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PubMed1986

Success rates of blind orotracheal intubation using a transillumination technique with a lighted stylet.

The technique of guided orotracheal intubation using a lighted stylet depends on the transillumination of the soft tissues of the neck to direct the tube through the glottis and into the trachea. We conducted an operating room study of this technique, recording success rates and intubation times of 50 patients undergoing elective surgery. All patients were intubated successfully, 35 of 50 (70%) on the first attempt, 12 of 15 (80%) on the second attempt, and three of three (100%) on the third attempt. The average time for intubation was 37 seconds. A new design of the lighted stylet method resulted from the experience gained. Intubator training and experience influenced initial success rates, and the cadaver laboratory was of particular value in teaching the technique.

Adolescent↗
PubMed1988

Emergency flexible fiberoptic nasotracheal intubation: a report of 60 cases.

We describe our experience with 60 consecutive intubations using flexible fiberoptic nasotracheal technique in the emergency setting. Fifty-seven of the procedures were carried out by two emergency physicians initially trained on intubation manikins. A learning curve is constructed demonstrating that time to intubation is decreased after nine or ten intubations. Complications are reviewed. Bleeding occurred in 22% of patients; the technique failed in 13%. Failure to intubate with fiberoptic technique was associated with specific problems such as bleeding, tumor, or agitation. Our results demonstrate both the limitations and special use of flexible fiberoptic technique.

Airway Obstruction↗
PubMed1989

Prehospital blind nasotracheal intubation by paramedics.

Blind nasotracheal intubation attempts by paramedics in the field were prospectively reviewed. In particular, we analyzed the frequency, success rate, complication rate, frequency of performance by each paramedic, indications, and patient outcome. Blind nasotracheal intubation was attempted in 324 patients and successful in 231. The average success rate for medical patients was 72.2% (195 of 270 attempts) and for trauma patients was 66.7% (36 of 54 attempts). This difference was not significant (P greater than .05). Even with 59.8% of the 82 participating paramedics attempting blind nasotracheal intubation less than four times over the 19-month study period, the average success rate was 71.3%. There was a significant increase in success when blind nasotracheal intubation was attempted more than three times during the study period (P less than .005). Major complications occurred in 0.9% (three) of the patients. The overall complication rate was 13% (42). The incidence of complications tended to decline with increasing paramedic frequency but did not reach statistical significance (P greater than .05). Blind nasotracheal intubation is a safe initial field airway approach in spontaneously breathing patients in whom there are no contraindications. Even with a low frequency of performance, success and complication rates are acceptable.

Allied Health Personnel↗
PubMed1998

Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study.

STUDY OBJECTIVE: To determine the clinical characteristics of endotracheal intubation in the French emergency prehospital medical system and compare these data with those of other systems. METHODS: This study was performed in lle de France (Paris Region) in mobile ICUs staffed by physicians. This prospective, descriptive study involved completion of a questionnaire by the operator just after endotracheal intubation was performed. RESULTS: Six hundred eighty-five (99.1%) of 691 consecutive prehospital intubations were performed successfully in the field. The orotracheal route was used in 96.0%, and no surgical approaches such as cricothyroidotomy were used. Mechanical complications occurred in 84 patients, at a rate of 15.9% for nonarrest patients and 8.1% for arrest patients. A wide variety of sedation protocols were used. Difficult intubations (10.8%) were comparable in incidence to the number seen in US emergency departments, not US prehospital systems. By the same token, intubation success rates (99.1%) were comparable to US EDs and much higher than US prehospital results. CONCLUSION: The characteristics of French prehospital airway management differ significantly from those of other countries. These differences may be explained by differences in approach to prehospital management rather than differences of skill.

Clinical Protocols↗
PubMed1997

Rapid sequence intubation in adults with elevated intracranial pressure: a survey of emergency medicine residency programs.

A questionnaire entitled "Survey of Protocols for Rapid Sequence Intubation in Previously Healthy Adults with Elevated Intracranial Pressure" was distributed to the program directors of all 100 emergency medicine residency programs listed in the Directory of Graduate Medical Education Programs in February 1995. The medical literature on rapid sequence intubation in patients with suspected intracranial pressure elevations was reviewed. The findings of the review were compared with the survey responses. Sixty-seven program directors responded to the survey. Sixty-five programs performed rapid sequence intubation in their institution. Five programs performed 0 to 10 procedures annually. Six performed 10 to 30 annually, 19 performed 30 to 50, 17 performed 50 to 100, and 18 performed more than 100. Succinylcholine and vecuronium were the most frequently used neuromuscular blockers. Midazolam and thiopental were the most frequently used sedative induction agents. Most programs use a defasciculating agent prior to succinylcholine administration. The majority of programs do not use a priming agent before the use of a nondepolarizing neuromuscular blocking agent. Intravenous lidocaine was routinely administered prior to neuromuscular blockade. Fentanyl was the most frequently used other pretreatment medication. Rapid sequence intubation is used to facilitate definitive, emergent airway management in patients with suspected intracranial pressure elevations in almost all of the emergency medicine residency programs that responded to the survey. Most of these programs follow the guidelines recommended in the medical literature. The majority of these guidelines, however, are based on statistical data performed in the laboratory or nonemergency environments. Further clinical studies in an emergency medicine environment must be performed to determine the optimal drug regimen for rapid sequence intubation in patients with elevated intracranial pressure.

