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PubMed1992

Blood pressure, heart rate and catecholamine response during fiberoptic nasotracheal intubation under general anesthesia.

Arterial blood pressure (ABP) and heart rate were recorded at one-minute intervals during several stages of intubation in the fiberscope group and the laryngoscope group, to determine if fiberoptic nasotracheal intubation would result in fewer hemodynamic and catecholamine responses than when intubation was performed with a Macintosh laryngoscope. Blood samples were also taken to measure plasma catecholamine concentration immediately after intubation with the fiberscope. The mean ABP in the laryngoscope group was slightly greater than that of the fiberscope group for 4 min after intubation. Heart rates at 2 min and 4 min after intubation in the laryngoscope group were significantly greater than those for the fiberscope group. Even immediately after intubation, the mean plasma levels of epinephrine and norepinephrine were unchanged in the fiberscope group. Arterial oxygen saturation (Sp(O)(2)) was maintained within normal range during both of intubation procedures, although the time required for intubation was longer than in the laryngoscope group. Other cardiovascular complications were more common in the laryngoscope group than in the fiberscope group. These results suggest that fiberoptic intubation results in less severe stress than does laryngoscopic intubation. Fiberoptic intubation should therefore be used not only in patients with difficult airway, hypertension, ischemic heart disease, or cerebrovascular atherosclerosis, but also it is recommended for all patients for whom nasotracheal intubation is indicated.

Journal Article↗
PubMed2003

The Combitube as a salvage airway device for paramedic rapid sequence intubation.

STUDY OBJECTIVE: The safety of out-of-hospital rapid sequence intubation depends on a reliable strategy when orotracheal intubation is unsuccessful. Here we describe our experience with the Combitube (esophageal-tracheal twin-lumen airway device) as a salvage airway device for paramedic rapid sequence intubation. METHODS: The San Diego Paramedic Rapid Sequence Intubation Trial was performed to assess the effect of paramedic rapid sequence intubation on outcome in severely head-injured patients. Adults with severe head trauma (Glasgow Coma Scale score 3 to 8) who were unable to be intubated without medications were enrolled. Midazolam and succinylcholine were administered, and paramedics were allowed a maximum of 3 attempts at orotracheal intubation. If the attempts were unsuccessful, Combitube insertion was mandated. After confirmation of tube position, rocuronium was given and standard ventilation protocols were used. The primary outcome measure for this analysis was the success rate for Combitube insertion after unsuccessful orotracheal intubation. In addition, Combitube insertion and orotracheal intubation patients were compared with regard to demographic, clinical, and outcome data. RESULTS: A total of 426 patients were enrolled in the trial, with 420 meeting inclusion criteria for this analysis. Orotracheal intubation was successful in 355 (84.5%) of 420; Combitube insertion was successful in 58 (95.1%) of 61 attempts, with no reported complications. Patients undergoing Combitube insertion had higher Face Abbreviated Injury Scale scores and were more likely to have oropharyngeal blood or vomitus. Arrival Pco(2) values were higher, and arrival Po(2) values were lower but still supranormal in patients undergoing Combitube insertion. There were no mortality differences between patients undergoing Combitube insertion and those undergoing orotracheal intubation. CONCLUSION: The Combitube can be an effective salvage airway device for paramedic rapid sequence intubation in an urban/suburban, high-volume emergency medical services system with paramedics who are experienced in Combitube placement and with stringent protocols for its use. The device should be tested in other sizes and types of systems and under less medical scrutiny than was used in this study.

Abbreviated Injury Scale↗
PubMed2000

Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients.

BACKGROUND: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients. METHODS: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation). RESULTS: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity. CONCLUSIONS: The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.

Carbon Dioxide↗
PubMed2005

Assessment of a new method to distinguish esophageal from tracheal intubation by measuring the endotracheal cuff pressure in a porcine model.

