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PubMed1993

Tracheal intubation after induction of anaesthesia with propofol, alfentanil and i.v. lignocaine.

We have assessed tracheal intubating conditions in 60 ASA I or II patients after induction of anaesthesia with propofol 2.5 mg kg-1 and alfentanil 10 or 20 micrograms kg-1 with or without i.v. lignocaine 1 mg kg-1. No neuromuscular blocking agents were administered. Patients were allocated randomly to four groups: group 1 = propofol-alfentanil 10 micrograms kg-1; group 2 = propofol-alfentanil 10 micrograms kg-1-lignocaine 1 mg kg-1; group 3 = propofol-alfentanil 20 micrograms kg-1; group 4 = propofol-alfentanil 20 micrograms kg-1-lignocaine 1 mg kg-1. Intubating conditions were assessed as acceptable or unacceptable on the basis of a scoring system dependent on ease of laryngoscopy, vocal cord position and coughing on insertion of the tracheal tube. Intubating conditions were acceptable in 20%, 73%, 73% and 93% of patients in groups 1-4, respectively. Intubating conditions were better and there was less coughing in the lignocaine group.

Adult↗
PubMed1994

Cricoid pressure impedes placement of the laryngeal mask airway and subsequent tracheal intubation through the mask.

We have studied 40 patients to see if cricoid pressure affects the success rate of ventilation through, and the position of, the laryngeal mask and subsequent fiberscope-aided tracheal intubation. Adequate ventilation of the lungs was produced through the laryngeal mask in 19 of 20 patients in the control group, but in only 10 of 20 patients in the cricoid pressure group (P < 0.002). The laryngeal mask was positioned correctly in 16 patients in the control group, but in only two patients in the cricoid pressure group (P < 0.001). Tracheal intubation was accomplished in 19 patients in the control group, but in only three patients in the cricoid pressure group (P < 0.001). Release of cricoid pressure after placement of the laryngeal mask improved the view of the glottis, but tracheal intubation was still difficult because of laryngeal deviation. These results show that cricoid pressure impedes placement of the laryngeal mask and subsequent fiberscope-aided tracheal intubation.

Adult↗
PubMed1994

A survey of nasotracheal intubating skills among Advanced Trauma Life Support course graduates.

The American College of Surgeons' Advanced Trauma Life Support procedure teaches that blind nasotracheal intubation should be performed in the presence of a suspected or proven cervical spine injury in an unconscious but breathing patient who requires an artificial airway. We studied a group of non-anaesthetically trained graduates of the Advanced Trauma Life Support course and examined their skill in performing blind nasal intubations. Only six in 90 attempts were successful. We conclude that, in British hospitals, blind nasotracheal intubation should not be recommended as the first line management in securing the airway of patients with suspected or proven cervical spine injury. Alternative techniques such as bag-and-mask ventilation with cricoid pressure or a laryngeal mask airway with cricoid pressure should be adopted until oral intubation with in-line traction is performed.

Cervical Vertebrae↗
PubMed1994

Prediction of difficult tracheal intubation.

Three hundred and fifty consecutive patients (322 non-obstetric, 28 obstetric; 185 female) were assessed before operation using the modified Mallampati test and by measuring thyromental and sternomental distances, forward protrusion of the mandible and interincisor gap with the mouth fully open. Tracheal intubation was difficult in 17 (4.9%) patients, of whom four (1.14%) had a grade III or IV view on laryngoscopy. A sternomental distance of 12.5 cm or less with the head fully extended on the neck and the mouth closed predicted 14 of the 17 patients in whom tracheal intubation was difficult. As a screening test, sternomental distance appeared to be more sensitive (82.4%) and more specific (88.6%) than thyromental distance (64.7% and 81.4%, respectively), the modified Mallampati test (64.7% and 66.1%, respectively) and forward protrusion of the mandible (29.4% and 85.0%, respectively). The interincisor gap ranged from 2.0 to 5.0 cm in all patients except one. There was no correlation between the interincisor gap and the view on laryngoscopy (P > 0.05, one-way ANOVA). There was also no difference in mean interincisor gap between those patients who presented no difficulty with tracheal intubation and those who did (P = 0.7-0.8, two sample t test). Sternomental distance may be a useful bedside screening test for preoperative prediction of difficult tracheal intubation.

Adolescent↗
PubMed1994

Does the choice of antihypertensive therapy influence haemodynamic responses to induction, laryngoscopy and intubation?

