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PubMed2006

Difficult intubation of a child through laryngeal mask airway with two tracheal tubes.

UNLABELLED: Difficult tracheal intubation occurs infrequently. It is estimated that difficult laryngoscopy occurs in 1-2% of patients. Tracheal intubation of especially small infants can be challenging. When faced with a difficult airway, intubation through a laryngeal mask airway is one method of obtaining a secure airway. Here, we report a 23-mo-old girl with chronic lung disease and severe pneumonia, who was admitted to our paediatric intensive care unit. Since the patient could not be intubated by the standard method, because her larynx was up and forward, she was intubated successfully with a laryngeal mask airway through which two consecutive tracheal tubes were inserted. CONCLUSION: Laryngeal mask airway has an important role as a back-up device in case direct visualization of the larynx is not possible.

Female↗
PubMedDate not supplied

A breathing manikin model for teaching nasotracheal intubation to EMS professionals.

OBJECTIVE: The widespread use of orotracheal intubation with rapid-sequence induction has made it difficult for emergency medical services (EMS) professionals to gain experience in nasotracheal intubation (NTI) in a controlled and supervised setting. The purpose of this study was to determine whether a training session on NTI with a breathing manikin can be used to improve the self-assessed skill level and comfort of EMS professionals. METHODS: A prospective trial was conducted with a convenience sample of 33 EMS professionals, previously trained in NTI techniques. For the training session, a Laerdal airway manikin was modified by replacing the lungs with self-inflating resuscitation bag. The bag could then be squeezed to simulate breathing, with an inspiratory and expiratory phase. Following didactic instruction, and with direct supervision, each participant practiced NTI using this breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self-assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre- and postintervention scores were compared using the Wilcoxon signed-rank test, alpha = 0.01. RESULTS: Following the training session, the comfort level for NTI by the participants increased significantly from a median value of 2 to 7 (p = 0.001). Furthermore, the self-assessed skill level for NTI following the training session increased significantly from a median value of 4 to 8 (p = 0.0001). As expected, there were no significant differences noted in self-assessed skill level for orotracheal intubation following the training session. However, there was statistically significant improvement in self-assessed comfort levels for orotracheal intubation after the skills laboratory, p = 0.0001. CONCLUSION: For EMS professionals, a training session for NTI using a relatively inexpensive and easily assembled breathing manikin model increases both comfort and self-assessed skill level.

Clinical Competence↗
PubMedDate not supplied

The effectiveness of midazolam as a single pharmacologic agent to facilitate endotracheal intubation by paramedics.

OBJECTIVE: Endotracheal intubation (ETI) remains the "gold standard" for securing a patient's airway. In recent years, the use of pharmacologic agents to assist paramedics achieve successful intubation of problematic airways has become more common. This study was done to determine the efficacy of intravenous midazolam, a short-acting benzodiazepine, as a drug to facilitate intubation in patients resistant to conventional ETI. METHODS: This retrospective observational study reviewed the 22-month experience of a suburban municipal EMS system after midazolam was introduced as an agent to be used for systemic sedation to facilitate ETI. All calls where midazolam was used were reviewed on a monthly basis by investigators via retrospective review of the prehospital care reports. RESULTS: During the study period 13,212 emergency responses occurred, resulting in 154 ETIs by paramedics. Midazolam was used to facilitate 20 (13%) of these ETIs. "Clenched teeth" and failed conventional intubation were the most commonly cited indications for facilitated intubation. Eleven patients had medical complaints and nine were trauma patients. Successful ETI with midazolam was achieved in 17 of 20 (85%) cases. In 85% (15 of 17) of these cases, a single dose of midazolam was sufficient for ETI [mean dose 3.6 mg (SD 1.1 mg)]. The three patients with failed ETI received multiple doses of midazolam [mean dose 5.0 mg (SD 2.0 mg)]. CONCLUSION: The prehospital use of single-dose IV midazolam is generally effective in accomplishing facilitated ETI in patients resistant to conventional (nonpharmacologic) ETI.

Allied Health Personnel↗
PubMed1986

Effect of halothane on cardiovascular and plasma catecholamine responses to tracheal intubation.

