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PubMed1996

Use of the Univent System tube for difficult intubation and for achieving one-lung anaesthesia.

BACKGROUND: One-lung ventilation in major thoracic surgery is the most commonly accepted technique, not only for surgery on the lung but also in procedures involving the oesophagus, mediastinum and thoracic aorta. Conventional double-lumen tubes may sometimes be difficult to place correctly in patients in whom intubation is difficult. In such cases, the Univent System tube may be of help. It has a curved movable blocker of small calibre, and is designed to slide inside the bronchial tree and occlude all or part of the target lung. CASE REPORT: We describe a new application of the Univent System tube in three cases where intubation was presumed to be difficult, and in another with unexpected difficult intubation. The laryngeal approach was carried out with the distally displaced blocker, inserting it through the sub-epiglottis or the posterior commissure visible orifice. The tube was firmly held and slid through the length of the blocker, rotating slowly until fully introduced. The advantages and criteria for its use are discussed. CONCLUSION: Although the double-lumen tube is the first choice for one-lung ventilation, the Univent tube is a good option for selective bronchial intubation and in patients in whom difficult intubation is predicted.

Adult↗

PubMed1998

1 MAC-incision sevoflurane prevents explicit awareness during surgical skin incision and tracheal intubation.

BACKGROUND: This study tested the hypothesis that 1 MAC-incision anesthesia secures unconsciousness during surgical skin incision and tracheal intubation. METHODS: Twenty patients scheduled for gynecological laparotomy were anesthetized with sevoflurane as the sole agent. At 1 MAC-incision steady-state conditions, the patients were observed for autonomic/movement responses and wakefulness (response to verbal commands) in the 1-min period following surgical skin incision and tracheal intubation. RESULTS: Blood pressure and heart rate increased significantly secondary to both stimuli, and significantly more after tracheal intubation than skin incision. Ten and 19 patients moved in response to skin incision and tracheal intubation, respectively. None of the patients showed wakefulness. CONCLUSION: It is concluded that 1MAC-incision sevoflurane secures unconsciousness during surgical skin incision and tracheal intubation.

Adult↗

PubMed1987

Endotracheal intubation following thyroidectomy.

Thirty-five patients requiring tracheostomy or endotracheal intubation, following thyroidectomy are reviewed. Conditions included 30 patients with multinodular goitre, three patients with Graves's disease and two patients with carcinoma of the thyroid. Early in the series, emergency tracheostomy was performed in three patients with airway obstruction following thyroidectomy. Ten patients were deemed at extremely high risk of developing airway obstruction and underwent prophylactic tracheostomy. Endotracheal intubation has been used in preference to tracheostomy in the latter part of the series. Emergency endoctracheal intubation was performed on one patient and prophylactic intubation was carried out in 20 patients. The morbidity and length of hospital stay in this latter group was considerably less than those requiring tracheostomy. It is concluded that patients with potential airway obstruction following thyroidectomy should have prophylactic endotracheal intubation, in preference to tracheostomy.

Adolescent↗

PubMed2005

Use of low-dose rocuronium for intubation of children during volunteer surgery abroad.

BACKGROUND: Low-dose rocuronium (ROC) might improve safety during volunteer surgery abroad (VSA) by facilitating intubation with a lower halothane concentration than is typically used. We hypothesized that 0.25 mg.kg(-1) of ROC would improve intubation conditions during 3% halothane induction and still allow for rapid return to spontaneous ventilation (SV). METHODS: During Operation Smile's 2002 mission to Honduras, patients aged 3 months-11 years were randomized to receive ROC 0.25 mg.kg(-1) (n = 19), or placebo (n = 23). Induction was with 3% halothane in 100% O(2), with ventilation assisted and controlled when possible, and normocarbia maintained. An i.v. was placed after induction, and ROC or placebo given. Direct laryngoscopy (DL) was performed 3 min later by a blinded laryngoscopist who assessed conditions according to predetermined criteria. RESULTS: Adequate intubation conditions occurred in 89 and 87% of patients (P = 0.59), and mean times from DL until the return to SV were 9.8 and 4.3 min (P = 0.003), in the ROC and placebo groups, respectively. For the placebo group, the presence of SV at DL was predictive of inadequate intubation conditions (P = 0.006). CONCLUSIONS: When administering 3% halothane for induction of VSA patients, a high frequency of adequate intubation conditions can be achieved without a relaxant, rendering the known benefits of 0.25 mg.kg(-1) of ROC unapparent. ROC 0.25 mg.kg(-1) does allow rapid return to SV.