OBJECTIVES: With the knowledge of differences in anatomic structures between the trachea and the esophagus, the authors conducted an animal study to evaluate the usefulness of endotracheal cuff pressure in distinguishing endotracheal and esophageal intubations. METHODS: Six swine were anesthetized and endotracheally intubated with 7.5-mm cuffed endotracheal tubes. The intubations were confirmed by fiber-optic bronchoscopy. Each pilot balloon was connected to a 10-mL syringe and a manometer via a three-way stopcock. The cuff pressures were measured for each 1-mL incremental filling of air (1-10 mL). After removal of the endotracheal tubes, each swine was then intubated with the same endotracheal tubes into its esophagus. The cuff pressures of the esophageal intubation were measured with the same procedure. The cuff pressures and the pressure-volume relationships in both intubations were compared. RESULTS: The cuff pressure increased significantly in the esophageal intubation in comparison with the endotracheal intubation in all the comparisons from 1 mL to 10 mL (p = 0.028 for all Wilcoxon signed-rank tests). The slope of the pressure-volume curve of the cuff pressure was also significantly higher in the esophageal intubation during the inflation of the cuff on average (0.047 vs. 0.032 cm H2O/mL; p = 0.001), particularly in the first 5 mL of air inflation. CONCLUSIONS: The cuff pressure in the esophageal intubation was significantly higher than that in the endotracheal intubation under the same inflated volume from 1 to 10 mL. This may provide the basis for an adjunctive, simple, rapid, and reliable method to verify endotracheal intubation.

Animals↗
PubMed2005

Facilitated blind nasotracheal intubation in paralysed patients with temporomandibular joint ankylosis.

OBJECTIVE: To assess the efficacy of blind nasal intubation technique, in cases of ankylosis of temporomandibular joint (TMJ) without the facility of fiber optic bronchoscope. DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Maxillofacial Surgery Department, Armed Forces Institute of Dentistry, Rawalpindi, Pakistan, from August 2002 to October 2003. PATIENTS AND METHODS: A total of 35 patients of ankylosis of TMJ were included in the study. Blind nasotracheal intubation technique was attempted after induction of anaesthesia and paralyzing the patients. Where blind nasotracheal intubation technique was not successful, one nasotracheal tube was passed into the esophagus and retained. Nasotracheal intubation was attempted through contralateral nares by second tube. RESULTS: Out of 35 patients male to female ratio was 1:1.2. The age of the patients ranged between 5 to 35 years with a mean age of 14.5 years. Blind nasotracheal intubation technique was successful in 23 cases (65.7%), whereas in 12 patients intubation was not successful. The 12 cases of failed blind nasotracheal intubation technique were successfully intubated nasotracheally by prior placement of nasotracheal tube into the esophagus through contralateral nares, which facilitated re-intubation (34.3%). CONCLUSION: In the selected patients blind nasotracheal intubation was facilitated by prior placement of the endotracheal tube into esophagus. This technique may be helpful in reducing the psychological trauma and complications of tracheostomy in such patients. However, to-date, fiber optic intubation remains the safest and widely accepted intubation technique in such patients.

Adolescent↗
PubMed1996

[Difficult intubation in adults].

GOAL OF THIS REVIEW: We review the recent literature and our experience in order to determine how one can recognize and handle patients with difficult endotracheal intubation. DEFINITION AND INCIDENCE: "An intubation is called difficult if a normally trained anesthesiologist needs more than 3 attempts or more than 10 min for a successful endotracheal intubation." The incidence of difficult intubation depends on the degree of difficulty encountered showing a range of 1-18% of all intubations to about 2/10000-1/million for "cannot ventilate-cannot intubate" situations. Three "cannot ventilate-cannot intubate" situations are presented that occurred at our institution in the last 10 years out of about 85000 anaesthesias. PREOPERATIVE RECOGNITION: Intubation will be overtly difficult in patients with a small mouth opening, protruding upper teeth, a stiff neck, engorgement of the tongue, cervical swelling after an operation for a face tumour, or in patients with an unstable cervical spine. In about 50-70%, a difficult intubation can be detected preoperatively in patients with grossly normal cervical anatomy by three indirect signs: if the soft palate cannot be visualized (Mallampati classification), if the inframandibular space is smaller than normal, and if the mobility of the atlanto-occipital joint is reduced to below 15 degrees. It is essential that these indirect parameters be tested preoperatively, especially in patients in whom general anaesthesial is planned for a caesarean section or if an ileus intubation is planned. HANDLING: General handling of difficult intubation, use of special material including a portable unit, and confirmation of the endotracheal position of an endotrachaeal tube are outlined (CO2 et, SaO2, fibreoptic bronchoscopy, direct visualization of the translaryngeal position of the tube). The laryngeal mask airway, transtracheal jet ventilation, and the mini-coniotomy are selectively presented as alternative airways. The American Society of Anesthesiologists' (ASA) difficult airway algorithm is presented. CONCLUSION: With better preoperative evaluation and clear guidelines and training for difficult intubation anaesthetic morbidity and mortality can be reduced.

