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PubMed1998

The vocal athlete and endotracheal intubation: a management protocol.

Endotracheal intubation is associated with significant laryngeal sequelae that range in severity from mild hoarseness to life-threatening tracheal stenosis. Although the most severe trauma appears to be related to prolonged intubation, even short-term intubation (< 1 day) can adversely affect laryngeal and vocal function. Concern is warranted for all intubated patients, but particularly for the vocal athlete whose livelihood and identity depend on optimal vocal function. It is proposed that the vocal athlete faced with endotracheal intubation risk warrants careful multidisciplinary management. A number of intubation risk factors have been identified in the literature; however, clinical management of vocal athletes who undergo intubation has not been addressed. In medical settings where adverse intubation outcomes can lead to litigation, this clinical management protocol is expected to improve the probability of favorable voice outcome following endotracheal intubation.

Counseling↗
PubMed2001

Comparison of the lightwand technique with direct laryngoscopy for awake endotracheal intubation in emergency cases.

STUDY OBJECTIVE: To clarify the efficacy of the lightwand technique compared with that of the conventional laryngoscopic technique for awake endotracheal intubation in patients requiring emergency surgery. DESIGN: Prospective clinical study. SETTING: Anesthesia department of a teaching hospital. PATIENTS: 60 ASA physical status IE patients undergoing emergency surgery. INTERVENTIONS: Awake intubations using the lightwand technique (LW group) and a laryngoscope (LS group) were performed with conscious sedation with midazolam and fentanyl. MEASUREMENTS AND MAIN RESULTS: Time to intubation and number of intubation attempts in the LW group were significantly shorter and smaller, respectively, than those in the LS group (p < 0.01). Fewer LW group patients complained of a sore throat than in the LS group. DeltaP [changes from "before intubation" to "immediately after intubation" in mean arterial pressure (MAP)] in the LS group was significantly larger than that in the LW group (p < 0.05), although doses of sedatives in the two groups were not different. No hypoxemia or apnea associated with sedation was found in either of the groups. CONCLUSIONS: The lightwand technique produces less magnitude of stress following tracheal intubation than does the conventional laryngoscopic technique for awake intubation. Lightwand-assisted awake intubation is thought to be a useful means for induction of anesthesia in cases of emergency surgery.

Analgesics, Opioid↗
PubMed1997

Intubation in children after 0.3 mg/kg of mivacurium.

STUDY OBJECTIVE: To distinguish among potential predictors of early, easy intubation in children, including apnea, neuromuscular block at two sites, and time, after administration of 0.3 mg/kg of mivacurium. DESIGN: Prospective, randomized study. SETTING: Operating rooms of Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. PATIENTS: 60 ASA physical status I and II children aged 2 through 7 years, scheduled for elective surgical procedures requiring endotracheal intubation. INTERVENTIONS AND MEASUREMENTS: After premedication with midazolam, general anesthesia was induced with halothane and nitrous oxide, and patients were randomly assigned to one of four groups. Mivacurium 0.3 mg/kg was given and tracheal intubation was begun 45 seconds after its injection, or when apnea, block of the orbicularis oculi, (OO) or block of the adductor pollicis (AP) was noted. Intubation conditions were evaluated by an experienced endoscopist. MAIN RESULTS: The first clinical event after administration of mivacurium 0.3 mg/kg was apnea at 43 seconds (median) (average 48 seconds, SEM 2 seconds) after injection. The difference in the time at which neuromuscular block occurred at the AP (median 75 seconds) (average 77 seconds, SEM 2 seconds) and the OO (median 63 seconds) (average 68 seconds, SEM 4 seconds) was statistically, but not clinically, significantly different. All nine intubations that were begun at least 90 seconds after administration of mivacurium resulted in good or excellent intubation conditions, as did 30 of the 51 intubations started earlier. CONCLUSIONS: In children, there is no advantage to monitoring neuromuscular function at the OO rather than the AP. After administration of 0.3 mg/kg of mivacurium, a 90-second interval before the start of intubation was a better predictor of good intubation conditions during halothane anesthesia (1% inspired) than were changes in evoked neuromuscular function.

Apnea↗
PubMed2003

[Techniques and complementary techniques. Intubation, sedation and adaptation to mechanical ventilation].

