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PubMedDate not supplied

Blind nasotracheal intubation in the presence of facial trauma.

Blind nasotracheal intubation (BNTI) is an effective procedure for the intubation of trauma patients. The presence of major facial trauma has been considered a relative contraindication due to the perceived risk of intracranial placement. The purpose of the present study was to assess the risk of intracranial placement in patients with facial fractures who undergo BNTI. The records of 311 patients with facial fractures were reviewed for methods of intubation and complications. Eighty-two patients underwent BNTI. There were no cases of intracranial placement, significant epistaxis requiring nasal packing, esophageal intubation, or osteomyelitis. Three patients (4%) developed sinusitis and eight (10%) developed aspiration pneumonia. We conclude that the presence of facial trauma does not appear to be a contraindication to BNTI.

Adult↗
PubMedDate not supplied

The esophageal detector device can give false positives for tracheal intubation.

The esophageal detector device is a useful, inexpensive, portable device for the detection of inadvertent intubation of the esophagus. It has been extensively tested. It is very accurate with occasional false negatives for tracheal intubation but only two reported cases of false positives for tracheal intubation previously described. This article presents two further cases of false positives for tracheal intubation using the esophageal detector device and warns that although it is the more accurate of the cheap and portable devices available, it is not perfect.

Aged↗
PubMedDate not supplied

Rocuronium for rapid sequence intubation of emergency department patients.

Rocuronium is a recently synthesized non-depolarizing neuromuscular blocking agent (NMBA) that has been demonstrated to have a faster onset of action than any other non-depolarizing NMBA. Although widely studied in the operating room, there are no reports regarding its use for emergent tracheal intubation in the emergency department (ED). The purpose of this study was to evaluate the use of rocuronium for rapid sequence intubation (RSI) in ED patients. An intubation data collection form was completed prospectively for any patient receiving rocuronium for RSI in the ED from July 1-December 31, 1997. Two hundred eighty-eight patients were intubated in the ED over this six-month period, of whom 261 (91%) underwent RSI. Fifty-eight of the patients undergoing RSI received rocuronium for paralysis (22%). The most common reason reported for use of rocuronium was a concern regarding hyperkalemia (53%). The mean dose used was 1.0 +/- 0.2 mg/kg. The mean onset to paralysis was 45 +/- 15 s. Of the complications reported, none appeared to be related to rocuronium. Use of rocuronium in the ED setting appears useful.

Adolescent↗
PubMed2000

Augmented fiberoptic intubation.

Patients who are difficult to intubate are randomly encountered. Patients who are in the postoperative period or who have suffered trauma have a greater chance of being difficult to intubate. The ability to quickly mobilize trained personnel and advanced equipment provides the best chance for a good outcome for these patients. Practice in placement of and intubation with LMAs is an important step toward providing an extensive safety net for patients needing intubation.

Airway Obstruction↗
PubMed2003

[Lesions to lips, oral and nasal cavities, pharynx, larynx, trachea and esophagus due to endotracheal intubation and its alternatives].

Dysphagia of greater than 48 h duration is an indication for indirect laryngoscopy and when odynophagia and otalgia occur simultaneously, the possibility of subluxation of the arytenoids demands an urgent ENT assessment. The potential seriousness of laryngeal lesions following intubation obliges us to use the smallest compatible endotracheal tube. The occurrence of pain cervical surgical emphysema and fever suggests a pharyngeal lesion necessitating the suspension of oral feeding and the initiation of antibiotic therapy with anaerobic activity, while awaiting possible surgical intervention. There is no argument to use a tooth-guard for each intubation, but tooth fragility must be researched. The incidence of nasal fossa trauma is reduced with the use of nasal packs impregnated with local anaesthetic containing a vasoconstrictor. This allows the introduction of a small flexible lubricated tube. Laryngeal mask-induced sore throat is more common than the more serious injuries. The classical technique of introducing a laryngeal mask of appropriate size (4 for women, 5 for men) in which the cuff is inflated to a leak pressure of 20 cm H(2)O reduces this frequency. The facial mask may cause injuries especially with prolonged use. The incidence of pulmonary aspiration, linked to the action of drugs, raised intra-abdominal pressure; an emergent situation or difficult intubation is decreased with the performance of the Sellick maneuver at intubation, rapid induction and the neutralization of gastric acidity. A meticulous technique of insertion of the, individualized anaesthesia, particular vigilance at the time of decurarisation and position changes and a calm awakening assure its optimal use, unless the Proseal laryngeal mask modifies this point of view.

