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PubMed2004

The experience with Ritleng intubation system in patients with congenital nasolacrimal duct obstruction.

BACKGROUND: To report the clinical experience and success rate with Ritleng intubation system in patients with congenital nasolacrimal duct obstruction. METHODS: Twenty-four patients (32 eyes) with congenital nasolacrimal duct obstruction treated with the Ritleng intubation system were enrolled in this study. The mean age was 20.1+/-9.6 months. The technique involved introduction of a Prolene monofilament guide thread, securely fastened to silicone tubing, into a tubular metal probe that opened into the inferior meatus. Success was defined as complete resolution of previous symptoms and a normal result of dye disappearance test in cooperative patients. To establish relationship of success rate with patients' ages, these data were compared and analyzed. RESULTS: All eyes were successfully intubated with the Ritleng system. The Prolene monofilament spontaneously emerged from the nose in 19 (60%) of 32 eyes, making retrieval simple and uncomplicated. The overall success rate (of all aged groups) was 90%. In the group over 24 months of age, there was no significant decrease in the success rate (p > 0.1), but obvious difficulty in intubation and lengthy operation time were noted. CONCLUSIONS: Silicone intubation with the Ritleng system is an effective treatment for patients with congenital nasolacrimal duct obstruction, especially at young age. Comparing with conventional metal probe system, there was minimal nasal bleeding and trauma to the nasal mucosa with Ritleng intubation system. With the advantage of easy retrieval, operation time can be shortened, thereby improving patient care and decreasing potential morbidity.

Age Factors↗
PubMed2004

Reducing cardiovascular responses to laryngoscopy and tracheal intubation: a comparison of equipotent doses of tramadol, nalbuphine and pethidine, with placebo.

The stress response to tracheal intubation may be obtunded by opioids given with induction of anesthesia. Tramadol is an opioid acting on mu-receptors and the monoaminergic pain modulating systems. This study examined vasomotor responses to tracheal intubation after equipotent doses of tramadol, nalbuphine and pethidine (3.0, 0.3 mg/kg(-1), and 1.5 mg/kg(-1), respectively), and placebo, given prior to induction of anesthesia in 118 healthy patients. Premedication and induction of anesthesia were standardized. Recordings of HR and SAP were made prior and subsequent to induction of anesthesia, and at 1, 3, 5 and 7 minutes after tracheal intubation. Prior to laryngoscopy and intubation, HR increased in all groups (p < or = 01, all comparisons), but least so after nalbuphine, whilst SAP remained unchanged after placebo, tramadol and pethidine, but fell after nalbuphine (p < 0.025). Maximum increases in HR (p < or = 0.005, all comparisons) and SAP (p < or = 0.02, all comparisons) occurred one minute after intubation. Maximum HR after placebo (108 SD 15 bpm), tramadol (107 SD 20 bpm), pethidine (113 SD 16 bpm) and nalbuphine (110 SD 26 bpm) was similar; with placebo HR remained faster than baseline until the seventh minute but had returned to baseline by the fifth minute with the opioids. Maximum SAP with tramadol (151 SD 26 mmHg) was similar to that with placebo (157 SD 20 mmHg), but was greater than after pethidine (136 SD 27 mmHg; p < 0.05) and nalbuphine (135 SD 19 mmHg; p < 0.02). With each test drug SAP returned to baseline by the third minute. It is concluded that, in these doses, 1) tramadol does not attenuate the chronotropic nor the inotropic response to tracheal intubation, and 2) pethidine and nalbuphine reduce only the inotropic response to airway instrumentation.

Adult↗
PubMed1992

[Effects of endotracheal intubation on the trachea--usefulness of the evaluation by MRI].