Endotracheal intubation consists on placing a tube in the trachea either through the mouth (orotracheal intubation) or through the nose (nasotracheal intubation). Although maintaining the airway patent and providing adequate ventilation are not synonymous with intubation, this procedure provides a closed ventilation system while ensuring patency and protecting the airway. Intubation is fairly safe in oxygenated and physiologically stable patients but it is not free from serious complication and consequently it should always be considered as a dangerous technique, especially in critically-ill patients. In addition, given that the anatomy of the airway in children differs according to age, the techniques used to intubate show considerable variations. For all these reasons and despite the often urgent nature of airway problems in children, the placement of an endotracheal tube must be approached in a deliberate and calm manner if trauma to the airway and patient instability are to be avoided. Thus, whenever circumstances permit, intubation should be carefully prepared with assessment of factors that might cause problems such as the indication for intubation, possible airway abnormalities, risk of aspiration, and hemodynamic, respiratory and neurological status. Such and evaluation allows the most appropriate intubation technique to be chosen.

Anesthetics↗
PubMed2002

Succinylcholine improves the time of performance of a tracheal intubation in prehospital critical care medicine.

BACKGROUND AND OBJECTIVE: The study aimed to evaluate and improve airway management in the prehospital setting, i.e. physicians working on board ambulances. A quality control programme focusing on anaesthesia was instituted to improve the time taken to perform endotracheal intubation. METHODS: All consecutive patients requiring tracheal intubation were prospectively analysed before (first period) and after the training programme focusing on anaesthetic protocols for tracheal intubation (second period). The number of attempts at laryngoscopy, the time taken to achieve tracheal intubation, the difficulties encountered and the related complications of the anaesthetic technique were recorded. At the end of the first period, the results were reported to the whole staff of the unit and the anaesthesia protocols were then modified by introducing succinylcholine into the induction sequence, as part of a training programme. RESULTS: Two-hundred-and-eighty patients were evaluated (97 in the first period, 183 in the second). All patients were successfully intubated in both periods. The percentage of difficult intubations (as assessed by the physician) was lower in the second period (20 versus 35%, respectively; P < 0.01). The success rate at the first attempt was significantly higher (74% [68-80] 95% CI versus 55% [45-65] 95% CI, P < 0.01) and the duration of intubation was significantly shorter in the second period than in the first (1.4 +/- 3.2 vs. 4.1 +/- 6.7 min, respectively; P < 0.001). The incidence of complications (hypoxaemia, laryngospasm, bronchospasm) was lower in the second period (15 versus 31%, P < 0.01). CONCLUSIONS: The time to perform tracheal intubation can be improved by the introduction of succinylcholine into the prehospital anaesthetic protocol. Rapid sequence induction should be taught as a way of improving tracheal intubation in the prehospital setting.

Adult↗
PubMed2003

Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol.

BACKGROUND AND OBJECTIVE: In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 microg kg(-1) or remifentanil 2, 3 or 4 microg kg(-1) followed by propofol 2 mg kg(-1). METHODS: In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 microg kg(-1) or remifentanil 2, 3 or 4 microg kg(-1) were injected over 90 s followed by propofol 2 mg kg(-1). Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. RESULTS: Seven patients who received remifentanil 2 microg kg(-1) and one patient who received remifentanil 3 microg kg(-1) could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 microg kg(-1) (45% of patients) or remifentanil in doses of 2 microg kg(-1) (20%), 3 microg kg(-1) (75%) or 4 microg kg(-1) (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 microg kg(-1) compared with those who received alfentanil 40 microg kg(-1) or remifentanil 2 microg kg(-1). No patient needed treatment for hypotension or bradycardia. CONCLUSIONS: Remifentanil 4 microg kg(-1) and propofol 2 mg kg(-1) administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.

Adolescent↗
PubMedDate not supplied

Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation?

OBJECTIVE: Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI. HYPOTHESIS: The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion. METHODS: Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p < 0.05). RESULTS: All intubation attempts were successful. The mean time for intubation in the station was 13.0 +/- 3.4 seconds. The mean time in the ambulance setting was 13.2 +/- 5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88). CONCLUSION: The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.

Ambulances↗
PubMed2000

Tracheal intubation without the use of muscle relaxants: remifentanil or alfentanil in combination with propofol.

