Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D.
Objective Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Design Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services (EMS) administrative database. Setting EMS system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e. rapid sequence intubation). Patients A total of 7,523 patients >12 years old in whom paramedics attempted prehospital endotracheal intubation. Interventions None Measurements and Main Results An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (N=1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, N=27) and bag-valve-mask ventilation (0.8%, N=60) were rarely performed by paramedics as final rescue airway strategies. Conclusions Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a
Prekker, Matthew E; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D
Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database. Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation). A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation. None. An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies. Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.
Lioutas, Vasileios-Arsenios; Marchina, Sarah; Caplan, Louis R; Selim, Magdy; Tarsia, Joseph; Catanese, Luciana; Edlow, Jonathan; Kumar, Sandeep
Many patients with acute intracerebral hemorrhages (ICHs) undergo endotracheal intubation with subsequent mechanical ventilation (MV) for "airway protection" with the intent to prevent aspiration, pneumonias, and its related mortality. Conversely, these procedures may independently promote pneumonia, laryngeal trauma, dysphagia, and adversely affect patient outcomes. The net benefit of intubation and MV in this patient cohort has not been systematically investigated. We conducted a large single-center observational cohort study to examine the independent association between endotracheal intubation and MV, hospital-acquired pneumonia (HAP), and in-hospital mortality (HM) in patients with ICH. All consecutive patients admitted with a primary diagnosis of a spontaneous ICH to a tertiary care hospital in Boston, Massachusetts, from June 2000 through January 2014, who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Patients with pneumonia on admission, or those having brain or lung neoplasms were excluded. Our exposure of interest was endotracheal intubation and MV during hospitalization; our primary outcomes were incidence of HAP and HM, ascertained using International Classification of Diseases-9 and administrative discharge disposition codes, respectively, in patients who underwent endotracheal intubation and MV versus those who did not. Multivariable logistic regression was used to control for confounders. Of the 2,386 hospital admissions screened, 1,384 patients fulfilled study criteria and were included in the final analysis. A total of 507 (36.6%) patients were intubated. Overall 133 (26.23%) patients in the intubated group developed HAP versus 41 (4.67%) patients in the non-intubated group (p < 0.0001); 195 (38.5%) intubated patients died during hospitalization compared to 48 (5.5%) non-intubated patients (p < 0.0001). After confounder adjustments, OR for HAP and HM, were 4.23 (95% CI 2.48-7.22; p < 0.0001) and 4.32 (95% CI 2
Driver, Brian E; Prekker, Matthew E; Klein, Lauren R; Reardon, Robert F; Miner, James R; Fagerstrom, Erik T; Cleghorn, Mitchell R; McGill, John W; Cole, Jon B
The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success
Endotracheal intubation (ETI) is a valuable procedure which must be learnt and practised, and performing ETI on cadavers is probably the best way to do this, although lesser alternatives do exist. Performing ETI on a cadaver is viewed with a real and reasonable repugnance and if it is done without proper authorisation it might be illegal. Some form of consent is required. Presumed consent would preferably be governed by statute and should only occur if the community is well informed and therefore in a position of being able to decline. Currently neither statute nor adequate informing exists. Endotracheal intubation on the newly dead may be justifiable according to a Guttman scale if the patient has already consented to organ donation and if further research supports the relevance of the Guttman scale to this question. A "mandated choice" with prior individual consent as a matter of public policy is the best of these solutions, however until such a solution is in place we may not practise endotracheal intubation on the newly dead. PMID:9358348
Su, Zhuquan; Li, Shiyue; Zhou, Ziqing; Chen, Xiaobo; Gu, Yingying; Chen, Yu; Zhong, Changhao; Zhong, Minglu; Zhong, Nanshan
Postintubation tracheal stenosis is a complication of endotracheal intubation. The pathological mechanism and risk factors for endotracheal intubation-induced tracheal stenosis remain not fully understood. We aimed to establish an animal model and to investigate risk factors for postintubation tracheal stenosis. Beagles were intubated with 4 sized tubes (internal diameter 6.5 to 8.0 mm) and cuff pressures of 100 to 200 mmHg for 24 hr. The status of tracheal wall was evaluated by bronchoscopic and histological examinations. The model was successfully established by cuffed endotracheal intubation using an 8.0 mm tube and an intra-cuff pressure of 200 mmHg for 24 hr. When the intra-cuff pressures were kept constant, a larger sized tube would induce a larger tracheal wall pressure and more severe injury to the tracheal wall. The degree of tracheal stenosis ranged from 78% to 91% at 2 weeks postextubation. Histological examination demonstrated submucosal infiltration of inflammatory cells, hyperplasia of granulation tissue and collapse of tracheal cartilage. In summary, a novel animal model of tracheal stenosis was established by cuffed endotracheal intubation, whose histopathological feathers are similar to those of clinical cases of postintubation tracheal stenosis. Excessive cuff pressure and over-sized tube are the risk factors for postintubation tracheal stenosis. PMID:28349955
Qureshi, Mosarrat J; Kumar, Manoj
Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation. Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation? We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review. Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates. We included seven trials that involved a total of 794 infants. Five
Blaivas, Michael; Tsung, James W
Determining the correct position of endotracheal tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation. Multiple detection techniques have been developed to determine the correct endotracheal tube position, recently including the use of sonography to evaluate lung expansion and diaphragmatic excursion. These techniques have also been applied to diagnosis of right endobronchial main stem intubation, which may be confused with a unilateral pneumothorax in some cases. We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application. Previous literature and future applications are discussed. Sonographic detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction. Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.
Woodhead, D D; Lambert, D K; Molloy, D A; Schmutz, N; Righter, E; Baer, V L; Christensen, R D
Respiratory support of neonates during and following laser surgery for retinopathy of prematurity (ROP) is commonly accomplished using endotracheal intubation and mechanical ventilation. However, most patients undergoing ROP surgery have been weaned off mechanical ventilation days or weeks before the surgery. When they are electively re-intubated for ROP surgery, it can be difficult to extubate them postoperatively. One of the three level III neonatal intensive care units (NICUs) in the Intermountain Healthcare system initiated a program of using nasopharyngeal prongs, rather than endotracheal intubation, for respiratory support during ROP surgery. We performed an historic cohort analysis of all neonates undergoing ROP surgery during their NICU stay at the three level III NICU's between 1 January 2002 and 31 March 2006. Data collected included birth weight, gestational age at delivery and corrected gestational age at ROP surgery, whether or not they were intubated in the days immediately preceding the ROP surgery, whether or not they were electively intubated for the ROP surgery, the respiratory modality used during and the 3 days following ROP surgery, and all blood gas determinations and respiratory charges during this period. Fifty-four patients underwent ROP surgery during this period. All 23 from NICUs 'A' and 'B' had endotracheal intubation for surgery, while in NICU 'C' 24 were managed using nasopharyngeal prongs. The birth weights of those intubated for surgery (661+/-180 g, mean+/-s.d.) were similar to those not intubated (732+/-180 g). Similarly, the gestational age at birth did not differ between those intubated for surgery (25.2+/-1.3 week) and those not (25.6+/-2.1 week). The day following surgery, 77% (23/30) of those who had been intubated for surgery remained intubated and on mechanical ventilation, whereas only one (4%) of those not intubated for surgery was intubated in the postoperative period (P<0.001). On day 3 following surgery, 50% (15/30) of
Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko
We report a case of difficult ventilation requiring emergency endotracheal intubation during awake craniotomy managed by laryngeal mask airway (LMA). A 45-year-old woman was scheduled to receive awake craniotomy for brain tumor in the frontal lobe. After anesthetic induction, airway was secured using ProSeal LMA and patient was mechanically ventilated in pressure-control mode. Patient's head was fixed with head-pins at anteflex position, and the operation started. About one hour after the start of the operation, tidal volume suddenly decreased. We immediately started manual ventilation, but the airway resistance was extremely high and we could not adequately ventilate the patient. We administered muscle relaxant for suspected laryngospasm, but ventilatory status did not improve; so we decided to conduct emergency endotracheal intubation. We tried to intubate using Airwayscope or LMA-Fastrach, but they were not effective in our case. Finally trachea was intubated using transnasal fiberoptic bronchoscopy. We discuss airway management during awake craniotomy, focusing on emergency endotracheal intubation during surgery.
Mayrose, James; Myers, Jeffrey W
Virtual reality simulation has been identified as an emerging educational tool with significant potential to enhance teaching of residents and students in emergency clinical encounters and procedures. Endotracheal intubation represents a critical procedure for emergency care providers. Current methods of training include working with cadavers and mannequins, which have limitations in their representation of reality, ethical concerns, and overall availability with access, cost, and location of models. This paper will present a human airway simulation model designed for tracheal intubation and discuss the aspects that lend itself to use as an educational tool. This realistic and dynamic model is used to teach routine intubations, while future models will include more difficult airway management scenarios. This work provides a solid foundation for future versions of the intubation simulator, which will incorporate two haptic devices to allow for simultaneous control of the laryngoscope blade and endotracheal tube.
Lauper, Josiane; Marolf, Vincent; Levionnois, Olivier; Schelling, Esther; Meylan, Mireille; Spadavecchia, Claudia
To investigate whether an intravenous (IV) lidocaine bolus in calves premedicated with xylazine-butorphanol reduces the amount of ketamine required to allow endotracheal intubation. Randomized, prospective clinical study. In total, 41 calves scheduled for elective umbilical surgery. Calves were randomly assigned to one of two groups (L: lidocaine or S: saline). The calves were administered xylazine (0.07 mg kg -1 ) and butorphanol (0.1 mg kg -1 ) intramuscularly and 10 minutes later lidocaine (2 mg kg -1 ; group L) or saline (group S) IV over 1 minute. After 2 minutes, ketamine (2.5 mg kg -1 ) was injected IV. If the depth of anaesthesia was insufficient for intubation, additional ketamine (1 mg kg -1 ) was administered every minute until intubation was successful. The amount of ketamine required for intubation, respiratory rate, pulse rate, arterial pressures, the depth of sedation and conditions of endotracheal intubation after induction of anaesthesia were compared between the two groups. The calves in group L were sedated more deeply than those in group S; however, neither the median (range) amount of ketamine required for intubation, 3.5 (2.5-4.5) mg kg -1 and 3.5 (2.5-3.5) mg kg -1 , respectively, nor the induction quality differed significantly between the groups. A bolus of lidocaine (2 mg kg -1 ) administered 10 minutes after xylazine-butorphanol in calves deepened the degree of sedation but did not decrease the requirement of ketamine for endotracheal intubation. No adverse effects were recorded in the physiological variables measured. Copyright © 2017. Published by Elsevier Ltd.
Smith, N A; Tandel, A; Morris, R W
Several overseas studies have suggested that opportunities for anaesthesia trainees to learn and practise endotracheal intubation have decreased over time. We analysed the operating theatre data collection system at a large Australian metropolitan teaching hospital from 1998 to 2008 to determine if numbers for trainees' caseloads in general, and endotracheal intubation in particular had changed. The total caseload per trainee of approximately 800 cases per year was stable throughout the study period. The number of gastrointestinal endoscopies per trainee increased significantly with a corresponding decrease in the number of other cases. The mean number of endotracheal intubations per trainee per year fell by 10% and of supraglottic devices by 16%, neither of which was statistically significant. Endotracheal intubation for caesarean sections did however fall significantly from an average of nine to an average of six cases per trainee per year. Our findings contrast with other reports of much larger decreases in the number of endotracheal intubations performed by trainees over the last decade, but suggest that our local practice is similar to the international experience of decreasing opportunities for endotracheal intubation in obstetric anaesthesia.
Pfeiffer, P; Bache, S; Isbye, D L; Rudolph, S S; Rovsing, L; Børglum, J
Ultrasound (US) may have an emerging role as an adjunct in verification of endotracheal intubation. Obtaining optimal US images in obese patients is generally regarded more difficult than for other patients. This study compared the time consumption of bilateral lung US with auscultation and capnography for verifying endotracheal intubation in obese patients. A prospective, paired and investigator-blinded study performed in the operating theatre. Twenty-four adult patients requiring endotracheal intubation for bariatric surgery were included. During post-intubation bag ventilation, bilateral lung US was performed for detection of lungsliding indicating lung ventilation simultaneous with capnography and auscultation of epigastrium and chest. Primary outcome measure was the time difference to confirmed endotracheal intubation between US and auscultation alone. The secondary outcome measure was time difference between US and auscultation combined with capnography. Both methods verified endotracheal tube placement in all patients. No significant difference was found between US compared with auscultation alone. Median time for verification by auscultation alone was 47.5 s [interquartile (IQR) 40-51 s], with a mean difference of -0.3 s in favor of US (95% confidence interval -3.5-2.9 s) P = 0.87. Comparing US with the combination of auscultation and capnography, there was a significant difference between the two methods. Median time for verification by US was 43 s (IQR 40-51 s) vs. 55 s (IQR 46-65 s), P < 0.0001. In obese patients, verification of endotracheal tube placement with US is as fast as auscultation alone and faster than the standard method of auscultation and capnography. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.
Abdollahifakhim, Shahin; Sheikhzadeh, Dariush; Shahidi, Nikzad; Nojavan, Gholamreza; Bayazian, Gholamreza; Aleshi, Hamideh
The aim of the current study was to identify the proper size of endotracheal tube for intubation of cleft lip and palate patients and intubation outcomes in these patients. In this analytic cross-sectional study, 60 nonsyndromic cleft lip and palate patients were selected who had surgery between April 2010 and April 2012 at Pediatrics Hospital, Tabriz University of Medical Sciences, Iran. Demographic findings, previous admissions, and surgical history were registered. The proper tube size was measured by normal children formulas. Then tube size was confirmed by patients' minimum resistance to intubation, proper ventilation reported by anesthesiologist, and appropriate air leakage at an airway pressure of 15-20 cm H₂O. If intubation was unsuccessful then smaller size of endotracheal tube would be tried. Frequency of intubation trials and the biggest endotracheal tube size were recorded. Their average age, weight and height were 21.39 ± 4.95 months, 9.97 ± 1.18 kg and 74.30 ± 26.61 cm, respectively. The average tracheal tube size and frequency of intubation trials were 4.34 ± 0.78 and 1.63 ± 0.80, respectively. Seven cases required an endotracheal tube size smaller than the recommended size for that age including one case in unilateral cleft palate, three cases in unilateral cleft lip, one case in unilateral cleft lip and palate, and two cases in bilateral cleft lip and palate. Findings proved that considering subglottic stenosis incidence in these children, it is reasonable to determine the tube size for nonsyndromic cleft lip and palate patients by applying the currently available standards for normal children. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Daniel, Yann; Habas, Sébastien; Cruc, Maximilien
Out-of-hospital endotracheal intubation is a frequent procedure for trauma care. Nevertheless, in warm climates, sunlight and heat can interfere with the flow of the usual procedure. They can affect the equipment and hinder the operator. There are few data on this issue. The presentation of this case highlights three common complications that may occur when intubating under a hot and bright sun. A 23-year-old man had a car accident in Djibouti, at 11:00 a.m., in broad sunlight. The heat was scorching. Due to a severe head trauma, with a Glasgow Coma Scale score of 8, it was decided to perform an endotracheal intubation. The operator faced three problems: the difficulty of seeing inside the mouth in the bright sunlight, the softening of the tube under the influence of the heat, and the inefficiency of colorimetric CO2 detectors in the warm atmosphere in confirming the proper endotracheal tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Solutions are simple, but must be known and planned ahead, prior to beginning the procedure: Putting a jacket over his head while doing the laryngoscopy would solve the problem of dazzle; adjuncts like a stylet or gum elastic bougie have to be used at the outset to fix the softening problem; alternative methods to exhaled CO2 detection, such as the syringe aspiration technique, to confirm the proper tube placement, should be available. Copyright © 2016 Elsevier Inc. All rights reserved.
Mayrose, James; Kesavadas, T; Chugh, Kevin; Joshi, Dhananjay; Ellis, David G
Tracheal intubation is performed for urgent airway control in injured patients. Current methods of training include working on cadavers and manikins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time, the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The haptic device along with the real-time performance of the simulator give it both visual and physical realism. The three-dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many endotracheal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.
Gonçalves, Roberta Lins; Tsuzuki, Lucila Midori; Carvalho, Marcos Giovanni Santos
Evidence-based practices search for the best available scientific evidence to support problem solving and decision making. Because of the complexity and amount of information related to health care, the results of methodologically sound scientific papers must be integrated by performing literature reviews. Although endotracheal suctioning is the most frequently performed invasive procedure in intubated newborns in neonatal intensive care units, few Brazilian studies of good methodological quality have examined this practice, and a national consensus or standardization of this technique is lacking. Therefore, the purpose of this study was to review secondary studies on the subject to establish recommendations for endotracheal suctioning in intubated newborns and promote the adoption of best-practice concepts when conducting this procedure. An integrative literature review was performed, and the recommendations of this study are to only perform endotracheal suctioning in newborns when there are signs of tracheal secretions and to avoid routinely performing the procedure. In addition, endotracheal suctioning should be conducted by at least two people, the suctioning time should be less than 15 seconds, the negative suction pressure should be below 100 mmHg, and hyperoxygenation should not be used on a routine basis. If indicated, oxygenation is recommended with an inspired oxygen fraction value that is 10 to 20% greater than the value of the previous fraction, and it should be performed 30 to 60 seconds before, during and 1 minute after the procedure. Saline instillation should not be performed routinely, and the standards for invasive procedures must be respected. PMID:26465249
Herbstreit, Frank; Fassbender, Philipp; Haberl, Helge; Kehren, Clemens; Peters, Jürgen
Teaching endotracheal intubation to medical students is a task provided by many academic anesthesia departments. We tested the hypothesis that teaching with a novel videolaryngoscope improves students' intubation skills. We prospectively assessed in medical students (2nd clinical year) intubation skills acquired by intubation attempts in adult anesthetized patients during a 60-hour clinical course using, in a randomized fashion, either a conventional Macintosh blade laryngoscope or a videolaryngoscope (C-MAC®). The latter permits direct laryngoscopy with a Macintosh blade and provides a color image on a video screen. Skills were measured before and after the course in a standardized fashion (METI Emergency Care Simulator) using a conventional laryngoscope. All 1-semester medical students (n = 93) were enrolled. The students' performance did not significantly differ between groups before the course. After the course, students trained with the videolaryngoscope had an intubation success rate on a manikin 19% higher (95% CI 1.1%-35.3%; P < 0.001) and intubated 11 seconds faster (95% CI 4-18) when compared with those trained using a conventional laryngoscope. The incidence of "difficult (manikin) laryngoscopy" was less frequent in the group trained with the videolaryngoscope (8% vs 34%; P = 0.005). Education using a video system mounted into a traditional Macintosh blade improves intubation skills in medical students.
Duke-Novakovski, Tanya; Ambros, Barbara; Auckland, Crissie D.; Harding, John C.S.
This randomized, prospective, blinded study compared the use of succinylcholine or rocuronium to aid endotracheal intubation of 27 adult sows [mean body weight 261 ± 28 (standard deviation) kg]. Preliminary trials allowed development of the intubation technique and skills. The sows were premedicated with azaperone, atropine, and morphine, and anesthesia was induced with thiopental [6 mg/kg body weight (BW)]. Nine sows each received succinylcholine (1.0 mg/kg BW), rocuronium (0.5 mg/kg BW), or saline (15 mL) after induction. Increments of thiopental (1 mg/kg BW) were used if swallowing impaired intubation. Intubation was performed 45 s after injection of the test drug and was timed and scored. The intubation scores were analyzed with Kruskal-Wallis analysis of variance (ANOVA). Time taken for intubation, body weight, and total dose of thiopental were analyzed with ANOVA and Bonferroni’s multiple-comparisons test. No significant differences (at P < 0.05) were found between the groups with regard to intubation score, time taken for intubation, or total thiopental dose. Thus, neuromuscular blocking agents did not aid endotracheal intubation of adult sows anesthetized with thiopental. PMID:22754096
Patel, Shreya; Lalwani, Kirk; Koh, Jeffrey; Wu, Lei; Fu, Rongwei
Uncuffed endotracheal tubes are still preferred over cuffed tubes in certain situations in pediatric anesthesia. Inaccurately sized uncuffed endotracheal tubes may lead to inadequate ventilation or tracheal mucosal damage during anesthesia. Endotracheal tube size in children is usually assessed by measuring the audible leak pressure; if the fit of the tube and the leak pressure decrease significantly with time, reintubation during surgery as a result of inability to ventilate effectively may be challenging, and could lead to patient morbidity. There is no evidence to indicate whether leak pressure increases or decreases with time following endotracheal intubation with uncuffed tubes in children. We measured leak pressure for 30 min following tracheal intubation in 46 ASA I children age 0-7 years after excluding factors known to modify leak pressure. The largest mean change in leak pressure occurred between time points 0 and 15 min, an increase of 3.5 cmH2O. Endotracheal tube size and type of procedure were associated with the leak pressure. In the final linear mixed model, there were no statistically significant variations in leak pressure over time (P = 0.129) in this group of children. We did not identify a consistent change in leak pressure within 30 min following tracheal intubation with uncuffed endotracheal tubes in this group of children.
Hamdan, Abdul-Latif; Sabra, Omar; Rameh, Charbel; El-Khatib, Mohamad
Voice production is a complex process that involves more than one system, yet most causes of dysphonia are attributed to disturbances in the laryngeal structures and little attention is paid to extralaryngeal factors. Persistent dysphonia after general anesthesia is a challenge to both anesthesiologists and otolaryngologists. The etiology is often multivariable and necessitates a team approach for proper diagnosis. Laryngeal symptoms are subdivided into phonatory disturbances and airway related complaints. When they become persistent for more than 72 hours or are coupled with airway symptoms such as hemoptysis, stridor, dyspnea or aspiration, the anesthesiologist should suspect injury to the vocal folds or cricoarytenoid joints. Here-below, the laryngeal manifestations of endotracheal intubation and the pathophysiology of vocal fold scarring are discussed.
