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PubMed1993

The cardiovascular and intracranial effects of laryngoscopy and endotracheal intubation in hypercarbic neonatal piglets.

Laryngoscopy and endotracheal intubation is a potent sympathetic stimulus in adults. Neonates are frequently intubated, but few data exist on the cerebral effects of this intervention. The cardiovascular and intracranial effects of laryngoscopy and endotracheal intubation were studied in 17 hypercarbic neonatal piglets. The mean arterial pressure in the study group (11 piglets) increased significantly within 2 minutes of the stimulus, and remained elevated for almost 14 minutes. The intubated animals showed significantly more haemorrhage in the basal area of the brain than the 6 control animals. The distribution suggests bleeding in the choroid plexus of the 4th ventricle. The significance of such bleeds is not immediately apparent, since none of the animals was grossly neurologically affected by the intervention. However, subtle long-term neurological deficits cannot be excluded and this aspect requires further study. Laryngoscopy and endotracheal intubation may cause non-lethal haemorrhage in the choroid plexus and central canal of the hindbrain in hypercarbic, neonatal piglets.

Animals↗
PubMed1995

Onset time and evaluation of intubating conditions: rocuronium in perspective.

The customary methods for assessment of intubating conditions, namely the onset time in the adductor pollicis muscle and qualitative rating scales of the conditions at intubation, are unsatisfactory. The onset time of neuromuscular block in the adductor pollicis is not a meaningful, quantifiable endpoint, defining optimal intubating conditions. Consequently, its meticulous recording in all studies is probably obsolete. Qualitative rating scales are very subjective and a single standardized qualitative rating scale for the assessment of intubating conditions is required in order to improve the comparability of data from various studies. Clinical studies simulating rapid sequence induction in elective patients indicate that rocuronium 0.9 mg kg-1 may be suitable for crash intubation. This, however, needs to be confirmed in emergency cases.

Androstanols↗
PubMed1995

Time-course of action and intubating conditions with rocuronium bromide under propofol-alfentanil anaesthesia.

Thirty ASA I and II patients received either an intubating dose of 0.6 mg kg-1 rocuronium (2 x ED95, group 1) or 0.06 mg kg-1 as a priming dose followed by an intubating dose of 0.24 mg kg-1 rocuronium (group 2) 4 min later. Anaesthesia was induced with propofol (2.0 mg kg-1) and alfentanil (0.02 mg kg-1) and maintained with nitrous oxide/oxygen and propofol (6.0 mg kg-1 h-1). Neuromuscular function was monitored mechanomyographically and electromyographically with train-of-four (TOF) stimulation at the wrist every 10 s. The following parameters were measured and compared between the two groups: time to 90% block (intubation time), time to maximum block (onset time), and the times for T1 (25%, 75% and 90%) and TOF > 70%. In group 1 the intubation time was significantly shorter (40 +/- 10 s) than in group 2 (51 +/- 11 s). Intubating conditions were good or excellent in both groups. The clinical duration of action was 28 +/- 8 min in group 1 and 15 +/- 3 min in group 2, respectively. Mechanomyography showed a significantly faster development of neuromuscular block than electromyography. The comparison of mechanomyographically and electromyographically measured recovery times did not show any differences. In 60% of the patients a priming dose of 0.06 mg kg-1 was followed by a considerable decrease in neuromuscular function.

Adult↗
PubMed1995

[Intubation in reconstructive surgery of posterior urethral strictures].

The authors operated in recent years (1989-1993) three patients with iatrogenic strictures of the posterior urethra which developed after transvesical prostatectomy. In one instance a stricture was involved which was difficult to intubate and in two instances a stricture impossible to intubate which was treated temporarily by epicystostomy. With regard to the site of the stricture which affected partly the prostatic and membranous urethra the authors selected the method of intubation plastic surgery in the modification of Michalowski-Modelski, nowadays rarely mentioned in the literature. During a period of one to two years after operation the patients were able to urinate without difficulties, the urethra was patent for intubation, in one patient mild stress incontinence persists. The authors consider intubation plastic surgery, making use of the intact urethra as a suitable alternative method of treatment of short strictures in the prostatic and membranous part of the urethra. It is a relatively simple one-stage operation with satisfactory functional results.

