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PubMed1999

Acromegaly and papillomatosis: difficult intubation and use of the airway exchange catheter.

We describe the anaesthetic management of a patient with acromegaly scheduled for transsphenoidal resection of a pituitary tumour who was found at intubation to have coexisting laryngeal papillomatosis. Oral intubation was impossible using both direct and fibreoptic techniques. Nasal fibreoptic intubation was successful but precluded the transsphenoidal approach to surgery. A Cook Airway Exchange Catheter [Cook (UK) Ltd, Monroe House, Letchworth SG6 1LN] was used with a Negus bronchoscope to convert to oral intubation and allow completion of surgery without resort to tracheostomy.

Acromegaly↗
PubMed1999

Electroencephalographic arousal response during tracheal intubation and laryngeal mask airway insertion after induction of anaesthesia with propofol.

Laryngoscopy and tracheal intubation, or insertion of a laryngeal mask airway may lead to an arousal response on the electroencephalogram. We studied whether more intense stimulation (laryngoscopy and tracheal intubation) causes a greater arousal response than less intense stimulation (laryngeal mask airway insertion). Thirty-four patients (ASA I-II) were anaesthetised with propofol 3 mg.kg-1, followed by vecuronium 0.15 mg.kg-1 and a propofol infusion of 10 mg.kg-1.h-1. Three minutes after induction of anaesthesia, either laryngoscopy and tracheal intubation (n = 18), or laryngeal mask airway insertion (n = 16) was performed. Laryngoscopy and tracheal intubation caused a significantly greater increase in blood pressure (but not heart rate) than laryngeal mask airway insertion (p < 0.05). Electroencephalogram responses were not different. More intense stimulation does not cause a greater arousal response during propofol anaesthesia.

Adult↗
PubMed1999

Comparison of remifentanil with alfentanil or suxamethonium following propofol anaesthesia for tracheal intubation.

Sixty ASA physical status I and II, premedicated patients were administered propofol 2 mg x kg-1 and remifentanil 2 microg x kg-1 (group R), alfentanil 50 microg x kg-1 (group A) or suxamethonium 1 mg x kg-1 (group S) as a rapid bolus. One minute after study drug administration, tracheal intubation was performed. Intubation conditions were then scored. Excellent or good conditions were observed in only 35% in group R compared with groups S and A (100% and 85%, respectively; p < 0.001). The haemodynamic response to tracheal intubation was blunted in groups R and A compared with group S (p < 0.001). The mean heart rate in groups R and A was significantly lower than group S (p < 0.001). We conclude that remifentanil 2 microg x kg-1 given as a rapid bolus will not produce intubating conditions as good as those obtained with alfentanil 50 microg x kg-1 or suxamethonium 1 mg x kg-1 if administered after propofol 2 mg x kg-1.

Adult↗
PubMed2001

A comparison of the intubating and standard laryngeal mask airways for airway management by inexperienced personnel.

Twenty-four inexperienced participants were timed inserting the intubating laryngeal mask airway and the laryngeal mask airway in 75 anaesthetised subjects. Adequacy of ventilation was assessed on a three-point scale. The pressure at which a leak first developed around the device's cuff was also measured. There was no significant difference in insertion time or the likelihood of achieving adequate ventilation between devices. However, the intubating laryngeal mask airway was better at providing adequate ventilation without audible leak (58/75 (77%) vs. 42/75 (56%); p = 0.009). The median (range [IQR]) pressure at which an audible leak developed was higher for the intubating laryngeal mask airway, 34.5 (14-40 [29-40]) cmH2O, than for the laryngeal mask airway, 27.5 (14-40 [22-33]) cmH2O (p < 0.001). The intubating laryngeal mask airway is worthy of further consideration as a tool for emergency airway management for inexperienced personnel.

Adolescent↗
PubMed2001

Identifying the more patent nostril before nasotracheal intubation.