Afreen, Mahrukh; Ansari, Murtaza Ahsan
Endotracheal intubation plays a key role in the management of upper airway obstruction in emergency situations. It is non-invasive and easily learned technique by medical professionals as compared to other more skilled, surgical procedures, e.g., tracheostomy and cricothyrotomies etc. But prolonged intubation may result in numerous complications, most notorious being tracheoesophageal fistula and narrowing of subglottic area. We report a profile of a patient who had been diagnosed as case of Guillian-Barre Syndrome, had difficulty in breathing due to paralysis of respiratory muscles. The patient was admitted in Medical Intensive Care Unit (MICU) for 40 days and was kept on artificial breathing through endotracheal intubation, which remained in place for 19 days. Later tracheostomy was performed. Patient ultimately developed severe subglottic stenosis and became dependent on tracheostomy tube.
Introduction Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC® video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy. Methods In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC®). Results A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC® were assessed. In patients with at least one predictor for difficult intubation, the C-MAC® resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC® (7%, C&L grade 3 and 4) (P < 0.0001). Conclusion Use of the C-MAC® video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur. PMID:22695007
Green, Robert S; Fergusson, Dean A; Turgeon, Alexis F; McIntyre, Lauralyn A; Kovacs, George J; Griesdale, Donald E; Zarychanski, Ryan; Butler, Michael B; Kureshi, Nelofar; Erdogan, Mete
Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians. A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from "always" to "never" to capture usual practice. The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would "always/often" be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would "always/often" administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00). Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.
Sun, Anke; Zhang, Tiezheng; Liu, Wenyuan; Tang, Weiwei; Guo, Xiaohong
To research the causes of postintubation vocal cord dyskinesia and its contributing factors. The causes of vocal cord dyskinesia were confirmed by laryngoscope, three-dimensional spiral CT, stroboscope, and the analysis of therapy. The factors relevant to the causes of vocal cord dyskinesia were analysed based on the following elements: (1) the anatomic or pathological condition of patients or the technical skills of anesthetists. (2) emaciated or obese body and neck. (3) the age of patients. (4) the duration of endotracheal tube retention. (5) the types of operations. (6) anesthesia procedure. Among 135 patients, 128 cases (94.81%) manifested arytenoid dislocation, 7 cases (5.19%) vocal cord paralysis. The study showed that the vocal cord dyskinesia associated with anatomic or pathological condition of patients and technical skills of anesthetists (with intubation difficulty) accounted for 76.30%. The patients with relative emaciated body or neck accounted for 90.62% in cases without intubation difficulty. Age had no significant analytical relationship with vocal cord dyskinesia. Prolonged intubation (endotracheal tube retention over 12 hours) was accounted for only 17.64%. The incidence of vocal cord dyskinesia was nearly 0.5% in patients underwent cardio-thoracic surgery, accounting for 59.26% of all the patients. There are two major causes of vocal cord dyskinesia: arytenoid dislocation and vocal cord paralysis, and the rate of vocal cord dyskinesia could be reduced by the improvement of technical skill of anesthetists and/or sufficient attention to the intubation condition of patients.
Tansatit, Tanvaa; Apinuntrum, Prawit; Phetudom, Thavorn
Preparing students to perform specific procedures on patients presents a challenge of student confidence in performing these tasks. This descriptive study determined the ability of the medical students to perform a basic clinical task after a short hands-on training workshop in cadavers. This basic procedural skills training was an attempt for developing conceptual understanding and increasing procedural skills in endotracheal intubation of the medical students. The students were trained to perform two different endotracheal intubations, uncomplicated intubation, and a traumatic difficult airway scenario. The training session consisted of two methods of endotracheal intubation, oral intubations using direct laryngoscopy (DL) in two cadavers with uncomplicated airway and the Flexible Snake Scope camera (FSSC) assisted nasal intubation procedures in two cadavers simulated trauma victims with difficult airway. In the assessment session, the students performed one timed trial with each device. All four cadavers were changed but the scenarios were the same. The groups of the medical students were randomly assigned to perform the tasks in one of two cadavers of the two scenarios. Thirty-two medical students participated in this training and assessment. The training session and the assessment lasted five hours and three hours respectively. No student was asked to perform the second trial. The average time for successful intubation with DL was 32.7 seconds (SD, 13.8 seconds) and for FSSC was 127.0 seconds (SD, 32.6 seconds). The intubation failure rate was 0% for the entire study. The medical students have the ability to accomplish a basic clinical task after a short hands-on training workshop.
Chopra, Vanilla; Mehta, Nandita; Dar, Mohd Reidwan
Enlarged thyroid gland with retrosternal extension has an increased incidence of difficult intubation, and it poses real airway challenge for the anesthesiologists. Here, we present a case of successful management of a difficult airway in a female patient of enlarged thyroid gland, planned for open reduction and internal fixation of the upper end of humerus. Endotracheal intubation was achieved after deliberate insertion of an endotracheal tube in esophagus. The patient was extubated over a ventilating bougie, with uneventful postoperative course. PMID:29284880
Boonmak, S; Boonmak, P; Bunsaengjaroen, P; Srichaipanha, S
To evaluate disposable LMA for endotracheal intubation using the FOB guidance and blind techniques. The authors included ASA class I-II patients between 15 and 60 years of age, with mouth opening more than 3 cm, scheduled for elective surgery. The authors excluded patients with any history of gastro-esophageal reflux, full stomach or a body weight < 30 kg. All of the patients received standard general anesthesia. After inducing anesthesia, a disposable LMA No. 3 or No. 4 (Soft Seal, Smiths Medical, Portex Inc, USA) was inserted while the patient was in the sniff position. The authors recorded the insertion time, the ease of insertion, the anatomic placement and position. The authors then inserted a flexible endotracheal tube (No. 6.5 for LMA No. 4 and No. 6 for LMA No. 3) and recorded the success rate and the ease of insertion. After three failures, the authors used FOB guidance. Sixty patients were enrolled (32 males). The mean +/- SD age and BMI was 43.2 +/- 13.4 years and 22.6 +/- 3.9, respectively. Most of the patients had a Mallampati of grade I. The mean +/- SD insertion time was 24.6 +/- 16.1 sec. After the FOB evaluation, only 27 patients had an anatomic placement in full view of the glottis. Eighteen patients had vocal cords in the middle part of the opening. The success rate of blind endotracheal intubation was 5 percent (95%CI 1.0-13.9) (3/60); while the success rate with FOB guidance was 85 percent (95%CI 73.4-92.9). A disposable laryngeal mask airway (Soft Seal) for blind endotracheal intubation had a low success rate, but it could be used more successfully with FOB guidance.
Wallenstein, Matthew B.; Birnie, Krista L.; Arain, Yassar H.; Yang, Wei; Yamada, Nicole K.; Huffman, Lynne C.; Palma, Jonathan P.; Chock, Valerie Y.; Shaw, Gary M.; Stevenson, David K.
OBJECTIVE To quantify the importance of successful endotracheal intubation on the first attempt among extremely low birth weight (ELBW) infants who require resuscitation after delivery. STUDY DESIGN A retrospective chart review was conducted for all ELBW infants ≤1000 g born between January 2007 and May 2014 at a level IV neonatal intensive care unit. Infants were included if intubation was attempted during the first five minutes of life, or if intubation was attempted during the first 10 minutes of life with heart rate < 100. The primary outcome was death or neurodevelopmental impairment. The association between successful intubation on the first attempt and the primary outcome was assessed using multivariable logistic regression with adjustment for birth weight, gestational age, gender, and antenatal steroids. RESULTS The study sample included 88 ELBW infants. Forty-percent were intubated on the first attempt and 60% required multiple intubation attempts. Death or neurodevelopmental impairment occurred in 29% of infants intubated on the first attempt, compared to 53% of infants that required multiple attempts, adjusted odds ratio 0.4 (95% confidence interval 0.1 - 1.0), p < 0.05. CONCLUSION Successful intubation on the first attempt is associated with improved neurodevelopmental outcomes among ELBW infants. This study confirms the importance of rapid establishment of a stable airway in ELBW infants requiring resuscitation after birth and has implications for personnel selection and role assignment in the delivery room. PMID:26540244
Shukla, Aparna; Misra, Shilpi
Clinical need for a nondepolarizing agent with a rapid onset time and a brief duration of action has led to the development of rocuronium bromide. The aim of this study was to evaluate optimal dose of rocuronium bromide for intubation and to compare the onset time, duration of action, intubating conditions, and hemodynamic effects of two doses of rocuronium bromide. A prospective, randomized, double-blind study. All the patients were divided in a randomized, double-blind fashion into two groups of twenty patients each. Group I patients received rocuronium bromide 0.6 mg/kg intravenously and intubated at 60 s, Group II patients received rocuronium bromide 0.9 mg/kg and intubated at 60 s. The neuromuscular block was assessed using single twitch stimulation of 0.1 Hz at adductor pollicis muscle of hand at every 10 s. The results were compiled and analyzed statistically using Chi-square test for qualitative data and Student's t -test for quantitative data. Time of onset was significantly shorter ( P < 0.01) and duration of action was prolonged ( P < 0.001) for Group II as compared to Group I. The intubating conditions were (excellent + good) in 100% patients of Group II and (excellent + good) in 80% of Group I. There was no significant change in pulse rate and mean arterial pressure from the baseline value after the administration of muscle relaxants in either of the two groups. Rocuronium bromide 0.9 mg/kg is a safer alternative to rocuronium bromide 0.6 mg/kg for endotracheal intubation with shorter time of onset and better intubating conditions.
Hatch, L. Dupree; Grubb, Peter H.; Lea, Amanda S.; Walsh, William F.; Markham, Melinda H.; Whitney, Gina M.; Slaughter, James C.; Stark, Ann R.; Ely, E. Wesley
Objective To determine the rate of adverse events associated with endotracheal intubation in newborns and modifiable factors contributing to these events. Study design We conducted a prospective, observational study in a 100-bed, academic, level IV Neonatal Intensive Care Unit (NICU) from September 2013 through June 2014. We collected data on intubations using standardized data collection instruments with validation by medical record review. Intubations in the delivery or operating rooms were excluded. The primary outcome was an intubation with any adverse event. Adverse events were defined and tracked prospectively as non-severe or severe. We measured clinical variables including number of attempts to successful intubation and intubation urgency (elective, urgent or emergent). We used logistic regression models to estimate the association of these variables with adverse events. Results During the study period, 304 intubations occurred in 178 infants. Data were available for 273 intubations (90%) in 162 patients. Adverse events occurred in 107 (39%) intubations with non-severe and severe events in 96 (35%) and 24 (8.8%) intubations, respectively. Increasing number of intubation attempts (odds ratio [OR] 2.1, 95% confidence intervals [CI], 1.6–2.6) and emergent intubations (OR 4.7, 95% CI, 1.7– 13) were predictors of adverse events. The primary cause of emergent intubations was unplanned extubation (62%). Conclusion Adverse events are common in the NICU, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety. PMID:26541424
Tong, You-liang; Sun, Ming; Wang, Zhen; Li, Bin; Xie, Jue; Ye, Hui
To examine the effect of a newly-developed tracheal detecting-bulb (TDB) in preventing the spray of contaminants in patients' exhalent during emergency endotracheal intubation procedure. 62 emergency patients (male or female, age 21-73 years, weight 47-83 kg, with different levels of consciousness and spontaneous breathing) were randomly divided into two groups (n =31 each) to receive endotracheal intubation by an anesthesiologist with more than 17 years of experience, with (TDB group) or without (control group) a TDB connected to the tracheal tubing. Records were taken regarding the patient's coughing, expansion / contraction of the TDB, the operator's feeling of the patient's exhalent on his face / neck and the contamination of these areas by blood / secretions from the patients in the due course. In TDB group, expansion / contraction of TDB occurred in all cases, but the operator felt no exhalent in any of them. In 9 cases the patients coughed but the operator was contaminated only in 2 cases. While in control group, the patients' exhalent was felt in 16 cases. Coughing were recorded in 7 cases, and the operator was contaminated in 11 cases. In comparison with the control group, TDB group had significantly lower(both P < 0.05), incidence in feeling the exhalent (0 vs. 16), and contamination by blood or secretions (2 vs. 11) although the two groups had no significant difference in the incidence of coughing (9 vs. 7, P > 0.05). TDB can play an important role in blocking the spray of contaminants in patients' exhalent during endotracheal intubation.
Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald
Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH 2 O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH 2 O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. We analyzed data for 55 patients. There was a mean age of 57 years (range 18-90). The mean ETT cuff pressure was 70 (95% CI= [61-80]) cmH 2 O. The mean lies 40 cmH 2 O above the maximum accepted value of 30 cmH 2 O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH 2 O, the maximum pressure on the analog gauge. Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow. Hospital and EMS providers should
Mirzazadeh, Azim; Ostadrahimi, Nima; Ghalandarpoorattar, Seyedeh Mojgan; Asghari, Fariba
This study was done to explore the views of patients and their companions concerning endotracheal intubation training on newly deceased patients and the necessity of obtaining their consent in this regard. In this cross-sectional descriptive analytical study, we used a questionnaire to collect data through structured interviews conducted by the researcher on patient discharge day. A convenient sample of over 18 year old patients hospitalized at a teaching hospital were enrolled, and after receiving patient consent, one of each patient’s companions was enrolled in the study as well. In this study, 150 of the approached patients agreed to participate (response rate = 85.0%); of those, 92 (61.3%) allowed their companions to be enrolled as well. Eighty-three persons (55.3%) in the patient group and 68 persons (73.9%) in the companion group agreed to have endotracheal intubation training on their own bodies after death. Among these consenting patients and companions, 75.9% (n = 63) and 91.2% (n = 62) believed it was necessary to acquire patient consent for this procedure. Obtaining relatives’ consent was thought to be necessary by 69.9% (n = 72) of the patients and 72.1% (n = 49) of the companions, even when there was patient prior consent. Therefore it seems that asking the patient’s consent for doing educational procedures on their dead body is crucial. PMID:25512826
Mirzazadeh, Azim; Ostadrahimi, Nima; Ghalandarpoorattar, Seyedeh Mojgan; Asghari, Fariba
This study was done to explore the views of patients and their companions concerning endotracheal intubation training on newly deceased patients and the necessity of obtaining their consent in this regard. In this cross-sectional descriptive analytical study, we used a questionnaire to collect data through structured interviews conducted by the researcher on patient discharge day. A convenient sample of over 18 year old patients hospitalized at a teaching hospital were enrolled, and after receiving patient consent, one of each patient's companions was enrolled in the study as well. In this study, 150 of the approached patients agreed to participate (response rate = 85.0%); of those, 92 (61.3%) allowed their companions to be enrolled as well. Eighty-three persons (55.3%) in the patient group and 68 persons (73.9%) in the companion group agreed to have endotracheal intubation training on their own bodies after death. Among these consenting patients and companions, 75.9% (n = 63) and 91.2% (n = 62) believed it was necessary to acquire patient consent for this procedure. Obtaining relatives' consent was thought to be necessary by 69.9% (n = 72) of the patients and 72.1% (n = 49) of the companions, even when there was patient prior consent. Therefore it seems that asking the patient's consent for doing educational procedures on their dead body is crucial.
Chavan, S G; Gangadharan, S; Gopakumar, A K
The effects of rocuronium at two different doses, that is, 0.6 mg/kg (2 × ED95) and 0.9 mg/kg (3 × ED95), were compared with succinylcholine (2 mg/kg) when used for endotracheal intubation in adult patients for elective surgeries under general anesthesia. Ninety patients were divided into three groups of 30 each. Groups A, B received injection rocuronium at 0.6 mg/kg, 0.9 mg/kg respectively and Group C received succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared. To compare the statistical difference in the age, weight, height of the study subjects, onset of action of relaxant, intubation conditions, time taken to intubate, and duration of action analysis of variance and unpaired t -test were used. The onset time was considerably shorter with rocuronium 0.9 mg/kg than 0.6 mg/kg. The onset time of rocuronium 0.9 mg/kg was found to be significantly longer than succinylcholine 2 mg/kg. Time taken to intubate was shortest with succinylcholine 2 mg/kg. The time taken to intubate with the rocuronium 0.9 mg/kg was found to be comparable to that of rocuronium 0.6 mg/kg. Intubation score of rocuronium 0.9 mg/kg was the best (17.75), which was comparable with succinylcholine. However, the intubation score obtained with rocuronium 0.6 mg/kg was inferior. Duration of action was shortest with succinylcholine. The duration of action is prolonged when the dose of rocuronium is increased from 0.6 to 0.9 mg/kg. Rapid sequence induction of anesthesia with propofol and fentanyl, succinylcholine allowed a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium. However, the technique of using a large dose of rocuronium to achieve perfect conditions for tracheal intubation may have application whenever succinylcholine is relatively contraindicated.
Schuerner, Philipp; Grande, Bastian; Piegeler, Tobias; Schlaepfer, Martin; Saager, Leif; Hutcherson, Matthew T; Spahn, Donat R; Ruetzler, Kurt
Sufficient ventilation and oxygenation through proper airway management is essential in patients undergoing cardio-pulmonary resuscitation (CPR). Although widely discussed, securing the airway using an endotracheal tube is considered the standard of care. Endotracheal intubation may be challenging and causes prolonged interruption of chest compressions. Videolaryngoscopes have been introduced to better visualize the vocal cords and accelerate intubation, which makes endotracheal intubation much safer and may contribute to intubation success. Therefore, we aimed to compare hands-off time and intubation success of direct laryngoscopy with videolaryngoscopy (C-MAC, Karl Storz, Tuttlingen, Germany) in a randomized, cross-over manikin study. Twenty-six anesthesia residents and twelve anesthesia consultants of the University Hospital Zurich were recruited through a voluntary enrolment. All participants performed endotracheal intubation using direct laryngoscopy and C-MAC in a random order during ongoing chest compressions. Participants were strictly advised to stop chest compression only if necessary. The median hands-off time was 1.9 seconds in direct laryngoscopy, compared to 3 seconds in the C-MAC group. In direct laryngoscopy 39 intubation attempts were recorded, resulting in an overall first intubation attempt success rate of 97%, compared to 38 intubation attempts and 100% overall first intubation attempt success rate in the C-MAC group. As a conclusion, the results of our manikin-study demonstrate that video laryngoscopes might not be beneficial compared to conventional, direct laryngoscopy in easily accessible airways under CPR conditions and in experienced hands. The benefits of video laryngoscopes are of course more distinct in overcoming difficult airways, as it converts a potential "blind intubation" into an intubation under visual control.
This study was performed retrospectively to evaluate the incidence of documented vocal fold injury as a result of elective endotracheal intubation during general surgical procedures. Medical record review was performed at a single institution and all surgical cases reviewed which required endotracheal intubation in the nonemergent setting between April 1, 2003 and August, 31, 2007. Cases with unexpected and documented vocal fold immobility postoperatively formed the study cohort, and data were gathered regarding diagnosis and procedures performed. Of 23,010 general surgery cases performed during the study period, only seven documented cases of vocal fold paralysis were discovered (0.03%). There were five women and two men in the group; all were adults. Only one patient had a primary diagnosis related to the head and neck. Comorbidities were recorded as well, but there were no statistically significant patterns discerned. Furthermore, during the study period, a total of 31 patients overall (both surgical and nonsurgical) were admitted who carried a primary diagnosis of vocal fold paralysis. Therefore, the study cohort therefore constituted 22.6% of this total. Finally, cohort patients spent a total of 150 days in hospital during the study period; this length of stay (an average of 16.7 hospital days per patient) was significantly longer than the average of 5.1 days, presumably at least in part related to the vocal paralysis. Copyright 2010 The Voice Foundation. Published by Mosby, Inc. All rights reserved.
Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald
Introduction Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. Methods We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. Results We analyzed data for 55 patients. There was a mean age of 57 years (range 18–90). The mean ETT cuff pressure was 70 (95% CI= [61–80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge. Conclusion Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow
Hayat, Umar; Lee, Peter J; Ullah, Hamid; Sarvepalli, Shashank; Lopez, Rocio; Vargo, John J
Prophylactic endotracheal intubation (PEI) is often advocated to mitigate the risk of cardiopulmonary adverse events in patients presenting with brisk upper GI bleeding (UGIB). However, the benefit of such a measure remains controversial. Our study aimed to compare the incidence of cardiopulmonary unplanned events between critically ill patients with brisk UGIB who underwent endotracheal intubation versus those who did not. Patients aged 18 years or older who presented at Cleveland Clinic between 2011 and 2014 with hematemesis and/or patients with melena with consequential hypovolemic shock were included. The primary outcome was a composite of several cardiopulmonary unplanned events (pneumonia, pulmonary edema, acute respiratory distress syndrome, persistent shock/hypotension after the procedure, arrhythmia, myocardial infarction, and cardiac arrest) occurring within 48 hours of the endoscopic procedure. Propensity score matching was used to match each patient 1:1 in variables that could influence the decision to intubate. These included Glasgow Blatchford Score, Charleston Comorbidity Index, and Acute Physiology and Chronic Health Evaluation scores. Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices. PEI before an EGD for brisk UGIB in critically ill patients is associated with an increased risk of unplanned cardiopulmonary events. The benefits and risks of intubation should be carefully weighed when considering airway protection before an EGD in this group of patients. Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
Truszewski, Zenon; Krajewski, Paweł; Fudalej, Marcin; Smereka, Jacek; Frass, Michael; Robak, Oliver; Nguyen, Bianka; Ruetzler, Kurt; Szarpak, Lukasz
Abstract Background: Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR. Methods: ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario. Results: The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5–22] sec, when compared to that of sETT at 21.5 [IQR, 20–25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5–24.5] sec (p < .001) and sETT was 27 [IQR, 24.5–31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19–25.5] sec for the ETView and 42.5 [IQR, 35–49.5] sec for sETT. Conclusions: In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were
Sitzwohl, Christian; Langheinrich, Angelika; Schober, Andreas; Krafft, Peter; Sessler, Daniel I; Herkner, Harald; Gonano, Christopher; Weinstabl, Christian; Kettner, Stephan C
To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity. Prospective randomised blinded study. Department of anaesthesia in tertiary academic hospital. 160 consecutive patients (American Society of Anesthesiologists category I or II) aged 19-75 scheduled for elective gynaecological or urological surgery. Patients were randomly assigned to eight study groups. In four groups, an endotracheal tube was fibreoptically positioned 2.5-4.0 cm above the carina, whereas in the other four groups the tube was positioned in the right mainstem bronchus. The four groups differed in the bedside test used to verify the position of the endotracheal tube. To determine whether the tube was properly positioned in the trachea, in each patient first year residents and experienced anaesthetists were randomly assigned to independently perform bilateral auscultation of the chest (auscultation); observation and palpation of symmetrical chest movements (observation); estimation of the position of the tube by the insertion depth (tube depth); or a combination of all three (all three). Correct and incorrect judgments of endotracheal tube position. 160 patients underwent 320 observations by experienced and inexperienced anaesthetists. First year residents missed endobronchial intubation by auscultation in 55% of cases and performed significantly worse than experienced anaesthetists with this bedside test (odds ratio 10.0, 95% confidence interval 1.4 to 434). With a sensitivity of 88% (95% confidence interval 75% to 100%) and 100%, respectively, tube depth and the three tests combined were significantly more sensitive for detecting endobronchial intubation than auscultation (65%, 49% to 81%) or observation(43%, 25% to 60%) (P<0.001). The four tested methods had the same specificity for ruling out endobronchial intubation (that is, confirming correct tracheal intubation). The average correct tube insertion depth was
Background In emergency settings, verification of endotracheal tube (ETT) location is important for critically ill patients. Ignorance of oesophageal intubation can be disastrous. Many methods are used for verification of the endotracheal tube location; none are ideal. Quantitative waveform capnography is considered the standard of care for this purpose but is not always available and is expensive. Therefore, this feasibility study is conducted to compare a cheaper alternative, bedside upper airway ultrasonography to waveform capnography, for verification of endotracheal tube location after intubation. Methods This was a prospective, single-centre, observational study, conducted at the HRPB, Ipoh. It included patients who were intubated in the emergency department from 28 March 2012 to 17 August 2012. A waiver of consent had been obtained from the Medical Research Ethics Committee. Bedside upper airway ultrasonography was performed after intubation and compared to waveform capnography. Specificity, sensitivity, positive and negative predictive value and likelihood ratio are calculated. Results A sample of 107 patients were analysed, and 6 (5.6%) had oesophageal intubations. The overall accuracy of bedside upper airway ultrasonography was 98.1% (95% confidence interval (CI) 93.0% to 100.0%). The kappa value (Κ) was 0.85, indicating a very good agreement between the bedside upper airway ultrasonography and waveform capnography. Thus, bedside upper airway ultrasonography is in concordance with waveform capnography. The sensitivity, specificity, positive predictive value and negative predictive value of bedside upper airway ultrasonography were 98.0% (95% CI 93.0% to 99.8%), 100% (95% CI 54.1% to 100.0%), 100% (95% CI 96.3% to 100.0%) and 75.0% (95% CI 34.9% to 96.8%). The likelihood ratio of a positive test is infinite and the likelihood ratio of a negative test is 0.0198 (95% CI 0.005 to 0.0781). The mean confirmation time by ultrasound is 16.4 s. No adverse effects
Moore, Jaime E; Hu, Amanda; Rutt, Amy; Green, Parmis; Hawkshaw, Mary; Sataloff, Robert T
Vocal fold injury is a well-know complication of intubation, with rates reported as high as 69%. Laryngology textbooks recommend the use of a small endotracheal tube (ETT) to help avoid these complications and optimize visualization. Case reports have suggested that the rigid stylet can lead to laryngeal injury. Given the additional risks, intubation without the stylet is our preferred practice. There is limited documentation in the literature regarding this viewpoint. Our study investigated the feasibility of and potential barriers to intubation using 5.0 ETT without a stylet. Prospective study. Consecutive adult patients undergoing laryngeal surgery were recruited for intubation with a 5.0 ETT without a stylet. Demographic data, specialty and training level of the intubator, and factors that would predict a difficult intubation were recorded. Descriptive statistical analysis was performed. Findings of the participants (n = 67) included average American Society of Anesthesiologists (ASA) physical status classification (2.2), average Mallampati score (1.7), average Cormack-Lehane grade (1.5), and average body mass index (28.0). Five patients (7.4%) required intubation using a stylet, and one of these five participants was intubated initially with a stylet. Of these five participants, 80% required use of a GlideScope (P < .001), and they had significantly higher ASA classification (P = .047) and number of intubation attempts (P = .042). One patient sustained an oropharyngeal injury during intubation with a stylet. No participants had laryngeal injury. Most patients can be intubated successfully using a 5.0 ETT without a stylet. There were no cases of laryngeal trauma with this technique. 2b. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.
Nambiar, M P; Gordon, R K; Moran, T S; Richards, S M; Sciuto, A M
ABSTRACT Guinea pigs are considered as the animal model of choice for toxicology and medical countermeasure studies against chemical warfare agents (CWAs) and toxic organophosphate pesticides because of the low levels of carboxylesterase compared to rats and mice. However, it is difficult to intubate guinea pigs without damaging the larynx to perform CWA inhalation experiments. We describe an easy technique of intubation of guinea pigs for accurate endotracheal placement of the intubation tube. The technique involves a speculum made by cutting the medium-size ear speculum in the midline leaving behind the intact circular connector to the otoscope. Guinea pigs were anesthetized with Telazol/meditomidine, the tongue was pulled using blunt forceps, and an otoscope attached with the specially prepared speculum was inserted gently. Insertion of the speculum raises the epiglottis and restrains the movements of vocal cord, which allows smooth insertion of the metal stylet-reinforced intubation tube. Accurate endotracheal placement of the intubation tube was achieved by measuring the length from the tracheal bifurcation to vocal cord and vocal cord to the upper front teeth. The average length of the trachea in guinea pigs (275 +/- 25 g) was 5.5 +/- 0.2 cm and the distance from the vocal cord to the front teeth was typically 3 cm. Coinciding an intubation tube marked at 6 cm with the upper front teeth accurately places the intubation tube 2.5 cm above the tracheal bifurcation. This simple method of intubation does not disturb the natural flora of the mouth and causes minimum laryngeal damage. It is rapid and reliable, and will be very valuable in inhalation exposure to chemical/biological warfare agents or toxic chemicals to assess respiratory toxicity and develop medical countermeasures.
Purpose Subglottic stenosis can result from endotracheal tube injury. The mechanism by which this occurs, however, is not well understood. The purpose of this study was to examine the role of angiogenesis, hypoxia and ischemia in subglottic mucosal injury following endotracheal intubation. Methods Six Yorkshire piglets were randomized to either a control group (N=3, ventilated through laryngeal mask airway for corrosion casting) or accelerated subglottic injury group through intubation and induced hypoxia as per a previously described model (N=3). The vasculature of all animals was injected with liquid methyl methacrylate. After polymerization, the surrounding tissue was corroded with potassium hydroxide. The subglottic region was evaluated using scanning electron microscopy looking for angiogenic and hypoxic or degenerative features and groups were compared using Mann–Whitney tests and Friedman’s 2-way ANOVA. Results Animals in the accelerated subglottic injury group had less overall angiogenic features (P=.002) and more overall hypoxic/degenerative features (P=.000) compared with controls. Amongst angiogenic features, there was decreased budding (P=.000) and a trend toward decreased sprouting (P=.037) in the accelerated subglottic injury group with an increase in intussusception (P=.004), possibly representing early attempts at rapid revascularization. Amongst hypoxic/degenerative features, extravasation was the only feature that was significantly higher in the accelerated subglottic injury group (P=.000). Conclusions Subglottic injury due to intubation and hypoxia may lead to decreased angiogenesis and increased blood vessel damage resulting in extravasation of fluid and a decreased propensity toward wound healing in this animal model. PMID:24401165
Carlson, Jestin N; Das, Samarjit; De la Torre, Fernando; Frisch, Adam; Guyette, Francis X; Hodgins, Jessica K; Yealy, Donald M
Adequate visualization of the glottic opening is a key factor to successful endotracheal intubation (ETI); however, few objective tools exist to help guide providers' ETI attempts toward the glottic opening in real-time. Machine learning/artificial intelligence has helped to automate the detection of other visual structures but its utility with ETI is unknown. We sought to test the accuracy of various computer algorithms in identifying the glottic opening, creating a tool that could aid successful intubation. We collected a convenience sample of providers who each performed ETI 10 times on a mannequin using a video laryngoscope (C-MAC, Karl Storz Corp, Tuttlingen, Germany). We recorded each attempt and reviewed one-second time intervals for the presence or absence of the glottic opening. Four different machine learning/artificial intelligence algorithms analyzed each attempt and time point: k-nearest neighbor (KNN), support vector machine (SVM), decision trees, and neural networks (NN). We used half of the videos to train the algorithms and the second half to test the accuracy, sensitivity, and specificity of each algorithm. We enrolled seven providers, three Emergency Medicine attendings, and four paramedic students. From the 70 total recorded laryngoscopic video attempts, we created 2,465 time intervals. The algorithms had the following sensitivity and specificity for detecting the glottic opening: KNN (70%, 90%), SVM (70%, 90%), decision trees (68%, 80%), and NN (72%, 78%). Initial efforts at computer algorithms using artificial intelligence are able to identify the glottic opening with over 80% accuracy. With further refinements, video laryngoscopy has the potential to provide real-time, direction feedback to the provider to help guide successful ETI.
Muramatsu, Keita; Matsuo, Koichiro; Kawai, Yusuke; Yamamoto, Tsukasa; Hara, Yoshitaka; Shimomura, Yasuyo; Yamashita, Chizuru; Nishida, Osamu
Endotracheal intubation of critically ill patients increases the risk of aspiration pneumonia, which can be reduced by regular oral care. However, the rinsing of the residual oral contaminants after mechanical cleaning carries the risk of aspirating the residue during the intubation period. Removing the contaminants by wiping with mouth wipes could be an alternative to rinsing with water because of no additional fluid. This study tested: (i) the amount of oral bacteria during endotracheal intubation and after extubation; and (ii) the changes in the bacterial count during oral care procedures. Thirty-five mechanically ventilated patients in the intensive care unit were enrolled. The amount of bacteria on the dorsal tongue surface was counted before and following oral care and then after the elimination of contaminants either by rinsing with water and suctioning or by wiping with mouth wipes. The oral bacterial amount was compared statistically between the intubation and extubation status and among set time points during the oral care procedure. The oral bacterial count was significantly decreased after extubation. During the oral care procedure, the oral bacterial amount was significantly lower after eliminating the contaminants either by rinsing or wiping, with no remarkable difference between the elimination techniques. The findings suggest that the oral bacterial amount is elevated during endotracheal intubation, which could increase the risk of aspiration pneumonia. The significant reduction in the bacterial count by wiping indicates that it might be a suitable alternative to rinsing for mechanically ventilated patients. © 2018 Japan Academy of Nursing Science.
Lingappan, Krithika; Arnold, Jennifer L; Fernandes, Caraciolo J; Pammi, Mohan
Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates. We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies. RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy. Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence. The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427
Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators.
Kim, Jong Won; Park, Sang O; Lee, Kyeong Ryong; Hong, Dae Young; Baek, Kwang Je; Lee, Young Hwan; Lee, Jeong Hun; Choi, Pil Cho
This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope(®)) by experienced intubators (>50 successful ETIs). This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices. Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL). The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions. Clinical Research Information Service (CRIS) in South Korea KCT0000849. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Wu, Meng-Ruey; Hsiao, Chia-Ying; Cheng, Chun-Han; Liao, Feng-Ching; Chao, Chuan-Lei; Chen, Chun-Yen; Yeh, Hung-I
Introduction Paraquat poisoning can result in dysfunction of multiple organs, and pulmonary fibrosis with respiratory failure is the major cause of mortality. For terminally ill patients, some life-prolonging treatments can be non-beneficial treatments (NBT). The objective of this study was to determine if intubation is a NBT for patients with respiratory failure due to paraquat poisoning. Methods The study included 68 patients with respiratory failure due to paraquat poisoning. Patients were hospitalized at MacKay Memorial Hospital, Taitung Branch, Taiwan, between 2005 to April 2016. Composite outcomes of intra-hospital mortality, the rate of do-not-resuscitate (DNR) orders, prescribed medications, length of stay, and medical costs were recorded and compared between the do-not-intubate (DNI) group and endotracheal intubation (EI) group. Results Intra-hospital mortality rate for the entire population was 100%. There were significantly more patients with DNR orders in the DNI group (P = 0.007). There were no differences in the length of hospital stay. However, patients in DNI group had significantly less vasopressor use and more morphine use, shorter time in the intensive care unit, and fewer medical costs. Conclusion The procedure of intubation in patients with respiratory failure due to paraquat poisoning can be considered inappropriate life-prolonging treatment. PMID:29590187
Szarpak, Lukasz; Smereka, Jacek; Ladny, Jerzy R
In the difficult airway, the intubation skills are critically important. In selected cases, particularly in airway edema, laryngeal or tongue edema, endotracheal intubation can turn out very difficult, and repeated attempts may even worsen the airway edema, causing trauma and bleeding, and finally leading to complete airway obstruction and inability to ventilate the patient. The aim of the study was to compare the efficacy of endotracheal intubation performed by novice physicians using a standard Macintosh laryngoscope and an Intubrite videolaryngoscope. The study was designed as a prospective, randomized, crossover, simulation study and continues our research assessing the effectiveness of selected endotracheal intubation techniques in prehospital settings. All participants were experienced with the Macintosh direct laryngoscope but remained novice to videolaryngoscopy. Instructions on the correct use of the Macintosh and Intubrite laryngoscopes were given before the procedure, and all the 30 novice physicians were allowed to practice at least 10 times before the study on manikin with normal airways. We employed an airway manikin (Trucorp Airsim Bronchi; Trucorp Ltd., Belfast, Northern Ireland) to simulate difficult airway, with was obtained by inflating the tongue with 50mL of air. The participants were asked to perform tracheal intubation using an endotracheal tube with 7.5mm of internal diameter (Portex; Smiths Medical, Hythe, UK) through the vocal cords, applying either a conventional Macintosh laryngoscope with a size 3 blade (MAC; Mercury Medical, Clearwater, FL, USA) or the Intubrite videolaryngoscope, also with a Macintosh No. 3 blade (INT; Intubrite Llc, Vista, CA, USA). In both intubation techniques, a guide stylet (Rusch Inc., Duluth, GA, USA) was introduced into the endotracheal tube in order to obtain a C-shape curve to facilitate tracheal intubation. Each participating physician was randomly assigned to three attempts of tracheal intubation with each
Ho, Anthony M H; Flavin, Michael P; Fleming, Melinda L; Mizubuti, Glenio Bitencourt
Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Buhari, Faiza Sulaiman; Selvaraj, Venkatesh
Background and Aims: Earlier studies have shown that the type of laryngoscope blade influences the degree of hemodynamic response to endotracheal intubation. The aim of the study was to evaluate the hemodynamic response to oral endotracheal intubation with C-MAC laryngoscopy and McCoy laryngoscopy compared to that of Macintosh laryngoscopy in adult patients under general anesthesia. Material and Methods: This is a prospective randomized parallel group study. Ninety American Society of Anesthesiologists I patients were randomly allotted into three groups. Group A – Macintosh laryngoscopy (control group). Group B – laryngoscopy with McCoy laryngoscope. Group C – laryngoscopy with C-MAC video laryngoscope. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were monitored at baseline (just before induction), just before intubation (T0), 1 min (T1), 3 min (T3), 5 min (T5), and 10 min (T10) after intubation. Intergroup comparison of study parameters was done by unpaired sample t-test for normal data and Mann-Whitney U-test for skewed data. For within-group comparison, the repeated measures of ANOVA for normal data and Friedman followed by Wilcoxon signed rank test for skewed data were performed. Results: In C-MAC group, the HR was significantly higher than the Macintosh group at 3 min after intubation, whereas SBP, DBP, and MAP were significantly higher at 1 min. McCoy group showed a similar response compared to Macintosh group at all time intervals. Conclusion: C-MAC video laryngoscope has a comparatively greater hemodynamic response than Macintosh laryngoscope. PMID:28096584
Truszewski, Zenon; Krajewski, Paweł; Fudalej, Marcin; Smereka, Jacek; Frass, Michael; Robak, Oliver; Nguyen, Bianka; Ruetzler, Kurt; Szarpak, Lukasz
Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR. ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario. The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5-22] sec, when compared to that of sETT at 21.5 [IQR, 20-25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5-24.5] sec (p < .001) and sETT was 27 [IQR, 24.5-31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19-25.5] sec for the ETView and 42.5 [IQR, 35-49.5] sec for sETT. In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were improved with the ETView. The time to glottis view, tube insertion
Chou, Hao-Chang; Chong, Kah-Meng; Sim, Shyh-Shyong; Ma, Matthew Huei-Ming; Liu, Shih-Hung; Chen, Nai-Chuan; Wu, Meng-Che; Fu, Chia-Ming; Wang, Chih-Hung; Lee, Chien-Chang; Lien, Wan-Ching; Chen, Shyr-Chyr
This study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). We performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air-mucosa (A-M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A-M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A-M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. Among the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95% CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively. Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Jiao, Dechao; Xie, Na; Han, Xinwei; Wu, Gang
To evaluate the feasibility and effectiveness of emergency endotracheal intubation (EEI) under fluoroscopy guidance for patients with acute dyspnea or asphyxia. From October 2011 to October 2014, of 1521 patients with acute dyspnea or asphyxia who required EEI in 6 departments, 43 patients who experienced intubation difficulty or failure were entered into this study. Data on technical success, procedure time, complications, and clinical outcome were collected. The pulse oxygen saturation and Hugh-Jones classification changes were analyzed. Fluoroscopy-guided EEI was technically successful in all patients. Acute dyspnea had resolved in all patients with clinical success rate 100% after the procedure. There were no serious complications during or after the procedure. The pulse oxygen saturation and Hugh-Jones classification showed significant increase after EEI (P < .05). Further treatments, including tracheal stents (n = 21), surgical resection (n = 16), palliative tracheotomy (n = 4), and bronchoscopic treatment (n = 2), were performed 1 to 72 hours after EEI. During a mean follow-up period of 13.2 months, 13 patients had died and 30 patients remained alive without dyspnea. Fluoroscopy-guided EEI is a safe and feasible procedure, and may serve as an alternative treatment option for patients when traditional EEI is unsuccessful. Copyright © 2016 Elsevier Inc. All rights reserved.
Hindman, Bradley J.; Santoni, Brandon G.; Puttlitz, Christian M.; From, Robert P.; Todd, Michael M.
Introduction Laryngoscopy and endotracheal intubation in the presence of cervical spine instability may put patients at risk of cervical cord injury. Nevertheless, the biomechanics of intubation (cervical spine motion as a function of applied force) have not been characterized. This study characterized and compared the relationship between laryngoscope force and cervical spine motion using two laryngoscopes hypothesized to differ in force. Methods Fourteen adults undergoing elective surgery were intubated twice (Macintosh, Airtraq). During each intubation, laryngoscope force, cervical spine motion, and glottic view were recorded. Force and motion were referenced to a pre-intubation baseline (stage 1) and were characterized at three stages: stage 2 (laryngoscope introduction); stage 3 (best glottic view); stage 4 (endotracheal tube in trachea). Results Maximal force and motion occurred at stage 3, and differed between the Macintosh and Airtraq: 1) Force: 48.8±15.8 vs. 10.4±2.8 N, respectively; P=0.0001; 2) occiput-C5 extension: 29.5±8.5 vs. 19.1±8.7 degrees, respectively; P=0.0023. Between stages -2 and -3, the motion/force ratio differed between Macintosh and Airtraq: 0.5±0.2 vs. 2.0±1.4 degrees/N, respectively; P=0.0006. Discussion The relationship between laryngoscope force and cervical spine motion is: 1) non-linear and 2) differs between laryngoscopes. Differences between laryngoscopes in motion/force relationships are likely due to: 1) laryngoscope-specific cervical extension needed for intubation, 2) laryngoscope-specific airway displacement/deformation needed for intubation, and 3) cervical spine and airway tissue viscoelastic properties. Cervical spine motion during endotracheal intubation is not directly proportional to force. Low force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion. PMID:24739996
Komatsu, Ryu; Nagata, Osamu; Sessler, Daniel I.; Ozaki, Makoto
Although the difficulty of tracheal intubation in the lateral position has not been systematically evaluated, airway loss during surgery in a laterally positioned patient may have hazardous consequences. We explored whether the intubating laryngeal mask airway (ILMA) facilitates tracheal intubation in patients with normal airway anatomy, i.e., Mallampati grade ≤ 3 and thyromental distance ≥ 5 cm, positioned in the lateral position. And we evaluated whether this technique can be used as a rescue when the airway is lost mid-case in laterally positioned patients with respect to success rate and intubation time. Anesthesia was induced with propofol, fentanyl, and vecuronium in 50 patients undergoing spine surgery for lumbar disk herniation (Lateral) and 50 undergoing other surgical procedures (Supine). Patients having disk surgery (Lateral) were positioned on their right or left sides before induction of general anesthesia, and intubation was performed in that position. Patients in control group (Supine) were anesthetized in supine position, and intubation was performed in that position. Intubation was performed blindly via an ILMA in both groups. The time required for intubation and number and types of adjusting maneuvers employed were recorded. Data were compared by Mann-Whitney U, Fisher’s exact, chi-square, or unpaired t-tests, as appropriate. Data presented as mean (SD). Demographic and airway measures were similar in the two groups, except for mouth opening which was slightly wider in patients in the lateral position: 5.1 (0.9) vs. 4.6 (0.7) cm. The time required for intubation was similar in each group (≈25 s), as was intubation success (96%). We conclude that blind intubation via an ILMA offers a frequent success rate and a clinically acceptable intubation time (< one min) even in the lateral position. Summary Blind intubation via the intubating laryngeal mask airway (ILMA) offers a high success rate and a clinically acceptable intubation time even in
Can High-flow Nasal Cannula Reduce the Rate of Endotracheal Intubation in Adult Patients With Acute Respiratory Failure Compared With Conventional Oxygen Therapy and Noninvasive Positive Pressure Ventilation?: A Systematic Review and Meta-analysis.