Aged↗
PubMed1995

Clinical characteristics of adult asthmatics requiring intubation.

Fifty eight admissions for 52 adult asthmatics who required intubation were reviewed for the years of 1988-1995 to examine factors related to specific clinical patterns and profile the course of these patients. Of the 56 admissions where patients were intubated for respiratory failure and/or cyanosis, 5 were associated with significant complications of mechanical ventilation/intubation (pneumothorax, subcutaneous emphysema, aspiration pneumonia, and laryngeal edema) and there were no fatalities. Patients > or = 35 years of age had significantly more profound respiratory acidosis in initial arterial blood gases (pH = 7.14 versus 7.23, p = 0.03). In contrast, patients with a history of drug abuse or psychiatric disorders had lower mean pCO2 (p < = 0.01). The overall mean length of intubation was 17.6 hours, while the overall mean hospital stay was 6.6 days. Longer intubation times were associated with the occurrence of major complications, female gender, and hospital administration of ipratropium. Hospital stay was correlated with length of intubation, later month of admission, and earlier year of admission. Common precipitating factors noted for first admissions were upper respiratory infections (61%), followed by allergy or smoke exposure (13%), compliance related problems (12%), and drug abuse/inhalation (6%). Inhaled anti-inflammatory drugs, oral steroids or either were taken at the time of admission by 35%, 35% and 65% of the patients, respectively. There was an even distribution of patients with respect to medical insurance coverage type, admissions per season or year, ethnicity, marital status, and gender. We conclude that severe asthma resulting in respiratory failure is common despite the frequent use of anti-inflammatory asthma medications. Mechanical ventilatory support can be administered safely in the majority of these patients and should be considered early in acute asthma.

Adult↗
PubMed1996

[A patient with Cornelia de Lange syndrome with difficulty in orotracheal intubation].

We experienced a difficult orotracheal intubation in a patient with Cornelia de Lange syndrome. The patient was an eight-year-old girl with Cornelia de Lange syndrome, cleft palate and tetralogy of Fallot who underwent emergency hemicolectomy for strangulation ileus. Orotracheal intubation using a Macintosh laryngoscope was unsuccessful. However, intubation using an endotracheal tube through the laryngeal mask airway with a fiberoptic bronchoscope was successful. The patient's condition was stable during both intubation and operation. In conclusion, we must be careful on endotracheal intubation of patients with congenital anomalies.

Anesthesia, General↗
PubMedDate not supplied

Fibreoptic assessment of post intubation laryngotracheal injuries.

The use of endotracheal intubation for respiratory support of critically ill patients has become a standard life saving form of therapy. Most complications of intubation become apparent only after extubation which may manifest in the early or late post extubation period. This study was undertaken to demonstrate the occurrence and extent of laryngotracheal injuries in intubated patients by performing flexible fibreoptic bronchoscopy at varying intervals following extubation. It was found that initial laryngoscopy findings were more pronounced in patients intubated for upto twelve days. Furthermore, it was also observed that the initial laryngeal pathology seen on fibreoptic laryngoscopy was not an accurate predictor for the development of adverse post extubation sequelae. Maxillary sinusitis developed significantly in patients intubated nasally. Routine flexible fibreoptic examination of the larynx following extubation is recommended for early detection of granulomas, synechia of vocal cords and vocal cord immobility to prevent troublesome sequelae.

Adult↗
PubMed1997

Haemodynamic response to tracheal intubation or laryngeal mask insertion in hypertensive patients.