Adult↗
PubMedDate not supplied

Time to intubation and survival in prehospital cardiac arrest.

OBJECTIVE: To examine the correlation between time to paramedic intubation and survival after prehospital cardiac arrest. METHODS: This was a retrospective cohort study of 693 patients who had paramedic endotracheal intubation for prehospital cardiac arrest in King County, Washington (excluding Seattle), between January 1991 and May 2003. Based on the time from patient collapse until intubation, cases were divided into quartiles. Survival in the slower three quartiles (defined as "slow intubation") was compared with survival in the fastest quartile (defined as "quick intubation"). RESULTS: In the quick intubation group (intubation time < or = 12 minutes), 46% of the patients survived; in the slow intubation group (intubation time > or = 13 minutes), 23% of the patients survived. Logistic regression was used to adjust for possible confounders that affect survival: age, gender, location, bystander cardiopulmonary resuscitation, cardiac rhythm, emergency medical technician response time, and paramedic response time. The fully adjusted odds ratio of survival for the slow intubation group compared with the quick intubation group was 0.42 (95% confidence interval 0.26, 0.69). CONCLUSIONS: This study is the first of its kind to compare survival with the time interval until an aspect of advanced life support is performed. These findings suggest that faster intubation times may increase odds of survival in prehospital cardiac arrest. Future prospective studies are merited to further understand this association.

Aged↗
PubMed2006

Mortality after trauma intubation without drugs in Scottish emergency departments.

BACKGROUND: Trauma patients who are intubated without anaesthetic drugs in the pre-hospital phase of care have universally poor outcomes. This study aimed to determine the mortality of trauma patients intubated without drugs in emergency departments in Scotland. METHODS: This retrospective cohort study used the prospective Scottish Trauma Audit Group (STAG) database to identify how many patients were intubated and how many required drugs for intubation between 1 January 1999 and 31 December 2002. The mortality of those intubated with drugs and without drugs was determined from the database. RESULTS: 24,756 patients were included in the STAG database. There were 1469 intubations: 1287 with drugs and 182 without drugs. 92.5% of all intubations were for blunt trauma. There was no difference in the proportion of males or median age between groups. Median GCS was 8 (E1M5V2) in the drugs group and 3 (E1M1V1) in the no drugs group (p<0.001). Median ISS was higher in those intubated without drugs (33 versus 25, p<0.001). Median RTS and probability of survival were lower in those intubated without drugs (both p<0.001). Mortality was higher in those intubated without drugs (91.2% versus 29.4%, p<0.001). Sixteen patients, intubated without drugs, survived. These patients had a higher median respiratory rate (9 versus 0, p=0.013) and higher median systolic blood pressure (80 mmHg versus 0 mmHg, p=0.041) than non-survivors. CONCLUSION: Trauma patients in Scottish emergency departments who are intubated without drugs have high mortality rates. Outcomes are not universally fatal and aggressive resuscitation efforts may be of benefit to a small number of such patients.

Age Distribution↗
PubMed1998

Monocanalicular intubation with Monoka tubes for the treatment of congenital nasolacrimal duct obstruction.