The catecholamine and cardiovascular responses to intubation were investigated during halothane anaesthesia. Thirty patients were allocated randomly to two groups. Following induction of anaesthesia and muscle relaxation, group 1 was ventilated with 70% nitrous oxide in oxygen before intubation; group 2 received 1% halothane in addition. After intubation, both groups received 0.5% halothane. Arterial pressure and heart rate, and plasma noradrenaline and adrenaline concentrations were measured throughout the induction sequence. In group 1 intubation was associated with increases (from pre-induction values) in systolic arterial pressure of 13% and diastolic arterial pressure of 35%, although the plasma concentrations of noradrenaline did not alter significantly. In group 2, although there was a pressor response to intubation, no overall change in systolic arterial pressure and only a 13% increase in diastolic arterial pressure occurred when compared with pre-induction values. This response was associated with a 78% increase in the noradrenaline concentration; the adrenaline concentration did not alter significantly.

Anesthesia, Inhalation↗
PubMed1989

Hypertensive and catecholamine response to tracheal intubation in patients with pregnancy-induced hypertension.

The pressor and catecholamine responses to laryngoscopy and intubation were studied in nine patients with pregnancy-induced hypertension (PIH) and in eight normotensive controls. Five of the PIH patients had received oral labetalol as antihypertensive therapy. Mean arterial pressure (MAP) increased significantly from the pre-induction value in all groups 1 min after intubation, and also at 3 min in those with PIH who had not received labetalol. Arterial pressure was significantly greater in both PIH groups than in the control group at all times. However, the percentage increase in MAP on intubation was significantly less in the labetalol treated group than in either the untreated or the control groups. There were no significant differences between the groups in plasma concentrations of either noradrenaline or adrenaline; noradrenaline concentration increased significantly after intubation only in the control group. Labetalol appears to confer some protection against the pressor response to intubation in parturients with PIH.

Adult↗
PubMed1991

Comparison of orthodox with fibreoptic orotracheal intubation under total i.v. anaesthesia.

Fibreoptic orotracheal intubation was compared with orthodox laryngoscopy and tracheal intubation using a total i.v. technique with propofol in 60 ASA I and II patients. There was no significant difference between the two techniques in haemodynamic profile (before, during and following the intubation procedure) and incidence of postoperative sore throat. Minimal oxygen saturation was 96% during the study; maximal end-tidal PCO2 after intubation was 5.4 kPa. Intubation time was faster (P less than 0.01) in the orthodox group (30.7 (SEM 2.3) s) than in the fibreoptic group (52.7 (4.8) s).

Anesthesia, Intravenous↗
PubMed1991

Effects of adenosine triphosphate on the cardiovascular response to tracheal intubation.

Laryngoscopy and tracheal intubation often cause hypertension and tachycardia, which may be exaggerated during rapid-sequence induction of anaesthesia. The efficacy of adenosine triphosphate (ATP) in attenuating this response was studied in patients receiving ATP 0.05 mg kg-1 or 0.1 mg kg-1 simultaneously with the start of laryngoscopy. These data were compared with those for a control group receiving saline. Each group consisted of 10 patients undergoing elective surgery. Anaesthesia was induced with thiopentone 5 mg kg-1 i.v. and tracheal intubation was facilitated with vecuronium 0.2 mg kg-1 i.v. During anaesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Patients receiving saline showed a significant increase in mean arterial pressure and rate-pressure product associated with tracheal intubation. These increase after tracheal intubation were reduced in ATP-treated patients compared with those of the control group (P less than 0.05). The data suggest that a bolus injection of ATP is a simple, practical and effective method for attenuating the hypertensive response to laryngoscopy and tracheal intubation.

Adenosine Triphosphate↗
PubMed1993

Effect of diabetes mellitus on the cardiovascular responses to induction of anaesthesia and tracheal intubation.

We have compared cardiovascular responses to induction of anaesthesia and to tracheal intubation after propofol 2.5 mg kg-1 and pancuronium 0.1 mg kg-1 in 10 diabetic and 10 matched, non-diabetic (control) ASA I patients. Anaesthesia was maintained with 0.8% enflurane and 50% nitrous oxide in oxygen, with assisted ventilation. The trachea was intubated 3 min after induction of anaesthesia. All 10 diabetic patients (but no controls) had abnormal autonomic function when tested on the day before surgery. There was no difference between the two groups in the pre-induction cardiovascular state. Mean arterial pressure and vascular resistance decreased after induction in each group (P < 0.05). Heart rate increased (P < 0.01) and cardiac index was sustained in the control group, but in the diabetic group heart rate did not change and cardiac index decreased (P < 0.01). There was an earlier decrease in stroke index in the diabetic group (2 min) compared with the controls (5 min). After tracheal intubation, heart rate and cardiac index in the control group and cardiac index in the diabetic group remained unchanged. However, there was a greater increase in heart rate, mean arterial pressure and vascular resistance in the diabetic group compared with the controls after tracheal intubation (P < 0.05). The exaggerated pressor response to tracheal intubation, in the diabetic patients, may reflect autonomic dysfunction.