Ni, Yue-Nan; Luo, Jian; Yu, He; Liu, Dan; Ni, Zhong; Cheng, Jiangli; Liang, Bin-Miao; Liang, Zong-An
The effects of high-flow nasal cannula (HFNC) on adult patients with acute respiratory failure (ARF) are controversial. We aimed to further determine the effectiveness of HFNC in reducing the rate of endotracheal intubation in adult patients with ARF by comparison to noninvasive positive pressure ventilation (NIPPV) and conventional oxygen therapy (COT). The PubMed, Embase, Medline, and the Cochrane Central Register of Controlled Trials databases, as well as the Information Sciences Institute Web of Science, were searched for all controlled studies that compared HFNC with NIPPV and COT in adult patients with ARF. The primary outcome was the rate of endotracheal intubation; the secondary outcomes were ICU mortality and length of ICU stay. Eighteen trials with a total of 3,881 patients were pooled in our final studies. Except for ICU mortality (I 2 = 67%, χ 2 = 12.21, P = .02) and rate of endotracheal intubation (I 2 = 63%, χ 2 = 13.51, P = .02) between HFNC and NIPPV, no significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with a lower rate of endotracheal intubation (z = 2.55, P = .01) while no significant difference was found in the comparison with NIPPV (z = 1.40, P = .16). As for ICU mortality and length of ICU stay, HFNC did not exhibit any advantage over either COT or NIPPV. In patients with ARF, HFNC is a more reliable alternative than NIPPV to reduce the rate of endotracheal intubation than COT. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
Xu, T; Li, M; Xu, M; Guo, X Y
To compare the efficacy and safety of two different shaping methods for double-lumen endotracheal tube (DLT).DLT was shaped with the rod of a Shikani optical stylet (SOS) with the tracheal orifice aligned with the convex aspect of the distal curvature or the concave aspect of the distal curvature. Patients scheduled for elective thoracic surgery and required intubation with a left-sided DLT were enrolled in this study. They were randomized into two groups. They were intubated with a DLT, which was shaped with the rod of a SOS with its tracheal orifice aligned with the convex aspect of the distal curvature (group T) or the concave aspect of the distal curvature (group U). Time for SOS manipulation, intubation attempts, intubation resistance score, malposition of bronchial intubation, time for fiberoptic bronchoscope (FOB) identification of bronchial placement, total intubation time and oral mucosal or dental injury were recorded. Hoarseness and throat sore of the patients were evaluated 1 hour and 24 hours after surgery. A total of 136 patients completed the study, with 68 in each group. Time for SOS manipulation was significantly shorter in group U [(35.1±6.1) s vs. 39.6±11.8) s, P=0.007]. First attempt success rate did not differ between the groups (92.6% vs.88.2%, P=0.561). Intubation resistance score was significantly lower in group U. Group T had fewer patients who suffered malposition of bronchial intubation than group U (4 vs.13, P=0.020) and cost less time for FOB identification of bronchial placement [(44.1±20.9) s vs.(53.6±29.2) s, P=0.032]. Total intubation time and the incidence of oral mucosal or dental injury did not differ between the groups. The severity and incidence of hoarseness were lower in group U than in group T 1 hour after surgery. The severity and incidence of sore throat were lower in group U than in group T 1 hour and 24 hours postoperatively. When lacing a left-sided DLT using a SOS, shaping the DLT with the tracheal orifice aligned
Gellerfors, Mikael; Svensén, Christer; Linde, Joacim; Lossius, Hans Morten; Gryth, Dan
Securing the airway by endotracheal intubation (ETI) is a key issue in prehospital critical care. Night vision goggles (NVG) are used by personnel operating in low-light environments. We examined the feasibility of an anesthesiologist performed ETI using NVG in a helicopter setting. Twelve anesthesiologists performed ETI on a manikin in an emergency room (ER) setting and two helicopter settings, with randomization to either rotary wing daylight (RW-D) or rotary wing in total darkness using binocular NVG (RW-NVG). Primary endpoint was intubation time. Secondary endpoints included success rate, Cormack-Lehane (CL) score, and subjective difficulty according to the Visual Analoge Scale (VAS). The median intubation time was shorter for the RW-D compared to the RW-NVG setting (16.5 seconds vs. 30.0 seconds; p = 0,03). We found no difference in median intubation time for the ER and RW-D settings (16.8 seconds vs. 16.5 seconds; p = 0.91). For all scenarios, success rate was 100%. CL and VAS varied between the ER setting (CL 1.8, VAS 2.8), RW-D setting (CL 2.0, VAS 3.0), and RW-NVG setting (CL 3.0, VAS 6.5). This study suggests that anesthesiologists successfully and quickly can perform ETI in a helicopter setting both in daylight and in darkness using binocular NVG, but with shorter intubation times in daylight. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.
Hindman, Bradley J; Santoni, Brandon G; Puttlitz, Christian M; From, Robert P; Todd, Michael M
Laryngoscopy and endotracheal intubation in the presence of cervical spine instability may put patients at risk of cervical cord injury. Nevertheless, the biomechanics of intubation (cervical spine motion as a function of applied force) have not been characterized. This study characterized and compared the relationship between laryngoscope force and cervical spine motion using two laryngoscopes hypothesized to differ in force. Fourteen adults undergoing elective surgery were intubated twice (Macintosh, Airtraq). During each intubation, laryngoscope force, cervical spine motion, and glottic view were recorded. Force and motion were referenced to a preintubation baseline (stage 1) and were characterized at three stages: stage 2 (laryngoscope introduction); stage 3 (best glottic view); and stage 4 (endotracheal tube in trachea). Maximal force and motion occurred at stage 3 and differed between the Macintosh and Airtraq: (1) force: 48.8 ± 15.8 versus 10.4 ± 2.8 N, respectively, P = 0.0001; (2) occiput-C5 extension: 29.5 ± 8.5 versus 19.1 ± 8.7 degrees, respectively, P = 0.0023. Between stages 2 and 3, the motion/force ratio differed between Macintosh and Airtraq: 0.5 ± 0.2 versus 2.0 ± 1.4 degrees/N, respectively; P = 0.0006. The relationship between laryngoscope force and cervical spine motion is: (1) nonlinear and (2) differs between laryngoscopes. Differences between laryngoscopes in motion/force relationships are likely due to: (1) laryngoscope-specific cervical extension needed for intubation, (2) laryngoscope-specific airway displacement/deformation needed for intubation, and (3) cervical spine and airway tissue viscoelastic properties. Cervical spine motion during endotracheal intubation is not directly proportional to force. Low-force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion.
Fuchs, G; Schwarz, G; Baumgartner, A; Kaltenböck, F; Voit-Augustin, H; Planinz, W
In patients with lesions of the cervical spine, direct laryngoscopy for endotracheal intubation entails the risk of injuring the spinal cord. In an attempt to avoid this complication, the authors used flexible fiberoptic nasal intubation in a series of 327 patients with cervical lesions undergoing elective neurosurgical procedures. The nasal route was preferred for laryngeal intubation because it is easier than the oral route and a restraining collar or halo device does not impair the intubating maneuver. Bronchoscopic intubation was possible in all patients. In 12 patients (3.6%), anatomic abnormalities prevented transnasal insertion of the endotracheal tube, and transoral fiberoptic intubation was necessary. Endotracheal intubation was graded as slightly difficult in 85 patients (26%). The minimal peripheral oxygen saturation during intubation exceeded 90% in 289 patients (88%). In the other 38 patients, the mean O2 saturation was 84.2+/-4.3% (range, 72-89%). Intubation was well tolerated by all patients and none had recall of the procedure. Cervical stabilizers did not have to be removed for intubation in any patient. None of the patients had postoperative neurologic deficits attributable to the intubation procedure. The authors consider fiberoptic transnasal intubation to be a useful alternative to direct laryngoscopic tracheal intubation in patients undergoing elective surgical procedures on the cervical spine to avoid potential injury to the cervical spinal cord.
Cho, Jin-Hyung; Park, Wonse; Park, Kyeong-Mee; Kim, Seo-Yul
Digital dentistry has influenced many dental procedures, such as three-dimensional (3D) diagnosis and treatment planning, surgical splints, and prosthetic treatments. Patient-specific protective appliances (PSPAs) prevent dental injury during endotracheal intubation. However, the required laboratory work takes time, and there is the possibility of tooth extraction while obtaining the dental impression. In this technical report, we utilized new digital technology for creating PSPAs, using direct intraoral scanners and 3D printers for dental cast fabrication. PMID:28879329
Cho, Jin-Hyung; Park, Wonse; Park, Kyeong-Mee; Kim, Seo-Yul; Kim, Kee-Deog
Digital dentistry has influenced many dental procedures, such as three-dimensional (3D) diagnosis and treatment planning, surgical splints, and prosthetic treatments. Patient-specific protective appliances (PSPAs) prevent dental injury during endotracheal intubation. However, the required laboratory work takes time, and there is the possibility of tooth extraction while obtaining the dental impression. In this technical report, we utilized new digital technology for creating PSPAs, using direct intraoral scanners and 3D printers for dental cast fabrication.
Fu, You; Xi, Xiuming
To investigate the prevalent condition of endotracheal cuff pressure and risk factors for under inflation. A prospective cohort study was conducted. Patients admitted to the Department of Critical Care Medicine of Fuxing Hospital Affiliated to Capital Medical University, who were intubated with a high-volume low-pressure endotracheal tube, and had undergone mechanical ventilation for at least 48 hours, were enrolled. The endotracheal cuff pressure was determined every 8 hours by a manual manometer connected to the distal edge of the valve cuff at 07 : 00, 15 : 00, and 23 : 00. Measurement of the endotracheal cuff pressure was continued until the extubation of endotracheal or tracheostomy tube, or death of the patient. According to the incidence of under inflation of endotracheal cuff, patients were divided into the incidence of under inflation lower than 25% group (lower low cuff pressure group) and higher than 25% group (higher low cuff pressure group). The possible influencing factors were evaluated in the two groups, including body mass index (BMI), size of endotracheal tube, duration of intubation, use of sedative or analgesic, number of leaving from intensive care unit (ICU), the number of turning over the patients, and aspiration of sputum. Logistic regression analysis was used to determine risk factors for under-inflation of the endotracheal cuff. During the study period, 53 patients were enrolled. There were 812 measurements, and 46.3% of them was abnormal, and 204 times (25.1%) of under inflation of endotracheal cuff were found. There were 24 patients (45.3%) in whom the incidence of under inflation rate was higher than 25%. The average of under inflation was 7 (4, 10) times. Compared with the group with lower rate of low cuff pressure, a longer time for intubation was found in group with higher rate of low cuff pressure [hours: 162 (113, 225) vs. 118 (97, 168), Z=-2.034, P=0.042]. There were no differences between the two groups in other factors
Pfeiffer, P; Rudolph, S S; Børglum, J; Isbye, D L
This study compared the time consumption of bilateral lung ultrasound with auscultation and capnography for verifying endotracheal intubation. A prospective, paired, and investigator-blinded study carried out in the operating theatre. Twenty-five adult patients requiring endotracheal intubation were included. During intubation, transtracheal ultrasound was performed to visualize passage of the endotracheal tube. During bag ventilation, bilateral lung ultrasound was performed for the detection of lung sliding as a sign of ventilation simultaneous with capnography and auscultation of the epigastrium and chest. Primary outcome measure was time difference to confirmed endotracheal intubation between ultrasound and auscultation alone. Secondary outcome measure was time difference between ultrasound and auscultation combined with capnography. Both methods verified endotracheal tube placement in all patients. In 68% of patients, endotracheal tube placement was visualized by real-time transtracheal ultrasound. Comparing ultrasound with the combination of auscultation and capnography, there was a significant difference between the two methods. Median time for ultrasound was 40 s [interquartile range (IQR) 35-48 s] vs. 48 s (IQR 45-53 s), P < 0.0001. Mean difference was -7.1 s in favour of ultrasound [95% confidence interval (CI) -9.4--4.8 s]. No significant difference was found between ultrasound compared with auscultation alone. Median time for auscultation alone was 42 s (IQR 37-47 s), P = 0.6, with a mean difference of -0.88 s in favour of ultrasound (95% CI -4.2-2.5 s). Verification of endotracheal tube placement with ultrasound is as fast as auscultation alone and faster than the standard method of auscultation and capnography. © 2011 The Authors. Acta Anaesthesiologica Scandinavica © 2011 The Acta Anaesthesiologica Scandinavica Foundation.
Reicher, Joshua; Reicher, Danielle; Reicher, Murray
Improper positioning of the endotracheal tube during intubation poses a serious health risk to patients. In one prospective study of 219 critically ill patients, 14% required endotracheal tube repositioning after intubation [Brunel et al. Chest 1989; 96: 1043-1045] While a variety of techniques are used to confirm proper tube placement, a chest X-ray is usually employed for definitive verification. Radio frequency identification (RFID) technology, in which an RFID reader emits and receives a signal from an RFID tag, may be useful in evaluating endotracheal tube position. RFID technology has already been approved for use in humans as a safe and effective tool in a variety of applications. The use of handheld RFID detectors and RFID tag-labeled endotracheal tubes could allow for easy and accurate bedside monitoring of endotracheal tube position, once initial proper placement is confirmed.
Truszewski, Zenon; Czyzewski, Lukasz; Smereka, Jacek; Krajewski, Paweł; Fudalej, Marcin; Madziala, Marcin; Szarpak, Lukasz
The aim of the trial was to compare the time parameters for intubation with the use of the Macintosh (MAC) laryngoscope and Pentax AWS-S100 videolaryngoscope (AWS; Pentax Corporation, Tokyo, Japan) with and without chest compression (CC) by paramedics during simulated cardiopulmonary resuscitation in a cadaver model. This was a randomized crossover cadaver trial. Thirty-five paramedics with no experience in videolaryngoscopy participated in the study. They performed intubation in two emergency scenarios: scenario A, normal airway without CC; scenario B, normal airway with continuous CC. The median time to first ventilation with the use of the AWS and the MAC was similar in scenario A: 25 (IQR, 22-27) seconds vs. 24 (IQR, 22.5-26) seconds (P=.072). A statistically significant difference in TTFV between AWS and MAC was noticed in scenario B (P=.011). In scenario A, the first endotracheal intubation (ETI) attempt success rate was achieved in 97.1% with AWS compared with 94.3% with MAC (P=.43). In scenario B, the success rate after the first ETI attempt with the use of the different intubation methods varied and amounted to 88.6% vs. 77.1% for AWS and MAC, respectively (P=.002). The Pentax AWS offered a superior glottic view as compared with the MAC laryngoscope, which was associated with a higher intubation rate and a shorter intubation time during an uninterrupted CC scenario. However, in the scenario without CC, the results for AWS and MAC were comparable. Copyright © 2016 Elsevier Inc. All rights reserved.
Attarde, Viren Bhaskar; Kotekar, Nalini; Shetty, Sarika M
Air-Q intubating laryngeal mask airway (ILA) is used as a supraglottic airway device and as a conduit for endotracheal intubation. This study aims to assess the efficacy of the Air-Q ILA regarding ease of insertion, adequacy of ventilation, rate of successful intubation, haemodynamic response and airway morbidity. Sixty patients presenting for elective surgery at our Medical College Hospital were selected. Following adequate premedication, baseline vital parameters, pulse rate and blood pressure were recorded. Air-Q size 3.5 for patients 50-70 kg and size 4.5 for 70-100 kg was selected. After achieving adequate intubating conditions, Air-Q ILA was introduced. Confirming adequate ventilation, appropriate sized endotracheal tube was advanced through the Air-Q blindly to intubate the trachea. Placement of the endotracheal tube in trachea was confirmed. Air-Q ILA was successfully inserted in 88.3% of patients in first attempt and 11.7% patients in second attempt. Ventilation was adequate in 100% of patients. Intubation was successful in 76.7% of patients with Air-Q ILA. 23.3% of patients were intubated by direct laryngoscopy following failure with two attempts using Air-Q ILA. Post-intubation the change in heart rate was statistically significant (P < 0.0001). 10% of patients were noted to have a sore throat and 5% of patients had mild airway trauma. Air-Q ILA is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation. It benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway.
Vukovic, Adam A; Hanson, Holly R; Murphy, Shelley L; Mercurio, Danielle; Sheedy, Craig A; Arnold, Donald H
Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted. Determine association between AO and hypoxemia in pediatric patients undergoing ETI. Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011-June 2011) and with (August 2014-March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO 2 ) < 90%. The χ 2 and Wilcoxon rank-sum tests examined differences between cohorts. Multivariable regression models examined adjusted associations between covariates and hypoxemia. 149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus <25% in the AO cohort. Median [IQR] lowest SpO 2 during ETI was 93 (69, 99) for pre-AO and 100 [95, 100] for the AO cohort (p < 0.001). In a multivariable logistic regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95% confidence interval [CI] 0.1-0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7-1.0), lowest SpO 2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8-1.0), and each additional intubation attempt (aOR 4.0, 95% CI 2.2-7.2). Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia. Copyright © 2018 Elsevier Inc. All rights reserved.
April, Michael D; Arana, Allyson; Pallin, Daniel J; Schauer, Steven G; Fantegrossi, Andrea; Fernandez, Jessie; Maddry, Joseph K; Summers, Shane M; Antonacci, Mark A; Brown, Calvin A
Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium. We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose. There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose. In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence
The endotracheal intubation of a patient for surgery requires an anaesthetist who is aided by a skilled and experienced helper. This paper explores reasons why some patients are difficult to intubate. Some are predictable on pre-operative assessment and others are not. Suggestions are given on how the helper is useful to the anaesthetist in this potentially critical situation.
Ramsingh, Davinder; Frank, Ethan; Haughton, Robert; Schilling, John; Gimenez, Kimberly M; Banh, Esther; Rinehart, Joseph; Cannesson, Maxime
Unrecognized malposition of the endotracheal tube (ETT) can lead to severe complications in patients under general anesthesia. The focus of this double-blinded randomized study was to assess the accuracy of point-of-care ultrasound in verifying the correct position of the ETT and to compare it with the accuracy of auscultation. Forty-two adult patients requiring general anesthesia with ETT were consented. Patients were randomized to right main bronchus, left main bronchus, or tracheal intubation. After randomization, the ETT was placed via fiber-optic visualization. Next, the location of the ETT was assessed using auscultation by a separate blinded anesthesiologist, followed by an ultrasound performed by a third blinded anesthesiologist. Ultrasound examination included assessment of tracheal dilation via cuff inflation with air and evaluation of pleural lung sliding. Statistical analysis included sensitivity, specificity, positive predictive value, negative predictive value, and interobserver agreement for the ultrasound examination (95% CI). In differentiating tracheal versus bronchial intubations, auscultation showed a sensitivity of 66% (0.39 to 0.87) and a specificity of 59% (0.39 to 0.77), whereas ultrasound showed a sensitivity of 93% (0.66 to 0.99) and specificity of 96% (0.79 to 1). Identification of tracheal versus bronchial intubation was 62% (26 of 42) in the auscultation group and 95% (40 of 42) in the ultrasound group (P = 0.0005) (CI for difference, 0.15 to 0.52), and the McNemar comparison showed statistically significant improvement with ultrasound (P < 0.0001). Interobserver agreement of ultrasound findings was 100%. Assessment of trachea and pleura via point-of-care ultrasound is superior to auscultation in determining the location of ETT.
Mitchell, Michael S; Lee White, Marjorie; King, William D; Wang, Henry E
Pediatric endotracheal intubation (ETI) is difficult and can have serious adverse events when performed by paramedics in the prehospital setting. Paramedics may use the King Laryngeal Tube airway (KLT) in difficult adult airways, but only limited data describe their application in pediatric patients. To compare paramedic airway insertion speed and complications between KLT and ETI in a simulated model of pediatric respiratory arrest. This prospective, randomized trial included paramedics and senior paramedic students with limited prior KLT experience. We provided brief training on pediatric KLT insertion. Using a random allocation protocol, participants performed both ETI and KLT on a pediatric mannequin (6-month old size) in simulated respiratory arrest. The primary outcomes were 1) elapsed time to successful airway placement (seconds), and 2) proper airway positioning. We compared airway insertion performance between KLT and ETI using the Wilcoxon signed-ranks test. Subjects also indicated their preferred airway device. The 25 subjects included 19 paramedics and 6 senior paramedic students. Two subjects had prior adult KLT experience. Airway insertion time was not statistically different between the KLT (median 27 secs) and ETI (median 31 secs) (p = 0.08). Esophageal intubation occurred in 2 of 25 (8%) ETI. Airway leak occurred in 3 of 25 (12%) KLT, but ventilation remained satisfactory. Eighty-four percent of the subjects preferred the KLT over ETI. Paramedics and paramedic students demonstrated similar airway insertion performance between KLT and ETI in simulated, pediatric respiratory arrest. Most subjects preferred KLT. KLT may provide a viable alternative to ETI in prehospital pediatric airway management.
Ono, Koyu; Goto, Tomoko; Nakai, Daishi; Ueki, Shuhei; Takenaka, Seiichiro; Moriya, Tomomi
The airway scope (AWS) improves views of the larynx during orotracheal intubation. However, the role of the AWS in routine nasotracheal intubation has not been studied adequately. One hundred and three patients undergoing dental and maxillofacial surgery that required general anesthesia and nasotracheal intubation were enrolled. The study was approved by our Institution Review Board, and written informed consent was obtained from all patients. We evaluated the success rate of AWS intubation and the incidence of difficult nasotracheal intubation using a modified intubation difficulty scale (IDS) to examine preoperative characteristics and intubation profiles. Categories were difficult intubation (IDS ≥5), mildly difficult (IDS = 1-4), and intubation without difficulty (IDS = 0). We also assessed the incidence of the use of Magill forceps or cuff inflation (the cuff of endotracheal tube is inflated with 10-15 ml air) to guide the endotracheal tube into the glottis. AWS nasotracheal intubation was 100% successful. The cuff inflation technique was used in 37 patients. Neither Magill forceps nor other devices were needed for any patient during AWS use. The incidence of difficult nasotracheal intubation was 10% (n = 10). Of the patients, 61% (n = 63) had mildly difficult intubation and 29% (n = 30) had no difficulty. Patients with difficult intubation were more likely to be male and to have a larger tongue and a higher Cormack grade than in the other two groups. Complications, involving minor soft tissue injury, were observed in only 1 patient (1%). The AWS achieves a high success rate for nasotracheal intubation with cuff inflation in patients undergoing dental and maxillofacial surgery.
