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PubMed2005

Comparison of fibreoptic-guided orotracheal intubation through classic and single-use laryngeal mask airways.

We compared times to intubate the trachea orally and success rates using two fibreoptically assisted techniques in 42 healthy patients with normal airways using (a) a 6.0-mm nasal RAE tracheal tube passed through a classic laryngeal mask airway (CLMA group) or (b) a 6.0-mm nasal RAE tracheal tube passed through a new disposable Portex Soft Seal laryngeal mask airway (PLMA group). The mean (SD) total intubation times were 82 (14) and 80 (17) s, respectively (p = 0.55). The success rates for intubation at the first attempt were similar (17/21 in the CLMA vs. 16/21 in the PLMA group; p = 0.50). We conclude that there is no clinically significant difference between the times to intubate the trachea or success rates using these two devices, but there may be other more subtle measures which might influence the choice of device in clinical practice. Finally, in the course of this study we developed a grading scale to describe the laryngeal views obtained when using a fibrescope passed through supraglottic airway devices.

Adult↗
PubMed2005

Haemodynamic effects of thoracic epidural anaesthesia during induction of anaesthesia: an investigation into the effects of tracheal intubation during target-controlled infusion of propofol.

We compared haemodynamic changes following induction of anaesthesia with propofol during tracheal intubation with and without epidural anaesthesia. Nineteen patients were divided into two groups to receive epidurally administered saline (Group C) or lidocaine 1.5% (Group E). The propofol infusion was started to produce blood concentrations of 3 microg.ml(-1), and following fentanyl and vecuronium administration, tracheal intubation was performed. Mean arterial blood pressure (MBP), heart rate (HR), Bispectral index and effect-site propofol concentration were recorded. Time to loss of consciousness was significantly shorter in Group E than in Group C. The effect-site propofol concentration at loss of consciousness was significantly lower in Group E than in Group C. MBP and HR were significantly lower following propofol induction in both groups, and were significantly increased following intubation in Group C but not in Group E. In conclusion, epidural anaesthesia did not produce profound hypotension following induction of anaesthesia and produced a reduction in the haemodynamic response to tracheal intubation during a target controlled infusion of propofol.

Adult↗
PubMed2005

Low-skill fibreoptic intubation: use of the Aintree Catheter with the classic LMA.

We describe a series of patients in whom anaesthetists - many of whom were trainees and had no prior experience of using the Aintree Intubation Catheter - successfully intubated the tracheas of patients in whom conventional attempts at intubation had failed. This was achieved by passing a fibrescope loaded with an Aintree Intubation Catheter through a classic Laryngeal Mask Airway (cLMA), which had already been placed to maintain the patient's airway.

Adult↗
PubMed2006

Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation.

This study examines the incidence and site of tracheal tube impingement during nasotracheal fibreoptic intubation, and the efficacy of anticlockwise tube rotation to overcome the problem. Forty-three patients underwent fibreoptic-assisted nasotracheal intubation using a preformed nasal tube, and a second fibrescope was used to observe any obstruction to passage of the tracheal tube. Impingement occurred in 10 cases, with the most common site being the right arytenoid cartilage. Rotation resulted in successful intubation in all 10 cases, but proximal rotation did not always result in an equal degree of rotation at the tube tip. We conclude that the site of impingement for nasotracheal intubation with preformed nasal tubes is located at the posterior structures of the laryngeal inlet and that anticlockwise rotation is a simple and effective solution.

Adolescent↗
PubMed2006

Use of the fibreoptic intubating LMA-CTrach in two patients with difficult airways.

We report two patients with difficult airways who underwent tracheal intubation using the new fibreoptic intubating Laryngeal Mask Airway CTrach. The imaging technology of the LMA-CTrach was decisive in the management of these two patients. The first patient had lingual tonsillar hyperplasia, and an omega-shaped retroflexed epiglottis. The second patient had a C2-occipital fusion and was completely unable to extend her head. Given the anatomical difficulties encountered, it was likely that intubation would have been difficult or impossible through the LMA-Fastrach. The aim of this report is to describe the successful use of this new intubating laryngeal mask airway in these two challenging patients.

Aged↗
PubMed2006

Effect of orientation of a standard polyvinyl chloride tracheal tube on success rates during awake flexible fibreoptic intubation.

