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The structure and function of the various tubes and wires that may be seen on radiography of neonates undergoing intensive care are described. The desired position for these and some examples of the consequences of malposition are considered and illustrated; practical conclusions are made.
Traumatic oesophageal perforation may occur during the intensive care of premature infants due to trauma of the laryngoscope blade, to traumatic intubation with an endotracheal tube or to forced passing of a nasogastric tube. Over a four-year period, three infants of 787 admitted to a neonatal intensive care unit were diagnosed as having this complication. The careful analysis of the position of the nasogastric tube in relation to surrounding structures can be an early clue to the diagnosis of this condition.
The new technology of low intensity roentgen ray imaging offers promise in rapid bedside location of tube and catheter placement in the surgical neonate. Using the Lixiscope we have been able to accurately detect in an animal model the exact location of various tubes and catheters used routinely in pre and postoperative neonatal care. Minimal training is required to be able to use the device. We think the Lixiscope offers detection of the positions of standard tubes and catheters with increased speed, as well as a reduction in the radiation exposure for patients and staff in the neonatal unit.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
OBJECTIVE: The objective of this paper is to assess the treatment protocols used in our institution for the management of airway obstruction among patients with Robin sequence and to suggest a rationale for management based on the findings. METHOD: A retrospective study of 110 children with Robin sequence seen from 1988 to 1997 at the Chang Gung Memorial Hospital was done. Results of the management in airway obstruction and feeding difficulty were studied. RESULTS: Prone posturing was effective in the treatment of mild airway obstruction in 82 patients who had noisy breathing sounds. Twenty-eight infants required endotracheal intubation due to severe respiratory distress. Seven received a tongue to lip adhesion (TLA) operation. Three of these patients showed a relief of airway obstruction, while four of them needed a tracheotomy to maintain a patent airway because of wound dehiscence. Two other patients underwent tracheotomy without TLA. All the six patients who received tracheotomy were eventually decannulated. A nasopharyngeal tube was inserted in two other patients, and one of them improved only temporarily. With regards to feeding difficulties, 46 patients needed nasogastric tube feeding, while the rest were aided through the use of a cleft palate bottle and nipple. A gastrostomy was not needed in any of the patients in this series. CONCLUSION: The morbidity and mortality among Robin sequence patients had been widely decreased through the teamwork of the pediatrician, anesthesiologist, otolaryngologist, dentist, and plastic surgeon. Based on our experience, conservative management was sufficient for those patients with mild airway obstruction, while endotracheal intubation was required for patients with cyanosis, respiratory failure and sleep apnea. Tracheotomy was a better option than TLA for airway management among patients with failed extubation.
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.
We report a case of accidental activated charcoal instillation into the lung of a 30-year-old man being managed for a cyclic antidepressant overdose. The patient was treated with multidose activated charcoal, and between his first and second doses, he pulled his nasogastric tube out of position. The tube was reinserted past the endotracheal tube into the right mainstem bronchus, and a dose of activated charcoal with sorbitol was administered into the lung. He subsequently developed an adult respiratory distress syndrome but gradually improved after bronchoscopic removal of charcoal and supportive care. He was discharged 14 days later.
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Inadvertent transbronchial insertion of a narrow-bore feeding tube using a metallic wire resulted, twice in less than 24 hours, in a right pneumothorax complicated by a bronchopleural fistula. This accident occurred in a conscious patient but with central neurologic chronic disorders recently aggravated by a postoperative Gayet-Wernicke syndrome. The incidence of transbronchial insertion is relatively important [2 to 4%]. Risk factors include a previous endotracheal intubation and an altered mental status. The insertion may be especially hazardous when the patient is uncooperative or unconscious or has lost the cough reflex. The presence of a cuffed endotracheal tube should not be considered as a safeguard for tracheobronchial penetration. Recommendations for prevention are presented. The usual procedure of testing for proper location of the tube following its insertion consisting in the injection of air through the tube with auscultation for gastric borborygmi, is inadequate and should no longer be used.