BACKGROUND: Alfentanil-propofol combination provides adequate conditions for tracheal intubation without neuromuscular blocking drugs in most patients. Providing an option for intense opioid effect without compromising recovery after short operations, remifentanil might offer benefits over alfentanil, especially in ambulatory surgery. In this study intubating conditions after remifentanil-propofol were compared to those after alfentanil-propofol. METHODS: In a randomized, double-blind study 60 healthy patients were assigned to one of three groups (n=20). After intravenous atropine, remifentanil 3 or 4 microg kg(-1) (Rem3 or Rem4) or alfentanil 30 microg kg(-1) (Alf30) was injected over 30 s followed by propofol 2.5 mg kg(-1). Sixty seconds after the administration of propofol, laryngoscopy and intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. RESULTS: Overall conditions at intubation were significantly (P<0.05) better, and the frequency of excellent conditions was significantly (P<0.05) higher in the Rem4 group compared with the Alf30 group. Intubation was judged to be impossible in 20%, 25% or 5% of the patients in the Alf30, Rem3 or Rem4 groups, respectively. No patient manifested signs of opioid-induced muscular rigidity. In terms of arterial pressures or heart rate, there were no differences between the groups. CONCLUSION: The best method was the combination of remifentanil 4 microg kg(-1) and propofol 2.5 mg kg(-1). This provided satisfactory intubating conditions in 93%, and prevented cardiovascular intubation response.

Adolescent↗
PubMed2003

Rocuronium combined with i.v. lidocaine for rapid tracheal intubation.

BACKGROUND: Rocuronium (ORG 9426) has been shown to have an onset of action more rapid than other nondepolarizing neuromuscular blocking agents and to provide intubating conditions similar to those of succinylcholine 60-90 s after administration. We compared the intubating conditions and hemodynamic changes after the administration of rocuronium 0.6 mg kg(-1) and lidocaine 1.5 mg kg(-1) with rocuronium alone and succinylcholine 60 and 90 s after administration. METHODS: One hundred and twenty-five adult patients of ASA physical status I or II scheduled for elective surgery were randomly divided into five groups. After propofol administration in all patients, patients in group Su (succinylcholine), group R60 (rocuronium) and group RL60 (rocuronium-lidocaine) were intubated within 60 s, while groups RL90 and R90 were intubated 90 s after the administration of rocuronium and succinylcholine. Laryngoscopy was performed and intubating conditions were graded by an experienced anesthetist blind to the muscle relaxant allocation. RESULTS: In this study, groups Su, RL60, R90 and RL90 had similar intubation scores, which were significantly better than that for group R60. Heart rate did not increase after intubation in groups Su, RL60 and RL90. CONCLUSION: The combination of lidocaine (1.5 mg kg(-1)) and low-dose rocuronium (0.6 mg kg(-1)) along with propofol is clinically equivalent to succinylcholine, improves intubating conditions in 60 s and effectively blocks increases in heart rate after intubation.

Adult↗
PubMed2003

Structure and process quality illustrated by fibreoptic intubation: analysis of 1612 cases.

The purpose of this investigation was the description of structure and process quality based on the analysis of 1612 fibreoptic intubations. We evaluated all fibreoptic intubations (nasotracheal in awake patients and orotracheal in anaesthetised patients) from a previously described database over a period of 2 years. We assessed structure quality by evaluating the distribution of the fibreoptic intubations across all staff anaesthetists, and process quality by analysing the number of attempts, the time required, the cases where we had to switch to conventional intubation and the complications. In all, 955 nasotracheal and 657 orotracheal intubations were evaluated. Almost all anaesthetists performed at least 15 nasotracheal and 10 orotracheal intubations. The success rate was 85.2% at the first attempt. Within 3 min, 93.9% of all fibreoptic intubations were successfully completed. In 24 cases, fibreoptic intubation was abandoned. Severe nasal bleeding as a major complication occurred in 1.3% of the nasotracheal intubations.

Adolescent↗
PubMed2002

Facilitation of neonatal nasotracheal intubation with premedication: a randomized controlled trial.