Clinical Protocols↗
PubMed1990

[Anesthetic technics for the difficult intubation].

Numerous anaesthetic techniques exist for a patient who presents with a difficult endotracheal intubation. They all require an anaesthetic protocol which cannot be improvised. When intubation is expected to be difficult at the pre-anaesthetic examination, the use of a fiberoptic bronchoscope is the technique of choice for intubating adults under local anaesthesia, and children under general anaesthesia. When a fiberoptic bronchoscope is not available, several alternatives can be suggested: local anaesthesia of the glottis, retro-molar and retrograde intubation, or the use of a guide threaded over a lighted stylet; these techniques can be used in an anaesthetized patient breathing spontaneously. In the paralyzed patient impossible to intubate, various trans-laryngeal techniques of ventilation can be used in emergency: jet ventilation via the trans-crico-thyroid route, the use of a cricotomy cannula, or a minitracheotomy set.

Anesthesia↗
PubMed1990

[Intubation in otorhinolaryngologic surgery: propofol versus propofol-suxamethonium].

This study was carried out to assess the conditions of intubation in head and neck surgery when using propofol alone or associated with suxamethonium. Sixty patients were randomly allocated in two groups of 30. Group I was given 3 mg.kg-1 propofol and Group II 3 mg.kg-1 propofol immediately followed by 1.5 mg.kg-1 suxamethonium. All patients were premedicated orally with midazolam 0.1 mg.kg-1, 0.5 to 1 mg atropine and 7 to 10 micrograms.kg-1 alfentanil, while a colloidal solute (Plasmion) up to 250-500 ml was infused. One minute after injection of propofol, lidocaine 5% was pulverized on the glottis and intubation performed. The mean time required for intubation was similar in both groups: 128 +/- 10 sec in group I vs 132 +/- 9.7 sec in group II. Thirty-five % of patients had to be considered as difficult to intube but the mean times in these cases were not statistically different: 169 +/- 14 sec in group I vs 175 +/- 13 sec in group II. Opening of the glottis was found to be better in group II than in group I (p less than 0.01) and bucking was more frequent in group I (p less than 0.01). Successful intubation was obtained after one attempt at a similar rate in the two groups. The haemodynamic variations consisted in a significant decrease of systolic blood pressure compared to the initial value but these variations were similar in the two groups at each time (2.3 and 5 min) from induction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

[Consequences and prevention methods of hemodynamic changes during laryngoscopy and intratracheal intubation].

In patients ranked ASA 1, laryngoscopy and intubation lead to an average increase in blood pressure of 40 to 50%, and a 20% increase in heart rate. These changes, which are greatest one minute after intubation, last for 5 to 10 min. They are due to sympathetic and adrenal stimulation, which may also result in some arrhythmias. About half the patient with coronary artery disease experience episodes of myocardial ischaemia during intubation when no specific prevention is undertaken. Among the different means available for this, narcotics seem to have a reliable and constant effect, but they may be responsible for postoperative respiratory depression. The protective effect of fentanyl starts at 2 micrograms.kg-1, and is at a maximum at 8 micrograms.kg-1. Lidocaine is the drug used most. Recent studies have questioned its efficacy. In clinical practice, it is particularly effective in preventing the pressor response to tracheal intubation, whatever its route of administration (intravenous or intratracheal), but not the increase in heart rate. Beta blockers with bradycardic, antihypertensive, antiarrhythmic and antiischaemic properties, have been advocated. As opposed to lidocaine, these agents are more effective in preventing the changes in heart rate than the pressor response. Because of their depressor effect on the myocardium, their place still remains to be defined, especially in the cardiac risk patient. Short-acting beta blockers should be preferred. Nitroglycerin is specifically indicated in coronary artery disease. Other agents, such as clonidine or calcium blockers, seem to be less effective or less convenient in preventing the haemodynamic alterations. In clinical practice, prevention will first rely on a sufficient dose of narcotics. In some cases, nitroglycerin or beta blockers may be used so as to decrease the doses of narcotics, without altering their efficacy; however, the risk of hypotension should be constantly borne in mind. If preventing measures have not been taken, short-acting antihypertensive agents (beta blockers, calcium blockers) should be used in patients who develop major hypertension during laryngoscopy and intubation.