Using an MRI apparatus, we observed the effects of endotracheal intubation on the trachea by measuring T1 value before and after an operation in ten surgical cases. T1 value of the anterior wall at the level of the first tracheal ring was 275.8 +/- 58 msec, and that of the posterior wall was 346.8 +/- 72 msec. The patients were all intubated under general anesthesia. Anesthesia was maintained with inhalation anesthesia such as nitrous oxide-oxygen-enflurane with the aid of vecuronium bromide. Periods of intubation varied between 80 to 46 minutes, and averaged 270 +/- 112 minutes. After the extubation, T1 value showed 312 +/- 62 msec at the anterior wall and 395 +/- 82 msec at the posterior wall. In the case of the posterior wall, T1 value was significantly prolonged compared with that of the pre-intubation period. Prolongation of T1 value is assumed to be related to the increase of tissue free water demonstrating the occurrence of tissue edema. From the findings that T1 value might be prolonged by endotracheal intubation, we conclude that the MRI apparatus is useful for investigating the effects of the intubation procedure on the trachea.

Adult↗
PubMed2005

[Pressor responses to inhalation of isoflurane during induction of anesthesia and subsequent tracheal intubation].

BACKGROUND: Marked hypertension may occur during induction of isoflurane anesthesia. The hemodynamic responses to mask ventilation using isoflurane and subsequent tracheal intubation were evaluated. METHODS: In 26 ASA physical status I patients, anesthesia was induced with thiamylal followed by mask ventilation with 0.5% isoflurane in oxygen. Isoflurane concentration was increased to 4% in 2 min, and the trachea was intubated after 3 min of ventilation with 4% isoflurane. Blood pressure (BP) and heart rate (HR) were recorded every minute from induction of anesthesia. RESULTS: In 9 patients, systolic BP before intubation increased significantly to more than 10 mmHg (26 +/- 16%) compared before induction, but decreased (-7 +/- 7%) in the others after a transient slight increase. Tracheal intubation induced a marked increase in BP in all patients, but there was a negative correlation between the isoflurane-induced increase in BP and that induced by intubation. Tachycardia was seen in all patients regardless of the values of BP. CONCLUSIONS: Inhalation of 4% isoflurane during induction of anesthesia induces lasting hypertension in some patients and this pressor response has no relation with the tachycardia. Tracheal intubation induced a larger increase in blood pressure in the isoflurane-induced hypertensive patients, but the increase is within the limits of that seen in patients without pressor response to isoflurane.

Adolescent↗
PubMed2005

A randomized controlled double blind study on quick intubation regimen using vecuronium priming infusion technique with the use of patient controlled analgesia pump vs bolus priming technique.

BACKGROUND & OBJECTIVES: Priming principle is implied to hasten intubation with the use of vecuronium. Priming dose is usually injected by bolus and certain side effects have been observed due to acute rise in plasma levels after bolus injection. In the present study priming infusion regimen of vecuronium using patient controlled analgesia (PCA) pump was compared for the intubation dose onset, intubation, and the side effects with the usual bolus priming. METHODS: Adult ASA grade 1 patients of both sexes (n=112) were randomized into four groups of 28 patients each. In group 1 patients, vecuronium (10 microg/kg) was given bolus (30 sec). In group 2, priming infusion (5 microg/kg/min) regimen for vecuronium (1200 microg/kg) was used by setting up the background infusion rate (ml/h) at 1/4th of the patient body weight on PCA pump. Priming infusion for 3 min delivered the priming dose (15 microg/kg). In group 3, higher priming infusion (10 microg/kg/min) was given by setting up the PCA pump at the 1/2 the patient body weight for 1.5 min, to deliver same dose (15 microg/kg). In group 4, the priming infusion (10 microg/kg/min) for 2 min delivered higher priming dose (20 microg/kg). After induction of anaesthesia with fentanyl, propofol, the intubating dose of vecuronium (0.06 mg/kg) was injected by activating patient demand button and grading laryngoscopy/intubation after 1 min in each group. RESULTS: In demographically similar patients, the laryngoscopy/intubation was excellent in 53 per cent (group 3) and in 64 per cent patients (group 4) after 1 min of the intubation dose. While in bolus priming (group 1), 50 per cent patients developed ocular side-effects, none had it on priming infusion in groups 2 or 3. Only 2 patients complained of diplopia at the higher priming dose (20 microg/kg) (group 4). INTERPRETATION & CONCLUSION: PCA pump regimen for vecuronium priming infusion significantly shortened the onset of intubation. Side effects from the smaller priming dose by bolus were not seen in priming infusion regimen.

