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PubMed2002

Difficult endotracheal intubation as a result of penetrating cranio-facial injury by an arrow.

UNLABELLED: Penetrating injury of the face and airway may make endotracheal intubation difficult or impossible. We report the case of a patient who attempted to commit suicide with a crossbow. Surgery under general anesthesia was required to remove the arrow. The oral intubation route was impossible, and a fiberoptic nasal intubation under local anesthesia was performed. IMPLICATIONS: We report a case of a 42-yr-old patient who underwent surgery for a penetrating craniofacial injury caused by an arrow. Because of the median vertical trajectory of the arrow (from the chin to the frontal skull), only the right nasal approach was accessible for endotracheal intubation. Fiberoptic nasal intubation and securing the airway under local anesthesia are described.

Adult↗
PubMed2006

Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study.

OBJECTIVES: To describe the current practice of physicians, to report complications associated with endotracheal intubation (ETI) performed in THE intensive care unit (ICU), and to isolate predictive factors of immediate life-threatening complications. DESIGN: Multiple-center observational study. SETTING: Seven intensive care units of two university hospitals. PATIENTS: : We evaluated 253 occurrences of ETI in 220 patients. INTERVENTIONS: From January 1 to June 30, 2003, data related to all ETI performed in ICU were collected. Information regarding patient descriptors, procedures, and immediate complications were analyzed. MEASUREMENTS AND MAIN RESULTS: The main indications to intubate the trachea were acute respiratory failure, shock, and coma. Some 148 ETIs (59%) were performed by residents. At least one severe complication occurred in 71 ETIs (28%): severe hypoxemia (26%), hemodynamic collapse (25%), and cardiac arrest (2%). The other complications were difficult intubation (12%), cardiac arrhythmia (10%), esophageal intubation (5%), and aspiration (2%). Presence of acute respiratory failure and the presence of shock as an indication for ETI were identified as independent risk factors for occurrence of complications, and ETI performed by a junior physician supervised by a senior (i.e., two operators) was identified as a protective factor for the occurrence of complications. CONCLUSIONS: ETI in ICU patients is associated with a high rate of immediate and severe life-threatening complications. Independent risk factors of complication occurrence were presence of acute respiratory failure and presence of shock as an indication for ETI. Further studies should aim to better define protocols for intubation in critically ill patients to make this procedure safer.

Aged↗
PubMed2026

Neuromuscular blocking agents for tracheal intubation of critically ill adults: a systematic review and meta-analysis.

BACKGROUND AND IMPORTANCE: Emergency tracheal intubation in critically ill adults is associated with a high risk of peri-intubation adverse events, making first-attempt success a key safety target. OBJECTIVE: This study aimed to evaluate whether the use of neuromuscular blocking agents (NMBAs) improves the proportion of first-attempt success and reduces adverse events during emergent intubations outside the operating room. METHODS: This was a systematic review and meta-analysis of randomized clinical trials or nonrandomized studies comparing sedative-hypnotic plus NMBA versus sedative-hypnotic alone in critically ill adults undergoing emergency endotracheal intubation in nonoperative settings. Animal, cadaveric, manikin/simulation, and pediatric studies were excluded. Articles were screened on 21 August 2025, in Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection. MAIN RESULTS: Of 4736 screened citations, 13 studies (8 cohort; 5 before-after studies) were included in the quantitative analysis, with 14 072 participants. NMBA use was associated with higher first-attempt success, which ranged from 69 to 92% (pooled odds ratio, 2.72; 95% onfidence interval: 1.42-5.21; low-certainty evidence). Secondary outcomes related to adverse events were rated as very low certainty due to sparse data, inconsistent reporting, and serious imprecision. CONCLUSION: NMBA use during emergency intubation was associated with improved first-attempt success, although the certainty of evidence was low.

Humans↗
PubMed1983

Capnography for detection of accidental oesophageal intubation.

The clinical diagnostic signs for detecting inadvertent oesophageal intubation may all be misleading. We therefore tested the practice of recording exhaled carbon dioxide during the intubation procedure as an additional measure for detection of accidental oesophageal intubation. Twenty patients were intubated simultaneously into the trachea and oesophagus and the carbon dioxide concentration was continuously recorded from both sources. Manual ventilation of the lungs always resulted in a typical CO2 curve pattern. Ventilation by mask prior to the intubation obviously resulted in some filling the stomach by exhaled gas in 9 of the 20 patients. In these cases some CO2 could be detected during oesophageal ventilation. As the oesophageal CO2 concentrations were very low initially, compared to the tracheal recordings, and carbon dioxide completely disappeared after a few ventilations into the oesophagus, distinguishing between the tracheal and oesophageal capnography tracings was easy.