Wood, Danielle; Heitschmidt, Mary; Fogg, Louis
Accurate body temperature measurement is essential in providing timely care to critically ill patients. Current practice within the Pediatric ICU (PICU) at a Midwestern academic medical center is to obtain axillary temperatures in endotracheally intubated patients. According to research, axillary temperatures have greater variance than other forms of temperature measurement. Research in adult patients show that oral temperature measurement in endotracheally intubated patients is acceptable as the heated gases from the ventilator has no significant effect on measured temperatures. This study sought to determine if the same is true in pediatrics. Oral and axillary temperatures of endotracheally intubated pediatric patients were obtained during unit prescribed vital assessment intervals. Patients were divided into neonate, infant, and children age groups with 25 sets of temperatures obtained for each group. Descriptive statistics and Bland-Altman plot interpretation were performed to determine confidence intervals for each age group. Bland-Altman plot analysis of oral and axillary routes of temperature measurement showed a high positive correlation within all age groups studied. The infant age group showed lower correlation in comparison to neonates and children. The infant age group also had an outlier of data sets with lower oral temperatures as compared to the axilla. Oral temperature measurement is a viable alternative to axillary temperature measurement in endotracheally intubated pediatric patients. Correction factors for age groups were calculated for prediction of axillary temperature based on measured oral temperature. This study serves as evidence for practice change within the studied unit. Copyright © 2018. Published by Elsevier Inc.
Lim, Tae Ho; Oh, Jaehoon; Lee, Juncheol; Shin, Hyungoo
Emergency physicians are at risk of infection during invasive procedures, and wearing a respirator can reduce this risk. The aim of this study was to determine whether the protection afforded by a respirator during intubation is affected by the type of airway device used. In this randomized crossover study, 26 emergency physicians underwent quantitative fit tests for a N95 respirator (cup-type or fold-type) before and during intubation with a direct laryngoscope, GlideScope®, or i-gel® airway device. The primary outcome was the fit factor value of the respirator and the secondary outcome was the level of acceptable protection provided (percentage of fit factor scores above 100). Compared with the GlideScope and i-gel device, the fit factor values and level of acceptable protection provided were lower when physicians wore the cup-type respirator while intubating using the direct laryngoscope (200 fit factor [152–200] and 200 fit factor [121.25–200] versus 166 fit factor [70–200], 100% and 100% versus 75%, respectively; all P < 0.001). There were no significant differences in the fit factor value or level of acceptable protection provided when the physicians wore the fold-type respirator while intubating using any of the three airway devices (all P > 0.05). The type of airway device used for endotracheal intubation may influence the protective performance of some types of respirators. Emergency physicians should consider the effects of airway device types on fit factor of N95 respirators, when they perform intubation at risk of infection. PMID:29672533
Johnson, Eric G; Meier, Alex; Shirakbari, Alicia; Weant, Kyle; Baker Justice, Stephanie
Rapid sequence intubation (RSI) involves a rapidly acting sedative plus a neuromuscular blocking agent (NMBA) to facilitate endotracheal intubation. Rocuronium and succinylcholine are NMBAs commonly used in RSI with drastically different durations of action. Evaluate whether patients receiving RSI with a longer-acting NMBA had a greater delay in sedation or analgesia than patients that received a short-acting NMBA. This was a retrospective review of patients presenting to the emergency department requiring endotracheal intubation. Exclusions included age < 18 years, pregnancy, prior intubation, and contraindication to sedation and analgesia. Primary endpoint was time to continuous sedation or analgesia after RSI in patients receiving rocuronium or succinylcholine. Secondary endpoints included hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), and impact of an emergency medicine pharmacist (EPh). A total 106 patients met inclusion criteria, 76 patients receiving rocuronium and 30 receiving succinylcholine. Mean time to sedation or analgesia was longer in the rocuronium group when compared to the succinylcholine group at 34 ± 36 min vs. 16 ± 21 min (p = 0.002). In the presence of an EPh, the mean time to sedation or analgesia was 20 ± 21 min, vs. 49 ± 45 min (p < 0.001). Time spent on ventilator, HLOS, and ICU LOS were not significantly different between groups. Patients receiving rocuronium in RSI had a significantly longer time to sedation or analgesia when compared to patients receiving succinylcholine. The presence of an EPh significantly decreased the time to administration of sedation or analgesia after RSI. Copyright © 2015 Elsevier Inc. All rights reserved.
Delaney, J Scott; Al-Kashmiri, Ammar; Baylis, Penny-Jane; Aljufaili, Mahmood; Correa, José A
To assess the effectiveness of a standard long-handle laryngoscope and a short-handle laryngoscope on ease of possible intubation in football, ice hockey, and soccer players. Prospective crossover study. University Sport Medicine Clinic. Sixty-two university varsity football (62 males), 45 ice hockey (26 males and 19 females), and 39 soccer players (20 males, 19 females). Athletes were assessed for different airway and physical characteristics. Three different physicians then assessed the use of laryngoscopes of different handle sizes in supine athletes who were wearing protective equipment while in-line cervical spine immobilization was maintained. The ease of passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was assessed using both a standard long-handle and a short-handle laryngoscope. Use of a short-handle laryngoscope was easier for all physicians in all sports as compared with a standard-sized laryngoscope. Passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was easiest in soccer players and most difficult in football and ice hockey players for both sizes of laryngoscope. Interference from chest or shoulder pads was a common cause for difficulty in passing the laryngoscope blade into the posterior oropharynx for football and ice hockey players. In the rare instances that an endotracheal intubation is to be attempted on an unconscious athlete, a short-handle laryngoscope may provide the best chance for successful intubation.
Siobal, M; Kallet, R H; Kraemer, R; Jonson, E; Lemons, D; Young, D; Campbell, A R; Schecter, W; Tang, J
A patient with extensive burns was intubated with an 8.0 mm internal diameter endotracheal tube (ETT) equipped with a subglottic suction port (Mallinckrodt HiLo Evac). The ETT was secured to a left upper molar with wire sutures throughout the hospitalization course to ensure airway stability. On the 40th day of intubation, the patient exsanguinated and died from a tracheo-innominate artery fistula. Postmortem examination revealed a 1 cm lesion of the left anterior tracheal wall at the position of the ETT tip. The prolonged stationary position of the ETT was considered the primary factor responsible for the fistula. Yet tracheo-innominate artery fistula normally is associated with high cuff pressures rather than with the tube tip. The special ETT construction required for the subglottic suction feature was suspected to have increased tube rigidity and may have played a contributory role. The rigidity of the Mallinckrodt HiLo Evac was measured with a mechanical model and compared to 5 other commercially-available ETTs. Rigidity was expressed as the force generated by the ETT tip when the tube curvature was altered by 5 cm and 10 cm of flexion from its resting position. The mean force exerted by the Mallinckrodt HiLo Evac was 10.1 +/- 2.8 g at 5 cm of flexion and 17.7 +/- 5.1 g at 10 cm of flexion. This was significantly greater than all other ETT brands tested (by one-way analysis of variance and Student-Newman-Kuels test, p < 0.05). This case of fatal tracheo-innominate artery fistula formation associated with an ETT tip was unusual because of the extended duration of endotracheal intubation and the complexity of the patient's airway management problems. Our data suggest that the higher rigidity of the HiLo Evac ETT may have contributed to fistula development at the tube tip. However, we do not believe that the higher rigidity of the HiLo Evac ETT necessarily poses any greater risk than other ETTs under normal circumstances, in which the tube tip is not fixed in a
Anaesthesia, 1989. 36(2): p. 141-144. 8. Hall, R., et al., Human Patient Simulation Is Effective for Teaching Paramedic Students Endotracheal Intubation...duration and # of attempts, checklist and GRS scores Calderwood -Medical students -Anesthetized cats -Success -PM Falck -449 intubation...optic intubation – realism and effectiveness -Pig -Mannequin -Secretions -Anatomy -Appearance Technique - Hall -36 paramedic students
Pratt, Jeffrey C; Hirshberg, Alan J
To evaluate the effectiveness of an intubation-training module and special-waiver project in which Emergency Medical Technician (EMT)-Basics were trained to perform endotracheal intubations in a rural community. This was a prospective observational study over a four-year period (July 1998 through May 2002) of all intubation attempts by EMT-Basics in the field. The authors observed intubation data, training methods, and quality-assurance methods of a special-waiver project agreed to by the State Department of Public Health to train and allow EMT-Basics to intubate patients. Data were from documentation unique to the project. Project documentation evaluated the placement and complication(s) of endotracheal tube (ETT) placement after arrival to the emergency department. An intubation attempt was defined as direct laryngoscopy. A successful attempt was defined as an appropriately sized ETT placed and secured in the trachea below the vocal cords and above the carina. Confirmation of placement in the field included accepted clinical methods and the use of qualitative colorimetric end-tidal carbon dioxide detectors. The EMT-Basics were trained using a paramedic curriculum, including operating room intubations on live adult patients. All patients were in either cardiopulmonary or respiratory arrest. Thirty-two intubations were performed by EMT-Basics. Thirty attempts were successful and two were unsuccessful (94%; 95% confidence interval [CI] 80-98%). Unsuccessful ETT placements were managed with accepted basic life support airway standards. There were no unrecognized esophageal ETT placements (0%; 95% CI 0-11%). This study demonstrated that with an intensive training program using selected highly motivated providers and close monitoring, a program of EMT-Basic ETT placement in a rural setting can achieve acceptable success rates in patients in cardiac or respiratory arrest.
Patel, Bhakti K; Wolfe, Krysta S; Pohlman, Anne S; Hall, Jesse B; Kress, John P
Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients. To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS. Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015. Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group. The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator-free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality. Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, -43.3%; 95% CI, -62.4% to -24.3%; P < .001). The number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5, P < .001). At 90 days, 15 patients (34.1%) in the helmet group died compared with 22 patients (56.4%) in the face mask group (absolute difference, -22.3%; 95% CI, -43.3 to -1.4; P = .02). Adverse events included 3
Goethals, Pauwel; Chaobal, Harshu; Reynaerts, Dominiek; Schaner, David
We present a new device for verifying endotracheal tube (ETT) position that uses specialized sensors intended to distinguish anatomical features of the trachea and esophagus. This device has the potential to increase the safety of resuscitation, surgery, and mechanical ventilation and decrease the morbidity, mortality, and health care costs associated with esophageal intubation and unintended extubation by potentially improving the process and maintenance of endotracheal intubation. The device consists of a tactile sensor connected to the airway occlusion cuff of an ETT. It is intended to detect the presence or absence of tracheal rings immediately upon inflation of the airway occlusion cuff. The initial study detailed here verifies that a prototype device can detect contours similar to tracheal rings in a tracheal model.
Uribe, Alberto A; Zvara, David A; Puente, Erika G; Otey, Andrew J; Zhang, Jianying; Bergese, Sergio D
Difficult tracheal intubation is a common source of mortality and morbidity in surgical and critical care settings. The incidence reported of difficult tracheal intubation is 0.1%-13% and reaches 14% in the obese population. The objective of our retrospective study was to investigate and compare the utility of body mass index (BMI) as indicator of difficult tracheal intubation in males and females. We performed a retrospective chart review of patients who underwent abdominal surgeries with American Society of Anesthesiologists I to V under general anesthesia requiring endotracheal intubation. The following information was obtained from medical records for analysis: gender, age, height, weight, BMI, length of patient stay in the Post Anesthesia Care Unit, past medical history of sleep apnea, Mallampati score, and the American Society of Anesthesiologists classification assigned by the anesthesia care provider performing the endotracheal intubation. Of 4303 adult patients, 1970 (45.8%) men and 2333 (54.2%) women were enrolled in the study. Within this group, a total of 1673 (38.9%) patients were morbidly obese. The average age of the study group was 51.4 ± 15.8 and the average BMI was 29.7 ± 8.2 kg/m(2). The overall incidence of the encountered difficult intubations was 5.23% or 225 subjects. Thus, our results indicate that BMI is a reliable predictor of difficult tracheal intubation predominantly in the male population; another strong predictor, with a positive linear correlation, being the Mallampati score. In conclusion, our data shows that BMI is a reliable indicator of potential difficult tracheal intubation only in male surgical patients.
Tomasello, Giovanni; Damiani, Francesco; Cassata, Giovanni; Palumbo, Vincenzo Davide; Sinagra, Emanuele; Damiani, Provvidenza; Bruno, Antonino; Cicero, Luca; Cupido, Francesco; Carini, Francesco; Lo Monte, Attilio Ignazio
Endotracheal intubation in the rat is difficult because of the extremely small size of anatomical structures (oral cavity, epiglottis and vocal cords), small inlet for an endotracheal tube and the lack of proper technical instruments. In this study we used seventy rats weighting 400-500 g. The equipment needed for the intubation was an operating table, a longish of cotton, a cotton tip, orotracheal tube, neonatal laryngoscope blades, KTR4 small animal ventilator and isoflurane for inhalation anaesthesia. Premedication was carried out by medetomidine hydrochloride 1 mg/mL; then, thanks to a closed glass chamber, a mixture of oxygen and isoflurane was administered. By means of a neonatal laryngoscope the orotracheal tube was advanced into the oral cavity until the wire guide was visualized trough the vocal cords; then it was passed through them. The tube was introduced directly into the larynx over the wire guide; successively, the guide was removed and the tube placed into the trachea. Breathing was confirmed using a glove, cut at the end of a finger, simulating a small balloon. We achieved a fast and simple orotracheal intubation in all animals employed. We believe that our procedure is easier and faster than those previously reported in scientific literature.
Hubble, Michael W; Brown, Lawrence; Wilfong, Denise A; Hertelendy, Attila; Benner, Randall W; Richards, Michael E
Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking. We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature. We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression. Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%-89.4%); OETI for non-cardiac arrest patients: 69.8% (50.9%-83.8%); DFI 86.8% (80.2%-91.4%); and RSI 96.7% (94.7%-98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%-95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%-83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year. We provide pooled estimates of placement success rates for prehospital airway
A prospective randomized controlled study to evaluate and compare GlideScope with Macintosh laryngoscope for ease of endotracheal intubation in adult patients undergoing elective surgery under general anesthesia
Jafra, Anudeep; Gombar, Satinder; Kapoor, Dheeraj; Sandhu, Harpreet Singh; Kumari, Kamlesh
Background: The aim of the study was to compare the ease the intubation using GlideScope video laryngoscope and Macintosh laryngoscope in adult patients undergoing elective surgery under general anesthesia. Materials and Methods: A total of 200 American Society of Anesthesiologists I–II patients of either sex, in the age group of 18–60 years were included in the study. Patients were randomly allocated to two groups. We assessed ease of intubation depending on time to tracheal intubation, number of attempts, glottic view (Cormack–Lehane grade [CL grade] and percentage of glottis opening [POGO]) and intubation difficulty score (IDS), hemodynamic variables and any intra- and post-operative adverse events. Results: The rate of successful endotracheal intubation (ETI) in both groups was 100% in the first attempt. The time required for successful ETI was 24.89 ± 5.574 in Group G and 20.68 ± 3.637 in Group M (P < 0.001) found to be statistically significant. There was significant improvement in glottic view with GlideScope (as assessed by POGO score 66.71 ± 29.929 and 94.40 ± 10.476 in group G and 75.85 ± 26.969 and 74.20 ± 29.514 Group M and CL grading [P < 0.001]). A comparison of mean IDS between two groups revealed intubation was easier with the use of GlideScope. The hemodynamic response to intubation was significantly lesser with the use of GlideScope when compared with Macintosh laryngoscope. The incidence of adverse events, though minor like superficial lip or tongue bleed, was similar in two groups. Conclusions: GlideScope offers superiority over Macintosh laryngoscope in terms of laryngeal views and the difficulty encountered at ETI in an unselected population. PMID:29628839
Doyle, Alex; Joshi, Manasi; Frank, Peter; Craven, Thomas; Moondi, Parvez; Young, Peter
Inadequate airway humidification can result in endotracheal tube occlusion. There is evidence that heat and moisture exchangers (HMEs) are more prone to endotracheal tube occlusion than heated humidifiers (HHs) that contain a heated wire circuit. We aimed to compare the incidence of endotracheal tube occlusion while introducing a new dual-heated wire circuit HH in place of an established hydrophobic HME. This was a prospective observational study. All patients who required intubation were included in our analysis. Univariate statistical analysis was performed using a Fisher exact test. P < .05 was considered statistically significant. There were 158 patients in the HME group and 88 patients in the HH group. The incidence of endotracheal tube occlusion was 5.7% in the HME group and 0% in the HH group. Statistical analysis revealed a significant difference between the 2 groups (P = .02). In light of this finding, we changed our practice to provide humidification exclusively by HH. In the subsequent 18-month period, there were no further episodes of endotracheal tube occlusion. Our study demonstrates that there is a significant increase in the incidence of endotracheal tube occlusion when using a hydrophobic HME compared with an HH and that using a dual-heated wire circuit HH can eliminate endotracheal tube occlusion. Copyright © 2011 Elsevier Inc. All rights reserved.
Bebarta, Vikhyat S; Ferre, Robinson M; Peck, Michael
Crotaline snake envenomations are common, but severe crotaline envenomations are infrequent. Death from severe envenomation is usually from upper airway edema and respiratory failure. Published reports of severe respiratory compromise and anaphylactoid reactions are rare. Currently, FabAV (Crotalidae polyvalent immune Fab [Ovine] [CroFab]) is the mainstay of crotaline envenomation treatment; however, FabAV has been approved for only mild and moderate envenomations. We describe a case of a male with severe systemic effects and airway compromise after crotaline envenomation. The patient's systemic effects and upper airway edema substantially improved after antivenom infusion and before epinephrine administration. Endotracheal intubation was averted, clinical deterioration was avoided, and improvement occurred after prompt FabAV use. Fab antivenom likely prevented endotracheal intubation in our case of severe crotaline envenomation. Published by Elsevier Inc.
Lee, Jiyoung; Kwak, Hyun Jeong; Lee, Ji Yeon; Chang, Min Young; Lee, Sook Young; Kim, Jong Yeop
Abstract Various videolaryngoscopes (VLs) have been developed to provide a better laryngeal view and facilitate difficult intubations. The goal of this study was to compare 2 VLs, the Pentax AWS and the McGrath VL, with respect to intubation time and ease of intubation. One hundred forty patients aged 19 to 65 years (American Society of Anesthesiologists classification I or II), who required tracheal intubation for elective surgery, were randomly assigned to 1 of the 2 groups: the Pentax AWS (n = 70) or the McGrath VL (n = 70). The primary outcome was time to intubation (TTI) measured by a blind observer. The intubation difficulty scale (IDS), percentage of glottic opening (POGO) scale, glottic grade, use of optimal external laryngeal manipulation (OELM), and ease of intubation were also recorded. The Pentax AWS provided a better laryngeal view than the McGrath VL with respect to the Cormack-Lehane (CL) glottic grade (1/2a/2b) (63/7/0 vs 43/24/3, P < .001) and the POGO scale (median [interquartile range, IQR]) (100 [100–100] vs 100 [80–100], P < .001). The IDS was significantly lower in the Pentax AWS group compared with the McGrath VL group (median [IQR]) (0 [0–0] vs 0 [0–1], P < .001). However, the TTI was similar in both the Pentax AWS and McGrath VL groups (median [IQR]) (30 [27–34] vs 32 [27–35] seconds, P = .440). OELM and ease of intubation were also similar between the 2 groups. The Pentax AWS offered a superior laryngeal view compared with the McGrath VL. There was no significant difference in either the intubation time or ease of intubation using these 2 devices in patients with normal airways. PMID:29145308
Kriege, Marc; Alflen, Christian; Noppens, Ruediger R
It is generally accepted that using a video laryngoscope is associated with an improved visualization of the glottis. However, correctly placing the endotracheal tube might be challenging. Channeled video laryngoscopic blades have an endotracheal tube already pre-loaded, allowing to advance the tube once the glottis is visualized. We hypothesized that use of a channel blade with pre-loaded endotracheal tube results in a faster intubation, compared to a curved Macintosh blade video laryngoscope. After ethical approval and informed consent, patients were randomized to receive endotracheal Intubation with either the King Vision® video laryngoscope with curved blade (control) or channeled blade (channeled). Success rate, evaluation of the glottis view (percentage of glottic opening (POGO), Cormack&Lehane (C&L)) and intubating time were evaluated. Over a two-month period, a total of 46 patients (control n = 23; channeled n = 23) were examined. The first attempt success rates were comparable between groups (control 100% (23/23) vs. channeled 96% (22/23); p = 0.31). Overall intubation time was significantly shorter with control (median 40 sec; IQR [24-58]), compared to channeled (59 sec [40-74]; p = 0.03). There were no differences in glottis visualization between groups. Compared with the King Vision channeled blade, time for tracheal intubation was shorter with the control group using a non-channeled blade. First attempt success and visualization of the glottis were comparable. These data do not support the hypothesis that a channeled blade is superior to a curved video laryngoscopic blade without tube guidance. ClinicalTrials.gov NCT02344030.
Añez Simón, C; Boada Pié, S; Solsona Dellá, B
The laryngeal mask for intubation (MLI), or "Fastrach", is a new device designed by Brain for airway management. The MLI, a modified version of the conventional laryngeal mask, allows for blind intubation through the device using endotracheal tubes up to 8 mm in diameter. Insertion with the head in a neutral position makes this system useful for managing the airway when neck injury is present. The device has been used successfully in patients assessed as having difficult-to-manage airways and its use in emergencies inside or outside the hospital is promising. The MLI has been used with high rates of success in combination with other techniques such as fiberoptic bronchoscopy (success rate 99 to 100%) and transillumination (95 to 100% success rate) in patients whose airways have been considered difficult to manage. Given such high rates of success for MLI placement (95 to 100%) and for blind orotracheal intubation (81 to 100%), the Fastrach may offer an alternative to the conventional laryngeal mask in algorithms for airway management.