We have studied the reliability of two simple pre-induction tests used to select the more patent nostril for nasotracheal intubation by comparing their results with those obtained from fibreoptic examination of the nostrils, in 75 maxillo-facial patients requiring nasotracheal intubation under general anaesthesia, who had no history of nasal obstruction. The tests comprised (1) estimation of the rate of airflow through each nostril during expiration by palpating the passage of air when the contralateral nostril was occluded, and (2) asking for the patient's assessment of airflow through the nostrils, following the administration of a vasoconstrictor. After each test, noses were classified as left or right nostril clearer or nostrils equally clear. After the induction of general anaesthesia, bilateral nasendoscopies were performed and videotape recordings of these were later analysed by an otolaryngologist who had no knowledge of the test results. Intranasal abnormalities were identified and noses were again classified as left or right nostril clearer or nostrils equally clear. There was no significant difference between the overall diagnostic success rates of the two tests (44% and 47%, respectively). In patients with intranasal abnormalities, the numbers of correct diagnoses made by the two tests were not significantly different and were also not significantly different from the number of correct selections made if only the right nostril or only the left nostril had been used for the intubation. In view of the relatively high diagnostic failure rates, anaesthetists should not rely on the two tests investigated when selecting the best nostril for nasotracheal intubation.

Adolescent↗
PubMed2003

The use of remifentanil for intubation in paediatric patients during sevoflurane anaesthesia guided by Bispectral Index (BIS) monitoring.

We studied the intubating conditions, haemodynamic and endocrine changes following tracheal intubation during sevoflurane anaesthesia guided by Bispectral Index (BIS) monitoring in 40 children who received either remifentanil 1 microg.kg-1 (group R) or saline 1 ml.kg-1 (group S). Acceptable intubating conditions were found in all patients in group R (n = 20), compared to only 12 patients in group S (p = 0.002). There were no intergroup differences in heart rate, systolic blood pressure and plasma concentrations of epinephrine and norepinephrine at any time point and changes in haemodynamic variables throughout the study period were moderate. Titration of sevoflurane delivery to a target BIS of 35 +/- 5 led to almost equal end-tidal sevoflurane concentrations in either group and remifentanil did not affect the BIS. There were no side-effects in either group that required intervention. Intubating conditions during sevoflurane anaesthesia in children were found to be improved by a single bolus dose of remifentanil 1 microg.kg-1.

Analgesics, Opioid↗
PubMed2001

The effect of lidocaine on neutrophil respiratory burst during induction of general anaesthesia and tracheal intubation.

BACKGROUND AND OBJECTIVE: Respiratory burst is an essential component of the neutrophil's biocidal function. In vitro, sodium thiopental, isoflurane and lidocaine each inhibit neutrophil respiratory burst. The objectives of this study were (a) to determine the effect of a standard clinical induction/tracheal intubation sequence on neutrophil respiratory burst and (b) to determine the effect of intravenous lidocaine administration during induction of anaesthesia on neutrophil respiratory burst. METHODS: Twenty ASA I and II patients, aged 18-60 years, undergoing elective surgery were studied. After induction of anaesthesia [fentanyl (2 microg kg-1), thiopental (4-6 mg kg-1), isoflurane (end-tidal concentration 0.5-1.5%) in nitrous oxide (66%) and oxygen], patients randomly received either lidocaine 1.5 mg kg-1 (group L) or 0.9% saline (group S) prior to tracheal intubation. Neutrophil respiratory burst was measured immediately prior to induction of anaesthesia, immediately before and 1 and 5 min after lidocaine/saline. RESULTS: Neutrophil respiratory burst decreased significantly after induction of anaesthesia in both groups [87.4 +/- 8.2% (group L) and 88.5 +/- 13.4% (group S) of preinduction level (P < 0.01 both groups)]. After intravenous lidocaine (but not saline) administration, neutrophil respiratory burst returned towards preinduction levels, both before (97.1 +/- 23.6%) and after (94.4 +/- 16.6%) tracheal intubation. CONCLUSION: Induction of anaesthesia and tracheal intubation using thiopentone and isoflurane, inhibit neutrophil respiratory burst. This effect may be diminished by the administration of lidocaine.

Adolescent↗
PubMed1998

Effects of endotracheal intubation on airway neuropeptide content, arterial oxygenation and lung volumes in anaesthetized rats.