Aged↗
PubMed2005

[Tracheostomy and endotracheal intubation: a short history].

The first descriptions of tracheostomy appear in old Hindu scripts around 2000 BC and Egyptian documents around 1500 BC. Since then, other reports in animals and humans established the tracheostomy as a life saving procedure. Vesalius in 1543 reported the first tracheal intubation in an animal. Trousseau reported 200 patients suffering from diphtheria who were saved by tracheostomy. In the early 1870's, Trendelenburg from Germany performed the first endotracheal anesthesia in man. Macewen in 1878 reported the first elective endotracheal intubation for anesthesia. He isolated the trachea by packing the hypopharynx, from leaking of blood and debris. Later, Rosenberg and Kuhn administered cocaine as local anesthetic to obtund the cough reflex during intubation. Tracheostomy and intubation have been broadly used during the First World War. Magill (1888-1986) recognized the advantages of tracheal intubation. Also, by his efforts, anesthesia has become an independent specialty. In 1913 the first anesthetic laryngoscope was invented by Jackson and modified by the Magill, Miller and Macintosh. In 1942, curare was introduced as a muscle relaxant for abdominal relaxation during general anesthesia and endotracheal intubation became routine in major abdominal and other surgeries. The article also reviews the Israeli contribution to the development of tracheostomy.

History, 16th Century↗
PubMed2006

[Cannot intubate, cannot ventilate: airway management of difficult airways in adults].

Cannot intubate, cannot ventilate (CICV) is one major cause of death associated with general anesthesia and thus proper airway management plans are necessary. To achieve safe airway management, it is necessary first to predict if the patient's trachea can be difficult to intubate or the lungs difficult to ventilate. When difficulty is predicted, the following factors should be considered: (1) if general anesthesia is truly necessary; (2) if tracheal intubation is mandatory; (3) if muscle relaxation is required; (4) if awake intubation is safer; (5) if surgical airway is required; and (6) if tracheal intubation can prevent airway obstruction. When CICV occurred after general anesthesia, it is important to remember that the primary task is to oxygenate the patient, and not to intubate the trachea: the patient may need to be awaken, surgical airway obtained, or cardiopulmonary bypass established. To make a right decision, it is necessary to know the advantages and disadvantages of each option, as well as of each airway device, and to be acquainted with these devices during routine anesthesia. In this article, I will present six typical cases of difficult airways, and will discuss appropriate options for safer airway management.

Adolescent↗
PubMed2006

Unplanned intubation during anesthesia: review of 31 cases from the Thai Anesthesia Incidents Study (THAI study).

OBJECTIVES: To examine the causes, outcomes, and contributing factors associated with patients requiring unplanned emergency intubation for adverse respiratory events. METERIAL AND METHOD: Appropriate unplanned intubation incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004, and analyzed using descriptive statistics. RESULTS: Thirty-one incidents of unplanned intubation were recorded, 21 of which were due to respiratory problems particularly after bronchoscopy with and without surgery of the upper airway. Six of the 21 cases (28.6%) were children under 10 years of age who suffered from papilloma of the larynx. Sixteen cases of the 31 cases (52%) of the unplanned intubations were due to inadequate ventilation; 13 cases (41%) due to laryngeal edema; 11 cases (36%) due to sedative agents. The other events were the result of unstable hemodynamics, severe metabolic acidosis, muscle relaxants, and intrapulmonary lesions. Eighteen cases of unplanned intubations (18/31) (58%) occurred in the Post-Anesthesia Care Unit, 5 cases (16%) in a ward, and 4 (13%) in the operating room. The reported contributing factors included inadequate experience, lack of supervision and the patient's condition. CONCLUSION: Major incidents of unplanned intubation occurred after bronchoscopy. Common contributing factors related to inadequate ventilation, airway obstruction, sedative agents and unstable hemodynamics. Quality assurance, additional training, and improved supervision tended to minimize the incidents.