The haemodynamic response to laryngeal mask insertion and tracheal intubation was studied in 27 hypertensive patients who underwent elective ophthalmic surgery. Both groups received alfentanil 15 micrograms/kg, thiopentone 3-4 mg/kg and vecuronium 0.1 mg/kg and were ventilated with oxygen, nitrous oxide and isoflurane for 3 minutes prior to laryngeal mask insertion or tracheal intubation. Blood pressure and heart rate decreased equally in both groups after induction of anaesthesia. Haemodynamic variables increased after tracheal intubation but were unchanged after laryngeal mask insertion (P < 0.05 for intergroup differences). Heart rate, but not blood pressure, increased above baseline levels in the tracheal intubation group. The anaesthetic technique used blunted the haemodynamic response to tracheal intubation, but completely blocked the response to laryngeal mask insertion.

Adult↗
PubMed1998

Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study.

STUDY OBJECTIVE: To compare thiopental, fentanyl, and midazolam for rapid-sequence induction and intubation (RSI). METHODS: Eighty-six patients undergoing RSI in the emergency department were randomly assigned in a double-blind fashion to receive either thiopental (5 mg/kg), fentanyl (5 microg/kg), or midazolam (.1 mg/kg) before paralysis was induced. Outcome measures were mortality, speed and ease of intubation, and hemodynamics. RESULTS: Of the patients who received thiopental, 93% were intubated within 2 minutes of paralysis (P=.037), but systolic blood pressure fell an average of 38 mm Hg in this group (P=.045). The midazolam group had a greater number of delayed intubations (31%) and an average heart rate increase of 17 beats/minute (P=.008). Mortality (24% inhospital) was unaffected by drug assignment. In all three groups, patients with pulmonary edema had the greatest decrease in blood pressure during RSI, and patients exposed to multiple attempts at intubation manifested pronounced hypertension. CONCLUSION: Fentanyl provided the most neutral hemodynamic profile during RSI, although factors other than choice of sedative can play a more significant role in determining hemodynamic response. Depth of sedation may influence the speed of RSI.

Adult↗
PubMed1997

[Prolonged endotracheal intubation after open heart surgery under the age of one year].

The aim of this study was to determine the impact of prolonged endotracheal intubation after open heart surgery in neonates and babies with respect to the cardiac diseases most frequently responsible and the reasons for delayed extubation and the related mortality. Intubation was considered to be prolonged if lasting over 48 hours. This was a retrospective study of all cases of open heart surgery performed before one year of age between 1991 and 1996. Prolonged intubation was noted in 43.1% of cases (266/617). The frequency was much higher than in children over 1 year of age: 8.3% (56/725). Truncus arteriosus (93.5%: 29/31), obstructed total anomalous venous drainage (93.3%: 14/15). Taussig-Bing anomaly (83.3%: 5/6), interruption of the aortic arch (78.9%: 15/19), double outlet right ventricle (61.1%: 11/18) and transposition of the great arteries (50.2%: 107/213) were the commonest responsible malformations. The reasons for delayed extubation, often multiple, were established in 222 cases: cardiogenic shock or circulating failure in 155 cases, pulmonary dysfunction in 142 cases, surgical complications in 65 cases and neurological complications in 14 cases. Twelve patients died: 5 of congestive heart failure, 3 of pulmonary hypertension, 2 of septic shock and 1 of diffuse stenosis of the pulmonary veins. The mortality rate was 4.5% (12/266) in cases of prolonged intubation and 5.2% (32/617) for all infants operated during the first year of life. The authors conclude that a large number of infants undergoing open heart surgery undergo prolonged intubation because of their poor preoperative status and the particularly severe effects of cardiopulmonary bypass at this age. However, the associated mortality was low in this series.

Age Factors↗
PubMed1998

Effect of oral clonidine premedication on hemodynamic response during sedated nasal fiberoptic intubation.