We have measured haemodynamic responses to induction of anaesthesia, laryngoscopy and intubation in 103 mild-moderate hypertensive patients (83 patients (diastolic pressures < or = 110 mm Hg) currently receiving one of four monotherapies (ACE inhibitors, group A; beta adrenoceptor blocking drugs, group B; calcium channel antagonists, group C; diuretics, group D) and 24 were untreated hypertensive patients). Anaesthesia was induced with fentanyl 1.5-2.0 micrograms kg-1 and thiopentone 3-5 mg kg-1. Tracheal intubation was facilitated by vecuronium 0.1 mg kg-1 and anaesthesia maintained with enflurane and nitrous oxide in oxygen. Systolic and diastolic pressures (SAP, DAP) were measured at 1-min intervals by a non-invasive oscillometric method and cardiac output (CO) and stroke volume (SV) by thoracic bioimpedance. Induction of anaesthesia was associated with a decrease in SAP, DAP and CO in groups A-D (P < 0.05). Heart rate (HR) decreased in groups A and D (P < 0.01) and systemic vascular resistance (SVR) decreased in groups A and B (P < 0.05). SAP and HR increased in all groups after laryngoscopy and intubation (P < 0.01) as did SVR in groups A, B and D (P < 0.02). CO was unaltered. Similar changes occurred in the untreated hypertensive patients, although nine of 24 patients exhibited HR > or = 100 beat min-1 after laryngoscopy and intubation. Comparison of the changes in SAP, DAP, CO and SVR with time showed no differences in the five treatment groups; changes in HR were significantly less in group B compared with the other groups (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗
PubMed1994

Tracheal intubation in a manikin: comparison of supine and left lateral positions.

Tracheal intubation in the left lateral position may be necessary in some circumstances. Using a manikin we demonstrated that anaesthetic trainees found tracheal intubation in the left lateral position was more difficult and took longer than in the supine position. However, the time to successful tracheal intubation decreased with practice, indicating the presence of a learning curve. We suggest that tracheal intubation in the left lateral position should become part of training in the management of the difficult airway.

Anesthesiology↗
PubMed1994

Postoperative throat complaints after tracheal intubation.

We have investigated the incidence of throat complaints 6-24 h after tracheal intubation in 1325 patients. Variables such as anaesthetic drug, intubation time, number of intubation attempts, gastric tube, sex and age were recorded. The incidence of sore throat was considerably lower (14.4%) compared with other reports in the literature and was significantly greater in females (17.0% vs 9.0%) and after thyroid surgery. The incidence of sore throat was not increased after multiple intubation attempts or after administration of suxamethonium or a non-depolarizing neuromuscular blocker.

Adolescent↗
PubMed1995

EEG arousal during laryngoscopy and intubation: comparison of thiopentone or propofol supplemented with nitrous oxide.

We studied EEG arousal after laryngoscopy and intubation with standardized bolus induction of anaesthesia. Twenty patients were prospectively allocated randomly to induction with propofol 3 mg kg-1 (n = 10) or thiopentone (6 mg kg-1 (n = 10) and 50% nitrous oxide in oxygen. Neuromuscular block was produced with vecuronium 0.2 mg kg-1 given 30 s after induction. Three minutes after induction, laryngoscopy was performed for 60 s, with intubation at 3 min 30 s, and study end at 5 min. Nociception to laryngoscopy and intubation was followed by loss of low (relative delta activity change: thiopentone -30%, propofol -7%; P < 0.05) and a shift to higher frequency EEG activity (beta activity change: thiopentone +647%, propofol +61%; P < 0.05). This EEG arousal was greater in the thiopentone group, despite the fact that EEG depression was similar to that produced by propofol before laryngoscopy and intubation. Propofol and thiopentone in combination with nitrous oxide had similar cortical depressant effects, but propofol appeared to depress subcortical nociceptive processing more than thiopentone. While the degree of cortical EEG depression seems less useful for predicting reaction to subsequent nociception, EEG arousal reactions may prove suitable for monitoring intra-anaesthetic nociception and its modulation.

Anesthetics, Inhalation↗
PubMed1996

A modification of sub-mental intubation.

In patients who have sustained base of skull fractures, the mode of intubation is controversial, with many anaesthetists arguing against nasal intubation. In several maxillofacial procedures temporary intermaxillary fixation (IMF) in the intraoperative period may be essential to achieve optimal results in fixation. For patients with combined facial and base of skull injury, tracheotomy may have to be performed. The submental approach to intubation allows IMF to be used without resort to nasal intubation or tracheotomy. We describe a modification of the original technique which is applicable to any reinforced tracheal tube and which does not compromise the airway.

Adult↗
PubMed1997

Halothane-propofol anaesthesia for tracheal intubation in young children.