OBJECTIVES: To determine if premedication reduces the time and number of attempts by junior medical staff to achieve nasotracheal intubation in neonates. The experimental design was a non-blinded randomized controlled pilot trial. The setting was a perinatal centre in a university teaching hospital. METHODS: Twenty infants (within the ranges of 25-40 weeks gestation, 650-3660 g and 1 h to 81 days of age) requiring semi-urgent intubation were randomized to either premedication with morphine, atropine and suxamethonium, or to awake intubation. RESULTS: There were no significant differences between the two groups in regard to prior intubation experience of the staff or infant weight or gestation. The intubation procedure, including intervening events, to completion was significantly faster in premedicated infants (median 60 s vs 595 s; P = 0.002) who were intubated at a younger postnatal age. It took twice as many attempts to intubate a conscious infant (median 2 vs 1; P = 0.010). There was a greater decrease in heart rate from the baseline in the unpremedicated group (mean 68 b.p.m. vs 29 b.p.m.; P = 0.017), but decreases in oxygen saturation were not different. Blood was observed in the oral and nasal passages after intubation in five of the awake infants and in one of the premedicated infants. CONCLUSIONS: The use of premedication reduces the total time and number of attempts taken to achieve successful nasotracheal intubation of neonates by junior medical staff under supervision.

Analgesics, Opioid↗
PubMed1997

Orotracheal fibreoptic intubation in children under general anaesthesia.

Orotracheal fibreoptic intubation under general anaesthesia in children was studied in eleven consecutive patients of three months to eight-years-of-age without anticipated intubation difficulties. One case report is also included. Three fibrescopes with a different diameter were used in the study. The fibrescope used was chosen so that it fitted snugly in the tracheal tube. The fibreoscopy was prolonged in one patient due to mucus and two tries were needed. Resistance to the tracheal tube upon intubation was encountered in five patients, only one of these patients was older than two years. Fibreoptic intubation succeeded in nine patients. Two patients were intubated with the Macintosh laryngoscope. The problems encountered in children during orotracheal fibreoptic intubation under general anaesthesia are the same as with adults: easy fibreoscopy is not always followed by easy tracheal intubation, there may be prolonged fibreoscopy and failed intubations. Manipulation of the tracheal tube can lead to successful tracheal intubation and resistance to the tube is more common in smaller children.

Anesthesia, General↗
PubMed2000

Complications of emergency tracheal intubation in severely head-injured children.

A high incidence of unsuccessful attempts and complications has been reported when emergency tracheal intubation (ETI) is performed outside the hospital in severely injured children. The aim of this prospective series was to analyse the incidence and related risk factors of complications of emergency tracheal intubation. The time to complete successful ETI and occurrence of incidents, e.g. cough reflex, hypoxia or spasm were related to the experience of the physician performing intubation and the use of drugs to facilitate ETI. The incidence of hypoxia, hypercarbia, postintubation complications such as extubation stridor and long-term sequelae were noted. Of the 188 children, 78% were successfully intubated at the site of the accident, 10% upon arrival at a local hospital from where they were secondarily transferred and 12% upon admission to our trauma centre. The most severely injured children were intubated in the field in 98% of cases without failure, nor life-threatening complications related to ETI. The experience of the operator influenced the number of attempts and the time to complete successful intubation. Immediate incidents were noted in 25% of children, e.g. cough in 18%. The regimen of drugs, but not level of consciousness, influenced the incidence of immediate incidents; without drugs, more than 67% experienced incidents. Early tracheal intubation and controlled ventilation resulted in adequate ventilation upon arrival (mean PaO2 of 35.8+/-24 kPa, mean PaCO2 of 4.35+/-1 kPa). Long-term complications, including transient stridor upon extubation in 33% of the cases, and laryngeal granuloma or tracheal stenosis, were comparable to those in other series. ETI in shocked patients and pulmonary infection in hospital, but not the technique of ETI, increased the risks of long-term complications. Emergency tracheal intubation can be performed safely in the field, and results in adequate ventilation during transportation of severely injured children, provided that it can be performed by trained physicians using adequate drugs to facilitate intubation.

Child↗
PubMed2002

A survey of practice of tracheal intubation without muscle relaxant in paediatric patients.