BACKGROUND: General anaesthesia affects lung volume and pulmonary gas exchange. What role is played by mechanical stimulation by the endotracheal tube? METHODS: We investigated the effects of intubation on arterial oxygenation and lung volume in rats. RESULTS: Endotracheal intubation caused an increase in PA-aO2 and volume of trapped gas in the lung. This was accompanied by a reduction in neuropeptides and calcitonin gene-related peptide (CGRP) in trachea, bronchi and lung, and in vasoactive intestinal peptide (VIP) in the trachea. The increase in PA-aO2 and volume of trapped gas due to intubation was not altered in the animals given capsaicin, in which neuropeptide levels were reduced. CONCLUSIONS: These data suggest that the decrease in CGRP and VIP content in the airway tissues may be one of the consequences, but not the cause, of impaired gas exchange by endotracheal intubation. The increase in volume of trapped gas in the lung is apparently not mediated by activation of capsaicin-sensitive sensory nerves.

Anesthesia, General↗
PubMed1997

Laryngotracheal stenosis in children after intubation. Report of five cases.

Acquired laryngotracheal stenosis is a serious long term complication of tracheal intubation with an incidence of 0.7 to 8% in intubated children. We report five cases of subglottic stenosis over a 4.5-year period and review the pathology and pathogenesis of the condition. A diagnosis of subglottic stenosis was suspected when extubation failed due to the onset of dyspnoea or laryngeal stridor. An incidence of 0.9% of all intubated children was observed. We conclude that the main components contributing to stenosis are pathologies with decreased mucosal capillary perfusion pressure and intubation conditions.

Child, Preschool↗
PubMed1997

Oral and nasotracheal light wand guided intubation after failed fibreoptic bronchoscopy.

Fibreoptic bronchoscopic guided tracheal intubation is often the first choice for clinicians familiar with the technique, when faced with a patient in whom tracheal intubation presents known or possible difficulties. Regardless of the technique chosen, anticipated and unanticipated problems may arise. We report three patients with known difficult airways that illustrate the utility of light wand guided oral and nasotracheal intubation when tracheal intubation with fibreoptic bronchoscopy proved impossible.

Adolescent↗
PubMed1999

Alfentanil for intubation under halothane anaesthesia in children.

Intubating conditions under halothane anaesthesia aided with alfentanil 20 micrograms.kg-1 were compared with suxamethonium 2 mg.kg-1 in 40 children presenting for day dental procedures. The condition of vocal cords, jaw relaxation and presence of movement and coughing were scored to give the overall intubating conditions. Successful intubation was achieved in 100% of the suxamethonium group and 94.7% of the alfentanil group. The cardiovascular response to intubation was attenuated in the alfentanil group. Some 43.7% of those receiving suxamethonium developed myalgia the day after surgery compared with 0% in the alfentanil group (P < 0.01).

Alfentanil↗
PubMed1999

A new modification of anaesthesia mask for fibreoptic intubation in children.

We made a paediatric anaesthesia mask suitable for fibreoptic intubation by modifying a commercially available disposable mask with a ventilation port (Vent port) on a side. We added a large fibreoptic port (FO port, 22 mm in ID) in the middle of the mask to allow the passage of all sizes of paediatric tracheal tubes. This FO port was covered with an elastic rubber membrane to allow air-tight fibrescopic manipulation Fibreoptic intubation was performed safely through the FO port under continuous manual ventilation with anaesthetic gases via a Vent port connected to the breathing circuit. We succeeded in tracheal intubation in several infants and children with difficult airway in less than ten min, mainly via the nasotracheal route. This fibreoptic mask provides a safer technique for fibreoptic intubation in patients with difficult airways, especially in infants and small children.

Anesthesia, Inhalation↗
PubMed2003

The intubation depth marker: the confusion of the black line.

BACKGROUND: Estimation of the correct depth of insertion of a tracheal tube (TT) in children is extremely important. Insertion of an excessive length may result in endobronchial intubation while an inadequate length of insertion may lead to accidental extubation. METHODS: We reviewed TTs commonly used in paediatric practice and also reviewed recommended guidelines for correct depth of insertion. RESULTS: Amongst the different brands of TTs used, there was a wide discrepancy in the placement of the intubation depth marker. This is important as the intubation depth marker is often used as a guideline for intubation. CONCLUSIONS: For optimal placement we can rely on various formulae and manufacturers' markings on the TTs. Clinical judgement, however, remains the cornerstone of optimal placement.

Equipment Design↗
PubMed2003

The intubating laryngeal-mask airway may be an ideal device for airway control in the rural trauma patient.