Carbon Dioxide↗
PubMed2006

Confirmation of endotracheal tube placement after intubation using the ultrasound sliding lung sign.

OBJECTIVES: To evaluate the performance of the ultrasound (US) sliding lung sign as a predictor of endotracheal tube (ETT) placement. Many other tools and examination findings have been used to confirm ETT placement; erroneous placement of the ETT has even been confirmed by US. METHODS: This was a laboratory study using fresh, recently dead cadavers. Cadavers were obtained at a medical school anatomy laboratory on the basis of availability during a four-month period. Subjects who died from significant trauma or after thoracic surgery were excluded. A numerical randomization tool was used to direct where the tube would be placed on intubation. Laryngoscopy was performed, and the ETT was placed in the esophagus, in the trachea, or in the right main stem (RMS) bronchus. Placement was confirmed by direct laryngoscopic visualization of ETT passage through vocal cords or with fiber optic visualization, as needed. US images of the sliding lung sign, sliding of visceral and parietal pleura past each other, were taken on both sides of the chest at the mid axillary line during ventilation with an ambu bag. Two board-certified emergency physicians with hospital credentialing in emergency US used a 4-2 MHz micro-convex transducer on a Sonosite 180 Plus for imaging. The sonologists were blinded to the location of the endotracheal tube and imaged and recorded their results individually. A positive sliding lung sign was taken to signify lung expansion with ventilation in a hemithorax. Endotracheal versus esophageal ETT placement, as well as tracheal versus RMS, was determined on the basis of sliding lung findings on both sides of the chest. Interpreter agreement, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LHR) were calculated for tracheal (including RMS) versus esophageal, as well as main trachea versus RMS intubation. RESULTS: Nine cadavers yielded 68 intubations. For esophageal versus tracheal (including RMS) intubation, sonologist 1 (S1) had a sensitivity of 95.4% (95% CI = 84.2% to 99.4%), a specificity of 100% (95% CI = 86.3% to 100%), an NPV of 92.6% (95% CI = 75.7% to 99.1%), and a PPV of 100% (95% CI = 91.4% to 100%) with an LHR of 0.05 (95% CI = 0.01 to 0.2) for a negative test. Sonologist 2 (S2) had a sensitivity of 100% (95% CI = 91.8% to 100%), a specificity of 100% (95% CI = 86.3% to 100%), an NPV of 100% (95% CI = 86.3% to 100%), and a PPV of 100% (95% CI = 91.8% to 100%); agreement was 97% (kappa = 0.94; 95% CI = 0.7 to 1.2). In RMS versus tracheal, S1 had a sensitivity of 69.2% (95% CI = 48.2% to 85.7%), a specificity of 93.3% (95% CI = 68.1% to 99.8%), a PPV of 94.7% (95% CI = 73.9% to 99.9%), and an NPV of 63.6% (95% CI = 40.7% to 82.8%) with an LHR for a positive test of 10.4 (95% CI = 2.2 to 59.1) and of 0.4 (95% CI = 0.2 to 0.6) for negative test. S2 had a sensitivity of 78.6% (95% CI = 59.1% to 91.7%), a specificity of 100% (95% CI = 78.2% to 100%), a PPV of 100% (95% CI = 84.6% to 100%), NPV of 71.4% (95% CI = 47.8% to 88.7%), with an LHR for a negative test of 0.2 (95% CI = 0.1 to 0.4); agreement was 85.9% (kappa = 0.6; 95% CI = 0.4 to 0.9). CONCLUSIONS: These results show that US imaging of the sliding lung sign in a cadaver model is an accurate method for confirmation of ETT placement. Further, the technique may have some utility in differentiating RMS bronchus from main tracheal intubations.

Emergency Medicine↗
PubMed1984

Field endotracheal intubation by paramedical personnel. Success rates and complications.