Adult↗
PubMed1996

Intubating conditions and time course of rocuronium-induced neuromuscular block in children.

We have investigated the potential of rocuronium 0.6 mg kg-1 (2xED95) and 0.9 mg kg-1 (3xED95) for rapid sequence induction in 100 children, aged 3-7 yr. Intubating conditions with the two different doses of rocuronium were assessed in 70 children (n = 35 in each group) undergoing elective surgery. Intubation was carried out by mimicking rapid sequence induction, and intubation conditions were evaluated according to a standard score. Intubating conditions were good to excellent in all 70 patients investigated (2xED95: excellent 29, good 6; 3xED95: excellent 33, good 2). In another 30 children (n = 15 in each group), we examined the times of rocuronium-induced neuromuscular block using electromyography. Lag time and recovery index did not differ significantly between the two groups (lag time: 37 (SD 12) vs 33 (14) s; recovery index: 9 (3) vs 10 (4) min). Three times the ED95 induced deeper neuromuscular block, 1 min after injection compared with 2xED95 (twitch height: 42 (24) vs 25 (19)%, respectively; P < 0.05). The same was true for onset time (193 (47) vs 118 (23) s; P < 0.01), clinical duration (21 (4) vs 34 (11) min; P < 0.01) and duration to 75% recovery (30 (6) vs 44 (4) min; P < 0.01). By mimicking rapid sequence induction, both doses of rocuronium offered clinically acceptable (good or excellent) intubating conditions.

Androstanols↗
PubMed1996

Influence of induction technique on intubating conditions after rocuronium in adults: comparison with rapid-sequence induction using thiopentone and suxamethonium.

We have assessed the effect of anaesthetic technique on intubating conditions after rocuronium 0.6 mg kg-1 in four groups (n = 25 each) of unpremedicated patients in whom anaesthesia was induced with either thiopentone 5 mg kg-1 or propofol 2.5 mg kg-1 alone, or supplemented with alfentanil 20 micrograms kg-1. Fifty control patients were anaesthetized with thiopentone followed by suxamethonium. Laryngoscopy was commenced at 45 s. Overall intubating conditions after rocuronium were similar to those after suxamethonium (good and excellent > or = 96%) only when alfentanil was part of the induction regimen. However, intubation time was similar in all five groups and averaged 55 (SD 3.2) s, and the tube could be passed through open vocal cords within 70 s. After rocuronium the response of the diaphragm to intubation was more pronounced in the two groups of patients not receiving alfentanil (P < 0.0001) and in patients anaesthetized using propofol with alfentanil (P < 0.01) than in the control group. Opioids (in doses equivalent to alfentanil 20 micrograms kg-1) constitute an integral part of an induction regimen containing rocuronium 0.6 mg kg-1, regardless of whether or not thiopentone or propofol is used, in order to achieve overall intubating conditions similar to those after suxamethonium.

Adolescent↗
PubMed1996

Comparative effects of thiopentone and propofol on respiratory resistance after tracheal intubation.

To compare the effects of propofol and thiopentone on tracheal intubation-induced bronchoconstriction, 37 patients were allocated randomly to anaesthesia with either thiopentone 4 mg kg-1 followed by a 15-mg kg-1 h-1 continuous infusion or propofol 3 mg kg-1 followed by a 9-mg kg-1 h-1 continuous infusion. Intubation was facilitated by vecuronium 0.1-0.2 mg kg-1. Respiratory system resistance (Rrs) was measured by a CP-100 pulmonary function monitor, 5 min after intubation. The 5-min post-intubation Rrs values were significantly lower in the propofol group (8.5 (SD 1.5) cm H2O litre-1 S-1) than in the thiopentone group (10.9 (3.2) cm H2O litre-1 S-1). Thirty minutes after commencing isoflurane-nitrous oxide anaesthesia, Rrs declined by 17.5 (SEM 3.6)% from baseline in the thiopentone group, but by only 1.6 (2.6)% in the propofol group. We conclude that the dose of propofol administered provided more protection against tracheal intubation-induced bronchoconstriction than an induction dose of thiopentone.