A review of the literature on advanced airway management indicates that the intubating laryngeal-mask airway (ILMA) may be an ideal device for airway control in the rural trauma patient. The ILMA is an advanced laryngeal-mask airway designed to allow oxygenation of the unconscious patient as well as blind tracheal intubation with an endotracheal tube. The ILMA is an easy-to-use airway with a high success rate of insertion, and requires little training. For the rural physician managing a difficult airway in a trauma patient, the ILMA has been found to be reliable and successful when other techniques fail, such as fiberoptic intubation and direct laryngoscopy. The ILMA has also been reported to cause less hemodynamic change and less injury to the teeth and lips than direct laryngoscopy. Further, the ILMA was found to be easier and faster to use with a higher success rate than either the combitube or endotracheal tube for unskilled healthcare providers. Limitations and complications of the ILMA may include aspiration, esophageal intubation, damage to the larynx or other tissues during blind passage of a tracheal tube, and edema of the epiglottis.

Emergency Medical Services↗
PubMed2001

Prehospital endotracheal intubation for severe head injury in children: a reappraisal.

Controversy exists regarding the efficacy of prehospital assisted ventilation by endotracheal intubation (ETI) versus bag-valve-mask (BVM) in serious pediatric head injury. The National Pediatric Trauma Registry (NPTR-3) data set was analyzed to examine this question. NPTR-3 (n = 31,464) was queried regarding the demographics, injury mechanism, injury severity, prehospital interventions, transport mode, mortality rate, injury complications, procedure and equipment failure or complications, and functional outcome of seriously head-injured patients (n = 578) with comparable injury mechanisms and injury severity who received endotracheal intubation (ETI) (n = 479; 83%) versus those who received BVM (n = 99; 17%). Mortality rate was virtually identical between the 2 groups (ETI = 48%, BVM = 48%), although children receiving ETI were significantly older (P < .01), more often transported by helicopter (P < .01), and more often received intravenous fluid in the field (P < .05). However, injury complications affecting nearly every body system or organ (except kidney, gut, and skin) occurred less often in children receiving ETI (ETI = 58%, BVM = 71%, P < .05). Procedure and equipment failure or complications, and functional outcome, were similar between the 2 groups. Prehospital endotracheal intubation appears to offer no demonstrable survival or functional advantage when compared with prehospital bag-valve-mask for prehospital assisted ventilation in serious pediatric head injury. Injury complications appear to occur somewhat less often among patients intubated in the field.

Adolescent↗
PubMed1998

Premedication for neonatal intubation.

The incidence of complications was recorded for 269 consecutive neonatal endotracheal intubations after instituting a routine policy of premedication. Two hundred and fifty-three of the intubations were premedicated with a combination of atropine, fentanyl and succinylcholine, 194 were without incident, 28 required two attempts, 22 required more than two attempts, and 9 required a second attempt with a smaller endotracheal tube. All infants were successfully intubated. We conclude that a policy of routine neonatal premedication for intubation is safe, feasible, and humane.

Adjuvants, Anesthesia↗
PubMed1998

[Tooth injury during intubation--diagnostic and therapeutic aspects].

This study analysis 16 cases of dental injuries occurring during endotracheal intubation. The overall rate was 1 out of 6000 cases of intubation. As expected, the upper jaw teeth are most often involved. Partial dislocations were the most common lesion, together with dental fractures. A well-documented dental evaluation before delivery of anesthetics and appropriate precautions and protective devices during intubation will prevent most dental trauma related to endotracheal intubation. Also, early use of dental and risk management services often will ensure timely resolution of such problems.

Humans↗
PubMed1983

[Direct complete intubation of the lacrimal ducts in dacryocystorhinostomy].

A new variant of the direct complete method of intubation of the lacrimal drainage system. The newly created lacrimal sac/nasal cavity anastomosis is intubated with a y-shaped silicon tube. A U-shaped bicanalicular silicon tube is inserted, end to side, into the y-shaped tubing, thus producing a complete intubation of the lacrimal drainage system. This technique has proved successful in 30 operations and is the operation of choice for revisions and "improvisations". At follow-up examinations performed between 3 weeks and 15 months later a total of 26 cases were found to have unobstructed passage from both the upper and lower punctum. Complete intubation of the lacrimal system permits safe orthograde and retrograde irrigation, promotes the reepithelialization of the new mucosa and prevents scarring and shrinkage in the area of the common duct orifice and the newly formed lacrimal sac/nasal-cavity anastomosis.

Female↗