Esophagus↗
PubMed1993

[Use of fiberoptic bronchoscope for difficult intubation in maxillofacial surgery].

This retrospective study analyzed the cases of difficult intubations carried out with a fiberoptic bronchoscope between March 1984 and May 1989. During this period, 222 such procedures were attempted in 131 male and 68 female patients. All cases were diagnosed at the preoperative visit. A fiberoptic bronchoscope was used as a guide under topical nasal and laryngeal anaesthesia, together with appropriate benzodiazanalgesia, in order to maintain spontaneous breathing. The nasotracheal route was used in 218 cases. Successful intubation was achieved in 219 cases (98.6%), 209 of them (95.4%) within fifteen minutes. Of the three failures, only one was unpredictable (inability to withdraw the fiberoptic bronchoscope from the endotracheal tube). In the two others, the technique was subsequently found to have been wrongly indicated: major nasopharyngeal secretions occluded the fiberoptic device in the first one, and an anatomically compromised airway led to apnoea under sedation in the other. A narrow nasotracheal passage, spreading oedema, bloody secretions or coughing gave rise to technical difficulties in 39 cases (17.5%). There was one case of regurgitation without any drawback. Benzodiazanalgesia was responsible for two cases of respiratory depression. This technique was otherwise very satisfactory, patients being cooperative and frequently having amnesia of intubation. The indications for the use of a fiberoptic bronchoscope were: insufficient oral opening, orofacial obstacles to laryngoscopy, and cases where laryngoscopy had to be avoided. The main drawbacks of this technique were the cost and fragility of fiberoptic device as well as operator efficiency. The anaesthesiologists involved in the present series performed ten easy intubations each with the fiberoptic bronchoscope, and routinely used the teaching eye-piece.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

[Intratracheal intubation using a fiberoptic laryngoscope].

Experience with a new type of laryngoscope (Bullard) is reported. It weighs 1,200 kg, and has fiberoptic fibers both for lighting and viewing. Angle of vision is about 55 degrees. Endotracheal intubation with this device requires a semi-rigid stylet to bend the tracheal tube at 90 degrees just above its cuff, so as to reproduce the curvature of the laryngoscope blade. Intubation is carried out in five steps: 1) introducing the laryngoscope blade, and visualising the vocal cords through its lens; 2) introducing the tube with its stylet, just above the laryngoscope blade; 3) placing the tube between the vocal cords under fiberoptic vision; 4) adjusting tube position in the trachea, the stylet still in place; 5) removing both stylet and laryngoscope. The use of this apparatus in an obese patient with reduced mobility of the cervical spine, who was ranked 4 on the Mallampati scale, is reported. The Bullard laryngoscope enabled easy tracheal intubation (duration 1 min 30 s), whereas direct laryngoscopy and the use of a Huffman prism were unsuccessful. The fiberoptic laryngoscope may be of help in case of difficult intubation.

Female↗
PubMed1993

[Recurrent selective bronchial intubation in laparoscopic cholecystectomy].

Selective endobronchial intubation occurred three times in a 38-year-old female patient undergoing laparoscopic cholecystectomy. She weighed 58 kg and was 165 cm tall. Anaesthesia was obtained with propofol, fentanyl and vecuronium. Endotracheal intubation was carried out with a Mallinckrodt tube, size 7.5. It was attached to the cheeks with the 22 cm marking at the teeth. The diagnosis of endobronchial intubation was made when he SpO2 fell abruptly to 79, 87 and 93% respectively. Simultaneously, the peak inspiratory pressure increased and PetCO2 decreased. The third time, both lung fields were auscultated; no breath sounds were found on the left side. The first two incidents were cured by exsufflating the artificial pneumoperitoneum. Pulling out the tube 4 cm definitely solved the problem. These endobronchial intubations were due to the tube being too close to the carina. During insufflation of the pneumoperitoneum, the carina is pushed upwards with the corresponding part of the mediastinum.

