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PubMed2006

Preoperative predictors of difficult intubation in patients with obstructive sleep apnea syndrome.

PURPOSE: It has been speculated that the severity of obstructive sleep apnea syndrome (OSAS) is related to difficult intubation. However, this has not been confirmed in OSAS patients. Thus, we undertook a retrospective study to assess this relationship in patients who had undergone uvulopalatopharyngoplasty (UPPP) surgery for OSAS. METHODS: A retrospective case-control study was undertaken following approval from the Institutional Review Board on human studies. The data from 90 patients with a polysomnograph-confirmed diagnosis of OSAS, who had undergone UPPP surgery under general anesthesia, were used to evaluate the apnea-hypopnea index (AHI), the preoperative lowest arterial saturation, the occurrence of difficult intubation as assessed by the operator intubation difficulty scale score, extubation time, lowest arterial saturation in postanesthesia care unit, and length of stay in postanesthesia care unit. We compared OSAS patients with 90 age and sex-matched control patients with respect to the prevalence of difficult intubation. RESULTS: The prevalence of difficult intubation was higher in the OSAS group than in the control group (16.7% vs 3.3%, P = 0.003). When evaluating the OSAS group according to the occurrence of difficult intubation, AHI was significantly higher in the difficult intubation subgroup (67.4 +/- 22.5 vs 49.9 +/- 28.0, P = 0.026), and patients with an AHI >or= 40 showed a significantly higher prevalence of difficult intubation. CONCLUSION: This study shows that the occurrence of difficult intubation can be predicted using AHI in patients who undergo UPPP surgery for OSAS.

Adult↗
PubMed2006

[Depth of anaesthesia during intubation: comparison between propofol and thiopentone].

In order to study the depth of anaesthesia during endotracheal intubation, 30 patients received either thiopentone or propofol for anaesthesia induction. The BIS value as a parameter for the depth of anaesthesia and the rate pressure product (RPP) were acquired online. Patients who received thiopentone for anaesthesia induction showed significantly higher BIS values at the moment of intubation and reached BIS values >60 significantly more frequently than patients receiving propofol. The RPP in the propofol group lay significantly below that of the thiopentone patients. For all patients there was an mean increase in BIS values of 8 index points and an increase in the RPP. Therefore, BIS values around 50 should be achieved before intubation in order to avoid the critical BIS value for awareness of >60 despite the increase caused by the intubation procedure. Within 24 h of intubation all patients were interviewed for possible signs of awareness. None of the patients was able to remember the intubation or reported other experiences that indicated an unconscious awareness. Nevertheless, the progress of BIS values in a standardized intubation as performed in the normal clinical routine, shows that the use of thiopentone for initiating anaesthesia results in a very flat level of anaesthesia during intubation. The risk for patients to experience awareness should therefore, not be underestimated. Therefore, when using thiopentone it is recommended to also use a rapid acting muscle relaxant or to select a high ED95 to compensate for the flat level of anaesthesia. Alternatively, repetetive boluses of the hypnotic shortly before intubation should be considered or to revert to propofol. The dosage and pharmacokinetics of the analgesic should also be taken into consideration because an insufficient analgesia leads to a faster flattening of the depth of anaesthesia.

Adolescent↗
PubMed1996

[The laryngeal mask--a valuable instrument for cases of difficult intubation in children. Anesthesiologic management in the presence of Pierre-Robin syndrome].

UNLABELLED: In cases of craniofacial and mandibulofacial malformations, which are mostly treated during childhood, difficult intubation conditions must generally be expected. In such cases, the laryngeal mask airway (LMA) an alternative instrument for use in endotracheal intubation is a new aid for ventilation. In certain instances, it can be used alone to induce general anaesthesia. Reports of endotracheal intubation by means of the LMA in adults have also been published. CASE REPORT: In our case, a 6-year-old boy with Pierre-Robin syndrome (triad: micrognathia, broad palatoschisis, glossoptosis) needed dental resetting. After induction of anaesthesia in this very cooperative boy with thiopentone and fluothane and relaxation with succinylcholine, it was not possible to examine the hypopharynx by laryngoscopy preparatory to nasal intubation as usual. Repeated blind attempts at nasal intubation (again with spontaneous breathing) failed, as did the attempt at fibreoptic bronchoscopic intubation, because of the narrow anatomical conditions. Finally, a laryngeal mask airway (LMA; size 2) was introduced, and as a result of this ventilation was achieved. However, endotracheal intubation was required for performance of the surgical resetting. With the fibreoptic bronchoscope, we could verify the central position of the LMA over the glottis. A tracheal tube (size 4) was inserted across the laryngeal airway without optic control. The tube connector was disconnected and a normal guide inserted into the tube to remove the LMA. The dental resetting was also performed by oral intubation. CONCLUSION: Therefore, the LMA is not only a ventilation aid, but also a valuable tool in difficult intubation conditions. In our opinion, it is necessary to provide this tool in every anaesthetic unit.