We conducted a randomised study in 70 patients to assess the effect of orientation of a standard polyvinyl chloride tracheal tube on the ease of railroading the tube during awake fiberoptic orotracheal intubation. Conventional orientation of the tube (with the bevel of the tube directed to the patient's left) was compared with orientation of the tube with the bevel facing posteriorly. The success rate of intubation at the first attempt was higher with the bevel oriented posteriorly (35/35; 100%) than with the conventional orientation (21/35; 60%; p = 0.0001), and the intubating time was shorter (median (range) 7 (5-11) s and 11 (5-60) s, respectively; p = 0.0001). We recommend that the tracheal tube should be aligned in this manner when railroading it over the fibrescope during awake fibreoptic orotracheal intubation.

Adult↗
PubMed1997

The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation.

In 10 cases of unexpected difficult tracheal intubation using the Macintosh laryngoscope blade, the larynx could not be seen. In each case, a good view was achieved using the Miller blade lateral to the tongue, which enabled tracheal intubation under direct vision. The results achieved using narrow, low-profile straight laryngoscope blades with this technique are reviewed. The improved view obtained with this technique is a consequence of reduced tongue compression as compared with the Macintosh technique. This leads both to an improved line of sight, and to a reduced risk of backward displacement of the tongue and epiglottis. In addition, the molar or retromolar variation of the technique reduces the intrusion of maxillary structures into the line of sight, so that a better view of the larynx is achieved for a given degree of soft tissue compression. Paraglossal straight blade laryngoscopy may have an advantage over use of the Macintosh technique when intubation proves unexpectedly difficult. It is perhaps time to question standard teaching about the role of the curved blade in such patients or, more particularly, whether the technique of laryngoscopy as currently taught is optimal. The paraglossal straight blade technique needs to be practised in routine intubation before it can be used with confidence in difficult cases.

Adult↗
PubMed1975

Complications to tracheostomy and long-term intubation: a follow-up study.

Hospital records of 79 patients treated with tracheostomy or long-term intubation from 1969 to 1971 were reviewed, and the 43 surviving patients were examined by laryngoscopy, x-ray and spirometry for complications subsequent to these treatments. Early complications included one tube occlusion and one case of postextubation stridor in each group, one dislocated tube, one bilateral pneumothorax, and one case of fatal innominate arterial hemorrhage in the tracheostomy group, and two cases of atelectasis in the long-term intubation group. Necropsy findings included necrotic ulcers in the larynx of intubated patients and eroded tracheal mucosa in both groups. Late complications in surviving patients were prolonged hoarseness in six patients treated with prolonged intubation, two of whom had also had tracheostomy. Radiologically verified tracheal stenosis (40-60%), four at the stoma level and one at the cuff level, all occurred in the tracheostomy group.

Adolescent↗
PubMed1982

Attenuation of circulatory response to laryngoscopy and tracheal intubation: a comparison of two methods of topical anaesthesia.

Circulatory responses to laryngoscopy and endotracheal intubation were compared between three groups of patients, two of which were subjected to a procedure of topical anaesthesia before induction of general anaesthesia. Topical anaesthesia, achieved with either a lidocaine dose aerosol or by gargling with viscous lidocaine, attenuated the magnitude of the pressor response to laryngoscopy and intubation but had no effect on the heart rate response. Lidocaine aerosol had some advantages over viscous lidocaine; these were the significantly smaller haemodynamic response to the local anaesthetic procedure itself and probably shorter duration of the circulatory changes produced by intubation. It is concluded that both of these simple methods are relatively ineffective in preventing haemodynamic changes associated with laryngoscopy and intubation and should probably be combined with another preventive method.

Adult↗
PubMed1983

Effect of combinations of topical anaesthesia, fentanyl, halothane or N2O on circulatory intubation response in normo- and hypertensive patients.

Attenuation of the circulatory intubation response was studied using the following combinations: oropharyngeal topical anaesthesia (OTA) + fentanyl 2 micrograms/kg (F2), OTA + 2% halothane with 70% nitrous oxide (H2N2O) or F2 + H2N2O. Firstly, it was observed in 48 normotensive patients that the combinations of OTA + F2 or F2 + H2N2O totally prevented the intubation response; OTA + H2N2O, on the other hand, was less effective. Secondly, the effect of OTA + F2 was studied in 26 hypertensive patients and their 26 normotensive controls of the same age group. The combination prevented the circulatory intubation response also in the hypertensive patients, whose circulatory reactions did not differ from those of the normotensive patients. Nitrous oxide had no beneficial effect on the intubation response.