Adult↗
PubMed1988

[Secondary lung diseases in patients with nasotracheal intubation. Role of nosocomial sinusitis].

Nosocomial pneumonia is a frequent infectious complication in ICU patients. All the patients with prolonged nasotracheal intubation presenting with nosocomial pneumonia according to Salata's criteria were examined for sinusitis in the prospective study. Diagnosis was confirmed via CT-scan views and transnasal sinus puncture. In eleven nasally intubated patients, CT-scan views showed air fluid levels and multiple sinus involvement. Bacteriological studies isolated the same gram negative bacilli in both sinus and bronchial aspirates. In four cases, a polymicrobial sinusitis was found with a single organism predominant. This predominant germ was always found in bronchial aspirate. Recovery from pneumonia was obtained only after sinus drainage. Treatment included removing the nasal tubes, or performing tracheostomy and systemic antibiotics. One patient required surgical maxillary sinus drainage after failure of medical management. The occurrence of nosocomial pneumonia in nasotracheally intubated patients should lead physicians to explore the paranasal sinuses. Sinus CT-scan views should be routinely obtained in the assessment of pulmonary sepsis in patients with prolonged nasotracheal intubation. Persistent or ignored nosocomial sinusitis in such circumstances could be a major source of treatment failure.

Adult↗
PubMed1989

[Retrograde orotracheal intubation].

Four different techniques of retrograde tracheal intubation were studied in 77 cadavers (patients who had died less than 4 h before). None had any laryngeal disease or a previous intubation. Following techniques were evaluated: cricothyroid membrane puncture; infracricoid puncture; catheter guide inserted through the endotracheal tube; catheter guide only inserted through the distal lateral eye (Murphy eye) of the endotracheal tube. An epidural catheter was used as a guide. Success rate was low (5 out of 17 attempts) when cricothyroid puncture was used, and the guide passed through the whole length of the tube. All 20 attempts were successful when infracricoid puncture was used and the guide passed through the distal lateral eye of the endotracheal tube. The different techniques and equipment needed are discussed in the light of the available literature. Retrograde tracheal intubation seems to be an easy and useful technique, which all anaesthetists should know, in case of difficult intubation.

Cadaver↗
PubMed1998

[A cause of intubation failure: a subglottic bridge].

We report the case of a patient with a history of facio-thoracic burns, the treatment of which included prolonged intubation, whose trachea could not be intubated because of a subglottic obstacle. The ventilation was easily controlled with a laryngeal mask. At the end of surgery for postburn cheloids, laryngoscopy through the laryngeal mask showed a transversal subglottic laryngeal band, a probable sequela of the previous prolonged intubation. The band was resected one week later. The conventional indicators for difficult intubation cannot detect the laryngotracheal obstacles to tracheal tube insertion.

Airway Obstruction↗
PubMed2000

Pharmacodynamics and intubating conditions of cisatracurium in children during halothane and opioid anesthesia.

STUDY OBJECTIVES: To determine the pharmacodynamics and intubating conditions of cisatracurium 0.2 mg/kg in children aged 2 to 12 years. DESIGN: Open-label, randomized study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 42 ASA physical status I and II patients, 24 to 155 months of age. INTERVENTIONS: Patients were assigned to one of two groups: halothane anesthesia (G1) and opioid anesthesia (G2). Subsequently, each group was divided into two age subgroups: 24-59 months and 60-155 months. All patients were premedicated with midazolam intranasal 0.1 to 0.2 mg/kg. In G1, anesthesia was induced with halothane up to 3% and N(2)O/O(2) (60-70/30-40%). Halothane was reduced to </=2%, 2 minutes before cisatracurium was administered. In G2, anesthesia was induced with fentanyl 2 mcg/kg and thiopental 5 mg/kg. Anesthesia was maintained with halothane 0.8-1.5% in N(2)O/O(2) in G1, and it was maintained with fentanyl, thiopental, and N(2)O/O(2) in G2. Electromyography (EMG) assessed the neuromuscular function of the adductor pollicis every 10 seconds with single-twitch supramaximal stimulus at induction and train-of-four at recovery. After obtaining EMG baseline, cisatracurium was administered. Onset time, time to 90% block, percentage of maximal block, clinical duration, and intubating conditions were recorded. For statistical analysis, Chi-square test, analysis of variance, and Tukey's test were used, with p-value less than 0.05. MEASUREMENTS AND MAIN RESULTS: Only first twitch (T(1)) recovery to 25% was significantly longer in patients aged 24 to 59 months who received halothane-based anesthesia, compared with those who received opioid-based anesthesia (p < 0.05). Onset time, maximum block, and intubating conditions did not differ between groups (p > 0.05). CONCLUSIONS: Cisatracurium 0.2 mg/kg offered acceptable intubating conditions at 90 seconds in 98% of pediatric patients, regardless of the anesthesia-based technique. Longer clinical duration in the halothane group in younger children may be due to age-related potentiation or to the small number of patients enrolled in the younger subgroup.