Anesthesia↗
PubMed1996

[Intubation conditions following administration of atracurium and vecuronium. Bolus method versus priming technique].

Prompted by the ongoing discussion of the pros and cons of using succinylcholine, this study was conducted to compare the responses to bolus injections of atracurium or vecuronium with those after sequential injection of these drugs (priming principle). We evaluated the earliest possible intubation times, intubating conditions, and the onset times (i.e. times from the end of injection to the maximum blockade) under conditions approaching real use as closely as possible. METHODS. The randomized and double-blind study was carried out with 80 ASA risk class 1 and 2 patients. Approval of the institutional ethics committee was obtained, and each patient gave informed consent. Patients were randomly allocated to four study groups of 20 patients each. Isotonic saline was administered to those patients assigned to the atracurium or vecuronium bolus groups, whereas the patients assigned to the other two groups received a priming injection of either atracurium (0.05 mg/kg) or vecuronium (0.01 mg/kg). We observed the patients for signs of incipient muscular weakness before the induction of anaesthesia. Anaesthesia was induced with thiopental 3.5 min after the first injection (5 mg/kg and 50-100 mg before intubation). After a further 1 min during which adequate mask ventilating with oxygen was assured, corresponding to a priming interval of 4.5 min, 0.5 mg/kg of atracurium or 0.1 mg/kg of vecuronium was administered to the patients in the bolus groups and 0.45 mg/kg of atracurium or 0.09 mg/kg of vecuronium as intubating doses to those in the priming groups. Intubation was attempted at 90, 120, 150 and 180 s thereafter. Intubating conditions were evaluated on the basis of laryngoscopy, vocal cord movement and coughing or bucking of the patients. Neuromuscular function was monitored via accelerometry at the adductor pollicis muscle (TOF stimulation of the ulnar nerve every 15 s). RESULTS. The priming doses did not diminish the elicited twitches of the adductor pollicis muscle, but led to heavy eyelids and double vision in 35% of the atracurium patients and 47% of the vecuronium patients; these symptoms were well tolerated by the patients. At the time of intubation the adductor pollicis muscle was relaxed to approximately the same degree in all groups (mean +/- SD for the TOF ratios in the bolus groups was 0.46 +/- 0.37 for atracurium, 0.45 +/- 0.4 for vecuronium; in the priming groups 0.52 +/- 0.39 for atracurium, 0.53 +/- 0.36 for vecuronium). The administration of the relaxants in divided doses significantly shortened the intubating time after atracurium (100 vs 124 s) and improved the intubating conditions of vecuronium (good vs tolerable), but had no effect on the time course of the neuromuscular blockade (onset times in the bolus groups 224 +/- 84 s for atracurium and 209 +/- 64 s for vecuronium; in the priming groups 249 +/- 112 s for atracurium and 205 +/- 52 s for vecuronium). CONCLUSIONS. The priming technique presented here is clinically superior to the bolus method and therefore should be preferred in all elective cases and in those patients in whom succinylcholine is contraindicated.

Adult↗
PubMed2005

Safety and efficacy of nasogastric intubation for gastrointestinal bleeding after myocardial infarction: an analysis of 125 patients at two tertiary cardiac referral hospitals.

Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 +/- 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, "coffee grounds"-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P < 0.0001, OR = 31.3, OR CI = 9.4-103.1). Among 85 patients undergoing EGD within 16 hr of NG intubation, stigmata of recent hemorrhage were present in 28 (42%) of 66 with a bloody NG aspirate versus 3 (16%) of 19 with a clear aspirate (P = 0.06, OR = 3.93). Among 35 patients undergoing lower GI endoscopy, lower endoscopy revealed the cause of bleeding in 14 (56%) of 25 patients with a clear NG aspirate versus 1 (10%) of 10 patients with a grossly bloody aspirate (P < 0.04, OR = 11.46, OR CI = 1.55-78.3). The two NG tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be particularly relevant in patients after recent MI due to their increased endoscopic risks.