Adolescent↗
PubMed2006

Factors that predict the need for intubation in patients with smoke inhalation injury.

Early identification of smoke inhalation patients who will require intubation is crucial. We conducted a retrospective chart review to identify predictors of respiratory distress in patients who present with smoke inhalation injury. Our study involved 41 patients who had been treated in the emergency room at a regional burn center. Eight of these patients required intubation. Intubation was positively correlated with physical examination findings of soot in the oral cavity (p < 0.001), facial burns (p = 0.025), and body burns (p = 0.025). The need for intubation was also predicted by fiberoptic laryngoscopic findings of edema of either the true vocal folds (p < 0.001) or the false vocal folds (p < 0.01). No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p = 1.0). Also, multivariate analysis revealed that facial burns correlated significantly with edema of the true vocal folds (p = 0.01) and body burns correlated significantly with edema of both the true (p = 0.047) and false (p = 0.003) vocal folds. We conclude that patients with soot in the oral cavity, facial burns, and/or body burns should be monitored closely because these findings indicate a higher likelihood of laryngeal edema and the need for intubation.

Adolescent↗
PubMed2006

[Reduction of the concentration of isoflurane prevents tachycardia and hypertension associated with tracheal intubation].

BACKGROUND: High concentration of isoflurane often induces not only tachycardia but also hypertension during induction of anesthesia and causes further hyperdynamic changes after tracheal intubation. METHODS: Forty patients, ASA physical status I, were randomly assigned to receive 4% or 2.5% isoflurane. Anesthesia was induced with thiamylal and vecuronium followed by mask ventilation with 0.5% isoflurane in oxygen. Isoflurane concentration was gradually increased to 4% or 2.5% in 2 min and the trachea was intubated after 3 min. Systolic blood pressure (SBP) and heart rate (HR) were recorded every minute from induction of anesthesia. RESULTS: Mask ventilation with isoflurane induced a significant increase in HR in both groups, but the HR just before intubation was significantly lower in the 2.5% group than in the 4% group. SBP was significantly decreased in the 2.5% group, but a transient increase was seen in the 4% group. Tracheal intubation induced a marked increase in HR in both groups, but the HR was significantly lower in the 2.5% group than in the 4% group (115 +/- 14 and 130 +/- 18 beats x min(-1), respectively; P < 0.01). SBPs just after intubation were 166 +/- 24 and 154 +/- 20 mmHg in the 4% and 2.5% groups, respectively. The difference between the groups was not significant, but the patients in whom the SBP increased more than 180 mmHg were significantly fewer in the 2.5% group than in the 4% group (P < 0.05). CONCLUSIONS: Reduction of the isoflurane concentration from 4% to 2.5% during induction of anesthesia made the circulation stable, and decreased the incidence of excessive tachycardia and hypertension after tracheal intubation.

Adult↗
PubMed2005

The Thai Anesthesia Incidents Study (THAI Study) of difficult intubation: a qualitative analysis.

OBJECTIVES: To examine the causes, outcomes and contributing factors including suggested corrective strategies associated with difficult intubation. MATERIAL AND METHOD: Difficult intubation and failed intubation incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003 to January 31, 2004 and analyzed by using descriptive statistics RESULTS: Two hundred and thirty-four cases of difficult intubation were recorded. Among those, 50 cases (21%) were failed intubation. The most common cause (95%) of incidents was due to patients difficult anatomy. Prediction of events was derived from physical examination (65%) and history taking (50%). Majority of incidents (44%) occurred in Mallampati II and III. Only 3 cases (1.3%) of morbid obesed and 3 cases (1.3%) of pregnant patients were attributed to the events. Most incidents (119 cases, 50.9%) were successfully managed by conventional techniques. The adverse effects included hypoxemia (54 cases, 23.1%), esophageal/ tracheal injury (40 cases, 17.1%) and prolonged ventilatory support (17 cases, 7.3%). One patient died from sepsis. The reported contributing factors included inadequate experience, lack of knowledge including inadequate preoperative evaluation and preparation. Additional training, quality assurance and protocol/algorithm tended to minimize the incidents. CONCLUSION: The majority of difficult intubation could be predicted. Proper preoperative evaluation and equipment preparation, appropriate technique including experienced anesthesia personnel could attenuate the morbidity and mortality.

