical EIT patterns were identified: bland, clinically uneventful intubations (n = 7), massive distraction and laterotrusion of the EIT compared to the MOT (n = 24), and blocked or limited TMJ movements resulting in intubation problems (n = 1). With the method presented, TMJ movements could be visualised during endotracheal intubation for the first time. It can be used to assess techniques, routes, and instruments for intubation as well as to evaluate potential traumatising movements during endotracheal intubation.

Adult↗
PubMed1998

Prehospital oral endotracheal intubation by rural basic emergency medical technicians.

STUDY OBJECTIVE: To determine whether basic emergency medical technicians (EMT-B) can perform prehospital oral endotracheal intubation with success rates comparable to those of paramedics. METHODS: This was a nonrandomized, controlled trial using historical controls. Seven basic life support emergency medical services systems in six counties and their corresponding emergency departments in rural Indiana participated. Eighty-seven full-time EMTs with no prior or concurrent paramedic training volunteered for intubation training. Apneic prehospital patients aged 16 years or older without an active gag reflex or massive facial trauma were eligible for intubation and study enrollment. The EMTs completed a 9-hour didactic and airway manikin training course in direct laryngoscopic endotracheal intubation. The course was adapted from the national paramedic curriculum. RESULTS: Thirty-four (39%) of the EMT-Bs attempted to intubate 57 eligible patients. In 49.1% of these patients, successful endotracheal tube placement was confirmed by the receiving physician (95% confidence interval, 36.4% to 61.9%); in contrast, the prehospital intubation success rates from three previous studies of manikin-trained paramedics ranged from 76.9% to 90.6% (P < .001). Complications included five (9%) inadvertent extubations, two endotracheal tube cuff ruptures, two prolonged intubation attempts, and one mainstem bronchus intubation. There were no unrecognized esophageal intubations. Two of the seven EMS agencies did not report any intubation data. CONCLUSION: Rural EMTs with didactic and airway manikin training failed to achieve prehospital intubation success rates comparable to those of paramedic controls. Possible explanations include training deficiencies, poor skill transference from manikin to human intubation, infrequent intubation experiences, and inconsistent supervision.

Aged↗
PubMedDate not supplied

Cabin configuration and prolonged oral endotracheal intubation in the AS365N2 Dauphin EMS helicopter.

INTRODUCTION: Most patients transported by air who require endotracheal intubation undergo endotracheal intubation before transport. However, in-flight endotracheal intubation may be indicated in the setting of certain scene conditions, in-flight patient deterioration, or endotracheal tube dislodgement. A previous report of high endotracheal intubation efficacy in the BK-117 in-flight recommended that flight programs review endotracheal intubation capabilities in their own aircraft. This study was conducted to determine whether in-aircraft endotracheal intubation times in the AS365N2 Dauphin were comparable to those previously reported for the BK-117. SETTING: AS365N2 and BK-117 helicopters stationary on a helipad. METHODS: Eight flight team members per formed three mannequin endotracheal intubations in each aircraft. Three time intervals were assessed: Setup, time required for equipping and positioning for endotracheal intubation; placement, time from laryngoscopy to endotracheal intubation; and total (Setup + Placement). Mean times for the BK-117 and AS365N2 were compared using the t test (a=0.05). RESULTS: All endotracheal intubation attempts were successful, but setup (p=0.0001), placement (p=0.0271), and total (p=0.0011) times were longer in the Dauphin. Crew members unanimously expressed endotracheal intubation difficulty caused by positioning problems in the Dauphin. CONCLUSION: In-aircraft intubation is significantly more time-consuming in the Dauphin than in the BK-117. This prolongation of intubation appears to be due to problems with positioning of the air medical crew and patient.

Air Ambulances↗
PubMed2003

Disposable laryngoscope blades do not interfere with ease of intubation in scheduled general anaesthesia patients.

BACKGROUND AND OBJECTIVE: Intubation of the trachea has been a risky cross-contamination procedure over the past decade because no perfect decontamination procedures exist. Infectious agents found on laryngoscopic devices have the potential for devastating spread of the human immunodeficiency virus, hepatitis viruses B and C and transmissible non-conventional agents. The purpose of this prospective observational study was to assess the quality of endotracheal intubation with disposable laryngoscope blades, under normal intubating conditions. METHODS: Anaesthetists were asked to complete daily questionnaires regarding the difficulty of intubation experienced using the Vital View disposable laryngoscope blade (Vital Signs Inc, Totowa, NC, USA). The choice of the type of blade (conventional or disposable blade) for the first attempt at intubation depended only on the operating room assignment. Glottic visualization during laryngoscopy was assessed by the modified Cormack and Lehane classification. Difficult tracheal intubation was evaluated by the intubation difficulty scale (> 5, procedure involving moderate to major difficulty). RESULTS: The anaesthetic staff recorded 219 intubations. One hundred-and-nineteen of first attempts at laryngoscopy were with disposable blades (DB group) and another 100 with conventional blades (CB group). There were no significant differences between the two groups for Cormack and Lehane score 3, for intubation difficulty scale scores > 5 and for intubation difficulty scale score 0. There were 12 blade changes before successful intubation. CONCLUSIONS: In routine use, the Vital View disposable laryngoscope blade appears to be an efficient device because it does not modify the ease of endotracheal intubation in most cases. Nonetheless, it may be advisable to maintain conventional laryngoscopes in reserve for difficult intubations.

Anesthesia, General↗
PubMed2003

Paediatric intubation in Scottish emergency departments.

BACKGROUND: Intubation of children in the emergency department setting is uncommon. This prospective observational study examines the practice of paediatric intubation in Scottish adult/paediatric urban emergency departments. METHODS: A prospective observational study of every intubation attempt was performed in seven urban Scottish emergency departments in 1999 and 2000. Children were defined as those patients who were less than 13 years of age on the day of presentation. Prehospital intubations were only included if they were performed by a mobile medical team doctor from one of the seven hospitals. RESULTS: A total of 1713 patients were identified, 44 of whom (2.6%) were children. The median age was 4 years (range 0-12 years), and 57% (25 of 44) of intubations were performed on patients with traumatic injuries. Emergency physicians attempted intubation in 27% (12 of 44) of cases, anaesthetists in 73% (32 of 44); 18% (eight of 44) of patients were intubated in nontraumatic cardiac arrest, 68% (30 of 44) underwent rapid sequence intubation (RSI), one (2%) had inhalational anaesthesia and 13 (30%) were intubated without drugs. Eighty per cent (35 of 44) of patients were intubated at the first attempt; eight patients required two attempts, and one required three attempts. Three children were intubated prehospital by mobile medical teams. Emergency physicians intubated more patients with 'physiological compromise' (100% vs 91%). CONCLUSIONS: Paediatric intubation in the emergency department is uncommon. Collaboration and appropriate training for doctors in emergency medicine, anaesthesia and paediatrics is essential.

Adolescent↗