BACKGROUND: Because of the renewed interest in intubation in children without relaxants, over a period of 1 month, the anaesthesiologists of five paediatric universitary teaching hospitals were asked to complete a questionnaire each time they performed a tracheal intubation without muscle relaxant. METHODS: Intubating conditions were assessed with five items. Each item was graded on a four-point scale. Intubating conditions were judged acceptable when all items scored 2 or less. Episodes of oxygen desaturation and failed intubations were noted. Data are expressed as mean +/- SD (extremes). RESULTS: Five hundred and two questionnaires were completed during the study period. Children were aged 61 +/- 50 (1-180) months old. Induction of anaesthesia was performed with sevoflurane for 62.6% of the children (endtidal concentration 5.9 +/- 1.5%) and propofol for 28.9% (dose 5.8 +/- 4.2 mg x kg(-1). Opioids were associated with these hypnotics in 53.2% of the children. Tracheal intubation was successful in 87.1% of the children. Sevoflurane produced better intubating conditions than propofol. Sevoflurane requirements for tracheal intubation may be higher in infants aged less than 6 months old than in older children. A severe decrease in SpO2 (< or = 90%) was observed in 15.9% of the infants aged less than 1 year old and in 1.7% of the children, respectively (P < 0.0001). CONCLUSIONS: Sevoflurane is the most commonly used agent for tracheal intubation without relaxants with higher doses being required in infants aged less than 6 months. Propofol, even with opioids, was not so successful.

Adolescent↗
PubMed2002

Difficult tracheal intubation induced by maxillary distraction devices in craniosynostosis syndromes.

BACKGROUND: Difficult intubation occurred during anaesthesia for removal of maxillary distraction devices in five of seven children with syndromal craniosynostoses (four with Apert, two with Pfeiffer and one with Crouzon syndrome). METHODS: Intubation was assessed in terms of laryngeal view and an established intubation difficulty score and had been straightforward before device insertion. Difficulty was induced by trismus due to device insertion and by increased maxillary prominence. This was compounded by preexisting mandibular hypoplasia. Cephalometric analysis, with each child acting as their own control, demonstrated anterior displacement of the maxilla and increased maxillary vertical height, as well as increased protuberance of the maxillary incisors. RESULTS: All five difficult tracheal intubations were associated with preoperative Mallampati scores of 3 or 4 and the nine straightforward intubations with scores of 1 or 2. Maximal interincisor distance was less than the lower 95% confidence limit for age in all five children who were difficult to intubate at the time of device removal. No child had a failed intubation, but all had significantly increased intubation difficulty. CONCLUSIONS: In view of the risks of trauma, hypoxia and aspiration associated with difficult direct laryngoscopy, we recommend elective fibreoptic intubation at anaesthesia for removal of maxillary distraction osteogenesis devices in these children.

Adolescent↗
PubMed1997

[Fiber optic intubation using a modified laryngeal mask. Report of experiences with use in 105 patients].

PURPOSE: This study was made to investigate the suitability of a modified laryngeal mask airway as an aid for fibreoptic endotracheal intubation in patients with a difficult airway. We used a laryngeal mask airway split lengthwise on its convex site, the incision going from a point corresponding to the teeth down to the base of the cuff. The cuff remains uncut. By this modification it is possible to ventilate an anaesthetised patient and to pass down a fibreoptic bronchoscope via splitting of the laryngeal mask airway into the trachea at the same time. An endotracheal tube of any diameter already mounted over the bronchoscope is then guided into the trachea. The feasibility of this technique was tested and haemodynamic reactions and changes of the parameters of respiration were recorded. METHODS: This technique was used in 105 patients, 68 male and 37 female, mean age 34 years, when difficult intubation was expected or occurred. Blood pressure, pulse rate and peripheral oxygen saturation was recorded on arrival in the anaesthetic room, after induction of anaesthesia, during and after fibreoptic endotracheal intubation. The respiratory minute volume was measured after insertion of the laryngeal mask airway and during the course of fibreoptic intubation. The time needed was recorded. RESULTS: In all cases endotracheal intubation was successful using this technique. The time needed was between 4 and 16 minutes. There was a statistically significant increase in peripheral oxygen saturation and decrease of the pulse rate after induction of anaesthesia. There were no further significant changes of the recorded haemodynamic parameters and the oxygen saturation during and after fibreoptic intubation compared to the results after induction of anaesthesia. CONCLUSION: It could be demonstrated that a fibreoptic intubation is possible in cases of a difficult airway using the technique described here. There is no haemodynamic strain on the patient. This method can be carried out without pressure of time and without to endanger the patient by hypoxia as the patient can be ventilated during the fibreoptic intubation. In cases of impossible intubation and insufficient mask ventilation it can be tried to establish ventilation and to avoid a emergency surgical airway or transtracheal jet ventilation by using this technique.