Aged↗
PubMed1987

The effects of suctioning techniques on the distal tracheal mucosa in intubated low birth weight infants.

Microscopic pathology of the distal trachea at autopsy was retrospectively reviewed in 51 low birth weight infants (less than 1250 g). Twenty-six patients from 1977 who had nasal and/or orotracheal intubation and who underwent suctioning with uncontrolled deep suctioning technique were compared to 25 patients from 1980 who had orotracheal intubation with suctioning to the tube tip only. Clinical diagnoses, duration of intubation and number of intubations were correlated to degree of distal tracheal injury: absent (normal epithelium), mild (focal epithelial loss), moderate (diffuse epithelial loss/some inflammation), or severe (submucosal ulceration/squamous metaplasia). From 1977 to 1980 the mortality rate, mean gestational age and mean birth weight all decreased by 20% (P less than 0.05), 1.1 week (P less than 0.05) and 118 g (P less than 0.01) in both autopsied and non-autopsied infants. In 1977, 15 of 26 autopsies (58%) revealed mild (6), moderate (5) or severe (4) pathology. The mean duration of intubation was 71.3, 11.8, and 265 h. respectively. No history of intubation was obtained in two patients with mild injury. No significant tracheal pathology was seen in 11 patients (42%) in 1977. In 1980, fewer patients, 10 of 24 autopsies (42%), revealed mild (3), moderate (4) or severe (3) pathology. The mean duration of intubation was 19.3, 318.3 and 1391.3 h, respectively. One patient with no history of intubation had mild tracheal injury. No significant tracheal pathology was seen in 15 patients (58%) in 1980. The diagnoses of hyaline membrane disease, anemia, hyperbilirubinemia and coagulation disorder were seen more frequently in patients with moderate and severe tracheal pathology both in 1977 and 1980. Despite factors which should lead to greater tracheal injury--longer duration of intubation, lower birth weights and younger gestational age--less tracheal injury was seen in infants undergoing careful suctioning techniques. Clinical implications for the low birth weight neonate are discussed.

Bronchi↗
PubMedDate not supplied

Intubation techniques in the helicopter.

The purpose of this study is an analysis of 630 field intubations of trauma patients by flight personnel of the San Diego Life Flight program. We compared nasotracheal intubation to rapid sequence induction orotracheal intubation and noninduced orotracheal intubation. We measured success of intubation route, complications, and overall patient outcome. Flight records, quality assurance flight procedure data, and hospitalization data from the San Diego Trauma Registry were reviewed over a 4-year period, from 1988 to 1991. The results of our study show that rapid sequence induction orotracheal intubation has a higher success rate, fewer complications, and a better patient outcome compared to noninduced orotracheal intubation and blind nasotracheal intubation. We recommend that rapid sequence induction oral intubation be the standard method for prehospital airway management in trauma patients.

Adult↗
PubMed2004

Gender may affect the hemodynamic response to induction and intubation in young adults.

STUDY OBJECTIVES: To determine whether gender affects the hemodynamic response to anesthesia induction and intubation in young adults. DESIGN: Randomized clinical trial. SETTING: University hospital. PATIENTS: 83 healthy patients, aged 20 to 30 years, scheduled for orthopedic, plastic, and general surgery. INTERVENTIONS: Patients were randomly allocated to one of three groups: Anesthesia was induced with fentanyl 1.5 microg/kg and thiopental 3 mg/kg in Group 1 (n = 28, men) and Group 2 (n = 28, women), or fentanyl 1.5 microg/kg and thiopental 2 mg/kg in Group 3 (n= 27, women) and maintained with enflurane 1% in N2O-O2 throughout the observational period. Three minutes after induction, direct laryngoscopy and intubation were performed. MEASUREMENTS: Noninvasive systolic (SBP) and diastolic (DBP) blood pressures, and heart rate (HR) were recorded before induction (baseline), immediately before intubation, immediately after intubation, and then every 1 minute for 5 minutes after intubation. RESULTS: SBP, DBP, and HR did not differ between men and women at baseline. However, SBP and DBP were lower in women than in men (p < 0.05) and immediately before intubation and at overall time points after intubation. There were no significant differences noted in SBP, DBP, and HR between Groups 2 and 3. When compared with baseline values, SBP and DBP were decreased in women, whereas only DBP was decreased in men immediately before intubation (p < 0.05). The increase in SBP was more prolonged in men after intubation. CONCLUSIONS: Pressor response is different in women than men, suggesting the difference of the response might result from the gender differences.