Although oral clonidine premedication is known to reduce the hemodynamic response under general anesthesia, effects of the hemodynamic response during sedated fiberoptic nasal intubation have not yet been examined. Our aim was to compare the effects of clonidine premedication on hemodynamic responses with those of atropine and hydroxyzine premedication during sedated fiberoptic nasal intubation. Thirty adult patients were randomly assigned to one of two groups: Group 1 patients (n = 15) were premedicated with atropine sulfate (0.01 mg/kg) and hydroxyzine hydrochloride (1mg/kg) intramuscularly, and group 2 patients (n = 15) were premedicated with clonidine (5 micrograms/kg) orally. We compared the hemodynamic response and sedation level in fiberoptic nasal intubation between the two groups. there were no significant differences in sedation levels and postoperative complaints between the two groups. But the oral clonidine premedication (Group 2) blunted hemodynamic changes during the fiberoptic intubation. No profound hypotension or marked bradycardia was noted in group 2. We concluded that the oral clonidine premedication might contribute to hemodynamic stability during sedated fiberoptic nasal intubation.

Administration, Oral↗
PubMed1994

Efficacy of the self-inflating bulb in detecting esophageal intubation. Does the presence of a nasogastric tube or cuff deflation make a difference?

BACKGROUND: The principle underlying the use of the self-inflating bulb in differentiating esophageal from tracheal intubation is that the trachea is held open by rigid cartilaginous rings, whereas the esophagus collapses when a negative pressure is applied to its lumen. This investigation was designed to test the efficacy of the bulb in detecting esophageal intubation in the presence of a nasogastric tube and after tracheal tube cuff deflation. METHODS: In anesthetized patients, the trachea and esophagus were intubated with identical tubes. The efficacy of the bulb was tested after a nasogastric tube was placed (group 1, n = 70) and after cuff deflation (group 2, n = 60) by a second anesthesiologist. RESULTS: In patients with nasogastric tubes (group 1), the anesthesiologists reported no reinflation of the compressed bulbs connected to tubes placed in the esophagus and immediate reinflation when connected to tracheally placed tubes in every case. In group 2, the determination of tube placement was correct in every case after cuff deflation. Mean (+/- SEM) negative pressures generated when compressed bulbs were connected to esophageally placed tubes were 57.8 +/- 0.48 mmHg (group 1) and 55.3 +/- 0.52 mmHg (group 2) and remained unchanged after the introduction of nasogastric tubes or after cuff deflation. CONCLUSIONS: These results confirm that a nasogastric tube or cuff deflation does not interfere with the reliability of the self-inflating bulb in detecting esophageal intubation and thus does not contribute to false positive results. Confirmation of tracheal tube placement by this simple method makes it ideal for use with other recognized methods both in and outside the operating rooms and enables physicians and emergency personnel to proceed with other resuscitative measures.

Adolescent↗
PubMed1988

Comparison of three oxygen monitors in detecting endobronchial intubation.

Rapid and reliable detection of inadvertent endobronchial intubation is an essential function of oxygen monitoring. We have studied the detection of this event by using three oxygen monitoring techniques: pulse oximetry, transcutaneous measurement of oxygen tension, and intraarterial fiberoptic measurement of oxygen tension. Four dogs were anesthetized, intubated, and monitored with these three techniques and with arterial and central venous cannulas. Endotracheal tubes were moved from the trachea into the right mainstem bronchi at several inspired oxygen fraction (FIO2) values for each dog, and the responses of the oxygen monitors were recorded for 20 minutes thereafter. The pulse oximeter showed little change in oxygen saturation (SpO2) during endobronchial intubation at FIO2 values above 0.3. SpO2 decreased by an average of 1.3 +/- 2.1% at an FIO2 of 1.0 and by 4.0 +/- 4.1% at an FIO2 of 0.5. Simultaneously measured transcutaneous oxygen tensions decreased by 42 to 64% and the optode reading decreased by 64 to 79%. At lower FIO2 values, the changes in SpO2 were more significant: a decrease of 6.0 +/- 6.3% at an FIO2 of 0.3 and of 9.8 +/- 6.1% at an FIO2 of 0.2. The transcutaneous oxygen and optode readings decreased by 31 to 45% under these conditions. Endobronchial intubations at FIO2 values greater than 0.3 may not yield immediate decreases in arterial saturation and hence may go undetected by pulse oximetry. Transcutaneous oxygen tension decreases significantly with endobronchial intubation at any FIO2. The experimental, intraarterial optode consistently yielded the greatest changes with the fastest time response.