OBJECTIVE: Nasolacrimal duct intubation with Silastic tubes often is used for the treatment of congenital nasolacrimal duct obstruction. The more established intubation technique uses tubing designed for bicanalicular intubation. A commercial product now is available for monocanalicular intubation (Monoka tube, FCI, Issy-Les-Moulineaux Cedex, France), made possible by a punctal anchor attached to the proximal end of the tubing. The authors evaluated the complications and results of their experience with Silastic tube monocanalicular intubation for treatment of congenital nasolacrimal duct obstruction. DESIGN: The study design was a retrospectively reviewed clinical trial with the results compared to a historic cohort treated with an alternative medical device. PARTICIPANTS: Thirty-nine pediatric patients with 48 obstructed congenital nasolacrimal ducts were available for treatment and postoperative follow-up. The historic cohort included 25 cases of congenital nasolacrimal duct obstruction. INTERVENTION: The participants were treated with monocanalicular Silastic tube intubation. The historic cohort was treated with bicanalicular Silastic tube intubation. The tubes were left in place for 4 to 6 months before planned removal. MAIN OUTCOME MEASURES: Dye disappearance tests were performed before and after surgery after removal of the tube. Intraoperative and postoperative complications were noted. RESULTS: Significant complications of the monocanalicular tubing included 1 case of bilateral preseptal cellulitis, 1 case of migration of the punctal anchor into the canaliculus that required surgical correction, 2 cases of a corneal abrasion, 1 case of a corneal ulcer, and 21 cases of premature removal of the tube. Of the 21 cases with premature tube removal, 13 (62%) of the eyes showed an improvement in the symptoms and results of dye disappearance test. Of the 27 cases that completed the full course of tube placement, all the tubes were removed successfully in an office setting, and 25 (93%) showed an improvement in the symptoms and results of dye disappearance test. Significant complications of the authors' bicanalicular intubation include stretching of the punctum, tube dislodgement, and tube removal requiring general anesthesia to the patient. Of the authors' 25 cases treated with bicanalicular intubation, 17 (68%) showed an improvement in the symptoms and results of dye disappearance test. CONCLUSION: The recently introduced Silastic monocanalicular tubing offers an alternative to bicanalicular tubing for treatment with intubation of congenital nasolacrimal duct obstruction. Complications due to intubation persist with the monocanalicular tube. However, some of the complications the authors encountered may be avoided by a recent change in the design of the tubing and by familiarity with recommended techniques. The overall success rate of 79% with the Monoka tube is lower than that for published reports of bicanalicular intubation.

Child↗
PubMed1990

Nasotracheal intubation using a flexible lighted stylet.

Nasotracheal intubation is an essential skill for clinicians involved in the care of acutely ill or injured patients. Unfortunately, it has the dangers and difficulties of any blind technique. Although usually performed in the awake patient, nasotracheal intubation has also been used in the apneic patient. Transillumination of the soft tissues of the neck with a lighted stylet has been shown to be a reliable method of orotracheal intubation. The usefulness of a longer, flexible lighted stylet as an aid to nasotracheal intubation in the apneic patient has been examined. Eighty patients, who were paralyzed, apneic, and about to undergo nasotracheal intubation for elective ear, nose, and throat or maxillofacial surgery were randomized to be nasotracheally intubated blindly or with a stylet by an emergency medicine resident or anesthesiologist. Sixty-three percent intubated in the lighted-stylet group and 41% in the blind nasotracheal intubation group were successfully intubated. There were no significant differences in the time needed to intubate or the number of attempts. There were notable differences in the success rates of individual intubators with each technique. Although not statistically significant, our results suggest a useful role for the lighted stylet in nasotracheal intubation in the apneic patient.

Adolescent↗
PubMed1988

Succinylcholine-assisted intubations in prehospital care.

Although endotracheal intubation is considered the optimal technique for airway management in critically ill patients, performance of this task in the prehospital setting is at times difficult due to increased masseter muscle tone, vocal cord spasm, or patient combativeness. Use of short-acting paralyzing agents by paramedics to facilitate intubation in these situations is an uncommon practice. We report the recent experience of an emergency medical service system that has used succinylcholine (SUX) for more than ten years. We reviewed prehospital patient intubations for two years; 215 patients were intubated by paramedics without the use of SUX and 95 patients were intubated with the use of SUX. The patient group intubated with SUX was characterized by a greater percentage of women (48% vs 35%; P less than .05), a higher mean Glasgow Coma Scale score (8.6 vs 3.4), fewer intubations for cardiac arrest (3% vs 81%), and more hospital survivors (58% vs 24%; P less than .005). The groups were not different with respect to mean age or frequency of trauma. Paramedics chose to use SUX in 69% of nonarrested patients requiring intubation. SUX-assisted intubation was used most often for the indications of airway protection and respiratory distress. Review of hospital records showed no difference between the groups for frequency of either aspiration pneumonia or mechanical ventilation in patients surviving to hospital admission. No patient receiving SUX required emergency cricothyrotomy, nor was esophageal intubation noted in either group. Succinylcholine-assisted intubation was used safely and selectively by the paramedics in this EMS system to permit airway control and ventilation of patients with more difficult intubations.