Adult↗
PubMed1995

The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury.

BACKGROUND: The potential merits and dangers of orotracheal and nasotracheal intubation in patients with injury to the cervical spine or spinal cord continue to be debated. To address this issue, a prospective study was conducted at a level 1 trauma center in patients with respiratory embarrassment and either or both of these injuries. MATERIALS AND METHODS: Over a 7-year period, all such patients underwent neurologic examination by a trauma surgeon on arrival at the trauma center, immediately after endotracheal intubation, and at frequent intervals throughout hospitalization. Cervical immobilization was maintained manually during endotracheal intubation. When necessary, patients were sedated or paralyzed with short-acting pharmacologic agents. RESULTS: During the study period, there were 81 patients with 98 cervical vertebral body fractures, but without evidence of spinal cord injury on initial examination. Sixty-seven patients (83%) were legally intoxicated, and 12 patients had closed head injury. Endotracheal intubation was performed in 26 patients with unstable fractures, and 22 patients were intubated via the oral route. No patient manifested a subsequent neurologic deficit. Sixty-nine additional patients presented with high spinal cord injury; 16 had no cervical spine fracture, and 53 patients had 61 fractures of the cervical vertebrae. Sixty patients (87%) were intoxicated, and 8 patients had closed head injury. Endotracheal intubation was performed in 29 of these patients, and 26 patients were intubated via the oral route. No patient experienced further neurologic deficit following endotracheal intubation. CONCLUSION: In trauma victims with or at high risk of cervical spinal cord injury, orotracheal intubation is a rapid, safe means of achieving airway control.

Adult↗
PubMed1996

Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease.

OBJECTIVE: This retrospective study evaluated the incidence of airway complications in neurological patients following translaryngeal intubation, tracheostomy, or both. DESIGN: The medical records of 315 consecutive patients (200 with traumatic brain injuries, 31 traumatic tetraplegics, and 84 with other neurological disorders) were reviewed. The type of artificial airway, duration of intubation, and use of nocturnal ventilation were recorded. Eighty-six percent of the patients underwent some combination of tracheal tomograms, flow-volume loop analysis, and fiberoptic tracheolaryngoscopy. Stenosis was classified as severe if it required surgery, if it required maintaining the tracheostomy, or was lethal. It was classified as benign if it was successfully treated by medical or local means. RESULTS: Fifty-five percent of the patients were intubated translaryngeally only (mean = 17 days). Three percent underwent tracheostomy only, and 42% underwent tracheostomy after intubation for a mean of 13 days. The overall incidence of airway stenosis was 20%, 1/4 of which was severe. Fifteen percent of these patients died as a result of tracheal complications. The incidence of stenosis was higher following tracheostomy than following intubation only (29% vs 13%, p < .01). The incidence of severe stenosis in intubated-only patients was low (1%) compared with that following tracheostomy (10%, p < .01). No significant relationship was found between the length of intubation or the timing of tracheostomy. CONCLUSION: Fewer complications are associated with transtracheal intubation than with tracheostomy. The data suggest that longer periods of intubation be used when attempting ventilator weaning before restoring to tracheostomy if weaning fails.

Adolescent↗
PubMed1997

Ketamine in the field: the use of ketamine for induction of anaesthesia before intubation in injured patients in the field.