Adolescent↗
PubMed1983

Airway complaints and laryngeal pathology after intubation with an anatomically shaped endotracheal tube.

In a group of 100 patients intubated with standard polyvinyl chloride (PVC) endotracheal tubes, 26 spontaneously complained of airway discomfort postoperatively. A further 55 patients complained of airway discomfort upon direct questioning. In a comparison group of 100 patients intubated with PVC orotracheal tubes shaped to conform with the anatomy of the airway, the corresponding figures were 14 and 21. Laryngoscopy before and 5 days after intubation revealed that among patients intubated with standard tubes there was a significantly higher frequency of mucosal lesions at the cricoid plate and at the posterior commissure of the larynx, but lesions at the medial side of the arytenoids occurred to approximately the same extent in the two groups.

Humans↗
PubMed1984

Cardiovascular response to endotracheal intubation during four anesthetic techniques.

In order to investigate the impact of four different anesthetic regimens on the cardiovascular response to endotracheal intubation, 24 patients were anesthetized to approximately the same depth of anesthesia (MAC-fraction) using one of four supplements to N2O-O2 (60:40) anesthesia: Group 1 = morphine 0.5 mg/kg i.v., Group 2 = Innovar 0.1 ml/kg i.v., Group 3 = halothane, 0.4% end-tidal, Group 4 = enflurane 0.7% end-tidal. Cardiovascular variables were recorded from radial arterial and thermistor-tipped pulmonary artery catheters and were determined at the following times: (1) while the patients were awake prior to induction of anesthesia; (2) after a stable level of anesthesia had been induced; and (3) within the first minute after endotracheal intubation. Only the groups receiving morphine and halothane sustained significant increases in heart rate, rate pressure product and pulmonary capillary wedge pressure after intubation. It is concluded that N2O-O2 anesthesia supplemented with either morphine or halothane at the 1 MAC dose level does not adequately prevent cardiovascular response after endotracheal intubation, and that these techniques require additional anesthetic depth or other adjuvant drugs in order to prevent cardiovascular complications.

Adult↗
PubMed1986

The effect of intranasally administered nitroglycerin on the blood pressure response to laryngoscopy and intubation in patients undergoing coronary artery by-pass surgery.

The effect of intranasally administered nitroglycerin (NTG) on the cardiovascular response to laryngoscopy and intubation was studied. Thirty patients scheduled to undergo coronary artery by-pass surgery under thiopentone, enflurane and pancuronium anaesthesia were randomly divided into three groups. Group I received lignocaine 1.5 mg/kg i.v. prior to laryngoscopy and intubation (control group). Group II received lignocaine 1.5 mg/kg i.v. and in addition 2 mg nitroglycerin (NTG) was given intranasally. Group III received only 2 mg NTG intranasally. In Group I laryngoscopy and intubation caused a significant increase in mean arterial pressure (MAP) (P less than 0.01), heart rate (HR) (P less than 0.01) and rate pressure product (RPP) (P less than 0.01) compared to preoxygenation values. In Group II and III MAP and RPP remained unchanged, whereas HR increased (P less than 0.01 and P less than 0.01 respectively). It can be concluded that intranasally administered NTG effectively attenuates the pressor response to laryngoscopy and intubation in patients presenting for coronary artery by-pass surgery and that it is more effective and convenient method than intravenous lignocaine.

Administration, Intranasal↗
PubMed1991

The effect of nasotracheal intubation on the paranasal sinuses. A prospective study of 434 intensive care patients.

A total of 434 patients admitted to the intensive care unit for mechanical ventilation were followed prospectively to investigate the influence of a nasotracheal tube on the paranasal sinuses. Twenty-five patients died before the examination was completed. The rest were examined for clinical symptoms of sinusitis. If sinusitis was suspected or the patients were intubated for 5 days or more, an x-ray of the sinuses was performed. In patients intubated for less than 5 days (N = 357), sinusitis was clinically suspected in three, but radiographically verified in only one. In patients intubated for 5 days or more (N = 47), 23 (49%) had affection of the paranasal sinuses. Patients needing a nasotracheal tube should be examined for sinusitis if they are intubated for more than 5 days or if unexplained fever, sepsis or purulent nasal secretion develops. If the suspicion is confirmed, the nasotracheal tube should be removed.

Adult↗
PubMed1991

Injection pain, intubating conditions and cardiovascular changes following induction of anaesthesia with propofol alone or in combination with alfentanil.