Adult↗
PubMed1997

Comparison of suxamethonium and different combinations of rocuronium and mivacurium for rapid tracheal intubation in children.

The use of suxamethonium in children is associated with undesirable side effects. The synergistic effect of a rocuronium-mivacurium combination can be considered as an acceptable alternative to suxamethonium in clinical practice. The calculated ED50 of the rocuronium-mivacurium mixture was only 62% of the predicted value assuming a purely additive interaction. The use of this combination has not been evaluated in children. In this two-part study, we assessed the intubating conditions and pharmacodynamics of suxamethonium, rocuronium, mivacurium or a rocuronium-mivacurium combinations in children. We studied 120 ASA I children of both sexes, aged 3-10 yr. Children were premedicated with trimeprazine 2 mg kg-1 orally, and received fentanyl 2 micrograms kg-1 and propofol 2 mg kg-1 for induction of anaesthesia. They were allocated randomly to receive one of the following drugs or drug combinations: suxamethonium 1.0 mg kg-1, mivacurium 0.2 mg kg-1, rocuronium 0.6 or 0.9 mg kg-1, mivacurium 0.1 mg kg-1 with rocuronium 0.3 mg kg-1 or mivacurium 0.15 mg kg-1 with rocuronium 0.45 mg kg-1. In part 1, 60 s after administration of the neuromuscular blocking drug or drug combination, tracheal intubation was performed in 60 children by mimicking rapid sequence induction, and intubating conditions were evaluated by a blinded investigator according to a standard score. In part 2, neuromuscular monitoring was established before administration of neuromuscular blocking agent(s) and the time from injection of drug or drug combination until complete ablation of T1 (onset) and recovery of T1 to 25% (duration) were recorded in another 60 children. The frequency of distribution of excellent or good intubating conditions in the higher dose of rocuronium and the combination groups were similar to those in the suxamethonium group, but significantly different (P < 0.05) from those in the mivacurium group. Mean onset time was faster in the suxamethonium (55.1 (SD 11.4) s), rocuronium 0.9 mg kg-1 (70.5 (37.7) s), mivacurium 0.1 mg kg-1 with rocuronium 0.3 mg kg-1 (67 (35.9) s) and mivacurium 0.15 mg kg-1 with rocuronium 0.45 mg kg-1 (55 (26.7) s) groups compared with the mivacurium 0.2 mg kg-1 (116 (26.8) s) and rocuronium 0.6 mg kg-1 (97.9 (29) s) groups. This study demonstrated that the combination of rocuronium 0.45 mg kg-1 and mivacurium 0.15 mg kg-1 could possibly be considered as an acceptable alternative to suxamethonium when rapid sequence induction of anaesthesia is indicated in children because it provides uniform excellent intubating conditions and complete neuromuscular block in < 60 s.

Androstanols↗
PubMed1998

Laryngoscopy and fibreoptic intubation in acromegalic patients.

Acromegaly is recognized as a cause of difficulty in airway management and tracheal intubation. We evaluated prospectively the conditions for laryngoscopy and fibreoptic intubation in 15 acromegalic patients. Each patient served as his or her own control. Ventilation of the lungs with a face mask was successful in all patients. In five of 15 patients the vocal cords could not be seen using the Macintosh laryngoscope with a size 5 blade. Difficult laryngoscopy was associated significantly with the number of attempts required to see the vocal cords with the fibrescope (P < 0.01, Spearman rank correlation). The larynx could not be seen with both techniques in one patient, and the trachea was intubated blindly with the help of an introducer. Our results showed that fibreoptic intubation may prove difficult or fail in acromegalic patients. Difficulties in seeing the vocal cords with a fibrescope were present most often in patients who also had probable intubation difficulties with a rigid laryngoscope.

Acromegaly↗
PubMed1998

Sevoflurane compared with halothane for tracheal intubation in children.

We have studied 40 healthy children, aged 3-10 yr, undergoing adenotonsillectomy, in a double-blind, randomized study. Intubating conditions were assessed when the pupils had become small and central after inhalation induction with either 5% halothane and 60% nitrous oxide in oxygen or 8% sevoflurane and 60% nitrous oxide in oxygen. The quality of tracheal intubation was graded according to ease of laryngoscopy, position of the vocal cords, coughing, jaw relaxation and movement of limbs. Fewer children had significant vocal cord movement on laryngoscopy (P < 0.01) and more had ideal intubating conditions when halothane was used (12 of 20 compared with seven of 20; ns). Time to reach the clinical end-point for intubation was reached sooner with halothane (P = 0.015). In all children the trachea was intubated successfully at the first attempt and all remained haemodynamically stable throughout induction.