Adolescent↗
PubMed2006

[Clinical experience of tracheal intubation using Trachlight in patients with unstable dentition].

BACKGROUND: Trachlight is a light-tipped stylet designed to guide tracheal intubation. It obviates the need for direct laryngoscopy and is reported to be particularly useful for managing difficult tracheal intubation. Its clinical application, however, is not limited to difficult airway management. METHODS: Here we report our experience of the use of Trachlight in 64 adult patients who were at risk of dental injury during direct laryngoscopy because of unstable teeth around the incisors or severe alveolar disease. RESULTS: Of 64 patients (33 men and 31 women) aged between 30 and 85, the trachea was successfully intubated using Trachlight without dental damage in 63 patients. In 1 patient, a tracheal tube was smoothly placed, but a tooth was injured after the removal of the stylet. No other complications associated with the use of Trachlight were noted. CONCLUSIONS: Our experience suggests that Trachlight can be a helpful tool for intubation in patients having dental problems. Because of the blind nature of the technique, but preexisting lesions of the larynx and vocal cords might be overlooked in intubation using Trachlight. Further investigation is warranted to recommend Trachlight as a intubation technique of choice in patients with unstable dentition.

Adult↗
PubMed2006

Lightwand-assisted nasotracheal intubation in awake ankylosing spondylitis.

Several techniques of airway management in ankylosing spondylitis (AS) have been reported. No study related specifically to the use of a lightwand-assisted intubation in AS has been previously described. The present case report demonstrates that an awake, nasotracheal intubation can be successfully performed to provide general anesthesia in a patient with AS. A 65-year-old Thai male was scheduled for exploratory surgery under general anesthesia. Past medical history consisted of hypertension and AS. The preoperative airway assessment showed limitation of mouth opening, an extremely anteriorly flexed and immobile cervical spine. An awake intubation under sedation and topical airway anesthesia were chosen. Multiple attempts at blind nasotracheal intubation and oral approach with lightwand were unsuccessful. Finally, intubation was successfully performed with lightwand by nasal route. This serves to show that an awake nasotracheal intubation with a lightwand may be a safe and useful alternative option for airway management in patients with severe ankylosing spondylitis.

Aged↗
PubMed1991

[Prostaglandin E1 (PGE1) prevents the pressure responses to tracheal intubation in hypertensive patients].

Forty-five hypertensive patients for elective abdominal surgery were investigated regarding the effects of PGE1 on the cardiovascular responses to tracheal intubation. Administration of PGE1 at the dose of 0.10 or 0.20 micrograms.kg-1.min-1 for 10 minutes before tracheal intubation significantly reduced the blood pressure responses immediately after the intubation and 2 minutes later. The increases in heart rate were not altered with and without the administration of PGE1. So the increases in rate pressure products were markedly reduced with PGE1 compared with the control values. Plasma concentration of catecholamines was measured before and after tracheal intubation. Norepinephrine was elevated markedly immediately after the intubation and this change was not affected by the infusion of PGE1. These results demonstrate that PGE1 ameliorates the pressure responses by the release of norepinephrine and thus reduces the increases in rate pressure products immediately after tracheal intubation.

Aged↗
PubMed1991

The effects of suxamethonium and pancuronium on the haemodynamic response to endotracheal intubation.