Adult↗
PubMed2002

Paramedic-performed rapid sequence intubation of patients with severe head injuries.

STUDY OBJECTIVE: We evaluate the ability of paramedic rapid sequence intubation (RSI) to facilitate intubation of patients with severe head injuries in an urban out-of-hospital system. METHODS: Adult patients with head injuries were prospectively enrolled over a 1-year period by using the following inclusion criteria: Glasgow Coma Scale score of 3 to 8, transport time of greater than 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy, and rocuronium was given after tube placement was confirmed by means of capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. Outcome measures included intubation success rates, preintubation and postintubation oxygen saturation values, arrival arterial blood gas values, and total out-of-hospital times for patients intubated en route versus on scene. RESULTS: Of 114 enrolled patients, 96 (84.2%) underwent successful endotracheal intubation, and 17 (14.9%) underwent Combitube intubation, with only 1 (0.9%) airway failure. There were no unrecognized esophageal intubations. On arrival at the trauma center, median oxygen saturation was 99%, mean arrival PO2 was 307 mm Hg, and mean arrival PCO2 was 35.8 mm Hg. Total out-of-hospital times were higher when RSI was performed on scene (26 versus 13 minutes). CONCLUSION: Paramedics can use RSI protocols that include neuromuscular blocking and sedative agents to facilitate intubation of patients with head injuries.

Adult↗
PubMed2003

Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage.

BACKGROUND: Aspiration of blood may cause significant morbidity during emergent endoscopy for severe upper GI bleeding. Endotracheal intubation is widely performed for airway protection in this setting, but there are few data regarding its efficacy. METHODS: Outcomes were compared for intensive care unit patients with upper GI bleeding for 1 year (1988) during which prophylactic endotracheal intubation was seldom performed before endoscopy, with outcomes during a subsequent year (1992) in which endotracheal intubation was routine for airway protection before or during EGD when there was hematemesis, altered mentation, unstable cardiopulmonary status, or large amounts of blood in the proximal GI tract, or before endoscopic treatment of lesions at high risk for bleeding. RESULTS: Background variables were similar for intensive care unit patients in 1988 (n = 101) and 1992 (n = 119) with respect to number of patients who had shock (respectively, 66.3% vs. 67.2%), cirrhosis (34.7% vs. 38.6%), variceal/portal hypertensive bleeding (22.8% vs. 33.6%), and endoscopic therapy (37.6% vs. 42.0%). Although use of endotracheal intubation specifically for EGD increased significantly between 1988 and 1992 (3.0% vs. 15.1%; p < 0.05), there were no significant changes in endotracheal intubation at any time during hospitalization (24.8% vs. 28.6%), in all EGD-related cardiopulmonary complications (5.0% vs. 3.4%), in new pulmonary infiltrates after EGD (12.9% vs. 15.1%), in mean number of intensive care unit days (7.1 vs. 6.4), or in mortality (15.9% vs. 11.8%). New infiltrates developed in 10 (48%) of 21 patients after EGD despite endotracheal intubation specifically for airway protection. However, in 1992 there were no fatal episodes of aspiration during EGD (2.0% vs. 0%; p = 0.21), no emergent post-EGD endotracheal intubation (6.0% vs. 0%; p < 0.05), and fewer in-hospital cardiopulmonary arrests (12.9% vs. 5.0%; p < 0.05). CONCLUSION: Frequent use of endotracheal intubation for airway protection during EGD for upper GI bleeding requiring intensive care unit admission did not significantly change the relatively high frequency of acquired pneumonia or cardiopulmonary events, but may have prevented the rare fatal episode of massive aspiration. Endotracheal intubation may benefit selected patients with upper GI bleeding, but its specific role remains unclear, and alternative methods of airway protection should be investigated.

Endoscopy, Digestive System↗