Adenoidectomy↗
PubMed1998

Assessment of intubating conditions in adults after induction with propofol and varying doses of remifentanil.

We have assessed intubating conditions in three groups of 60 ASA I or II patients after induction of anaesthesia with propofol 2 mg kg-1 and remifentanil 0.5, 1.0 or 2.0 micrograms kg-1. Tracheal intubation was graded according to ease of laryn-goscopy, position of the vocal cords, coughing, jaw relaxation and movement of the limbs. Intubation was successful in 80%, 90% and 100% of patients after remifentanil 0.5, 1.0 or 2.0 micrograms kg-1, respectively. Overall intubating conditions were regarded as acceptable in 20%, 50% and 80% of patients, respectively. All three groups had a decrease in arterial pressure after induction but there was no difference between groups. The decrease in arterial pressure was not regarded as clinically significant. Intubating conditions were best after induction with remifentanil 2 micrograms kg and propofol 2 mg kg-1.

Adult↗
PubMed1998

The intubating laryngeal mask airway (ILMA): initial experience in Singapore.

We have evaluated the intubating laryngeal mask airway (ILMA) for ventilation and for blind tracheal intubation. After induction of anaesthesia with fentanyl 1 microgram kg-1 and propofol 3 ml kg-1, the ILMA was placed successfully on the first attempt in all 100 patients. After administration of atracurium 0.5 mg kg-1, blind tracheal intubation was successful in 97% of patients--50% on the first attempt, 42% on the second and 5% on the third. Success was improved by pulling the metal handle of the ILMA towards the intubator in an "extension" manoeuvre, if intubation was not possible on the first attempt. These findings confirm the effectiveness of the ILMA in an Asian population.

Asian People↗
PubMed1999

Neuropeptide Y response to tracheal intubation in anaesthetized children: effects of clonidine vs midazolam as premedication.

We have determined if tracheal intubation causes an increase in neuropeptide Y (NPY), a marker of major adrenergic activation, and investigated if rectal premedication with clonidine 2.5 micrograms kg-1 might be capable of attenuating the stress response to tracheal intubation compared with midazolam 300 micrograms kg-1, in 20 paediatric patients (1-9 yr). Prospective randomization was performed in a double-blind manner. After induction of anaesthesia with 1% isoflurane, tracheal intubation was performed, and norepinephrine, NPY concentrations and haemodynamic variables were recorded. Tracheal intubation did not increase NPY plasma concentrations, despite transient increases in norepinephrine concentrations, heart rate and arterial pressure. There was no significant difference between the two groups. We conclude that the adrenergic stress reaction in response to tracheal intubation in children was short-lived and of limited magnitude, as indicated by the lack of NPY release.

Adrenergic alpha-Agonists↗
PubMed1999

Sevoflurane requirements for tracheal intubation with and without fentanyl.

We studied 80 healthy ASA 1 patients (aged 20-52 yr) to determine if fentanyl affects sevoflurane requirements for achieving 50% probability of no movement in response to laryngoscopy and tracheal intubation (MAC-TI). Patients were allocated randomly to one of four fentanyl dose groups (0, 1, 2 and 4 micrograms kg-1). Patients in each group received sevoflurane at a pre-selected end-tidal concentration according to an 'up-down' technique. After steady state sevoflurane concentration had been maintained for at least 10 min, fentanyl was administered i.v. Tracheal intubation was performed 4 min after administration of fentanyl, and patients were assessed as moving or not moving. Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction of anaesthesia, just before administration of fentanyl, just before laryngoscopy for intubation, and after intubation. The MAC-TI of sevoflurane was 3.55% (95% confidence intervals 3.32-3.78%), and this was reduced markedly to 2.07%, 1.45% and 1.37% by addition of fentanyl 1, 2 and 4 micrograms kg-1, with no significant difference in the reduction between 2 and 4 micrograms kg-1, showing a ceiling effect. Fentanyl attenuated haemodynamic responses (HR and MAP) to tracheal intubation in a dose-dependent manner, even with decreasing concomitant sevoflurane concentration. Fentanyl 4 micrograms kg-1 suppressed the changes in HR and MAP more effectively than fentanyl 1 or 2 micrograms kg-1 at sevoflurane concentrations close to MAC-TI.

Adult↗