Analgesics, Opioid↗
PubMed1992

[Tracheal intubation in patients with cervical spine injuries using a fiber optic laryngoscope].

Eleven patients, with a cervical spine injury and scheduled for elective cervical spine fusion at least 48 h after their initial trauma, were intubated using a new fiberoptic laryngoscope (Bullard). This technique uses either a semi-rigid guide independent of the laryngoscope blade, or a rigid one attached to the blade. The cervical spine was immobilized with either a collar or a halo. General anaesthesia was carried out with thiopentone, fentanyl and vecuronium bromide. Orotracheal intubation was successful at the first attempts in 10 out of the 11 patients. No mobilization of the cervical spine occurred. In the first six patients, the semi-rigid guide was used, and the rigid one in the remaining five. The anaesthetist who carried out the intubations was always the same. Using the rigid guide was easier than the semi-rigid one. This is confirmed by the time required, 44 +/- 22 sec for the rigid guide, and 97 +/- 92 sec for the semi-rigid one. In the patient in whom this technique failed at the first attempt, endotracheal intubation was carried out by the nasal route and controlled by the fiberoptic laryngoscope. This technique enables a rapid and easy orotracheal intubation in trauma patients with an immobilized cervical spine, but careful training is necessary.

Adolescent↗
PubMed1994

[Proposal for a new multifactor screening score of difficult intubation in ORL and stomatognathic surgery: preliminary study].

This study assessed prospectively in 295 ENT adult patients the predictive value of clinical indicators for difficult intubation and of a new multifactorial score, established by the allocation of points (0, 3, 5 or 7) depending on the degree of presence of seven factors: pathology known to be associated with a difficult intubation, clinical signs of airways' pathology, inter-incisors gap and mandible's luxation, submental mandibular-thyroid distance, normal or short and broad neck, head and neck movements, and Mallampati's test. The incidence of difficult laryngoscopy was 14% and the use of particular techniques for tube insertion was required in 8% of patients. The presence of malformation or pathology often associated with a difficult intubation and the presence of functional signs of airways' pathology predict the difficulties of laryngoscopy and tracheal intubation with a good sensitivity and specificity. The analysis of the "Receiver Operating Characteristic curves" showed that a score higher or equal to 11 allows the prediction of difficult intubations with a sensitivity of 96% and a specificity of 90%.

Humans↗
PubMed1994

[Diprivan: intubation without curare].

To intubate under ideal conditions, i.e. with the vocal cords abducted and no motor response to the insertion of the endotracheal tube, the anaesthetist has two alternatives: to use muscle relaxants or to anaesthetize the patient deeply. Apart from cases where muscle relaxants are contra-indicated or required by the type of procedure: Intubation using muscle relaxants means: maintaining the option of varying the depth of anaesthesia, while keeping optimal conditions for intubation; reducing the risk of airways trauma. Intubation without muscle relaxants means: avoiding the risk of allergic complications; producing deep anaesthesia and controlling any resulting haemodynamic effects. The recommended induction agent is propofol, given as a bolus injection at a dose equal to or greater than 2.5 mg.kg-1 in adults and 3.5 mg.kg-1 in children. Alfentanil is the opioid of choice, the dose being between 30 and 40 micrograms.kg-1. Lidocaine, injected as premedication at a dose of 1.5 mg.kg-1 potentiates the effect of alfentanil. The order of injection of the induction agents is important, as it determines the exact moment for laryngoscopy and intubation.

Anesthesia, Intravenous↗
PubMed1991

[A rare cause of difficult intratracheal intubation: Langenbeck's disease].

A case of difficult tracheal intubation due to insufficient mouth opening once anaesthesia had been induced is described. At the pre-anaesthetic visit, the 47-year-old female patient had painless restricted mouth opening (two fingers' breadth), dental malpositions, and slight lateral mandibular deviation. Cervical spine movements were normal. She was ranked 3 on the Mallampati scale. The anaesthetic technique preserved spontaneous breathing (induction with propofol 1.5 mg.kg-1 and alfentanil 15 micrograms.kg-1). Manual ventilation was impossible. An oral cannula could not be inserted. As intubation by the normal route was impossible, the retromolar approach had to be used. Several attempts were required for successful intubation by this route. At the end of surgery, the patient was extubated without any difficulties. Postoperative investigations revealed hypertrophic coronoid processes. In this condition, the mandible is jammed by hitting the maxilla, especially when mandibular lifting manoeuvres are used to facilitate manual ventilation and tracheal intubation. Clinical and paraclinical predictors of difficult tracheal intubation seem to be unreliable in such dynamic abnormalities of mouth opening.