Anesthesia, Inhalation↗
PubMed1990

Timing of injection and plasma concentration of lidocaine before endotracheal intubation.

The optimal time of intravenous lidocaine for attenuation of pressor responses to laryngoscopy and endotracheal intubation was evaluated in fifty adult patients and the correlation between plasma lidocaine level and its clinical effects were also studied. The plasma lidocaine levels were highest 0.5 min after administration of lidocaine 1.5 mg.kg(-1) intravenously. However, endotracheal intubation 0.5 min after lidocaine administration caused significant increase in mean arterial pressure (MAP) and heart rate (HR). Mean arterial pressure and HR increased with endotracheal intubation following 1, 2 and 3 min after lidocaine administration, but the magnitude of increase was not statistically significant. There were no significant differences in MAP changes among these three groups. It was concluded that the plasma lidocaine levels did not correlate with its suppressive effect on circulatory responses due to laryngoscopy and endotracheal intubation. Laryngoscopy and endotracheal intubation should be carried out at least 1 min after intravenous lidocaine administration.

Journal Article↗
PubMed2000

Nicardipine versus lidocaine for attenuating the cardiovascular response to endotracheal intubation.

PURPOSE: The aim of this study was to compare the efficacy of nicardipine and lidocaine in attenuation of cardiovascular responses to endotracheal intubation. METHODS: In a randomized, double-blind, controlled trial, 60 unpremedicated (ASA I) patients undergoing elective surgery were given either 30 microg.kg(-1) nicardipine or 1.5 mg.kg(-1) lidocaine intravenously 2 min before intubation. Laryngoscopy and tracheal intubation were performed 1 min after induction of anesthesia with 5 mg.kg(-1) thiopentone, followed by administration of 1.5 mg.kg(-1) succinylcholine intravenously. Blood pressure and heart rate were monitored at baseline and every minute until 4 min after intubation. Repeated-measures ANOVA, Student's t test, the chi-square test, and 95% confidence intervals were used as appropriate. P < 0.05 was considered statistically significant. RESULTS: Baseline hemodynamic variables were not different between the groups. After administration of either agents, diastolic blood pressure and mean blood pressure were significantly lower in the nicardipine group. The heart rate in the nicardipine group was significantly higher. The mean between-group differences in diastolic blood pressure, mean blood pressure, heart rate, and rate-pressure product at baseline and 1 min after starting laryngoscopy were statistically significant. CONCLUSION: Nicardipine can be used as an alternative to lidocaine in attenuation of cardiovascular response to tracheal intubation in patients without ischemic heart disease.

Clinical Trial↗
PubMed1983

Effect of positive end-expiratory pressure on breathing patterns of normal subjects and intubated patients with respiratory failure.

The aims of this study included assessment of accuracy of respiratory inductive plethysmography when pulmonary hyperinflation was induced by application of PEEP, and examination of breathing patterns of normal subjects, intubated patients requiring mechanical ventilation and intubated patients immediately before extubation during application of PEEP by demand valve and high gas flow reservoir bag systems. Validation of tidal volume (VT) and end-expiratory level measured with respiratory inductive plethysmography to simultaneous spirometry (SP) was achieved with PEEP levels up to 12.5 cm H2O in 7 normals. In 17 intubated patients, almost all VT values measured with respiratory inductive plethysmography fell within +/- 10% of SP even with 2 to 3 changes of body posture. In normal subjects, increasing levels of PEEP from the demand valve system produced nonprogressive rises of VT and mean inspiratory flow, falls of frequency and fractional inspiratory time (TI/TTOT), and no changes of minute ventilation (Vmin) nor mean expiratory flow. PEEP from the high gas flow reservoir bag system produced nonprogressive rises of VT and rib cage (RC) contribution to VT, and rises of Vmin and mean inspiratory and expiratory flows between 10.0 and 12.5 cm H2O of PEEP. Intubated patients requiring intermittent mandatory ventilation (IMV) had a rapid, shallow breathing pattern unaltered by PEEP levels delivered by either system up to 12.5 cm H2O despite increases of end-expiratory level. Intubated patients who were about to be extubated breathed with patterns closer to ambulatory normal subjects with the exception of their elevated RC contribution to VT.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Use of the Pala-nate device in the prevention of palatal grooves in premature, intubated infants.