Adolescent↗
PubMedDate not supplied

Regional EMS experience with etomidate for facilitated intubation.

OBJECTIVE: To report the preliminary experience of the Central New York emergency medical services (EMS) region with etomidate for prehospital facilitated intubation. METHODS: Prospective recording of all intubations (facilitated and nonfacilitated) was completed during the first six months of the etomidate protocol, from January 1 to June 30, 2000. These results were compared with retrospective comparison data obtained for an 18-month period from stored documented prehospital care reports (PCRs), a period when diazepam was used for facilitated intubation. RESULTS: During the study period, 343 (84%) of 409 attempted intubations were successful. Of these, 24 facilitated intubations (using etomidate) were attempted (all on breathing, agitated patients), and 19 (79%, CI 63%-95%) were successful. Eighteen of these (95%) were intubated successfully on the first attempt. The median age of the patients requiring intubation was 70 years (range 14-90), and 60% were female. There were no reported incidences of vomiting, broken teeth, or bleeding. The region's prior 18-month experience using diazepam for facilitated intubation resulted in ten (23%, CI 1%-36%) successful intubations of 43 facilitated intubation attempts. CONCLUSIONS: Preliminary data suggest increased rates of success for facilitated intubation using etomidate, when compared with diazepam, with most intubations successful on the first attempt. Limitations of this study include a small sample size and self-reporting of airway data by paramedics.

Adolescent↗
PubMed1991

Comparison of two methods of fibrescope-guided tracheal intubation.

We have compared intubation time and cardiovascular effects of fibrescope-guided orotracheal intubation aided by the Berman 11 Intubating Airway with those of the tongue traction method of fibreoptic intubation and with conventional Macintosh intubation. We studied 75 patients who received a standard general anaesthetic which included non-depolarizing neuromuscular block; they were allocated randomly to one of the three groups immediately before intubation. The mean time required to effect Berman airway intubation (34.9 s) was similar to that required for tongue traction intubation (35.3 s) and significantly greater than that required for Macintosh intubation (11.7 s). The cardiovascular responses to both types of fibreoptic intubation were significantly greater and more prolonged than those of Macintosh intubation. There were no significant differences between the responses to the two fibreoptic techniques. Haemodynamic effects should be considered when performing fibrescope-guided tracheal intubation under general anaesthesia and, when necessary, appropriate measures should be taken to minimize them.

Adolescent↗
PubMed2006

Pressure support ventilation during fibreoptic intubation under propofol anaesthesia.

GOAL OF THE STUDY: To assess the benefit of pressure support ventilation during fibreoptic intubation performed under propofol anaesthesia in patients having an anticipated difficult intubation. PROCEDURES: Thirty-two patients with ENT cancer, and having at least two criteria for anticipated difficult intubation were prospectively included. All patients received topical lidocaine 2% and propofol by plasma target control infusion (initial target concentration 3 microg ml(-1), then adjusted to maintain loss of consciousness without apnoea). They were randomly assigned between two groups: spontaneous breathing (SB) or pressure support ventilation (with a support level set at 10 cm H(2)O) both using Fi(o(2))=1. Conditions for fibreoptic intubation, respiratory parameters (pulse oxymetry, ventilatory frequency, tidal volume and PetCO2 after intubation) and haemodynamic parameters were recorded. RESULTS: Patient characteristic data and intubation conditions were similar between both groups. All patients had a successful fibreoptic intubation and none needed a rescue procedure because of desaturation. In spite of a longer duration of intubation, PE'CO2 after intubation was lower and tidal volume during intubation was higher with pressure support ventilation than in SB patients [38.1 (4.2) vs 42.3 (4.7) mm Hg and 371 (139) vs 165 (98) ml, respectively]. Desaturation episodes were observed in two SB patients conversely to no episode during pressure support ventilation, probably because of the higher minute ventilation. CONCLUSION: Pressure support represents a useful method to improve ventilation during fibreoptic intubation under propofol anaesthesia in patients with an anticipated difficult intubation.