Lee, Sun-Yeul; Kim, Yoon-Hee; Ko, Young-Kwon; Park, Sang-Il; Lee, Jung-Un; Chung, Woo-Suk; Lim, Chae-Seong
The objective of this study was to identify the effects of nicardipine on neuromuscular blockade of rocuronium, such as the onset time and intubation conditions, using a nicardipine dose that attenuates cardiovascular responses during endotracheal intubation. Randomized, double-blinded, placebo-controlled clinical comparison was used as the design of this study The study was conducted at the operating room of a university hospital. Participants of this study comprise 78 American Society of Anesthesiologists physical status 1 and 2 patients, aged 18 to 60 years who were undergoing elective surgery under general anesthesia. The nicardipine group was given an intravenous bolus of 20 μg/kg nicardipine before tracheal intubation: the control group was given an intravenous bolus of a comparable volume of normal saline before tracheal intubation. Using a TOF-Watch SX monitor, the time from the end of the injection of rocuronium to maximum depression of T1 (onset time) was measured. Intubation was performed 1 minute after rocuronium administration, and the status of the intubation conditions was assessed. The mean blood pressure and heart rate were each measured after endotracheal intubation. Rate pressure product values were also calculated. Intubation conditions were clinically acceptable in 37 (94.9%) of 39 patients in group N compared with 29 (74.4%) of 39 in group C (P < .05). The onset time of rocuronium was significantly faster in group N than in group C (P < .05). The mean blood pressure was significantly lower in group N than in group C (P < .05). The heart rate was significantly higher in group N than in group C (P < .05). Rate pressure product values showed no significant difference between the two groups (P > .05). Pretreatment with 20 μg/kg nicardipine improves intubation conditions, shortens the onset time of rocuronium, and attenuates cardiovascular responses to tracheal intubation. Copyright © 2016 Elsevier Inc. All rights reserved.
Sattler, Christopher; Chiao, Franklin; Stein, David; Murphy, Denise
A 3-day-old, 2.2-kg former 34-week premature infant with imperforate anus required loop ileostomy surgery. At delivery, the child had respiratory distress. Endotracheal intubation was "confirmed" by detection of exhaled carbon dioxide with a Pedi-Cap (Covidien, Dublin, Ireland) and subsequent chest x-ray. On arrival to the operating room, the pulse oximeter reading was 100% despite a large leak around the endotracheal tube and high-airway pressures. Packing the throat reduced the leak and increased the tidal volume. Intraoperative bronchospasm occurred during the surgery. On postoperative day 1, fiberoptic examination by an otolaryngologist revealed esophageal intubation and the absence of laryngeal opening. Subsequent computed tomography scan revealed Floyd type II tracheal agenesis. To our knowledge, this is the only case of tracheal agenesis diagnosed after a non-airway related procedure. We discussed how the diagnosis was missed.
Murdoch, E; Holdgate, A
During the transfer of intubated patients, endotracheal tube security is paramount. This study aims to compare two methods of securing an endotracheal tube in adults: tying with a cloth tape versus the Thomas Endotracheal Tube Holder (Laerdal). A manikin-based study was performed using paramedics and critical care doctors (consultants and senior trainees) as participants. Each participant was asked to secure an endotracheal tube that had been placed within the trachea of a manikin a total of six times, the first three times using tied cloth tape and the last three times using a Thomas Endotracheal Tube Holder. Following each 'fixation' and after the participant had left the room, the security of the tube was tested by applying a fixed force laterally and to the right by dropping a 1.25 kg weight a distance of 50 cm. The amount of movement of the tube with respect to the teeth was measured and recorded in millimetres. Two-hundred-and-seventy tube fixations (135 tied vs. 135 tube holder) were performed by 45 participants. The degree of tube movement was significantly higher when the tube was secured with a tie compared with when the tube holder was used (median movement 22 mm vs. 4 mm, P < 0.0001). We have demonstrated that the tube holder device minimised tube movement in a manikin model when compared with conventional tape tying. The use of this device when transporting intubated patients may reduce the risk of tube displacement though further clinical studies are warranted.
Mota, Luiz Alberto Alves; de Cavalho, Glauber Barbosa; Brito, Valeska Almeida
The injuries caused for the orotracheal intubation are common in our way and widely told by literature. Generally the pipe rank of or consequence of its permanence in the aerial ways of the patient is caused by accidents in. It has diverse types of larynx injuries, caused for multiple mechanisms. To verify, in literature, the main causes of laryngeal complications after- orotracheal intubation and its mechanisms of injury. Revision of Literature: The searched databases had been LILACS, BIREME and SCIELO. Were updated, books and theses had been used, delimiting itself the period enters 1953 the 2009. The keywords used for the search of articles had been: complications, injuries, larynx, intubation, endotracheal, orotracheal, granulomas, stenosis. 59 references had been selected. The used criteria of inclusion for the choice of articles had been the ones that had shown to the diverse types of injuries caused for the orotracheal intubation and its pathophysiology. This revision of literature was motivated by the comment in the practical clinic of a great number of laryngeal sequels in patients submitted to the orotracheal intubation. Of that is ahead important the knowledge, for the professionals of the area of health, the types of complications and its causes, with intention to prevent them, adopting measured of prevention of these injuries.
Sosis, M B; Braverman, B
The occurrence of airway fires during laser airway surgery necessitates the use of special techniques to improve patient safety. For example, it is recommended that the endotracheal tube cuff be inflated with saline. However, in the event of an endotracheal tube fire, the tube must be quickly removed. This study was designed to determine the time necessary for red rubber (RR) or polyvinylchloride (PVC) endotracheal tubes to be removed from a model airway after inflating the cuffs with saline. A model larynx and trachea was suspended vertically. It was intubated with either 7.0 RR or PVC endotracheal tubes. Six milliliters of saline was used to inflate the endotracheal tube cuffs. After inflation, a clamp was used to occlude the pilot tube on the RR endotracheal tubes. A 4-lb weight was then suspended from the endotracheal tube. The time to spontaneous extubation of the model trachea after unclamping the pilot tubes on 12 RR endotracheal tubes was determined. For the PVC endotracheal tubes, the times to spontaneous extubation using the 4-lb weight were determined in 12 endotracheal tubes after cutting the pilot tube and in 12 by maximum aspiration of the saline from the endotracheal tube cuff with a 10-ml syringe. A time of 0.94 +/- 0.10 sec (mean +/- SD) was required for spontaneous extubation of the RR endotracheal tubes after unclamping the pilot tube. For the PVC endotracheal tubes, extubation occurred 3.28 +/- 1.08 and 1.81 +/- 0.60 sec after cutting the pilot tube or deflating the cuff with a syringe, respectively. The mean times for each of the 3 groups were significantly different (p < 0.05) from each other as determined by the ANOVA. This study shows that if PVC endotracheal tubes are used, deflation of the saline-filled cuff by aspiration with a 10-ml syringe is faster than cutting the pilot tube. Unclamping the pilot tube on the RR endotracheal tubes resulted in the fastest time to endotracheal extubation.
Kim, Eugene; Kim, Byung-Gun; Lim, Young-Jin; Jeon, Young-Tae; Hwang, Jung-Won; Lee, Seo-Yun; Park, Hee-Pyoung
Positioning of a lightwand in the midline of the oral cavity can be challenging in patients with cervical immobilization. Direct laryngoscopy may permit the lightwand tip to more easily access the glottic opening. We tested our hypothesis that a laryngoscope-assisted lightwand technique allows more successful endotracheal intubation than does a conventional lightwand approach. A total of 162 patients requiring cervical immobilization during intubation for cervical spine surgery were allocated randomly to 2 groups. The conventional lightwand technique (group C, n = 80) or the laryngoscope-assisted lightwand technique (group L, n = 82) was used for endotracheal intubation. In the group L, a Macintosh laryngoscope was inserted into the oral cavity, advanced until the epiglottis tip was visible, but not used to lift the epiglottis tip. The lightwand tip was placed below the epiglottis under direct view of the epiglottis tip. The primary outcome (the initial intubation success rate) and secondary outcomes (intubation time, hemodynamic changes, and postoperative airway complications) were evaluated. The initial intubation success rate was significantly lower (75% vs 89%; relative risk [95% confidence interval]: 1.2 [1.0-1.4]; P = .034) in group C than group L. The intubation time (22 ± 13 vs 24 ± 12 seconds; mean difference [98.33% confidence interval]: 2.4 [-2.3 to 7.2]; P = .217) did not differ between groups. Postoperative sore throat score, incidences of hypertension and tachycardia, postoperative oral mucosal bleeding, and hoarseness also did not differ between groups. Laryngoscope-assisted lightwand intubation did not increase intubation time, and it increased first attempt intubation rates compared with traditional lightwand intubation in patients requiring cervical immobilization for cervical spine surgery.
Javed, H; Nair, M P; Koul, R L; Chacko, A; Fazalullah, M
No definite criteria exists in Guillian-Barre syndrome in children regarding prolonged ventilation through an endo-tracheal tube without tracheostomy and successful weaning using a T-piece. Here we report two such cases of Guillian-Barre syndrome requiring prolonged intubation for 56 days and ventilation for 30 days and ultimately successfully weaning them using the T-piece. Both the children eventually made a complete recovery, highlighting the point that in children prolonged intubation and ventilation using the portex tube is equally good, if not, better than tracheostomy with its attendant risks.
Miller, Melissa A; Arndt, Jennifer L; Konkle, Mark A; Chenoweth, Carol E; Iwashyna, Theodore J; Flaherty, Kevin R; Hyzy, Robert C
The aim of this study was to determine whether the use of a polyurethane-cuffed endotracheal tube would result in a decrease in ventilator-associated pneumonia rate. We replaced conventional endotracheal tube with a polyurethane-cuff endotracheal tube (Microcuff, Kimberly-Clark Corporation, Rosewell, Ga) in all adult mechanically ventilated patients throughout our large academic hospital from July 2007 to June 2008. We retrospectively compared the rates of ventilator-associated pneumonia before, during, and after the intervention year by interrupted time-series analysis. Ventilator-associated pneumonia rates decreased from 5.3 per 1000 ventilator days before the use of the polyurethane-cuffed endotracheal tube to 2.8 per 1000 ventilator days during the intervention year (P = .0138). During the first 3 months after return to conventional tubes, the rate of ventilator-associated pneumonia was 3.5/1000 ventilator days. Use of the polyurethane-cuffed endotracheal tube was associated with an incidence risk ratio of ventilator-associated pneumonia of 0.572 (95% confidence interval, 0.340-0.963). In statistical regression analysis controlling for other possible alterations in the hospital environment, as measured by rate of tracheostomy-ventilator-associated pneumonia, the incidence risk ratio of ventilator-associated pneumonia in patients intubated with polyurethane-cuffed endotracheal tube was 0.565 (P = .032; 95% confidence interval, 0.335-0.953). Use of a polyurethane-cuffed endotracheal tube was associated with a significant decrease in the rate of ventilator-associated pneumonia in our study. Copyright © 2011 Elsevier Inc. All rights reserved.
Lim, D; Ma, B C; Parumo, R; Shanmuhasuntharam, P
Submental intubation has been used as an alternative to conventional intubation in the field of oral and maxillofacial surgery since its introduction by Francisco Hernández Altemir in 1986. A review of submental intubation was performed using data from all case reports, case-series, and prospective and retrospective studies published between 1986 and 2016. The indications, variations in incision length, incision sites, types of endotracheal tube used, methods of exteriorization, and complications were recorded and analyzed. A total of 70 articles reporting 1021 patients were included. The main indication was maxillofacial trauma (86.9%, n=887), followed by orthognathic surgery (5.8%, n=59), skull base surgery (2.8%, n=29), and rhinoplasty and rhytidectomy (1.5%, n=15). The complication rate was relatively low: 91.0% of patients (n=929) were complication-free. The most common complication was infection, occurring in 3.5% (n=36) of the total number of patients, followed by scarring (1.2%, n=12) and formation of an orocutaneous or salivary fistula (1.1%, n=11). In summary, submental intubation is a good alternative airway with minimal complications. Copyright © 2018 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Rimoli, Caroline Fernandes; Martins, Regina Helena Garcia; Catâneo, Daniele Cristina; Imamura, Rui; Catâneo, Antonio José Maria
Laryngeal granulomas post intubation are benign but recurrent lesions. There is no consensus for its treatment. To describe the effectiveness of different treatment modalities for primary or recurrent laryngeal granulomas resulting from endotracheal intubation. Systematic review and proportional meta-analysis. Eligibility criteria - experimental or observational studies with at least five subjects. Outcomes studied - granuloma resolution, recurrence, and time for resolution. Databases used - Pubmed, Embase, Lilacs, and Cochrane. The Stats Direct 3.0.121 program was used. Six studies were selected, with 85 patients. The treatments registered were: antireflux therapy, speech therapy, anti-inflammatory drugs, steroids, antibiotics, zinc sulfate and surgery. 85 patients from six studies had primary treatment: surgery±associations (41 patients), resolution chance 75% (95% CI: 0.3-100%, I 2 =90%), absolute relapse risk 25% (95% CI: 0.2-71%); medical treatment (44 patients), resolution chance 86% (95% CI: 67-97%); and absolute relapse risk 14% (95% CI: 3-33%). There was no significant difference between groups. Three studies, encompassing 19 patients, analyzed secondary treatment (failure or recurrence after primary treatment); three subjects presented new recurrence. The time needed to resolve the lesions varied from immediate, after surgery, to 23 months, for inhaled steroid. There is no evidence of high quality that proves the efficacy of any treatment for laryngeal granulomas resulting from endotracheal intubation. Published by Elsevier Editora Ltda.
Tran, Diem T T; Newton, Ethan K; Mount, Victoria A H; Lee, Jacques S; Wells, George A; Perry, Jeffrey J
Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015. To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation. In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations. We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg. Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model. The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants
Baker, Jay B; Maskell, Kevin F; Matlock, Aaron G; Walsh, Ryan M; Skinner, Carl G
We compared intubating with a preloaded bougie (PB) against standard bougie technique in terms of success rates, time to successful intubation and provider preference on a cadaveric airway model. In this prospective, crossover study, healthcare providers intubated a cadaver using the PB technique and the standard bougie technique. Participants were randomly assigned to start with either technique. Following standardized training and practice, procedural success and time for each technique was recorded for each participant. Subsequently, participants were asked to rate their perceived ease of intubation on a visual analogue scale of 1 to 10 (1=difficult and 10=easy) and to select which technique they preferred. 47 participants with variable experience intubating were enrolled at an emergency medicine intern airway course. The success rate of all groups for both techniques was equal (95.7%). The range of times to completion for the standard bougie technique was 16.0-70.2 seconds, with a mean time of 29.7 seconds. The range of times to completion for the PB technique was 15.7-110.9 seconds, with a mean time of 29.4 seconds. There was a non-significant difference of 0.3 seconds (95% confidence interval -2.8 to 3.4 seconds) between the two techniques. Participants rated the relative ease of intubation as 7.3/10 for the standard technique and 7.6/10 for the preloaded technique (p=0.53, 95% confidence interval of the difference -0.97 to 0.50). Thirty of 47 participants subjectively preferred the PB technique (p=0.039). There was no significant difference in success or time to intubation between standard bougie and PB techniques. The majority of participants in this study preferred the PB technique. Until a clear and clinically significant difference is found between these techniques, emergency airway operators should feel confident in using the technique with which they are most comfortable.
Komatsu, Ryu; Nagata, Osamu; Kamata, Kotoe; Yamagata, Katsuyuki; Sessler, Daniel I.; Ozaki, Makoto
Summary An intubating laryngeal mask airway (ILMA) facilitates tracheal intubation with the neck in neutral position, which is similar to the neck position maintained by a rigid cervical collar. However, a cervical collar virtually obliterates neck movement, even the small movements that normally facilitate airway insertion. We therefore tested the hypothesis that the ILMA facilitates tracheal intubation even in patients wearing a rigid cervical collar. In 50 cervical spine surgery patients with a rigid Philadelphia collar in place and 50 general surgery patients under general anaesthesia, we performed blind tracheal intubation via an ILMA. The time required for intubation, intubation success rate, and numbers and type of adjusting manoeuvres employed were recorded. Inter-incisor distance was significantly smaller (4.1 [0.8] cm vs. 4.6 [0.7] cm, mean [SD], P<0.01) and Mallampati scores were significantly greater (P<0.001) in the collared patients. ILMA insertion took longer (30  vs. 22  seconds), more patients required 2 insertion attempts (15 vs. 3; P<0.005), and ventilation adequacy with ILMA was worse (P<0.05) in collared patients. However, there were no significant differences between the collared and control patients in terms of total time required for intubation (60  vs. 50  seconds), number of intubation attempts, overall intubation success rate (96 vs. 98%), or the incidence of intubation complications. Blind intubation through an ILMA is thus a reasonable strategy for controlling the airway in patients who are immobilized with a rigid cervical collar, especially when urgency precludes a fiberoptic approach. PMID:15321932
Smischney, Nathan J; Seisa, Mohamed O; Heise, Katherine J; Busack, Kyle D; Loftsgard, Theodore O; Schroeder, Darrell R; Diedrich, Daniel A
To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic's campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. Critically ill adult (≥18 years) patients admitted to a medical-surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.
Wang, Man-Ling; Hung, Ming-Hui; Chen, Jin-Shing; Hsu, Hsao-Hsun; Cheng, Ya-Jung
Intraoperative hypoxaemia during one-lung ventilation (OLV) remains a major concern in thoracic surgery. Non-intubated video-assisted thoracic surgery (VATS) involves a greater risk of consequent emergent conversion to endotracheal intubation. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has recently been reported to be beneficial for higher oxygen reserves during difficult intubations and for enhancing postoperative recovery after thoracic surgery. However, the effects of THRIVE on oxygenation and carbon dioxide elimination before and during OLV in non-intubated VATS have not been investigated. Between September 2016 and October 2016, 30 patients underwent non-intubated VATS for lung tumour and were maintained with THRIVE at a flow of 20 l/min. These patients were compared with a historical control group comprising 30 patients who were maintained with oxygen masks at an oxygen flow of 10 l/min using a propensity score matching algorithm between September 2015 and July 2016. The preoperative arterial oxygen tension was significantly higher in patients maintained with THRIVE than it was in patients maintained with oxygen masks (mean 416.0 vs 265.9 mmHg, P < 0.01). During OLV, arterial oxygen tension remained significantly higher in the THRIVE group than in the oxygen mask group (mean 207.0 vs 127.8 mmHg, P = 0.01). The arterial carbon dioxide tension was comparable before and during OLV. The results indicated that THRIVE effectively increases the oxygen reserve both during OLV and after anaesthesia. Furthermore, non-intubated VATS is safer if THRIVE with flow adjustment is incorporated into a minimally invasive surgical approach, although carbon dioxide elimination is not facilitated.
Park, Hee-Sun; Kim, Ha-Jung; Ro, Young-Jin; Yang, Hong-Seuk; Koh, Won-Uk
Abstract Rationale: Recurrent laryngeal nerve block is an uncommon complication that can occur after an interscalene brachial plexus block (ISB), which may lead to vocal cord palsy or paresis. However, if the recurrent laryngeal nerve is blocked in patients with a preexisting contralateral vocal cord palsy following neck surgery, this may lead to devastating acute respiratory failure. Thus, ISB is contraindicated in patients with contralateral vocal cord lesion. To the best of our knowledge, there are no reports of bilateral vocal cord paresis, which occurred after a continuous ISB and endotracheal intubation in a patient with no history of vocal cord injury or surgery of the neck. Patient concerns: A 59 year old woman was planned for open acromioplasty and rotator cuff repair under general anesthesia. General anesthesia was induced following an ISB using 0.2% ropivacaine and catheter insertion for postoperative pain control. Diagnoses: While recovering in the postanesthesia care unit (PACU), however, the patient complained of a sore throat and hoarseness without respiratory insufficiency. On the morning of the first postoperative day, she still complained of mild dyspnea, dysphonia, and slight aspiration. She was subsequently diagnosed with bilateral vocal cord paresis following an endoscopic laryngoscopy examination. Interventions: The continuous ISB catheter was immediately removed and the dyspnea and hoarseness symptoms improved, although mild aspiration during drinking water was still present. Outcomes: On the 4th postoperative day, a laryngoscopy examination revealed that the right vocal cord movement had returned to normal but that the left vocal cord paresis still remained. Lessons: When ISB is planned, a detailed history-taking and examination of the airway are essential for patient safety and we recommend that any local anesthetics be carefully injected under ultrasound guidance. We also recommend the use of low concentration of local anesthetics to avoid
Birnbach, David J; Rosen, Lisa F; Fitzpatrick, Maureen; Carling, Philip; Arheart, Kristopher L; Munoz-Price, L Silvia
Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected
Athiraman, UmeshKumar; Gupta, Rohit; Singh, Georgene
Placement of a cuffed endotracheal tube for the administration of general anesthesia is routine. The cuff of the endotracheal tube is inflated with air to achieve an adequate seal to prevent micro-aspiration. Over inflation of the cuff can decrease the mucosal perfusion, leading to pressure necrosis and nerve palsies. Inadequate seal can lead to micro aspiration. So the cuff pressure has to be monitored and kept within the prescribed limits of 20-30 cms of water. To observe the effect of different positions on the endotracheal cuff pressure in patients undergoing neurosurgical procedures. This is an observational study conducted on 70 patients undergoing neurosurgical procedures in various positions. After intubation, the cuff pressure was checked with a cuff pressure manometer, Endotest (Teleflex Medical, Rush) and adjusted to be within the allowable pressure limits as is the routine practice. The cuff pressure was checked again at three time points after achieving the final position with the head on pins, at the end of the procedure and before extubation. Various factors such as the age, position, duration of surgery were studied. There were no major complications like aspiration, stridor or hoarseness of voice post extubation in any of the patients. A significant decline in the cuff pressures were noted from the initial supine position to extubation (P < .001) in the supine group. Also a significant decline in the cuff pressures were found in the prone group from their initial intubated supine position to all the other three corresponding time points namely after final positioning (P < .001), at the end of the procedure (P < .001) and before extubation (P < .001). Cuff pressure has to be checked after achieving the final positioning of the patient and adjusted to the prescribed limits to prevent micro aspiration.
Sowers, Nicholas; Kovacs, George
Difficulty with intubation is not uncommon in the emergency setting. Video laryngoscopes (VLs) are commonly used to manage the difficult airway in the emergency department (ED). Intubation using a flexible bronchoscope, while considered the gold standard for managing the anticipated difficult airway in the operating room, is not commonly used in the ED. We present a case describing VL-assisted flexible scope intubation performed in the ED as a novel feasible approach to managing the difficult airway. A 65-year-old male, post cardiac arrest, with multiple unsuccessful attempts at prehospital intubation had rapid sequence intubation (RSI) performed and, despite obtaining a view with a King Vision™ VL, the skilled operator was unable to advance the endotracheal tube (ETT). An Ambu™ aScope3 flexible intubating scope (FIS) was placed through the ETT loaded in the channel of the King Vision and advanced through the cords to a position proximal to the carina. The ETT was then advanced easily over the FIS and down the trachea. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although video laryngoscopy is commonly used in the ED, intubation can prove difficult, despite having an adequate view of the glottis. Use of an FIS, however, through a channeled VL makes navigation of the ETT easier and facilitates tube advancement, which can be difficult with VL. Channeled VL-assisted use of an FIS is a viable option for managing the difficult airway. Copyright © 2016 Elsevier Inc. All rights reserved.