Intubating the subconscious, struggling patient in a pre-hospital setting can be a difficult task even in experienced hands. We performed a clinical prospective study to evaluate the applicability of ketamine for induction of anaesthesia before intubation in the field. Ketamine was distributed to all air medical rescue teams--trained reserve army volunteers from various medical specialties. Lectures and literature concerning the use of ketamine for anaesthesia induction before intubation were given. The physicians were instructed to administer ketamine, in a dose of 2 mg/kg intravenously, if a single intubation attempt failed. Following the administration of ketamine, a questionnaire was filled in by the physician. Analysis of the data was performed after 24 months. During the study period, intubation was indicated in 161 injured patients evacuated by air in Israel. In 29 patients (18 per cent) the first intubation attempt had failed and they were given ketamine. The reasons for failure of the first intubation attempt were restlessness or trismus in 23 patients and traumatic distortion of the upper airway anatomical landmarks in six. Following ketamine administration, intubation was successful in 19 patients (65.5 per cent) in all of whom the indication for ketamine administration was restlessness or trismus. All patients with upper airway anatomy distortion were given a cricothyroidotomy. There were no complications attributed to ketamine. All patients reached hospital alive. This preliminary study suggests that the use of ketamine in this pre-hospital setting is safe. The drug is effective in cases where the primary reason for failure to intubate is restlessness or trismus. The drug is not effective in cases of anatomical damage to the upper airway. In these cases, cricothyroidotomy should probably be performed as early as possible.

Adult↗
PubMed2004

Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.

STUDY OBJECTIVE: We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis. METHODS: Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days. Emergency medicine residents intubated patients who arrived without notification or who needed immediate intubation before anesthesia arrived. The study was conducted in an inner-city, Level I trauma center with approximately 50,000 ED patients and 1,800 major trauma cases a year. Main outcomes were success or failure at laryngoscopy and the number of laryngoscopy attempts needed for intubation. RESULTS: Six hundred fifty-eight trauma patients were intubated during the study period. Laryngoscopy was successful in 654 of 656 cases. Two (0.3%) patients underwent cricothyrotomy after failed laryngoscopy, and 2 (0.3%) patients had awake nasal intubation without laryngoscopy. The specific number of laryngoscopy attempts was unknown in 6 cases (3 from each service), resulting in 650 cases for laryngoscopy performance analysis. Overall, 87% of patients were intubated on first attempt, and 3 or more attempts occurred in 2.9% of patients. Laryngoscopy performance by service (broken down by 1, 2, and >or=3 attempts) was as follows: emergency medicine 86.4%, 11%, and 2.6% versus anesthesia 89.7%, 6.7%, and 3.6%. Analysis by service was done by using Wilcoxon Mann-Whitney testing (P=.225). CONCLUSION: There were no differences in laryngoscopy performance and intubation success in trauma airways managed on an every-other-day basis by emergency medicine versus anesthesia residents.

Adult↗
PubMed1985

Use of a lighted stylet for guided orotracheal intubation in the prehospital setting.

Management of the airway in acutely injured patients demands special skills of the emergency physician. A technique of light-guided orotracheal intubation has been described in the literature and was performed under protocol by resident physicians in an urban mobile intensive care system. The method utilizes a flexible lighted stylet to provide a guide to correct placement through transillumination of the soft tissues of the neck. During the 12-month period of the study, 24 intubations were attempted in 21 patients using this technique. Twenty-one attempts (88%) were successful. The average time for intubation was 20 seconds, with none requiring more than 45 seconds. Fourteen intubations (67%) were successful on the first attempt. Of the three unsuccessful procedures, two were attempted in bright sunlight, and all three patients had vomited prior to the attempts. Trauma to the soft tissues in one successfully intubated patient was the only complication reported with the technique. The advantages of this method, including rapidity of intubation, ability to intubate without manipulation of the head or neck, and the apparently few complications, make it particularly attractive to emergency personnel. We conclude that guided orotracheal intubation using a lighted stylet is an effective and safe method of emergency intubation, even in the adverse prehospital environment.

Critical Care↗
PubMed1989

Endotracheal intubation of pediatric patients by paramedics.

Although a number of studies have described endotracheal intubation of adult patients in the prehospital setting, there are few studies on prehospital endotracheal intubation of pediatric patients. The purposes of our study were to determine how frequently prehospital endotracheal intubation was used in pediatric cardiopulmonary arrests when a paramedic trained in endotracheal intubation was present, to determine the success rate and complications associated with the procedure in the field, and to compare resuscitation rates and outcome in patients with and without prehospital endotracheal intubation. Our retrospective study covered a 38-month period and included all prehospital victims of medical cardiopulmonary arrest under the age of 19 years. Data were collected from field assessment forms and validated by hospital charts, autopsy reports, coroner's reports, death certificates, and emergency medical services central dispatch logs. Of 63 victims of medical cardiorespiratory arrest, 42 had intubating paramedics present at the scene. Twenty-eight of 42 patients (66%) had endotracheal intubation attempted. Eighteen of 28 attempts (64%) were successful, associated with a major complication rate of 7% (two of 28) and a minor complication rate of 39% (11 of 28). In patients less than 1 year old, only six of 16 (38%) had endotracheal intubation attempted and only three of six (50%) attempts were successful. Of the 18 patients who were intubated successfully before arrival at the hospital, nine (50%) survived to hospital admission and one (6%) survived to discharge. The remainder died in the emergency department.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2003

Rescuer position for tracheal intubation on the ground.