Aged↗
PubMed1998

Propofol concentration required for endotracheal intubation with a laryngoscope or fiberscope and its interaction with fentanyl.

UNLABELLED: The administration of fentanyl with propofol reduces the blood concentration of propofol required to achieve adequate anesthesia for tracheal intubation. However, different intubation procedures have variable intensities of noxious stimulation and may require different levels of anesthesia. The goal of this study was to determine the propofol blood concentration at which 50% of patients did not respond to stimulation (Cp50) for laryngoscopy, intubation with a laryngoscope, insertion of a slotted oral-pharyngeal airway (Ovassapian airway), and intubation with a fiberscope when administered in conjunction with fentanyl. Patients undergoing elective surgery were given varying amounts of propofol or propofol with fentanyl, and their responses to the four procedures listed above were assessed. These experiments demonstrated that the propofol concentration required for intubation with a laryngoscope was similar to that for intubation with a fiberscope, and that the required level was reduced by fentanyl. Hemodynamic responses to intubation were lower with a fiberscope than with a laryngoscope. We conclude that almost the same concentrations of propofol or fentanyl are necessary for suppressing both of the somatic responses to tracheal intubation with a fiberscope or a laryngoscope. Hemodynamic responses were attenuated more during intubation with a fiberscope. IMPLICATIONS: The propofol blood concentrations at which 50% of patients did not respond to stimulation for laryngoscopy, tracheal intubation with a laryngoscope, and tracheal intubation with a fiberscope were 10.9, 19.6, and 19.9 microg/mL, respectively. These were reduced by fentanyl. Hemodynamic responses to intubation were less with a fiberscope than with a laryngoscope.

Adult↗
PubMed2001

Endotracheal intubation with thiopental/succinylcholine or sevoflurane-nitrous oxide anesthesia in adults: a comparative study.

We performed a double-blinded, prospective, randomized controlled trial to compare intubating conditions facilitated by succinylcholine or sevoflurane. One hundred twenty patients were randomized to receive either succinylcholine or sevoflurane for tracheal intubation. For the Succinylcholine group, patients were induced with thiopental 5 mg. kg(-1) and tracheally intubated after administration of succinylcholine 1.5 mg. kg(-1) IV. Patients receiving sevoflurane took three vital capacity breaths of 8% sevoflurane and 66% N(2)O in O(2). At the loss of eyelash reflex, ventilation was assisted to establish end-tidal CO(2) between 25-30 mm Hg, and intubation was performed when end-tidal sevoflurane was approximately 6%. Criteria of jaw relaxation, vocal cords position, and intubating response were used to assess intubation condition. If the intubation score was < or = 6 of 12, it was described as acceptable, otherwise it was described as an unacceptable intubation condition. Tracheal intubation was successful in all patients. Intubator and observer blinded as to patient group judged that four patients (6.7%) in the Sevoflurane group and only one patient (1.7%) in the Succinylcholine group had an unacceptable intubation condition. However, there was no significant difference between groups (P > 0.05). Therefore, the three vital capacity breaths inhalation technique with sevoflurane may be an alternative for endotracheal intubation in adults.

Adult↗
PubMed2002

Intubating laryngeal mask airway size selection: a randomized triple crossover study in paralyzed, anesthetized male and female adult patients.