Doreswamy, Srinivasa Murthy; Almannaei, Khaled; Fusch, Chris; Shivananda, Sandesh
Neonatal intubation is a technically challenging procedure, and pressure-related injuries to surrounding structures have been reported. The primary objective of this study was to determine the pressure exerted on the upper jaw during tracheal intubation using a neonatal mannequin. Multidisciplinary care providers working at a neonatal intensive care unit were requested to intubate a neonatal mannequin using the standard laryngoscope and 3.0-mm (internal diameter) endotracheal tube. Compression force exerted was measured by using pressure-sensitive film taped on the upper jaw before every intubation attempt. Pressure, area under pressure and time taken to intubate were compared between the different types of health-care professionals. Thirty care providers intubated the mannequin three times each. Pressure impressions were observed on the developer film after every intubation attempt (n = 90). The mean pressure exerted during intubation across all health-care providers was 568 kPa (SD 78). The mean area placed under pressure was 142 mm(2) (SD 45), and the mean time taken for intubation was 14.7 s (SD 4.3). There was no difference in pressure exerted on the upper jaw between frequent and less frequent intubators. It was found that pressure greater than 400 kPa was inadvertently applied on the upper jaw during neonatal intubation, far exceeding the 250 kPa shown to cause tissue injury in animal models. The upper jaw is exposed to a significant compression force during intubation. Although such exposure is brief, it has the potential to cause tissue injury. Contact of the laryngoscope blade with the upper jaw occurred in all intubation attempts with the currently used design of laryngoscope. © 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
Ydemann, M; Rovsing, L; Lindekaer, A L; Olsen, K S
Several potential problems can arise from airway management in morbidly obese patients, including difficult mask ventilation and difficult intubation. We hypothesised that endotracheal intubation of morbidly obese patients would be more rapid using the GlideScope(®) (GS) (Verathon Inc Corporate Headquarters, Bothell, WA, USA) than with the Fastrach™ (FT) (The Laryngeal Mask Company Ltd, Le Rocher, Victoria, Mahe, Seychelles). One hundred patients who were scheduled for bariatric surgery were randomised to tracheal intubation using either a GS or an FT. The inclusion criteria were age 18-60 years and a body mass index of ≥ 35 kg/m(2) . The primary end point was intubation time, and if intubation was not achieved after two attempts, the other method was used for the third attempt. The mean intubation time was 49 s using the GS and 61 s using the FT (P = 0.86). A total of 92% and 84% of the patients were intubated on the first attempt using the GS and the FT, respectively. One tracheal intubation failed on the second attempt when the GS was used, and five failed on the second attempt when the FT was used. There were no incidents of desaturation and no differences between the groups in terms of mucosal damage or intubation difficulty. We experienced one oesophageal intubation using GS and six oesophageal intubations in five patients using FT. There was no difference between the pain scores or incidence of post-operative hoarseness associated with the two intubation techniques. No significant difference between the two methods was found. The GS and the FT may therefore be considered to be equally good when intubating morbidly obese patients. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.
Kumar, Rakesh; Gupta, Ekta; Kumar, Sunil; Rani Sharma, Kavita; Rani Gupta, Neera
Softer endotracheal (ET) tubes are more difficult to navigate in the oropharynx than the stiffer polyvinyl chloride (PVC) tubes during nasotracheal intubation (NTI). Cuff inflation has been used to guide PVC tubes into the laryngeal inlet during blind NTI, but it has not been tested when performing NTI under direct laryngoscopic guidance. We assessed the role of cuff inflation in improving oropharyngeal navigation of 3 ET tubes of varying stiffness during direct laryngoscope-guided NTI. Simultaneously, we also assessed and compared the nasotracheal navigability and incidence of nasal injury with these ET tubes during cuff inflation-supplemented, laryngoscope-guided NTI. One hundred sixty-two adults were randomized to undergo NTI with either a conventional PVC (n = 54), wire reinforced (WR; n = 54) or a silicone-tipped WR (SWR; n = 54) ET tube. Ease of insertion of these tubes was assessed during passage from nose into oropharynx, from oropharynx into laryngeal inlet aided by cuff inflation if needed, and from laryngeal inlet into trachea. Nasal morbidity was assessed by a blinded observer. All ET tubes could be inserted into the trachea. Seventy-one of 162 ET tubes could be inserted from the oropharynx into the laryngeal inlet without cuff inflation. Eighty-six of the remaining 91 tubes that did not enter the laryngeal inlet without cuff inflation could be inserted when using the cuff inflation technique. Thus, a total of 157 ET tubes could be inserted into the laryngeal inlet with cuff inflation (95% confidence interval of difference of proportions between total number of tubes passed  and those without cuff inflation : 53% [45%-61%]). The remaining 5 tubes had to be inserted with the help of Magill forceps. The incidence of epistaxis was lowest with the SWR tube (difference of proportions [95% confidence interval] SWR versus PVC 27% [8%-45%]; SWR versus WR 20% [1%-38%]; WR versus PVC 7% [-12% to 26%]). The cuff inflation technique consistently improved
Mutlak, Haitham; Rolle, Udo; Rosskopf, Willi; Schalk, Richard; Zacharowski, Kai; Meininger, Dirk; Byhahn, Christian
OBJECTIVE: Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation. METHODS: In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis. RESULTS: A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation. CONCLUSION: All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients. PMID:24473556
Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study
Jena, Sritam; Kamath, Sriganesh; Masapu, Dheeraj; Veenakumari, H. B.; Ramesh, Venkatapura J.; Bhadrinarayan, Varadarajan; Ravikumar, R.
Background: Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome. Methods: Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube. Results: The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay. Conclusions: In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation. PMID:27275073
Lonchena, Tiffany; So, Sokpoleak; Ibinson, James; Roolf, Peter; Orebaugh, Steven L
Sonography has been suggested as a possible means of endotracheal tube (ETT) placement confirmation. However, optimum ultrasound transducer placement has not been established. Using a cadaveric model, ETT placement by the sonographic appearance at the thyroid cartilage, cricoid cartilage, and suprasternal notch in the upper airway was assessed to determine which ultrasound transducer placement offered the most optimal images for ETT confirmation in the airway. One provider intubated 5 cadavers, with the ultrasound transducer at each of the 3 levels, for a total of 30 intubations per specimen, while 2 providers assigned a visual score of 1 (subtle), 2 (clear), or 3 (pronounced) to each sonogram of the ETT in the airway. At the level of the thyroid cartilage, tracheal intubation was detected at a rate of 40%, with a median visualization scale of 1 (subtle movement). At the level of the cricoid cartilage, the visualization scale improved to a median of 2 (clear movement), with a 70% intubation detection rate. At the level of the suprasternal notch, 100% of the tracheal intubations were visualized on sonography, with a median score of 3 (pronounced movement). In comparing sonographic detection of ETT placement at 3 levels of the upper airway in a cadaveric model, our results clearly indicate that visualization was superior at the level of the suprasternal notch, with 100% of intubations detected with the best visualization scores. © 2017 by the American Institute of Ultrasound in Medicine.
Ghoochani Khorasani, Ahmad; Shadnia, Shahin; Mashayekhian, Mohammad; Rahimi, Mitra; Aghabiklooei, Abbas
Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5%) were male. VAP was detected in 24 of 43 (55.8%) patients in the case group and 23 of 48 (47.9%) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10%) and Acinetobacter spp. (19.68%). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients.
Ads, Ayman; Auerbach, Frederic; Ryan, Kelly; El-Ganzouri, Abdel R
We report the successful use of the Air-Q laryngeal airway (Air-Q LA) as a ventilatory device and a conduit for tracheal intubation to rescue the airway in a patient with difficult airway and tracheal stenosis. This is the first case report of the device to secure the airway after two episodes of hypoxemia in the operating room and intensive care unit. Consent for submission of this case report was obtained from our institution's human studies institutional review board given that the patient died a few months after his discharge from the hospital before his personal consent could be obtained and before preparation of this report. All personal identifiers that could lead to his identification have been removed from this report. A 59-year-old man was scheduled for a flexible and rigid bronchoscopy with possible laser excision of tracheal stenosis. He had a history of hypertension, atrial fibrillation, and diabetes. Assessment of airway revealed a thyromental distance of 6.5 cm, Mallampati class II, and body weight of 110 kg. He had hoarseness and audible inspiratory/expiratory stridor with Spo2 90% breathing room air. After induction and muscle relaxation, tracheal intubation and flexible bronchoscopy were achieved without incident. The patient was then extubated and a rigid bronchoscopy was attempted but failed with Spo2 dropping to 92%; rocuronium 60 mg was given, and reintubation was accomplished with a 7.5-mm endotracheal tube. A second rigid bronchoscopy attempt failed, with Spo2 dropping to 63%. Subsequent direct laryngoscopy revealed a bloody hypopharynx. A size 4.5 Air-Q LA was placed successfully and confirmed with capnography, and Spo2 returned to 100%. The airway was suctioned through the Air-Q LA device, and the airway was secured using a fiberoptic bronchoscope to place an endotracheal tube of 7.5-mm internal diameter. The case was canceled because of edema of the upper airway from multiple attempts with rigid bronchoscopy. The patient was transported
Finholt, D A; Audenaert, S M; Stirt, J A; Marcella, K L; Frierson, H F; Suddarth, L T; Raphaely, R C
Endotracheal tube "leak" is often estimated in children to judge the fit of uncuffed endotracheal tubes within the trachea. Twenty-five swine were intubated with uncuffed tracheal tubes to determine whether a more sensitive measurement of leaks could be devised and whether leak pressure estimates fit between tracheal tube and trachea. We compared leak pressure measurement using a stethoscope and aneroid manometer with a technique using a microphone, pressure transducer, and recorder, and found no differences between the two methods. The tracheas were then removed and slides prepared of tracheal cross-sectional specimens. Regression analysis revealed a linear relationship between tracheal lumen size and tracheal tube size for both low leak pressure (y = -0.4 + 0.79x, r = 0.88, P less than 0.05) and high leak pressure (y = -2.9 + 0.71x, r = 0.92, P less than 0.05) groups. We conclude that leak testing with a stethoscope and aneroid manometer is sensitive and accurate, and that tracheal tube leak pressure accurately portrays fit between tube and trachea.
Rao, Amrut K; Chaudhuri, Souvik; Joseph, Tim T; Kamble, Deependra; Gotur, Gopal; Venkatesh, Sandeep
A well-secured endotracheal tube (ETT) is essential for safe anesthesia. The ETT has to be fixed with the adhesive plasters or with tie along with adhesive plasters appropriately. It is specially required in patients having beard, in intensive care unit (ICU) patients or in oral surgeries. If re-adjustment of the ETT is necessary, we should be cautious while removal of the plasters and tie, as there may be damage to the cuff inflation system. This can be a rare cause of ETT cuff leak, thus making maintenance of adequate ventilation difficult and requiring re-intubation. In a difficult airway scenario, it can be extremely challenging to re-intubate again. We report an incidence where the ETT cuff tubing was severed while attempting to re-adjust and re-fix the ETT and the patient required re-intubation. Retrospectively, we thought of and describe a safe, reliable and novel technique to prevent cuff deflation of the severed inflation tube. The technique can also be used to monitor cuff pressure in such scenarios.
Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro
Disabled patients may face respiratory problems during general anesthesia because of head and neck anomalies. We describe a case of dental treatment under general anesthesia using a laryngeal mask airway in a disabled patient who faced difficulty in endotracheal intubation on several occasions, 5 of which resulted in dental injuries. PMID:25849470
Grgurich, Erin; Arnemann, Cynthia; Amon, Kim; Horton, Rose; Carlson, Jestin N
As neonatal endotracheal intubation (ETI) is a low-frequency, high-consequence event, it is essential that providers have access to resources to aid in ETI. We sought to determine the impact of video laryngoscopy (VL) with just-in-time training on intubation outcomes over direct laryngoscopy (DL) when performed by neonatal nurses. We conducted a prospective, randomized, crossover study with neonatal nurses employed at a level 2 neonatal intensive care unit (NICU). Nurses performed both DL and VL on a neonatal mannequin using a CMAC (Karl Storz Corp, Tuttlingen, Germany) either with the assistance of the screen (VL) or without (DL). Before performing the intubation, providers were given a just-in-time, brief education presentation and allowed to practice with the device. Each ETI attempt was reviewed to obtain the percentage of glottic opening (POGO) score, time to intubation (TTI, time from insertion of the blade into the mouth until the first breath was delivered), and time from blade insertion until the best POGO score. We enrolled 19 participants, with a median (interquartile range) of 20 (9-26) years of experience and having a median of 2 (1-3) intubations within the past year. None had used VL in the NICU previously. Median TTI did not differ between DL and VL: 19.9 (15.3-41.5) vs 20.3 (17.9-24.4) (P = 1). POGO scores and the number of attempts also did not differ between DL and VL. In our simulated setting, just-in-time VL training provided similar intubation outcomes compared with DL in ETI performed by neonatal nurses. Just-in-time VL education may be an alternative to traditional DL for neonatal intubations.
Chung, Frances; Yegneswaran, Balaji; Herrera, Francisco; Shenderey, Alex; Shapiro, Colin M
Upper airway abnormalities carry the risk of obstructive sleep apnea (OSA) and difficult tracheal intubations. Both conditions contribute to significant clinical problems and have increased perioperative morbidity and mortality. We hypothesized that patients who presented with difficult intubation would have a very high prevalence of OSA and that those with unexpected difficult intubation may require referral to sleep clinics for polysomnography (PSG). Patients classified as a grade 4 Cormack and Lehane on direct laryngoscopic view, and who required more than two attempts for successful endotracheal intubation, were referred to the study by consultant anesthesiologists at four hospitals. Apnea-hypopnea index (AHI) data and postoperative events were collected. Patients with AHI >5/h were considered positive for OSA. Clinical and PSG variables were compared using t-tests and chi(2) test. Over a 20-mo period, 84 patients with a difficult intubation were referred into the study. Thirty-three patients agreed to participate. Sixty-six percent (22 of 33) had OSA (AHI >5/h). Of the 22 OSA patients, 10 patients (64%) had mild OSA (AHI 5-15), 6 (18%) had moderate OSA (AHI >15/h), and 6 (18%) had severe OSA (AHI >30/h). Of the 33 patients, 11 patients (33%) were recommended for continuous positive airway pressure treatment. Between the OSA group and the non-OSA group, there were significant differences in gender, neck size, and the quality of sleep, but there were no significant differences in age and body mass index. Sixty-six percent of patients with unexpected difficult intubation who consented to undergo a sleep study were diagnosed with OSA by PSG. Patients with difficult intubation are at high risk for OSA and should be screened for signs and symptoms of sleep apnea. Screening for OSA should be considered by referral to a sleep clinic for PSG.
Van Oeveren, Lucas; Donner, Julie; Fantegrossi, Andrea; Mohr, Nicholas M; Brown, Calvin A
Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance. We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network. Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics. Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia. The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success. Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.
Hedberg, Pia; Eklund, Carolina; Högqvist, Sandra
The most common complication due to intubation is a high cuff pressure. A high cuff pressure can cause postanesthetic tracheal mucosal injuries in patients undergoing surgery. The aim of this cross-sectional study was to describe whether anesthetic nurses and anesthesiologists identified a very high cuff pressure by manual palpation of the external cuff balloon on an endotracheal tube. An airway device was intubated with an endotracheal tube cuffed to 95 cm H2O. Each participant palpated the external cuff balloon and then filled out a questionnaire, including estimation of the cuff pressure and user frequency of the cuff pressure manometer. The results showed that 89.1% estimated that the cuff pressure was high. Among the participants who rated the cuff pressure as high, 44.8% rated the pressure as quite high and 60.6% rated the pressure as very high. There was no significant relationship between profession and skill in identifying a very high cuff pressure (P = .843) or between work experience and skill in terms of identifying a very high cuff pressure (P = .816). These findings indicate that 10% of patients are at risk of tracheal erosion because of a high cuff pressure.
Bala, Indu; Bharti, Neerja; Ramesh, Nanjangud P
This randomized, double-blind study was conducted to evaluate the effect of gabapentin pretreatment on the hemodynamic response to laryngoscopy and endotracheal intubation (LETI) in treated hypertensive patients undergoing surgery. A total of 100 controlled hypertensive patients aged 35-60 years, undergoing elective surgery under general anesthesia with endotracheal intubation, were randomly allocated into three groups. Group 1 patients received placebo at night and 2 hours prior to induction of anesthesia. Group 2 patients received placebo at night and 800 mg gabapentin 2 hours prior to induction of anesthesia. Group 3 patients received 800 mg gabapentin at night and 2 hours prior to induction of anesthesia. Anesthesia was induced with thiopentone, fentanyl, and vecuronium and maintained with isoflurane in oxygen and nitrous oxide. Patients' heart rate (HR), blood pressure (BP), and electrocardiography (ECG) changes were recorded prior to induction, after induction, and at 0 minutes, 1 minute, 3 minutes, 5 minutes, and 10 minutes after intubation. Any episodes of hypotension, bradycardia, tachycardia, hypertension, arrhythmia, and ST-T wave changes were recorded and treated accordingly. The HR was comparable among groups, with a transient rise just after intubation, followed by a gradual fall thereafter at 3 minutes, 5 minutes, and 10 minutes compared with baseline. A significant increase in BP after intubation was reported in Group 1 but not in Group 2 and Group 3. The mean arterial pressure (MAP) was significantly higher in Group 1 at 0 minute, 1 minute and 3 minutes postintubation as compared with Group 2 and Group 3 (p=0.014). Three patients in Group 1, four patients in Group 2, and 10 patients in Group 3 developed hypotension and were treated with ephedrine, whereas five patients in Group 1 and one patient in Group 2 had hypertension after tracheal intubation. There was no significant difference between the groups with respect to the number of patients who
Thompson, Kate R; Rioja, Eva
To compare the effects of intravenous (IV) and topical laryngeal lidocaine on heart rate (HR), mean arterial pressure (MAP) and cough response to endotracheal intubation (ETI) in dogs. Prospective, randomized, blinded clinical study. Forty-two client-owned dogs (American Society of Anesthesiologists class I and II status) undergoing elective orthopaedic surgery. Dogs were randomized to three groups. Dogs in group SALIV received 0.1 mL kg(-1) IV saline. Dogs in group LIDIV received 2 mg kg(-1) IV 2% lidocaine. Dogs in group LIDTA received 0.4 mg kg(-1) topically sprayed laryngeal 2% lidocaine. All dogs were premedicated with methadone (0.2 mg kg(-1) IV). After 30 minutes, IV propofol was administered to abolish the lateral palpebral reflex and produce jaw relaxation. The allocated treatment was then administered and, after 30 seconds, further propofol was administered to abolish the medial palpebral reflex and facilitate ETI. HR and MAP were measured at four time-points using cardiac auscultation and automated oscillometry, respectively. The cough response at ETI was recorded. One-way anova and post hoc Tukey adjustment were used to analyse parametric data. The Kruskal-Wallis test was used to analyse non-parametric data. Odds ratios were calculated for the cough response. A p-value of ≤0.05 was considered to indicate statistical significance. In response to ETI, changes in MAP differed significantly between groups. In SALIV, MAP increased (4 ± 6 mmHg), whereas it decreased in LIDIV (6 ± 13 mmHg) (p = 0.013) and LIDTA (7 ± 11 mmHg) (p = 0.003). Dogs in SALIV were almost 10 times more likely to cough than dogs in LIDIV (odds ratio 9.75, 95% confidence interval 0.98-96.60; p = 0.05). In propofol-anaesthetized dogs, IV and topical laryngeal lidocaine attenuated the pressor response to ETI, whereas IV lidocaine reduced the cough response. © 2015 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and
The Influence of Two Different Doses of Magnesium Sulfate on Intraocular Pressure Variations after Injection of Succinylcholine and Endotracheal Intubation: A Prospective, Randomized, Parallel Three-Arm, Double-blind, Placebo-controlled Clinical Trial.
Yassin, Hany Mahmoud; Abdel Moneim, Ahmed Tohamy; Mostafa Bayoumy, Ahmed Sherin; Bayoumy, Hasan Metwally; Taher, Sameh Galal
The use of succinylcholine for rapid sequence induction in patients with open globe injuries may be detrimental to the eye. The aim of this study is to determine if the premedication with magnesium sulfate (MgSO 4 ) could attenuate the increase in intraocular pressure (IOP) associated with succinylcholine injection and intubation. Operation theaters in a tertiary care University Hospital between December 2014 and July 215. This was a prospective, randomized, parallel three-arm, double-blind, placebo-controlled clinical trial. One hundred and thirteen patients' physical status ASA Classes I and II underwent elective cataract surgery under general anesthesia. These patients allocated into three groups: Group C (control group) received 100 ml normal saline, Group M1 received 30 mg/kg MgSO 4 in 100 ml normal saline, and Group M2 received 50 mg/kg MgSO 4 in 100 ml normal saline. IOP, mean arterial pressure (MAP), and heart rate (HR) reported at 5-time points related to study drug administration. In addition, any adverse effects related to MgSO 4 were recorded. Intragroup and between-groups differences were examined by analysis of variance test. We noticed a significant decrease in IOP in M1 ( n = 38) and M2 ( n = 37) groups as compared with C group ( n = 38) after study drugs infusion, 2 and 5 min after intubation, P < 0.001. While the difference between M1 and M2 groups was insignificant, P = 0.296 and P = 0.647, respectively. There was a significant decrease in MAP and HR in M1 and M2 groups as compared with C group 2 and 5 min after intubation, P = 0.01. While the difference between M1 and M2 groups was insignificant, P = 1. MgSO 4 30 mg/kg as well as 50 mg/kg effectively prevented the rise in IOP, MAP, and HR associated with rapid sequence induction by succinylcholine and endotracheal intubation.