BACKGROUND: Emergency oral tracheal intubations in the pre-hospital setting can be more difficult because the rescuer's position with respect to a patient lying on the ground may not provide optimal conditions for intubation. Since optimal visualisation of the larynx often depends on the force generated during laryngoscopy, we measured the pressure required for intubation (P(i)) as well as the maximum pressure (P(max)) that can be generated with the laryngoscopy blade in seven intubator positions. METHODS: Nineteen hospital personnel with intubation experience participated in this study. A modified #3 Macintosh laryngoscope blade was used to measure the pressure exerted on the tongue of a manikin placed on the ground during intubation. The following positions were studied: standard, sitting, prone, kneeling, left and right lateral decubitus and straddling. RESULTS: Intubating in the straddling position required the lowest P(i), as a percent of P(max) (68+/-14%). This was significantly less than the prone, right lateral decubitus and sitting positions. (Tukey's W procedure, P<0.05) CONCLUSION: The straddling position affords the intubator significantly more reserve force than the prone, right lateral decubitus or sitting position. We suggest that the straddling position may be an advantageous position for pre-hospital intubations especially when visualisation of the glottis is difficult.

Adult↗
PubMed1997

Intubation with laryngoscope versus transillumination performed by paramedic students on manikins and cadavers.

Seventeen paramedic students, all of whom are novice intubators, performed laryngoscopic and Trachlight intubation after supervised training for 90 min on two manikins (Laerdal, AMBU) and 30 min on cadavers. A maximum of two intubation attempts lasting a maximum 30 s each were permitted on each manikin and the cadaver. The time for confirming tube placement by auscultation and securing the tube was added. Laryngoscopic intubation was successful on cadavers and both manikins in 94-100% of the trials. Intubation with the Trachlight was 100% successful in the Laerdal manikin, but significantly lower than with the laryngoscope in the AMBU manikin (65%), and in cadavers (50%). The mean intubation time was significantly longer (30-44 s) with the Trachlight compared with laryngoscopic intubation (10-23 s) in both manikins and cadavers. The present results do not indicate that intubation with the Trachlight is an improvement upon laryngoscopic intubation for novices.

Allied Health Personnel↗
PubMed1998

Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis.

Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.

Adolescent↗
PubMed1995

[Cervicofacial cellulitis of dental origin and tracheal intubation].

OBJECTIVES: To evaluate the difficulty of intubation in relation with the localisation and spread of cervico-facial cellulitis of odontogenic origin and to recognize the optimal technique of intubation in such circumstances. STUDY DESIGN: Prospective clinical open study. PATIENTS: Hundred patients, including 16 children, undergoing surgical drainage of a cervico-facial cellulitis of odontogenic origin under general anesthesia were studied. METHODS: Difficulty of intubation was evaluated with the following four criteria: active mouth opening in the awake patient, Mallampati's classifying system, presence of trismus, clinical and radiological control of localisation and extension of the cellulitis (mandibular, maxillar or mouth floor). In case of a foreseen difficult intubation, a fibrescope was used in the awake patient. Otherwise the endotracheal tube was inserted after administration of propofol (3 mg.k-1) and alfentanil (10 to 20 micrograms.kg-1). A Cormack's grading was performed during intubation. RESULTS: Mouth opening depended on the localisation of the cellulitis. Trismus occurred more often with mandibular than maxillary localisations. Trismus and a Mallampati's class > 2 were associated with difficulty in intubation (Cormack's grade > 2), except in maxillary localisations. CONCLUSIONS: The localisation of cellulitis of odontogenic origin is responsible for the difficulty grade of intubation. Awake fibreoptic intubation should be systematically performed in patients with a floor of the mouth cellulitis to reduce the risk of rupture of the abscess by a laryngoscope blade. As trismus associated with mandibular localisations is not relieved by general anaesthesia, awake fibreoptic endotracheal intubation should be preferred.

Adolescent↗