Age Factors↗

PubMed1992

Can ambulance personnel intubate?

To assess the performance of intubation skills by advanced trained ambulance personnel, a prospective study was carried out of the intubation of cardiac arrest victims by ambulance personnel in the field. Twenty-eight ambulance personnel attempted the intubation of 87 patients over 2 years. Eighty-five patients were initially successfully intubated, one endotracheal tube became displaced and cuff leakage occurred on three occasions. This was treated appropriately in each instance. Ambulance personnel can perform the skills of intubation successfully in out-of-hospital cardiac arrest victims.

Ambulances↗

PubMed2000

Premedication before intubation in UK neonatal units.

AIMS: To establish the extent and type of premedication used before intubation in neonatal units in the United Kingdom. METHODS: A structured telephone survey was conducted of 241 eligible units. Units were subdivided into those that routinely intubated and ventilated babies (routine group) and those that transferred intubated and ventilated babies (transfer group). RESULTS: Of the units contacted, 239 (99%) participated. Only 88/239 (37%) gave any sedation before intubating on the unit and only 34/239 (14%) had a written policy covering this. Morphine was used most commonly (66%), with other opioids and benzodiazepines used less frequently. Of the 88 units using sedation, 19 (22%) also used paralysis. Suxamethonium was given by 10/19 (53%) but only half of these combined it with atropine. Drug doses varied by factors of up to 200, even for commonly used drugs. CONCLUSION: Most UK neonatal units do not sedate babies before intubating, despite evidence of physiological and practical benefits. Only a minority have written guidelines, which prohibits auditing of practice.

Anti-Anxiety Agents↗

PubMed2002

Bilateral vocal cord dysfunction complicating short-term intubation and the utility of heliox.

Bilateral vocal cord paralysis is an extremely rare complication of short-term endotracheal intubation. Its etiology following intubation is likely due to recurrent laryngeal nerve injury on intubation. The anterior ramus of the recurrent laryngeal nerve is especially susceptible to pressure injury in intubated patients. Heliox is reported as a successful means of decreasing the work of breathing in upper airway obstruction via decreases in airway resistance. Two cases of bilateral vocal cord dysfunction following short-term intubation are reported. The first case of bilateral vocal cord paresis treated with Heliox is described.

Aged↗

PubMed1987

Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients.

The clinical distinction between bacterial colonization of the tracheobronchial tree and nosocomial pneumonia is difficult, especially in intubated patients. We studied 51 intubated, intensive care unit patients prospectively by serial examinations of tracheal aspirates for elastin fibers, graded Gram's stains, and quantitative bacterial cultures in conjunction with clinical and radiologic observations in an attempt to develop criteria for the early detection of pulmonary infection. Patients with infection had new or progressive pulmonary infiltrates plus 1 of the following: positive blood culture results, radiographic evidence of cavitation, or histologic evidence of pneumonia, or 2 or more of the following: new fever, new leukocytosis, or grossly purulent tracheal aspirates. Twenty-one patients developed infection, 22 remained colonized, and 8 had an uncertain status. Infiltrates developed in 34 patients (21 infected, 8 colonized, 5 uncertain status). Gram-negative bacilli were most commonly isolated and were more frequent in infected patients (81 versus 47%, p less than 0.05); Pseudomonas aeruginosa and Serratia marcescens were most often associated with infection. No differences were observed between infected and colonized patients in demographic features, smoking history, underlying disease, previous antibiotic therapy, days in hospital before intubation, preexisting pneumonia upon intubation, or highest temperature or leukocyte count during course. By univariate analysis, infected patients had a longer duration of intubation (p less than 0.05), higher Gram's stain grading for neutrophils (p less than 0.05) or bacteria (p less than 0.005), higher bacterial colony counts (p less than 0.05), and more frequent detection of elastin fibers in tracheal aspirates (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2003

Multiple single-breath measurements of nitric oxide in the intubated patient.