Female↗
PubMed1991

[Comparative value of clinical signs of difficult tracheal intubation in women].

A prospective study was designed to compare the value of clinical signs aimed to predict difficult intubation in women. A group of 663 women, scheduled for elective surgery, were assessed by an anaesthetist at the preanaesthetic visit. Following parameters were assessed: the degree of mouth opening, the chin-hyoid bone and the chin-thyroid cartilage distances, dental and facial abnormalities, age, weight. All patients were ranked on the Mallampati scale. Another anaesthetist carried out the anaesthetic induction and endotracheal intubation. The latter was deemed to have been difficult if special procedures had been required (use of a stylet, a fibroscope, or Sellick's manoeuvre). In accordance with these criteria 12.5% of women were difficult to intubate. Furthermore, he assessed the degree of glottic exposure, using a Macintosh blade and according to Cormack's classification. Six per cent of women were ranked C or D in Cormack's classification (C: the glottic aperture was not seen; D: the epiglottis was not seen). Finally 66% of women with difficult intubation and 84% of those with severely abnormal glottic exposure were ranked greater than 1 on the Mallampati scale. This scale had high sensitivity (0.84), but a specificity of only 0.66. Other clinical criteria (mouth opening, the chin-hyoid bone distance) had a lower sensitivities, but seemed more specific. Multivariate analysis showed that specificity could be improved (0.84) if the distance between the upper and lower incisor teeth (mouth opening) was associated with Mallampati's rank, without any loss in sensitivity. A simple chart is proposed to assess the risk of difficult intubation.

Adult↗
PubMed1997

[Assessment of a new light guide (Trachlight) for tracheal intubation].

OBJECTIVE: To assess the learning curve of a new lighwand device, Trachlight (Laerdal), for blind orotracheal intubation in patients without foreseen difficulty in airway management. STUDY DESIGN: Open, prospective, clinical study. USERS: Twelve persons practicing anaesthesia (specialists, trainees, nurses) underwent videotape learning and manikin training with ten successful intubation manoeuvres required with the device. METHODS: Each person had to carry out a tracheal intubation in ten consecutive patients undergoing scheduled surgery and without history or clinical sign of difficults airway management. RESULTS: One hundred and twenty patients were included. The overall success rate with the Trachlight was 87%. An easy learning curve was obtained as demonstrated by the low failure rate in the first three patients, and by the success rate on the first or second attempt in the last four patients. There was no significant difference in failure rate with or without muscle relaxation (10 vs 20%, NS). Finally, all failures with the Trachlight were followed by successful intubation using direct laryngoscopy, and no traumatic complications were recorded with the device. CONCLUSION: Trachlight is a new lightwand device enabling blind tracheal intubation with a easy learning curve in patients without difficulty in airway management, even for non-selected operators.

Adult↗
PubMedDate not supplied

Binge neonatal alcohol intubations induce dose-dependent loss of Purkinje cells.

Previous work using artificial rearing methods to administer alcohol to neonatal rats identified postnatal days (PD) 4-6 as a period of enhanced vulnerability to alcohol-induced Purkinje cell loss. To develop an alternative to artificial rearing, alcohol was administered to pups in a binge pattern of exposure using acute intubations, and dose-related effects on blood alcohol concentrations (BACs), somatic growth, and cerebellar Purkinje cell survival were assessed. Pups were intubated with alcohol in milk formula, twice a day, 2 h apart, with total daily doses of 4.5, 5.25, or 6.0 g/kg of alcohol. After intubations on PD 4, the blood alcohol concentration (BAC)-time curves systematically increased with increasing dose. Intubation of these doses on PD 4-6 produced significant, dose-dependent reductions in the total number of cerebellar Purkinje cells on PD 10, counted using the stereological optical fractionator. Somatic growth was significantly affected only by the highest dose. These dose manipulations using intubations confirmed that Purkinje cell death systematically increased as a function of BAC profiles within the PD 4-6 window of vulnerability.

Alcohol Drinking↗
PubMed2000

Rocuronium versus succinylcholine-atracurium for tracheal intubation and maintenance relaxation during propofol anesthesia.