One-hundred thirty mobile intensive care unit paramedics were trained in the technique of direct laryngoscopic endotracheal intubation of cardiac arrest or deeply comatose patients. Three attempts at intubation were permitted. Of the 779 patients studied, 701 (90.0 percent) were successfully intubated: 57.9 percent on the first attempt, 26.1 percent and 5.5 percent on the second and third respectively. Reported and observed complications of the procedure numbered 74 (9.5 percent) of the 779 patients included in the study. There were three unrecognized esophageal intubations. The success rate rose to more than 94 percent toward the end of the study. It is concluded that endotracheal intubation of deeply comatose patients is a field procedure safely and skillfully performed by well-trained and monitored paramedical personnel, with success and complication rates at least comparable to other invasive airway techniques.

Allied Health Personnel↗
PubMed1959

Use and abuse of nasogastric intubation.

The value of nasogastric intubation in the treatment of paralytic ileus and in some cases of mechanical obstruction, as well as in the preparation of obstructed patients for operation, cannot be denied. However, it is felt that intubation is oftentimes employed unnecessarily, and that the complications of this procedure are not fully appreciated. Fluid and electrolyte loss, sinusitis, parotitis, laryngeal obstruction, esophagitis, knotting and difficulty in withdrawing tubes and perforations of the gastrointestinal tract are complications that can occur when nasogastric intubation is employed. Two hundred consecutive operations on the gallbladder and bile ducts were reviewed, and the need for intubation in these cases was evaluated. It was needed in only 7.5 per cent of the cases in the series. In light of the hazards and the rather rare necessity for nasogastric intubation, "routine" use should be eschewed.

Gastrointestinal Tract↗
PubMedDate not supplied

Progression of sinus disease in the intubated patient.

BACKGROUND: Sinus disease in the intubated patient remains a frequent reason behind otolaryngological consultation to the Intensive Care Unit. Previous prospective studies often have been limited to only one computed tomography (CT) scan of the sinuses. The purpose of this study was to verify the development of sinus disease in the orotracheally intubated patient and determine a radiographic pattern of its progression if present. METHODS: The charts of all patients admitted to the hospital with a diagnosis of aneurysm or subarachnoid hemorrhage over a 2-year period were evaluated. Patients who were orotracheally intubated with at least one postintubation CT scan of the head were included. CT scans obtained after the initiation of antibiotics or tracheostomy were excluded. The Lund-Mackay staging system was used to evaluate the scans. RESULTS: A total of 50 patients with 172 scans were evaluated. Analysis revealed a significant trend toward increasing severity of radiological sinus disease over the first 7 days of intubation (p < 0.001). The presence of a nasogastric tube (NGT) resulted in an increased Lund-Mackay score, but the trend remained significant for patients without an NGT as well. CONCLUSION: This study shows that the presence and progression of sinus findings is fairly common in the intubated patient and that although the placement of an NGT increased the rate of development of sinus findings, the lack of one did not preclude sinus disease. Clinical exam remains a more important indicator of disease when evaluating the Intensive Care Unit patient for rhinosinusitis.

Adult↗
PubMed2001

Bacterial colonization of endotracheal tubes in intubated neonates.

OBJECTIVE: To obtain in vivo bacterial colonization profiles on endotracheal tubes at different sites in the neonatal airway in an attempt to better characterize one potential element of chondritis. DESIGN: A case series in which cultures were obtained from calculated segments of 33 endotracheal tubes immediately following extubation. This allowed for sampling at specific levels of the airway corresponding to the trachea, the subglottis, and the oropharynx. Data collected included gender, race, duration of intubation, use of antibiotic therapy, comorbidities, gestational age at birth and extubation, crown-rump length, weight, radiographic distance from tube tip to carina, and culture results. SETTING: Newborn intensive care unit at a tertiary care medical center. PATIENTS: Twenty-nine neonates intubated for longer than 24 hours (range, 24 hours to 15 days). MAIN OUTCOME MEASURES: Bacterial and fungal cultures obtained from 3 endotracheal tube segments for each extubation. RESULTS: A statistically significant difference (P < .05) was found in colonization rates between patients intubated for less than 4 days and those intubated for longer periods. No significant difference was noted in bacterial profile between the 3 sites. CONCLUSIONS: Data demonstrate that bacterial colonization of an indwelling object in the neonatal airway increases with the duration of intubation. Furthermore, 4 days seems to represent a critical period in the formation of such colonization (possibly in the form of a biofilm). These bacteria may contribute to the chondritis known to precede the development of subglottic stenosis. Further studies are indicated to suggest ways to interrupt this process and reduce the incidence of airway injury.

Bacteria↗
PubMed1992

Is nasotracheal intubation safe in surgery for mandibular cancer?