Multiple flow rate measurements of exhaled nitric oxide (NO) have been advocated to fractionate NO from alveolar and bronchial sources. The aim of this study was to develop a method by which multiple single-breath exhalations at various flow rates could be performed in intubated, mechanically ventilated patients. Nine patients without lung disease were studied awake and after intubation, during general anesthesia. A suction ejection system connected to a restrictor valve was used to control the exhalation flow rate. From these measurements the fraction of alveolar NO (FANO), the fraction of airway wall NO (FawNO), and the airway wall transfer rate (DNO) were calculated. The fraction of exhaled NO was reduced by 50% after intubation. DNO was also reduced by intubation (from 10 +/- 1.3 to 6.4 +/- 2.1 nl second(-1) ppb(-1) x 10(-3)) whereas neither FawNO nor FANO was affected. The peak NO concentration after 20 seconds of apnea during general anesthesia was similar to calculated FawNO. The vacuum aspiration method used in this study allowed for reproducible multiple single-breath measurements and calculation of alveolar and bronchial NO parameters. Further studies will reveal whether this methodology will improve the value of exhaled NO analysis in intubated, mechanically ventilated patients with pulmonary disease.

Adult↗

PubMedDate not supplied

Prolonged orotracheal intubation in the newborn.

One hundred seventy-four consecutive cases of newborn infants who required orotracheal intubation for longer than three days were studied retrospectively. The duration of intubation varied from 3 to 211 days with an overall mortality rate of 22.9%. There was one complication directly related to orotracheal intubation. One tracheotomy was performed. Orotracheal intubation is felt to be superior to nasal tracheal intubation and tracheotomy in managing infants in this age group who require prolonged assisted ventilation.

Humans↗

PubMedDate not supplied

Do weighted nasoenteric feeding tubes facilitate duodenal intubations?

A widely held assumption is that postpyloric intubations occur more often with weighted than with unweighted nasally inserted feeding tubes. This randomized, prospective study compared the frequency of duodenal intubations using weighted and unweighted nasoenteric feeding tubes. One hundred sixteen patients had either weighted (61 patients) or unweighted (55 patients) 10F silicone elastomer feeding tubes inserted nasally 85 cm. Tubes were placed with wire stylets. Tube positions were verified radiographically within 4 hr after insertions. Radiographs were repeated daily for 3 days or until duodenal intubation occurred. Successful duodenal intubations were achieved in 35 patients (57%) with weighted feeding tubes and in 37 patients (67%) with unweighted feeding tubes. This difference was not significant. Weighted nasoenteric feeding tubes offer no advantage over unweighted tubes in achieving duodenal intubations.

Adolescent↗

PubMed2007

Pre-emptive swallowing stimulation in long-term intubated patients.

OBJECTIVE: To evaluate the effect of pre-emptive swallowing stimulation on the recovery of swallowing function in long-term intubated patients. DESIGN AND SUBJECTS: Patients in the intensive care unit intubated for at least 48 hours due to respiratory distress from March to August 2004 were randomly divided into two groups. Fifteen patients of mean age 55.39+/-17.9 years were stimulated (experimental group) and 18 patients of mean age 61.39+/-13.5 years were not stimulated (control group). The duration of intubation was 15.59+/-6.7 days in the experimental group and 15.79+/-6.5 days in the control group. Duration of stimulation in the experimental group was 7.39+/-3.6 days. After extubation, we compared the severity of dysphagia via video-fluoroscopic swallow study. RESULTS: There were no statistically significant differences in the percentage of aspiration and the swallowed volume between the two groups. However, oral transit time in the experimental group (0.379+/-0.07 seconds) was significantly shorter than that of the control group (0.839+/-0.10 seconds), and the oropharyngeal swallowing efficiency of the experimental group (73.39+/-17.4%/s) was significantly higher than that of the control group (50.19+/-13.0%/s). CONCLUSION: Pre-emptive swallowing stimulation during intubation assists in the recovery of swallowing function in long-term intubated patients.

Adult↗

PubMed2000

Use of a fibreoptic stylet to visually evaluate tracheal intubation technique.

To compare the tracheal intubation by novices with that of instructors, we videotaped the view obtained through a fibreoptic stylet during standard tracheal intubations with a Macintosh direct laryngoscope. The duration of visualization of the vocal cords was longer during intubation by instructors than during trainee attempts. The tracheal tube contact (with pharyngeal wall) time duration was higher during intubation attempts by trainees than instructors. The quality of the image of the vocal cords through the stylet was related to these video-view parameters. Our results demonstrated that visualization of the vocal cords by direct laryngoscope and manipulation of the tracheal tube in the oral cavity were different between anaesthesia trainees and instructors, and suggested that visually monitoring the tracheal intubation procedure through a fibreoptic stylet might be useful for the education of anaesthesia trainees.