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STUDY OBJECTIVE: To evaluate the effect of ultra-rapid opioid detoxification on spontaneous respiration. DESIGN: Prospective study. SETTING: University of Illinois, Chicago, Hospital. PATIENTS: 20 ASA physical status I and II patients undergoing ultra-rapid opioid detoxification, and 5 ASA physical status I and II control patients undergoing surgical procedures. INTERVENTIONS: Ultra-rapid opioid detoxification patients were anesthetized with propofol, intubated, and spontaneously ventilating. Opioid detoxification was achieved by giving repeated increasing intragastric doses of naltrexone. Control patients were anesthetized with propofol and 70% nitrous oxide and were time-based controls for opioid detoxification. MEASUREMENTS AND MAIN RESULTS: Respiratory rate and minute ventilation were measured and increased 80% to 100% during opioid detoxification (p < 0.05). Respiratory rate and minute ventilation did not change in controls. Oxygen consumption and carbon dioxide (CO2) production were measured in separate studies and increased during ultra-rapid opioid detoxification with increases in spontaneous ventilation, but not when the patients were paralyzed. CONCLUSIONS: Spontaneous ventilation increases during opioid detoxification without a change in end-tidal CO2. An increase in metabolism is produced in opioid withdrawal that is mediated by elevated muscle activity.
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BACKGROUND AND OBJECTIVE: ProSeal Laryngeal Mask Airway (PLMA) and Laryngeal Tube Suction (LTS), supraglottic airway devices allowing gastric drainage, were compared in this prospective, randomized study for airway management under conditions with elevated intra-abdominal pressure induced by capnoperitoneum. METHODS: Fifty patients undergoing elective gynaecological laparoscopic surgery were randomized to two groups of 25 each. After induction of general anaesthesia, devices were inserted, correct placement was verified, airway leak pressure was measured, and a gastric tube was inserted. Ease of insertion, quality of airway seal, risk of gastric insufflation and patient comfort were investigated. RESULTS: There were no differences in patient characteristics data for both groups. First-time insertion success rates were comparable for both groups: 92%--first attempt, 8%--second attempt for PLMA and LTS. Time until delivery of the first tidal volume for PLMA and LTS was 23.2 +/- 6.1 and 23.5 +/- 6.6s, airway leak pressure was 45.4 +/- 4.9 cmH2O and 45.6 +/- 6.7 cmH2O with cuff pressures adjusted to 60 cmH2O. No gastric insufflation, gas loss or signs of regurgitation were detected. Placement of a gastric tube was successful in all patients. Patients were questioned for sore throat and dysphagia after removal of devices. Sore throat was stated in 1%/0% (PLMA) and 8%/4% (LTS) after 6/24 h, dysphagia in 4%/4% (PLMA) and 12%/4% (LTS). CONCLUSIONS: Both devices provide a secure airway even under conditions of elevated intra-abdominal pressure. In this pilot study, no differences concerning handling or quality of airway seal were detected between PLMA and LTS.
HYPOTHESIS: Advanced airway intervention techniques are being considered for use by basic emergency medical technicians (EMTs). It was hypothesized that basic EMTs would be able to discriminate reliably between intratracheal and esophageal endotracheal tube placement in a mannequin model. DESIGN: An airway mannequin with a closed chest cavity was intubated randomly either esophageally or tracheally, and the cuff was inflated. A stethoscope, bag ventilator, and laryngoscope were available next to the mannequin. Placement was assessed by auscultation or direct visualization at the discretion of the EMT. A blinded investigator graded the student. SETTING: A classroom in a large, urban medical center. PARTICIPANTS: Subjects were basic EMTs who volunteered to take part after the conclusion of a six-hour endotracheal intubation training course. RESULTS: Thirty-three subjects were tested. Seventeen of 18 (94%) tracheal intubations and 11 of 15 (73%) esophageal intubations were identified correctly. Only 72% of the students listened to the epigastrium, 81% listened to the lungs, and 85% attempted ventilation. The 10 students who visualized the cords discovered all five esophageal intubations. The 23 students who did not visualize the cords missed four and found six esophageal intubations. CONCLUSION: Basic EMTs had difficulty assessing endotracheal tube placement in a mannequin model. The 27% miss rate for identifying esophageal intubations suggests that basic EMTs will require additional training for safe field use of any airway that requires assessment of tube placement.