A retrospective study of problems of postoperative airway maintenance after surgery for mandibular cancers was conducted. Twenty-seven patients treated in an intensive care unit after mandibular resection and primary reconstruction were included. The mean duration of nasotracheal intubation in 22 patients was 33.7 hours. Reintubation because of breathing difficulties was required in four cases. In one of these cases, failed intubation led to an emergency cricothyroidostomy. Failure to perform reintubation resulted in the death of one patient. One patient was tracheostomized after 5 days of nasotracheal intubation. Prolonged nasotracheal intubation after major surgery for oral malignant neoplasms may be an alternative to tracheostomy, provided that adequate monitoring is available after extubation. The safe duration of endotracheal intubation is difficult to determine. Primary reconstruction does not eliminate the need for an artificial airway after tumor surgery.

Adult↗
PubMed1997

Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries.

Accidental extubation is a potentially serious event for pediatric or neonatal patients with respiratory failure, especially in clinical settings in which personnel capable of performing reintubation may not be readily available. Thus the rate of accidental extubation in small intensive care units that operate without 24-hour in-house physician availability may be an important quality assurance indicator. The objective of this study were to determine the accidental extubation rate at a single small pediatric intensive care unit (PICU) and compare it with published reports. This study was carried out in a six-bed PICU at Washoe Medical Center in Reno, Nevada, with a relatively low level of patient acuity, as measured by PRISM score and the frequency of intubation, and without 24-hour in-house physician availability. All intubated patients admitted during the 5-year period from January 1, 1989 to December 31, 1993 were included. The primary outcome measure was the occurrence of accidental extubation. We observed only two accidental extubations in 1,749 intubated-patient-days (IPD) (0.114 accidental extubations/100 IPD [95% confidence interval 0.014-0.413 accidental extubations/ 100 IPD]). This rate of accidental extubation was compared with data in published reports from neonatal intensive care units (NICUs) and PICUs, which ranged from 0.14 accidental extubations/100 IPD to 4.36 accidental extubations/100 IPD. The dependence of the observed accidental extubation rate on unit size and institutional experience with intubated patients, as measured by the average number of intubated patients, was examined. We found no evidence that the accidental extubation rate is higher in smaller units or units with less institutional experience. Low rates can be achieved in small units with low acuity.

Adolescent↗
PubMed1989

Nontypable Haemophilus influenzae nosocomial pulmonary infections in children following intubation.

Twenty-nine intubated pediatric patients were prospectively studied to determine whether nontypable Haemophilus influenzae (NTHI) is associated with the development of nosocomial pneumonia. Throat cultures and tracheal Gram stains, leukocyte counts and cultures were obtained immediately following intubation, then serial studies on tracheal secretions were performed. Median patient age was 13 months. One patient had preexisting lung disease and 14 (48%) had pneumonia when intubated. There were five deaths. NTHI was recovered from the initial throat or tracheal culture in seven patients (24%); none developed a nosocomial lower respiratory tract infection. NTHI was not associated with any of three cases of nosocomial pneumonia. Three of 12 NTHI isolates were beta-lactamase producers. Tracheal leukocyte counts and Gram stains were not predictive of pneumonia, either at the time of intubation or subsequently. We conclude that NTHI in the oropharynx or trachea is not predictive of pneumonia among intubated pediatric patients.

Adolescent↗
PubMed1986

Acute epiglottitis: management by short duration of intubation and hospitalisation.

One hundred and thirty-seven patients with acute epiglottitis were studied retrospectively with regard to the efficacy and safety of short duration of intubation and hospitalisation. All patients were treated by nasotracheal intubation and antibiotic therapy. Inhalation anesthesia with halothane/oxygen was the preferred method for intubation (80.3%). Extubation was based on clinical improvement in 88.1% and on laryngoscopy in 11.9% of cases. Fifty-four percent of the patients were extubated successfully within 24 h and 94.8% within 48 h. Three patients (2.2%) had to be reintubated once. The mean duration of intubation was 27.6 h (range 8-86) and of hospitalisation 4.0 days (range 2-9). Two children (1.5%) died because of severe hypoxic brain damage due to cardiorespiratory arrest prior to hospital admission. A follow-up study conducted via the family physician revealed only two major complications (granulation polyp of the vocal cords, 1; long-lasting hoarseness, 1). It is concluded that short duration of intubation and hospitalisation are effective and safe in the management of acute epiglottitis.