Anesthesia↗
PubMed2001

A comparison of the Bullard laryngoscope versus the flexible fiberoptic bronchoscope during intubation in patients afforded inline stabilization.

STUDY OBJECTIVE: To compare the Bullard laryngoscope (BL) with the flexible fiberoptic bronchoscope (FFB) in a cervical spine injury model, using inline stabilization. DESIGN: Randomized clinical trial. SETTING: Main operating room of a tertiary care hospital. PATIENTS: 50 adult, ASA physical status I, II, and III patients undergoing an elective general anesthetic. INTERVENTIONS: Each patient's trachea was intubated with both techniques. Cricoid pressure was applied to half of the study patients. MEASUREMENTS: The time for laryngoscopic view and the time to intubation were recorded for each technique. The effects of cricoid pressure on laryngoscopic view and intubation time were determined. MAIN RESULTS: The times for laryngoscopy and intubation were longer in the FFB group than in the BL group (p < 0.004). There was a significantly lower success rate of laryngoscopy view in the FFB group in the presence of cricoid pressure (15 of 25 patients, or 60%) than either of the BL groups or the FFB no-cricoid pressure group. CONCLUSIONS: The BL is more reliable, quicker, and more resistant to the effects of cricoid pressure than is the FFB.

Adult↗
PubMed2001

Effect of tracheal intubation or laryngeal mask airway insertion on intraocular pressure using balanced anesthesia with sevoflurane and remifentanil.

STUDY OBJECTIVES: To study the effect of tracheal intubation or laryngeal mask airway (LMA) insertion on intraocular pressure (IOP) in strabismus patients undergoing balanced anesthesia with sevoflurane and remifentanil. DESIGN: Open, prospective, randomized study. SETTING: Tertiary care academic medical institution. PATIENTS: 40 adult ASA physical status I and II patients scheduled for elective strabismus surgery. INTERVENTION: Patients were randomized to receive either tracheal intubation or LMA insertion following mask induction with sevoflurane in combination with IV remifentanil. MEASUREMENTS: Intraocular pressure, mean arterial pressure (MAP), and heart rate (HR) were measured before induction, immediately following induction, and after airway insertion. MAIN RESULTS: Intraocular pressure after tracheal intubation or LMA insertion did not differ significantly from preoperative baseline values. Mean arterial pressure and HR did not significantly differ between groups at any time point. CONCLUSIONS: Remifentanil and sevoflurane are not associated with an increase in IOP response during tracheal intubation or LMA insertion above baseline in healthy patients undergoing ophthalmic surgery.

Adjuvants, Anesthesia↗
PubMed1998

Cardiovascular stability during carotid endarterectomy: endotracheal intubation versus laryngeal mask airway.