Anesthesiology↗

PubMed2002

Effect of age on haemodynamic response to tracheal intubation. A comparison of young, middle-aged and elderly patients.

The effect of age on the haemodynamic response to tracheal intubation was studied. Ninety ASA 1 or 2 patients were divided into three groups of 30 each based on age; ie., young (18-25 years), middle-aged (40-50 years) and elderly (65-80 years). The haemodynamic response after tracheal intubation was observed as percentage change in heart rate and blood pressure compared to the baseline. Inter-group comparison was also done at different time points. The greatest percentage change in the systolic arterial pressure after tracheal tube insertion was seen in the elderly group (15%). The increase in systolic arterial pressure was significantly less in theyounggroup compared with the two older groups at one, two, three and four minutes post-intubation. The greatest percentage increase in the diastolic blood pressure compared to the baseline was seen in the middle aged group (24%). The elderly and young patients showed a significant difference in the diastolic blood pressure response only at one minute post-intubation. The heart rate response was greatest in the middle-aged patients (40%) and least in the elderly (16%). These differences may have clinical significance and should be considered in assessing and performing research into the haemodynamic response to intubation.

Adult↗

PubMed1988

Criteria for estimating likelihood of difficulty of endotracheal intubation with the Macintosh laryngoscope.

Many anatomical factors in difficult intubation at direct laryngoscopy have been evaluated. Lateral radiographs were taken of nineteen patients in whom tracheal intubation proved particularly difficult, and fourteen patients whose intubation was reasonably straightforward. Stepwise discriminant analysis was used to select the best measurements for distinguishing between the difficult and straightforward groups. The variables which together are most reliable in predicting likely difficulty in intubation are reduced atlanto-occipital extension, reduced mandibular space, and lastly, increased antero-posterior thickness of the tongue. A formula and graph have been derived to relate these variables with likelihood of difficulty, and a method has been described of applying this information at the bedside, without using X-ray examination, to estimate the likelihood of difficulty in intubating a new patient. Eighteen months' experience of the application of this clinical evaluation have so far found it reliable.

Adolescent↗

PubMed1991

The effect of the depth of neuromuscular blockade on the haemodynamic response to tracheal intubation.

The effect of two different doses of vecuronium on the heart rate and mean arterial pressure response to tracheal intubation was compared in 32 adult ASA class I patients. It was found that the higher dose of vecuronium (2.5 X ED95) produced greater depression of the evoked electromyogram (P less than 0.01), and provided better intubating conditions (P less than 0.01) than the lower dose of vecuronium (1 X ED95). However, the heart rate and the mean arterial pressure response to tracheal intubation was similar with both doses. The results indicate that, within the range of neuromuscular blockade commonly used to facilitate tracheal intubation, the depth of neuromuscular blockade per se does not affect the haemodynamic response to intubation.

Adult↗

PubMed1997

Predicting difficult intubation--a comprehensive scoring system.

A study was conducted in an attempt to devise a simple and more accurate method of predicting difficult intubation. Prospective assessments were made in 282 patients and retrospective assessment in 16 patients with regard to 21 anatomical factors which were correlated with the laryngoscopic view at intubation. Twelve factors correlated significantly with difficult intubation. Four of these were eliminated after multifactorial analysis. A scoring system was devised, assigning points to each variable based on its discriminative value. A score of 6 or more correctly identified 22 out of the 23 difficult intubations and there were 50 false positives (sensitivity, specificity and PPV of 96%, 82% and 31% respectively). When negative scoring was done for factors favouring easy intubation, false positives were reduced to 36, but only 20 difficult cases could be identified correctly.

Adult↗

PubMed1999

Ventilated patients' self-esteem during intubation and after extubation.

The primary purpose of this study was to determine if there was a difference in patients' self-esteem during intubation and after extubation, when differences in acuity were controlled. A secondary purpose was to examine and compare the self-esteem of subjects intubated for medical or surgical reasons. A descriptive longitudinal design compared the self-esteem of 29 subjects during intubation and after extubation. A repeated measures analysis of covariance found self-esteem to be significantly higher after extubation in subjects as a whole, when acuity at extubation was controlled. A repeated measures multivariate analysis of variance revealed a significant interaction effect for reason of intubation. Only medical patients experienced an increase in self-esteem over time. Their self-esteem was also lower when they were intubated. The findings support the dynamic nature of self-esteem in hospitalized patients. The implications of the study for research and practice are discussed.

Adolescent↗