In this double-blind, randomized study, we have investigated 100 healthy children, aged 3-6 yr. We compared intubating conditions and cardiovascular changes during light halothane anaesthesia and propofol 3 mg kg-1 with those during deep halothane anaesthesia. Light halothane anaesthesia was defined as an end-tidal concentration of 1%, deep halothane anaesthesia as 2%. Intubating conditions were graded according to ease of laryngoscopy, vocal cord position and coughing. There were no statistically significant differences in the assessment of intubating conditions between the two groups; 94% of the children in the 1% halothane-propofol group and 100% of the children in the 2% halothane group had acceptable intubating conditions. Systolic arterial pressure decreased by 13% in the 1% halothane-propofol group compared with 20% in the 2% halothane group (P < 0.01).

Anesthetics, Combined↗
PubMed1997

Rapid tracheal intubation with propofol, alfentanil and a standard dose of vecuronium.

We studied 60 ASA I patients with Mallampati grade 1 airways to compare emergency intubating conditions with either alfentanil 20 micrograms kg-1, propofol 2.5 mg kg-1 and vecuronium 0.1 mg kg-1, or with thiopentone 5 mg kg-1 and suxamethonium 1 mg kg-1. Ease of laryngoscopy, vocal cord status and cough response were graded. The trachea of all patients was intubated; 83% of patients in the alfentanil-propofol-vecuronium group and 86% in the thiopentone-suxamethonium group were considered to have satisfactory intubating conditions at 60 s. We conclude that the combination of alfentanil 20 micrograms kg-1, propofol 2.5 mg kg-1 and vecuronium 0.1 mg kg-1 provided adequate conditions for rapid tracheal intubation.

Adult↗
PubMed1999

Bolus dose remifentanil for control of haemodynamic response to tracheal intubation during rapid sequence induction of anaesthesia.

The effect of three bolus doses of remifentanil on the pressor response to laryngoscopy and tracheal intubation during rapid sequence induction of anaesthesia was assessed in a randomized, double-blind, placebo-controlled study in four groups of 20 patients each. After preoxygenation, anaesthesia was induced with thiopental 5-7 mg kg-1 followed immediately by saline (placebo) or remifentanil 0.5, 1.0 or 1.25 micrograms kg-1 given as a bolus over 30 s. Cricoid pressure was applied just after loss of consciousness. Succinylcholine 1 mg kg-1 was given for neuromuscular block. Laryngoscopy and tracheal intubation were performed 1 min later. Arterial pressure and heart rate were recorded at intervals until 5 min after intubation. Remifentanil 0.5 microgram kg-1 was ineffective in controlling the increase in heart rate and arterial pressure after intubation but the 1.0 and 1.25 micrograms kg-1 doses were effective in controlling the response. The use of the 1.25 micrograms kg-1 dose was however, associated with a decrease in systolic arterial pressure to less than 90 mm Hg in seven of 20 patients.

Adolescent↗
PubMed1999

Cuffed oropharyngeal airway (COPA) as an adjunct to fibreoptic tracheal intubation.

The cuffed oropharyngeal airway (COPA) was evaluated as an adjunct to oral and nasal fibreoptic tracheal intubation in 40 adult patients during general anaesthesia. Time from start to completion of intubation decreased rapidly with experience (median time 138 s). We conclude that the COPA may be a useful adjunct to fibreoptic tracheal intubation, allowing control and support of the airway during the procedure, using various anaesthetic techniques, in an acceptable amount of time. The ability to perform fibreoptic tracheal intubation while effectively supporting the airway using the COPA may be advantageous in managing the difficult airway and in trainee education.

Adult↗
PubMed1999

Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation.

We have studied the prevalence of intranasal abnormalities that may influence the choice of nostril for intubation, using the fibreoptic laryngoscope, in 60 oral surgery patients presenting for nasotracheal intubation under general anaesthesia, who had no symptoms or signs of nasal obstruction. Videotape recordings were made during each nasendoscopy and later analysed by an anaesthetist and an otolaryngologist. A total of 68% of patients had intranasal abnormalities (10% bilateral and 58% unilateral) which resulted in one nostril being more patent than the other and therefore considered more suitable for intubation. The most common abnormality was deviated nasal septum which occurred in 57% of the study group; 22% were minor deviations, 13% were major deviations and 22% were impactions. Other abnormalities were simple spurs, unilateral polyp and hypertrophy of the inferior turbinate. In view of the relatively high incidence of intranasal pathology revealed on endoscopic examination, anaesthetists should consider using the fibreoptic laryngoscope to select the best nostril when performing nasotracheal intubation.