UNLABELLED: We determined the optimal size of intubating laryngeal mask airway (ILM) for ventilation and blind tracheal intubation in men and women. We also determined the distance the tracheal tube needs to protrude beyond the distal aperture to ensure that the cuff is through the vocal cords. Fifty male and 50 female anesthetized, paralyzed patients (ASA physical status I or II, aged 18-80 yr) were studied. Three operators (A, B, and C) were involved for the purposes of blinding. The size 3, 4, or 5 ILM was inserted into each patient in random order by Operator A, and the quality of ventilation was scored (adequate, suboptimal, or failed) by Operator B. The fiberoptic position (correct, too shallow, or too deep) and the distance between the distal aperture and the vocal cords was determined by Operator B. A single attempt at blind intubation was made by Operator C. Operators B and C were blinded to the size of the ILM. Operator C was also blinded to the information recorded by Operator B. All ILMs were inserted into the laryngopharynx at the first attempt. For men and women, the ventilation score was smaller for the Size 3 than the Size 4 or 5 (all: P < 0.002). For men, correct positioning was less common with the Size 3 than the Size 4 or 5 (both: P < 0.02). For women, correct positioning was similar among sizes. For men, tracheal intubation was successful less frequently with the Size 3 (84%) than the Size 4 (100%) or 5 (98%) (both: P < or = 0.01). For women, tracheal intubation success was similar among sizes (Size 3, 4, and 5: 86%, 96%, and 92%, respectively). Intubation was always successful if the ILM was correctly positioned and always failed if it was too shallow or deep. In both male and female patients, the distance between the distal aperture and the vocal cords increased with increasing ILM size (all: P < 0.04) and patient height (P < 0.0001) and was always longer for men (all: P < 0.0001). The overall mean distance (95% confidence interval) that the tracheal tube needed to protrude was 10-12 cm (8-13 cm) in men and 8-11 cm (8-12 cm) in women. We conclude that for men, the Size 4 and 5 ILMs are better than the Size 3 for ventilation and blind intubation. For women, the Size 4 and 5 ILMs are better than the Size 3 for ventilation, but there is no difference among sizes for blind intubation. The length the tracheal tube must protrude from the distal aperture to ensure that the cuff is completely through the vocal cords is 8-13 cm, depending on ILM size, the tracheal tube size, and the sex and height of the patient. IMPLICATIONS: For men, the Size 4 and 5 intubating laryngeal mask airways are better than the Size 3 for ventilation and blind tracheal intubation. For women, the Size 4 and 5 are better than the Size 3 for ventilation, but there is no difference among sizes for blind intubation. The length the tracheal tube must protrude from the distal aperture of the intubating laryngeal mask airway to ensure that the cuff is completely through the vocal cords is 8-13 cm, depending on the size of the mask and tracheal tube and on the sex and height of the patient.

Adolescent↗
PubMed2002

Fentanyl attenuates the hemodynamic response to endotracheal intubation more than the response to laryngoscopy.

UNLABELLED: We examined the effectiveness of avoiding laryngoscopy in reducing the hemodynamic responses to orotracheal intubation during the induction of anesthesia. One hundred surgical patients who required orotracheal intubation were randomly allocated into four groups. The first and third groups underwent fiberoptic intubation, in which an anesthesiologist inserted the endotracheal tube into the trachea under TV monitoring through a bronchoscope, and the second and fourth groups underwent conventional orotracheal intubation using a rigid laryngoscope. The third and fourth groups were pretreated with 2 microg/kg fentanyl IV immediately before the induction of anesthesia. Blood pressure and heart rate were measured noninvasively. A significant reduction in hemodynamic response was seen in only the group treated with fentanyl and intubated using the fiberoptic technique. Without fentanyl, there was no significant difference in hemodynamic changes between the groups. We conclude that the administration of fentanyl suppresses the hemodynamic responses to endotracheal intubation more than it does to laryngoscopy. There was no significant difference in the hemodynamic responses to orotracheal intubation by fiberscopy and laryngoscopy without fentanyl pretreatment, whereas 2 microg/kg fentanyl significantly reduced the hemodynamic responses in the group intubated by fiberscopy. IMPLICATIONS: We assessed the effectiveness of avoiding laryngoscopy for orotracheal intubation. There was no significant difference in the hemodynamic responses to orotracheal intubation by fiberscopy and laryngoscopy without fentanyl pretreatment, whereas 2 microg/kg fentanyl significantly reduced the hemodynamic responses in the group intubated by fiberscopy. Pretreatment of fentanyl and fiberoptic intubation might be recommended for avoiding hyperdynamic responses.

Adult↗