In a double-blind study, propofol (P) 2-2.5 mg.kg-1 preceded by saline (Sal) or alfentanil (A) 20-30 micrograms.kg-1 was used for anaesthetic induction in 59 young patients of ASA physical class I or II, premedicated with oxycodone 0.1 mg.kg-1 and atropine 0.01 mg.kg-1 i.m. The patients were randomly allocated to one of the four groups: Group 1 Sal + P2.5, Group 2 A20 + P2.5, Group 3 A30 + P2.5 and Group 4 A30 + P2. Pain on injection of propofol occurred in 67, 36 and 7% of the patients in the Sal + P2.5, A20 + P2.5 and A30 + P2 groups, respectively, but not at all in the A30 + P2.5 group. Intubating conditions were assessed as good, moderate, poor or impossible on the basis of jaw relaxation, ease of insertion of the tube and coughing on intubation, each on a three-point scale. In impossible cases, suxamethonium was used. In the Sal + P2.5 group, the frequencies of good, moderate, poor and impossible intubating conditions were 0, 38, 8 and 54%, respectively. The corresponding figures in the A30 + P2.5 group were 43, 46, 7 and 14% (P less than 0.05 between the groups). The other groups did not differ significantly from the Sal + P2.5 group. After injection of propofol, both systolic and diastolic arterial pressures decreased significantly in all other groups, with the exception of diastolic pressure in the Sal + P2.5 group, whereas heart rate did not differ from the control level. After intubation, systolic arterial pressure increased statistically significantly in the Sal + P2.5 and A30 + P2 groups and diastolic arterial pressure in all other groups with the exception of the A30 + P2.5 group when compared with the corresponding preceding values.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Hemodynamic and catecholamine responses to laryngoscopy with vs. without endotracheal intubation.

To study the relationship between the intensity of the stimulus exerted against the base of the tongue during direct laryngoscopy and the magnitude of associated hemodynamic and catecholamine responses, a study was conducted in 40 ASA I or II patients. Laryngoscopy lasting 40 s was performed with a size 3 Macintosh blade connected to a force-displacement transducer. The intensity of the stimulus exerted during laryngoscopy is expressed by the product of its average force (N) and duration (s) and given as impulse in Ns. Highly significant relationships were found between the impulse during laryngoscopy and the maximal hemodynamic and catecholamine responses. Also, when laryngoscopy was followed by orotracheal intubation, significant relationships were found with steeper slopes of the regression lines for systolic blood pressure, heart rate and plasma epinephrine concentrations. A more rapid regression of hemodynamic data was seen in intubated patients, whereas their plasma catecholamine concentrations regressed more slowly. The mechanisms of the responses to laryngoscopy and orotracheal intubation are proposed to be by somato-visceral reflexes. Stimulation of proprioceptors at the base of the tongue during laryngoscopy induces impulse-dependent increases of systemic blood pressure, heart rate and plasma catecholamine concentrations. Subsequent orotracheal intubation recruits additional receptors that elicit augmented hemodynamic and epinephrine responses as well as some vagal inhibition of the heart.

Adult↗
PubMed1995

Laryngeal mask airway guided tracheal intubation in a neonate with the Pierre Robin syndrome.

Endotracheal intubation in infants with the Pierre Robin syndrome may sometimes be impossible to accomplish by conventional means. To aid difficult tracheal intubation many different techniques have been described. We present a case, in which we successfully intubated a small-for-date newborn boy with the Pierre Robin syndrome by using a modified laryngeal mask airway (no. 1) as a guide for the endotracheal tube. The technique is easy to perform, less traumatic and less time-consuming than multiple attempts at laryngoscopy or blind tracheal intubation.

Equipment Design↗
PubMed1996

Prediction of difficult intubation.

The incidence of a difficult laryngoscopy or intubation varies from 1.5% to 13%, and failed intubation has been identified as one of the anaesthesia-related causes of death or permanent brain damage. Problems in the airway management can be predicted based on previous anaesthesia records, the medical history of the patient and a physical examination. Several radiological measurements have been reported to be associated with a difficult intubation. The sensitivities of the commonly used bedside tests i.e. the Mallampati classification and the thyromental distance have been reported to be from 42% to 81%, and from 62% to 91%, respectively. The figures for the specificity have varied from 66% to 84% and from 25% to 82%, respectively. The other subjective assessments and objective measurements employed for the prediction of a difficult intubation reach comparable sensitivities and specificities. Evidently, the positive predictive value is improved, if combinations of tests are used.

Anesthesia↗