STUDY OBJECTIVE: To compare cardiovascular stability during carotid endarterectomy in groups managed either with laryngeal mask airway (LMA) or endotracheal intubation. DESIGN: Randomized, retrospective, blinded study. SETTING: Teaching hospital. PATIENTS: 61 ASA physical status II, III, and IV unpremedicated adult males scheduled for carotid endarterectomy. INTERVENTIONS: Following standardized anesthetic technique, including intravenous (i.v.) induction with thiopental sodium 3 to 4 mg/kg, fentanyl 2 to 3 microg/kg), and isoflurane, standard intraoperative cardiovascular monitoring plus direct arterial blood pressure measurements were instituted. Patients were randomly assigned to an endotracheal intubation or LMA group. MEASUREMENTS AND MAIN RESULTS: Distinct intraoperative episodes of +/- 25% increase or decrease of mean arterial blood pressure (MABP) and heart rate (HR) when compared with preinduction baseline values, and the number of such episodes requiring interventional therapy were recorded from a blinded anesthesia record retrospectively. Mean end-tidal isoflurane determination and total case duration enabled calculation of minimum alveolar concentration (MAC) hours of isoflurane administered. The LMA group had a significantly (p < 0.05) lower incidence of increased MABP and HR episodes and such episodes requiring drug therapy than did the endotracheal intubation group. No difference was found in the length of surgery, mean end-tidal isoflurane concentration, or the total number of MAC hours of isoflurane administered. CONCLUSIONS: During carotid endarterectomy, a reduced incidence of hypertensive and tachycardic episodes, as well as such episodes requiring interventional drug therapy, was found in the group whose airway is managed by LMA when compared with endotracheal intubation.

Aged↗
PubMed1998

Difficult intubation from gastroesophageal reflux disease in adults.

Two cases of difficult intubation are presented. Both cases presented with red swollen arytenoids, swollen false vocal cords, and subglottic stenosis. Tracheal intubation could not be achieved for these reasons. Both patients were placed on gastrointestinal prokinetic drugs and histamine-two blocker, as a diagnosis of gastroesophageal reflux disease (GERD) was made. In one case, follow-up by an otolaryngotic surgeon showed reversal of the above findings. In the other case, one tracheal intubation was achieved eventually. GERD occurs frequently. Clinicians need to maintain a high index of suspicion for GERD-related airway changes so as to avoid potential difficult intubations.

Arytenoid Cartilage↗
PubMed1999

Tracheal intubation in a child with trismus pseudocamptodactyly (Hecht) syndrome.

Tracheal intubation of a child with trismus pseudocamptodactyly (Hecht) syndrome is described. This disorder is characterized by progressive trismus and the need for repeated surgeries. Children intubated orally on a prior occasion may require an alternative approach subsequently due to progressive inability to open the mouth. An antegrade fiberoptic-guided nasotracheal technique initially was chosen due to extremely limited mouth opening. After this approach was unsuccessful, a retrograde guidewire-assisted fiberoptic intubation was performed. The manifestations of Hecht syndrome, as well as both techniques for tracheal intubation employed, are reviewed.

Child↗
PubMed1999

Influence of the priming technique on pharmacodynamics and intubating conditions of cisatracurium.

STUDY OBJECTIVES: To determine the effects of the priming technique on the intubating conditions and pharmacodynamics of different doses of cisatracurium. DESIGN: Open-label, randomized study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 60 ASA physical status I, II, and III female patients. INTERVENTIONS: Patients were randomly assigned to one of four groups. Patients from Groups 1, 2, and 3 received 0.01 mg/kg cisatracurium as a priming dose, and patients from Group 4 received placebo. Four minutes later, patients from Groups 1, 2, 3, and 4 received the following intubating doses of cisatracurium: 0.09 mg/kg, 0.14 mg/kg, 0.19 mg/kg, and 0.2 mg/kg, respectively. Anesthesia was induced with thiopental sodium, sufentanil, droperidol, and nitrous oxide (N2O; 6 L/min) in oxygen (O2; 4 L/min) and maintained with isoflurane up to 0.7%, N2O in O2, and sufentanil. Mechanomyography assessed the neuromuscular function of the adductor pollicis with train-of-four supramaximal impulses. The trachea was intubated when the amplitude of the first twitch decreased to 10% to 15% of control. MEASUREMENTS AND MAIN RESULTS: There were no significant differences among the groups regarding the demographic data, the value of the first twitch at 60 seconds, the time to 90% block, and the onset time. Clinical duration of cisatracurium was significantly different between Group 3 and Groups 1 and 2, whereas Group 4 differed significantly from Group 1. Intubating conditions did not differ significantly among the groups. CONCLUSION: When primed, cisatracurium 0.09 mg/kg and 0.14 mg/kg produced an onset time comparable with that of 0.2 mg/kg and allowed an earlier spontaneous recovery (p < 0.05). In this study, there was no benefit in priming cisatracurium 0.19 mg/kg.

Adjuvants, Anesthesia↗