STUDY OBJECTIVES: To compare the onset and offset time (clinical duration), and intubating conditions obtained with rocuronium bromide 0.6 mg/kg and succinylcholine 1.0 mg/kg after induction with propofol and fentanyl; and to compare rocuronium with atracurium for maintenance during propofol anesthesia. DESIGN: Prospective, open-label, parallel group comparative, randomized study. SETTING: Operating rooms of a university hospital. PATIENTS: 30 ASA physical status I and II adult patients scheduled for elective surgeries with general anesthesia. INTERVENTIONS: Patients premedicated with midazolam 2 mg were anesthetized with fentanyl 2 microg/kg followed by propofol 2.5 mg/kg and muscle relaxants. Group 1 (n = 15) received succinylcholine 1.5 mg/kg and Group 2 (n = 16) received rocuronium bromide 0.6 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxant. Patients in Group 1 received atracurium and patients in Group 2 received rocuronium for maintenance if required. MEASUREMENTS: The ease of intubation was scored using a scale of 1 to 4. Onset and offset time monitored with evoked twitch response of the adductor pollicis were recorded. MAIN RESULTS: Intubation was successful in all patients and there was no difference in scores between the two groups. Although onset time was shorter with succinylcholine than with rocuronium, neuromuscular blockade was successfully antagonized in both groups, and the recovery profile was not different between the two groups. CONCLUSIONS: Rocuronium bromide at a dose of 0.6 mg/kg, when used with propofol and fentanyl for induction, provides intubating conditions similar to succinylcholine 1.0 mg/kg at 1 minute. The actual onset time and offset time, however, are significantly longer with rocuronium. There was no difference between atracurium and rocuronium as a maintenance drug. Rocuronium is suitable for surgical procedures greater than 30 minutes, eliminating the need for an additional relaxant to succinylcholine.

Adolescent↗
PubMed2002

Airway length in adults: estimation of the optimal endotracheal tube length for orotracheal intubation.

STUDY OBJECTIVE: To estimate the optimal endotracheal tube (ETT) length in orotracheally intubated patients. DESIGN: Prospective study. SETTING: Operating room of a medical center hospital. PATIENTS: 293 ASA physical status I and II patients (150 male and 143 female), requiring general anesthesia and orotracheal intubation. INTERVENTIONS: We used fiberoptic bronchoscope within the ETT to identify the carina and vocal cords. MEASUREMENTS: The length from carina to vocal cords, vocal cords to right mouth angle (corner), and carina to right mouth angle were measured. The optimal ETT tip was defined as 5 cm above the carina. Patient's height and sternum length were recorded. MAIN RESULTS: The correlation between airway length and body height was significant. By linear regression, a formula was obtained to estimate the optimal ETT length in orotracheally intubated patients: the length from 5 cm above carina to right mouth angle (cm) =< body height (cm)/5> - 13. CONCLUSION: The optimal insertion length of the ETT for orotracheally intubated adult patients with the head placed in a neutral position is correlated with body height. The proposed formula can provide a useful guide to determine the optimal ETT tip position in most of the patients who required orotracheal intubation.

Adult↗
PubMed2002

A new video laryngoscope-an aid to intubation and teaching.

In recent decades, video techniques have been employed in the majority of endoscopic procedures because of several distinct advantages provided. These include the following: The displayed anatomy is magnified. Recognition of the anatomical structures and anomalies is easier, and manipulation of airway devices is facilitated. When assistance is required, the operator and assistant can coordinate their movements because each sees exactly the same image on the video monitor. As a result, video techniques have become the method of choice in teaching. The Video Macintosh Intubating Laryngoscope System (VMS) was designed employing a standard Macintosh blade and laryngoscope handle. A camera was incorporated into the handle with a short image and light bundle. The magnified anatomy is displayed on an 8-inch monitor, which is attached to a swivel arm on a small cart. Observation and manipulation can be performed in one axis.A total of 235 patients were studied and were divided into two groups: Group A (n = 217), in whom intubation was thought unlikely to be difficult, and Group B (n = 18), in whom difficulty with intubation was anticipated. External laryngeal manipulation (ELM) was required in 22 of the 217 Group A patients (10%). All intubations but one in this group were successful. In the second group (B) of 18 patients who had anatomical conditions that suggested that direct laryngoscopy might be challenging, all 18 cases required ELM but all were successfully intubated using the VMS. The improved coordination afforded by an image on a video monitor seen by both the assistant providing laryngeal manipulation and the anesthesiologist handling the laryngoscope results in a significant advantage over the conventional laryngoscope technique. As a consequence, the learning curve is short. In our view, video laryngoscopy will become the method of choice in teaching.

Anesthesiology↗