The pharmacological effects of suxamethonium and pancuronium on the cardiovascular system may vary and therefore alter the haemodynamic response to intubation. The arterial blood pressure, the heart rate and the rate pressure product were measured as parameters of haemodynamic change in forty adult ASA. I and II patients undergoing laryngoscopy and endotracheal intubation in a randomised controlled study. The patients were induced with either thiopentone/suxamethonium (Group A) or thiopentone/pancuronium (Group B). There was no significant difference between the groups on comparison of systolic and diastolic blood pressure changes. Pancuronium, however, caused a significantly higher rise in the heart rate after endotracheal intubation compared to suxamethonium. In both groups the maximum rate pressure product occurred one minute after intubation, rising by 56% in the suxamethonium group and 64% in the pancuronium group compared to control values. In conclusion, there were significant and statistically similar increases in systolic and diastolic blood pressures and rate pressure product following intubation in both groups with values significantly above baseline until three minutes post intubation but the increase in heart rate in group A was significantly less than that in group B.

Adolescent↗
PubMed1991

Review of intubation in severe laryngotracheobronchitis.

Of 208 children who required relief of severe airway obstruction due to laryngotracheobronchitis by an artificial airway (nasotracheal intubation or tracheostomy) during a 10-year-period, 181 (87%) were intubated and later extubated. Twenty-seven children (13%) had tracheostomies performed. The tracheostomies were for severe subglottic narrowing precluding the passage of an adequate size endotracheal tube in 10 children, and for severe endotracheal tube trauma in 17 children. Five children developed acquired subglottic stenosis (2.4% of 208) and 1 of these has a retained tracheostomy. One child died of cardiac disease. The remaining 202 children had no long-term complications of laryngotracheobronchitis, intubation, or tracheostomy. It is concluded that nasotracheal intubation is a satisfactory artificial airway for laryngotracheobronchitis. Endoscopic evaluation in a selected group of these children will identify those with significant intubation trauma or severe subglottic narrowing in whom continued intubation may cause permanent subglottic damage. The low incidence of acquired subglottic stenosis in this series supports the practice of selective endoscopy and tracheostomy.

Airway Obstruction↗
PubMed1990

Metabolic and cardiovascular responses following oral and nasal intubation of the trachea.

The cardiovascular and metabolic responses to oral and nasal intubation of the trachea were studied in 24 unpremedicated patients, free from cardiovascular disease and scheduled for excision of breast lump. Systolic blood pressure (SBP) and heart rate (HR) were recorded with a Dinamap 1846 SX before and at 1 minute intervals for 10 minutes following oral (group A = 12 patients) or nasal (group B = 12 patients) intubation. Oxygen consumption (VO2) and carbon dioxide production (VCO2) were measured at 1 minute intervals for 10 minutes following tracheal intubation using the Engström Metabolic Computer and an infrared CO2 analyzer. No significant differences in SBP and HR preinduction and postintubation values were found between the two groups. Both oral and nasal intubation were associated with significant increases in VO2 (p less than 0.001 and p less than 0.001 respectively), VCO2 (p less than 0.001 and p less than 0.001), SBP (p less than 0.001 and p less than 0.001) and HR (p less than 0.001 and p less than 0.001). Nasal intubation of the trachea was associated with significantly higher VO2 (p less than 0.05-0.01) and VCO2 (p less than 0.05-0.001) values when compared with the VO2 and VCO2 values following oral intubations.

Adolescent↗
PubMed1989

Intubation with low-dose atracurium in children.

The objective of this study was to compare intubating conditions and neuromuscular effects using smaller doses of atracurium (0.25 mg/kg and 0.3 mg/kg) with the recommended dose of 0.4 mg/kg for intubation in children anesthetized with halothane, N2O and oxygen undergoing strabismus repair. All patients (10 in each group) had good or excellent intubating conditions at 80% depression of twitch height [T1 of train-of-four (TOF) stimulation]. Mean times to intubation were 2.6 +/- 0.2 minutes following 0.25 mg/kg and 2.2 +/- 0.2 minutes following 0.3 mg/kg. These times were significantly longer (P less than 0.05) than the mean intubation time of 1.5 +/- 0.2 minutes following 0.4 mg/kg. Mean times to recovery, defined as times from injection of atracurium to return of T1 of TOF to 10%, 25%, and 95% of control measurements, were significantly shorter with the smaller doses. Atracurium at these low doses may provide an alternative to succinylcholine for intubating children during halothane anesthesia for surgical procedures lasting 20-30 min.

Anesthesia↗