Adolescent↗
PubMed2000

Onset/offset characteristics and intubating conditions of rapacuronium: a comparison with rocuronium.

We compared onset and offset of action and tracheal intubating conditions after rapacuronium and rocuronium in 60 patients in a randomized, assessor-blinded study. Following induction of anaesthesia with propofol 2.5 mg kg-1, either rapacuronium 1.5 mg kg-1 (n = 30) or rocuronium 0.6 mg kg-1 (n = 30) was administered to facilitate tracheal intubation. Anaesthesia was maintained with either a propofol infusion (100 micrograms kg-1 min-1) or sevoflurane (1% end-tidal) with 66% nitrous oxide (N2O), n = 15 in each subgroup. Neuromuscular monitoring was performed using an electromyographic (EMG) device (Datex Relaxograph). The lag times (mean 42 (SD 11) s and 44 (16) s), maximum block (99 (2)% and 98 (3)%) and intubating conditions at 60 s (good-to-excellent in 86% and 84% of patients) were similar for rapacuronium and rocuronium, respectively. The onset time of rapacuronium was shorter than rocuronium (87 (20) vs 141 (65) s, P < 0.001), and the degree of block at 60 s was greater (69 (26) vs 50 (27)%, P < 0.05). Twenty-five per cent recovery was shorter with rapacuronium than rocuronium during propofol (15.0 (3.2) vs 39.1 (14.2) min, P < 0.001) and sevoflurane (15.1 (4.2) vs 47.8 (19.0) min, P < 0.001) anaesthesia. We conclude that rapacuronium 1.5 mg kg-1 had a more rapid onset, similar intubating conditions, and shorter recovery times than rocuronium 0.6 mg kg-1.

Adult↗
PubMed2001

Attenuation of haemodynamic responses to tracheal intubation by the styletscope.

Tracheal intubation often causes a haemodynamic response probably generated by direct laryngoscopy. The StyletScope is a new intubation device that does not require direct laryngoscopy. We prospectively measured haemodynamic changes after tracheal intubation using the StyletScope. The increase of heart rate was less during tracheal intubation with the StyletScope when compared with the Macintosh laryngoscope.

Adult↗
PubMed2001

Use of angulated video-intubation laryngoscope in children undergoing manual in-line neck stabilization.

Laryngeal views obtained during direct laryngoscopy with and without manual in-line neck stabilization (MILNS) and during video-assisted intubation with MILNS using the angulated video-intubation laryngoscope were assessed in 100 paediatric patients (aged 0.25-17.3 yr). Visualization of the larynx (Cormack and Lehane score) as well as time taken for video-assisted tracheal intubation by six nurses and four resident anaesthetists not experienced in the technique were recorded. Cormack and Lehane scores were significantly worse during direct laryngoscopy when MILNS was applied. Video-assisted visualization of the larynx during MILNS produced scores, which were as good or better than those observed during direct laryngoscopy alone. Intubation times ranged from 19-75 s (mean 35 (SD 13.4); median 32).

Adolescent↗
PubMed2003

Failure of simulation training to change residents' management of oesophageal intubation.

BACKGROUND: There are few scientific reports documenting the effects of simulation training on learning. Issues of scientific validity challenge investigators who measure such outcomes. We perceived a failure of residents to change their technical management of oesophageal intubation after simulation training and sought clarification of this observation. METHODS: Twenty-one residents were randomly exposed to two deliberate oesophageal intubation scenarios, first as a junior assistant (JS group) or as a senior managing resident (SS group), and secondly as a senior managing resident. After the first episode, residents were given an explanation and demonstration of the suggested technical management strategy, including: (i) confirmation of oesophageal intubation with a second direct laryngoscopy; and (ii) concurrent insertion of a second tube into the trachea. After the second episode, we retrospectively sought to confirm improvement in technical management within the SS group by measuring videotaped performances. Questionnaires were sent to the residents before and after reporting their performance results. RESULTS: There were 14 SS and seven JS subjects. Within SS, there was no improvement in "confirmation of oesophageal intubation with direct laryngoscopy" (8/14 vs 9/14) or any improvement in "concurrent insertion of a second ETT (tracheal) tube" (1/14 vs 2/14). Questionnaire responses offered considerable insight into these negative results. CONCLUSIONS: This failure to change may have been secondary to a lack of criterion validity, lack of repetition or a long duration between episodes. The expectations for management were not regarded as being advantageous in simulation, but they were successfully adopted in actual clinical emergencies.

Anesthesiology↗