Anti-Bacterial Agents↗
PubMedDate not supplied

The need for intubation in serious upper respiratory tract infection in pediatric patients (a retrospective study).

Serious bacterial infections occurred in ten children (1.4%) of 710 patients with croup admitted to the Soroka Medical Center during the years 1983-1989. Sixty-four patients (9% of all croup patients) were admitted to the pediatric intensive care unit (PICU), and 13 of them (20%) required intubation. Bacterial infections were noted in nine of the 13 intubated patients, in none of the other 51 PICU patients who did not require intubation and in one of the 646 patients (0.2%) who were not admitted to the PICU (p less than 0.0001). There was no difference in age, ethnic origin, or body temperature on arrival between the two PICU groups. Causative microorganisms were isolated from blood samples (three cases) and tracheal pus (eight cases). All intubated PICU patients were seriously ill: eight had bacterial tracheitis and one supraglottitis. Patients with bacterial tracheitis required frequent suctioning of the trachea for copious purulent secretions. The single patient with bacterial infection who was not admitted to the PICU had transient bacteremia. We conclude that the need for intubation in croup patients was an indicator for the presence of a serious bacterial infection.

Anti-Bacterial Agents↗
PubMed1990

Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation.

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n = 53) or nasotracheal (n = 58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48 h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral; p less than 0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p less than 0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.

Aged↗
PubMed1984

Rapid long tube intubation of the jejunum--an improved technique.

This study details improvements in the intubation of a long intestinal decompression tube by use of a new flexible tip guide wire and a new intestinal decompression tube. The intubation route of the endoscope was changed from the oral to the nasal cavity. Although the guide wire formerly used (TGBD-65-345) could be inserted into the descending part of the duodenum by passing it through the biopsy channel of the endoscope, with this new method, the guide wire (TGBD-65-450) could be inserted into the upper jejunum. The endoscope could also be left in the stomach, when this method was used. The long tube was introduced along this guide wire into the upper jejunum. As a result of these improvements, the intubation rate for long intestinal decompression tubes was significantly more rapid and the time reduced. Intubation rate to the jejunum was 96 percent successful, as compared with a former success rate of 75 percent. The intubation time was decreased to 11.3 +/- 5.6 min. to the duodenum and 18.6 +/- 8.6 min. to the upper jejunum. This differs markedly from the former method which required 16.0 +/- 5.3 min. and 39.6 +/- 22.7 min, respectively.

Humans↗
PubMed1994

Epistaxis and nasotracheal intubation--prevention with vasoconstrictor spray.

Eighty patients having anaesthesia for oral surgery requiring nasal intubation were randomly allocated to be intubated with either a plain Magill red rubber or cuffed polyethylene endotracheal tube and in a double blind manner, to receive xylometazoline 0.1% vasoconstrictor nasal spray. The extent of any epistaxis occurring was assessed by an independent observer. With the Magill tube there was bleeding in one out of twenty patients in both the vasoconstrictor group and non vasoconstrictor group at intubation and no bleeding in either of the two groups at extubation. With the polyethylene tube sixteen out of twenty patients had bleeding in the non vasoconstrictor group. This improved to seven out of twenty with the administration of vasoconstrictor drops at intubation (chi square 10.2; p < 0.01) in the polyethylene tube group. At extubation ten out of twenty patients had bleeding in the non vasoconstrictor group improving to two out of twenty with the administration of the vasoconstrictor (chi square 9.6; p,0.01). The use of the vasoconstrictor xylometazoline helped to reduce epistaxis that occurred during nasal intubation and further study into the type of endotracheal tube is recommended.

Adolescent↗
PubMed1978

Late complications of prolonged tracheal intubation.

Questionnaires were sent to patients who had tracheal intubation for periods longer than three days in a large multidisciplinary Intensive Care Unit. The information sought was of complaints related to talking, breathing, coughing, swallowing and chest infection. Of patients who had been intubated for seven days or less, 63 per cent of the 52 patients responding had no complications while only one of the remainder had a major complication requiring surgical removal of a granuloma. Forty-eight per cent of patients intubated for more than seven days had no complaints and the rest of the patients had minor complaints which did not persist. Most complained of hoarseness. Of patients who had a tracheostomy following prolonged intubation, only 23 per cent were free of complications. From this it is concluded that tracheal tubes can be left in place for seven days and at this time direct laryngoscopy should be done. If no significant laryngeal pathology is seen at this examination, tracheal intubation may be continued.

Adult↗