OBJECTIVE: Previous studies demonstrated that the use of a custom-made intraoral acrylic appliance, known as a palatal stabilizing device, prevents palatal groove formation and reduces the frequency rate of accidental extubations in premature, intubated babies. In this study, we compared the effectiveness of a prefabricated palatal device with an acrylic custom-made palatal stabilizing device. Specifically, we compared the stability, fit, and retention of these two devices. DESIGN: Randomized comparative study. SETTING: Clincal trial. PATIENTS: A total of 70 medically stable, premature, intubated babies. INTERVENTIONS: A total of 70 medically stable, premature, intubated babies randomly received Pala-nate (experimental group, n = 34) or palatal stabilizing device (control group, n = 36). MEASUREMENTS AND MAIN RESULTS: Differences among birth weight, gestational age, and period of intubation of the two groups were statistically nonsignificant at p </=.05. Although both appliances were effective in the prevention of palatal grooves, the Pala-nate was less retentive, thus requiring greater monitoring, and it was associated with a larger number of accidental extubations. The differences between the two groups were statistically significant at p </=.05. CONCLUSIONS: We concluded that the custom-made, acrylic, palatal stabilizing device was more stable and more effective in the prevention of spontaneous extubations in premature orally intubated infants.

Journal Article↗
PubMed1997

Myasthenic crisis: clinical features, mortality, complications, and risk factors for prolonged intubation.

We retrospectively reviewed the hospital records of 53 patients admitted for 73 episodes of myasthenic crisis at Columbia-Presbyterian Medical Center over a period of 12 years, from 1983 to 1994. Median age at the onset of first crisis was 55 (range, 20 to 82), the ratio of women to men was 2:1, and the median interval from onset of symptoms to first crisis was 8 months. Infection (usually pneumonia or upper respiratory infection) was the most common precipitating factor (38%), followed by no obvious cause (30%) and aspiration (10%). Twenty-five percent of patients were extubated at 7 days, 50% at 13 days, and 75% at 31 days; the longest crisis exceeded 5 months. Using survival analysis and backward stepwise Cox regression, we identified three independent predictors of prolonged intubation: (1) pre-intubation serum bicarbonate > or = 30 mg/dl (p = 0.0004, relative hazard 4.5), (2) peak vital capacity day 1 to 6 post-intubation < 25 ml/kg (p = 0.001, relative hazard 2.9), and (3) age > 50 (p = 0.01, relative hazard 2.4). The proportion of patients intubated longer than 2 weeks was 0% among those with no risk factors, 21% with one risk factor, 46% with two risk factors, and 88% with three risk factors (p = 0.0004). Complications independently associated with prolonged intubation included atelectasis (p = 0.002), anemia treated with transfusion (p = 0.03), Clostridium difficile infection (p = 0.01), and congestive heart failure (p = 0.03). Three episodes of crisis were fatal, for a mortality rate of 4% (3/73); four additional patients died after extubation. All seven deaths were due to overwhelming medical comorbidity. Over half of those who survived were functionally dependent (home or institutionalized) at discharge. In addition to prospective controlled studies of immunotherapies, the prevention and treatment of medical complications offers the best opportunity for further improving the outcome of myasthenic crisis.

Adult↗