Van Berkel, Megan A; Exline, Matthew C; Cape, Kari M; Ryder, Lindsay P; Phillips, Gary; Ali, Naeem A; Doepker, Bruce A
This study compared the incidence of clinical hypotension between ketamine and etomidate within a 24 hour period following endotracheal intubation. This single-center, retrospective propensity-matched cohort study included septic patients admitted to our medical intensive care unit who received either etomidate or ketamine for intubation. Clinical hypotension was defined as any one of the following: mean arterial pressure (MAP) decrease >40% compared to baseline and MAP <70 mmHg, MAP <60 mmHg, initiation of a vasopressor, or increase to >30% of the initial vasopressor dose. Patients were matched based on propensity scores determined by demographics and baseline characteristics. A total of 384 (200 etomidate and 184 ketamine) patients were included for analysis with 230 patients (115 in each group) matched. Clinical hypotension was less prevalent in patients who received ketamine as compared to etomidate [51.3% vs. 73% (odds ratio=0.39, 95% confidence interval=0.22-0.67, P=.001]. The etomidate group experienced significantly lower MAPs at time periods 6.1-12 hours (65.1 mmHg vs. 69.3 mmHg, P=.01) and 12.1-24 hours (63.9 mmHg vs. 68.4 mmHg, P=.003). Ketamine was associated with a lower incidence of clinical hypotension within the 24 hour period following endotracheal intubation in septic patients. Copyright © 2016 Elsevier Inc. All rights reserved.
Lucius, Ralph; Ewald, Kristian
Background The aim of the study was to evaluate the leakage of liquid past the cuffs of tracheal tubes in fresh frozen human heads. Methods Six truncated fresh frozen heads were used and intubated with 8.0 mm endotracheal tubes. The intracuff pressures tested were 30 and 100 cmH2O. Subsequently, 20 ml of each of two oral antiseptic rinses (0.2% chlorhexidine and octenidine [octenidol®, Schülke & Mayr GmbH, Norderstedt, Germany]) was applied for thirty seconds in the mouth. During the trial, leakage of the cuffs was examined. Results The sealing between the tracheal cuff and tracheal wall was leakage-proof for all tested intracuff pressures and all tested antiseptic rinses. However, approximately 5.6 ml and 1.8 ml leaked into the esophagus and remained as a cuff-puddle, respectively. Conclusions The sealing between an endotracheal tube cuff with an intracuff pressure of 30 cmH2O and the tracheal wall is leakage-proof during oral care with antiseptic rinsing. An increase of intracuff pressure to 100 cmH2O does not appear to be required. PMID:24363847
Chen, Cheryl Chia-Hui; Wu, Kuo-Hsiang; Ku, Shih-Chi; Chan, Ding-Cheng; Lee, Jang-Jaer; Wang, Tyng-Guey; Hsiao, Tzu-Yu
To describe the sequelae of oral endotracheal intubation by evaluating prevalence rates of structural injury, hyposalivation, and impaired vocal production over 14days following extubation. Consecutive adults (≥20years, N=114) with prolonged (≥48h) endotracheal intubation were enrolled from medical intensive care units at a university hospital. Participants were assessed by trained nurses at 2, 7, and 14days after extubation, using a standardized bedside screening protocol. Within 48-hour postextubation, structural injuries were common, with 51% having restricted mouth opening. Unstimulated salivary flow was reduced in 43%. For vocal production, 51% had inadequate breathing support for phonation, dysphonia was common (94% had hoarseness and 36% showed reduced efficiency of vocal fold closure), and >40% had impaired articulatory precision. By 14days postextubation, recovery was noted in most conditions, but reduced efficiency of vocal fold closure persisted. Restricted mouth opening (39%) and reduced salivary flow (34%) remained highly prevalent. After extubation, restricted mouth opening, reduced salivary flow, and dysphonia were common and prolonged in recovery. Reduced efficiency of vocal cord closure persisted at 14days postextubation. The extent and duration of these sequelae remind clinicians to screen for them up to 2weeks after extubation. Copyright © 2017 Elsevier Inc. All rights reserved.
Tawhai, Merryn H; Hunter, Peter J
Intubation of the artificially ventilated patient with an endotracheal tube bypasses the usual conditioning regions of the nose and mouth. In this situation any deficit in heat or moisture in the air is compensated for by evaporation and thermal transfer from the pulmonary airway walls. To study the dynamics of heat and water transport in the intubated airway, a coupled system of nonlinear equations is solved in airway models with symmetric geometry and anatomically based geometry. Radial distribution of heat, water vapor, and velocity in the airway are described by power-law equations. Solution of the time-dependent system of equations yields dynamic airstream and mucosal temperatures and air humidity. Comparison of model results with two independent experimental studies in the normal and intubated airway shows a close correlation over a wide range of minute ventilation. Using the anatomically based model a range of spatially distributed temperature paths is demonstrated, which highlights the model's ability to predict thermal behavior in airway regions currently inaccessible to measurement. Accurate representation of conducting airway geometry is shown to be necessary for simulating mouth-breathing at rates between 15 and 100 l x min(-1), but symmetric geometry is adequate for the low minute ventilation and warm inspired air conditions that are generally supplied to the intubated patient.
Phillips, Luke; Orford, Neil; Ragg, Michael
The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
Bernard, Stephen A; Nguyen, Vina; Cameron, Peter; Masci, Kevin; Fitzgerald, Mark; Cooper, David J; Walker, Tony; Std, B Paramed; Myles, Paul; Murray, Lynne; David; Taylor; Smith, Karen; Patrick, Ian; Edington, John; Bacon, Andrew; Rosenfeld, Jeffrey V; Judson, Rodney
To determine whether paramedic rapid sequence intubation in patients with severe traumatic brain injury (TBI) improves neurologic outcomes at 6 months compared with intubation in the hospital. Severe TBI is associated with a high rate of mortality and long-term morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics perform intubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes. In a prospective, randomized, controlled trial, we assigned adults with severe TBI in an urban setting to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favorable versus unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge. A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1-6) in patients intubated by paramedics compared with 3 (interquartile range, 1-6) in the patients intubated at hospital (P = 0.28).The proportion of patients with favorable outcome (GOSe, 5-8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00-1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge. In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.
Fuentes, Ricardo; De la Cuadra, Juan Carlos; Lacassie, Hector; González, Alejandro
Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al. An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15mm adapter was reattached to the tracheal tube. The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Vannozzi, Ilaria; Ciantelli, Massimiliano; Moscuzza, Francesca; Scaramuzzo, Rosa T; Panizza, Davide; Sigali, Emilio; Boldrini, Antonio; Cuttano, Armando
Neonatal respiratory distress syndrome (RDS) is a major cause of mortality and morbidity among preterm infants. Although the INSURE (INtubation, SURfactant administration, Estubation) technique for surfactant replacement therapy is so far the gold standard method, over the last years new approaches have been studied, i.e. less invasive surfactant administration (LISA) or minimally invasive surfactant therapy (MIST). Here we propose an originally modified MIST, called CALMEST (Catheter And Laryngeal Mask Endotracheal Surfactant Therapy), using a particular laryngeal mask as a guide for a thin catheter to deliver surfactant directly in the trachea. We performed a preliminary study on a mannequin and a subsequent in vivo pilot trial. This novel procedure is quick, effective and well tolerated and might represent an improvement in reducing neonatal stress. Ultimately, CALMEST offers an alternative approach that could be extremely useful for medical staff with low expertise in laryngoscopy and intubation.
Chadha, Neil K; Gordin, Arie; Luginbuehl, Igor; Patterson, Greg; Campisi, Paolo; Taylor, Glenn; Forte, Vito
To assess whether dynamically modulating endotracheal tube (ETT) cuff pressure, by decreasing it during each ventilatory cycle instead of maintaining a constant level, would reduce the extent of intubation-related laryngotracheal injury. Single-blind, randomized controlled animal study using a previously validated live porcine model of accelerated intubation-related tracheal injury. Animal research facility. Ten piglets (weight, 16-20 kg each) were anesthetized and underwent intubation using a cuffed ETT. The animals were randomized into the following 2 groups: 5 pigs had a novel device to modulate their cuff pressure from 25 cm H₂O during inspiration to 7 cm H₂O during expiration, and 5 pigs had a constant cuff pressure of 25 cm H₂O. Both groups underwent ventilation under hypoxic conditions for 4 hours. Laryngotracheal mucosal injury after blinded histopathological assessment. The modulated-pressure group showed significantly less overall laryngotracheal damage than the constant-pressure group (mean grades, 1.2 vs 2.1; P < .001). Subglottic damage and tracheal damage were significantly less severe in the modulated-pressure group (mean grades, 1.0 vs 2.2; P < .001, and 1.9 vs 3.2; P < .001, respectively). There was no significant difference in glottic or supraglottic damage between the groups (P = .06 and .27, respectively). This novel device reduces the risk of subglottic and tracheal injury by modulating ETT cuff pressure in synchronization with the ventilatory cycle. This finding could have far-reaching implications for reducing the risk of airway injury in patients undergoing long-term intubation. Further clinical study of this device is warranted.
Jaeger, K; Ruschulte, H; Osthaus, A; Scheinichen, D; Heine, J
Management of the difficult airway requires an appropriate approach based on personal clinical experiences. For every physician involved in rescue and emergency medicine, it is important to know the difficult airway algorithm and be familiar with alternative techniques of managing the difficult airway. We report a case of tracheal injury caused by multiple attempts at intubating the trachea. Based on current knowledge, apart from surgical equipment for cricothyroidotomy the laryngeal mask airway (LMA) and the Combitube (ETC) should be available on any ambulance vehicle staffed by an emergency physician. In future, blind intubation through the intubating laryngeal mask airway (ILMA) could offer a new opportunity.
... bleeding from the esophagus or stomach. Risks include: Bleeding Infection Trauma to the voice box (larynx), thyroid gland, vocal cords and windpipe (trachea), or esophagus Puncture or tearing ( ...
Kalmar, Alain F; Absalom, Anthony; Rombouts, Pieter; Roets, Jelle; Dewaele, Frank; Verdonck, Pascal; Stemerdink, Arjanne; Zijlstra, Jan G; Monsieurs, Koenraad G
Unrecognised endotracheal tube misplacement in emergency intubations has a reported incidence of up to 17%. Current detection methods have many limitations restricting their reliability and availability in these circumstances. There is therefore a clinical need for a device that is small enough to be practical in emergency situations and that can detect oesophageal intubation within seconds. In a first reported evaluation, we demonstrated an algorithm based on pressure waveform analysis, able to determine tube location with high reliability in healthy patients. The aim of this study was to validate the specificity of the algorithm in patients with abnormal pulmonary compliance, and to demonstrate the reliability of a newly developed small device that incorporates the technology. Intubated patients with mild to moderate lung injury, admitted to intensive care were included in the study. The device was connected to the endotracheal tube, and three test ventilations were performed in each patient. All diagnostic data were recorded on PC for subsequent specificity/sensitivity analysis. A total of 105 ventilations in 35 patients with lung injury were analysed. With the threshold D-value of 0.1, the system showed a 100% sensitivity and specificity to diagnose tube location. The algorithm retained its specificity in patients with decreased pulmonary compliance. We also demonstrated the feasibility to integrate sensors and diagnostic hardware in a small, portable hand-held device for convenient use in emergency situations. Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.
Hurtado Nazal, Claudia; Araneda Vilches, Andrea; Vergara Marín, Carolina; García Contreras, Karen; Napolitano Valenzuela, Carla; Badía Ventí, Pedro
General anesthesia is a safe, frequent procedure in clinical practice. Although it is very unusual in procedures not related to head and or neck surgery, vocal cord paralysis is a serious and important complication. Incidence has been associated with patient age and comorbidities, as well as the position of the endotracheal tube and cuff. It can become a dangerous scenario because it predisposes aspiration. To present a case and analyze the risk factors associated with increased risk of vocal cord paralysis described in the literature. 53 year-old diabetic man, who developed hoarseness in the postoperative period after receiving general anesthesia for an elective abdominal laparoscopic surgery. Otolaryngological evaluation showed left vocal cord paralysis. Vocal cord paralysis can be a serious complication of general anesthesia because of important voice dysfunction and risk of aspiration. The management is not yet fully established, so prevention and early diagnosis is essential. Copyright © 2018 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Dunn, Robert E.; Heidari, Andrew E.; Moghaddam, Samer; Zhang, Mengke; Han, Changhoon; Oh, Kyung-Jin; Leven, Steve; Brenner, Matthew; Genberg, Carl; Chen, Zhongping
The development of nosocomial ventilator-associated pneumonia (VAP) has been linked to the presence of specific bacteria found in the biofilm that develops in intubated endotracheal tubes of critical care patients. Presence of biofilm has been difficult to assess clinically. Here, we use Optical coherence tomography (OCT), to visualize the biofilm at both the proximal and distal tips. Ultimately, the goal will be to determine if OCT can be a tool to visualize biofilm development and potential interventions to reduce the incidence of VAP.
A Randomized Crossover Study Comparing Cervical Spine Motion During Intubation Between Two Lightwand Intubation Techniques in Patients With Simulated Cervical Immobilization: Laryngoscope-Assisted Versus Conventional Lightwand Intubation.
Kim, Tae Kyong; Son, Je-Do; Seo, Hyungseok; Lee, Yun-Seok; Bae, Jinyoung; Park, Hee-Pyoung
In patients with cervical immobilization, jaw thrust can cause cervical spine movement. Concurrent use of a laryngoscope may facilitate lightwand intubation, allowing midline placement and free movement of the lightwand in the oral cavity without jaw thrust. We compared the effects of laryngoscope-assisted lightwand intubation (LALI) versus conventional lightwand intubation (CLI) on cervical spine motion during intubation in patients with simulated cervical immobilization. In this randomized crossover study, the cervical spine angle was measured before and during intubation at the occiput-C1, C1-C2, and C2-C5 segments in 20 patients with simulated cervical immobilization who underwent intubation using both the LALI and CLI techniques. Cervical spine motion was defined as the change from baseline in angle measured at each cervical segment during intubation. Cervical spine motion at the occiput-C1 segment was 5.6° (4.3) and 9.3° (4.5) when we used the LALI and CLI techniques, respectively (mean difference [98.33% CI]; -3.8° [-7.2 to -0.3]; P = .007). At other cervical segments, it was not significantly different between the 2 techniques (-0.1° [-2.6 to 2.5]; P = .911 in the C1-C2 segment and -0.2° [-2.8 to 2.5]; P = .795 in the C2-C5 segment). The LALI technique produces less upper cervical spine motion during intubation than the CLI technique in patients with simulated cervical immobilization.
Castañeda Pascual, M; Batllori Gastón, M; Unzué Rico, P; Murillo Jaso, E; Dorronsoro Auzmendi, M; Martín Vizcaíno, M P
In fibroscopic intubation, the fact of achieving a direct view in real time does not guarantee the correct advance of the endotracheal tube (ET) to its intratracheal position. The use of oral cannulas helps in achieving a free airway in order to pass the fibroscope and the ET. This study compares the VAMA(®) (V) and Berman(®) (B) cannulas as regards the time required for the intubation, fibroscopic view, and the ease in positioning the ET. 90 patients with no signs of difficult airway were randomised into 2 groups, Berman(®) (B) and VAMA(®) (V), depending on the type of cannula employed. After inducing general anaesthesia, they were intubated using a flexible fibroscope. The fibroscope and intubation times were recorded, as well as the quality of the fibroscopic view, and the level of difficulty in positioning the ET. No statistically significant differences were observed between the cannulas, although the intubation time (P=.292) and the difficulty found in positioning the ET were slightly less (P=.447) in the VAMA(®) group compared to the Berman(®) group. The vision quality was good with both devices, with only some degree of obstruction being encountered in only 22% of the patients. In no case was there complete obstruction, thus all the patients could be intubated correctly. The VAMA(®) cannula is an effective alternative to the classic cannulas for fibreoptic assisted intubation. Furthermore, the novel design provides advantages for the correct orientation of the fiberscope and the withdrawal of the cannula after intubation. Copyright © 2011 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.
Pournajafian, Ali Reza; Ghodraty, Mohammad Reza; Faiz, Seyed Hamid Reza; Rahimzadeh, Poupak; Goodarzynejad, Hamidreza; Dogmehchi, Enseyeh
Background: To determine if the GlideScope® videolaryngoscope (GVL) could attenuate the hemodynamic responses to orotracheal intubation compared with conventional Macintosh laryngoscope. Objectives: The aim of this relatively large randomized trial was to compare the hemodynamic stress responses during laryngoscopy and tracheal intubation using GVL versus MCL amongst healthy adult individuals receiving general anesthesia for elective surgeries. Patients and Methods: Ninety five healthy adult patients with American Society of Anesthesiologists physical status class I or II that were scheduled for elective surgery under general anesthesia were randomly allocated to either Macintosh or GlideScope arms. All patients received a standardized protocol of general anesthesia. Hemodynamic changes associated with intubation were recorded before and at 1, 3 and 5 minutes after the intubation. The time taken to perform endotracheal intubation was also noted in both groups. Results: Immediately before laryngoscopy (pre-laryngoscopy), the values of all hemodynamic variables did not differ significantly between the two groups (All P values > 0.05). Blood pressures and HR values changed significantly over time within the groups. Time to intubation was significantly longer in the GlideScope (15.9 ± 6.7 seconds) than in the Macintosh group (7.8 ± 3.7 sec) (P< 0.001). However, there were no significant differences between the two groups in hemodynamic responses at all time points. Conclusions: The longer intubation time using GVL suggests that the benefit of GVL could become apparent if the time taken for orotracheal intubation could be decreased in GlideScope group. PMID:24910788
Mansfield, J P; Lyle, R P; Voorhees, W D; Wodicka, G R
A prototype instrument to guide the placement and continuously monitor the position of an endotracheal tube (ETT) was developed. An incident audible sound pulse is introduced into the proximal ETT and detected as it travels down the ETT via a miniature microphone located in the wall. This pulse is then emitted from the tube tip into the airways and the reflected signal from the airways is detected by the microphone. A well defined reflection arises from the point where the total cross sectional area of the airways increases rapidly, and the difference in timing between detection of the incident pulse and this reflection is used to determine ETT position or movement. This reflection is not observed if the ETT is erroneously placed in the esophagus. The amplitude and polarity of an additional reflection that occurs at the ETT tip is used to estimate the cross-sectional area of the airway in which the ETT is placed. This combined information allows discrimination between tracheal and bronchial intubation and can be used to insure an adequate fit between the ETT and trachea. The instrument has proven extremely reliable in multiple intubations in eight canines and offers the potential to noninvasively and inexpensively monitor ETT position in a continuous manner.
April, Michael D; Schauer, Steven G; Brown Rd, Calvin A; Ng, Patrick C; Fernandez, Jessie; Fantegrossi, Andrea E; Maddry, Joseph K; Summers, Shane; Sessions, Daniel J; Barnwell, Robert M; Antonacci, Mark
Emergency airway management is a critical skill for military healthcare providers. Our goal was to describe the Emergency Department (ED) intubations at Brooke Army Medical Center (BAMC) over a 12-month period. Physicians performing endotracheal intubations in the BAMC ED complete data collection forms for each intubation event as part of the National Emergency Airway Registry, including patient demographics, intubation techniques, success and failure rates, adverse events, and patient disposition. We cross-referenced these forms against the numbers of intubation events reported in the ED nursing daily reports to ensure capture of all intubations. Providers completed forms for every intubation within 6 weeks of the procedure. We analyzed data from March 28, 2016, to March 27, 2017. During the study period, providers performed 259 intubations in the BAMC ED. Reasons for intubation were related to trauma for 184 patients (71.0%) and medical conditions for 75 patients (29.0%). Overall, first-attempt success was 83.0%. Emergency medicine residents performed a majority of first attempts (95.0%). Most common devices chosen on first attempt were a video laryngoscope for 143 patients (55.2%) and a direct laryngoscope for 115 patients (44.4%). One patient underwent cricothyrotomy. The 2 most common induction agents were ketamine (59.8%; 95% CI, 55.2%-67.4%) and etomidate (19.3%; 95% CI, 14.7%-24.7%). The most common neuromuscular blocking agents were rocuronium (62.9%; 95% CI, 56.7%-68.8%) and succinylcholine (18.9%; 95% CI, 14.3%-24.2%). In the BAMC ED, emergency intubation most commonly occurred for trauma indications using video laryngoscopy with a high first-pass success.
Lau, Arthur C W; Lam, S M; Yan, W W
OBJECTIVES. To compare three endotracheal tubes for leakage across the cuff (microaspiration) under a comprehensive set of simulated clinical situations. These were the Mallinckrodt TaperGuard (Covidien, US) with a tapered polyvinyl chloride cuff; the KimVent Microcuff (Kimberly-Clark Health Care, US) with a cylindrical polyurethane cuff; and a conventional Portex (Smiths Medical International Ltd, UK) with a globular polyvinyl chloride cuff. DESIGN. A benchtop experimental study. SETTING AND MATERIALS. A silicone cylinder serving as the model trachea was intubated with each of the three endotracheal tubes, one at a time. A total of 20 mL of water were added above the cuff and leakage measured every minute for 20 minutes under five simulated mechanical ventilation scenarios, including different positive end-expiratory pressure levels, and disconnection with and without spontaneous breathing efforts. Each scenario was studied under three cuff pressures of 10, 20 and 30 cm H2O, and then repeated with the application of a continuous suction force of 200 cm H2O, and leakage measured every minute for 3 minutes. RESULTS. The outcome of interest was the cumulative amount of leakage. The Microcuff endotracheal tubes with an ultrathin polyurethane cuff consistently provided the best protection against microaspiration under all simulated clinical situations, followed by TaperGuard with a tapered cuff, and lastly Portex with a globular polyvinyl chloride cuff. Clinical scenarios associated with the greatest leakage were mechanical ventilation with zero positive end-expiratory pressure, circuit disconnection with spontaneous breathing efforts, application of suction, and a low cuff pressure. CONCLUSIONS. Microcuff endotracheal tubes outperformed TaperGuard and Portex endotracheal tubes in preventing microaspiration, which is one of the major mechanisms for ventilator-associated pneumonia.
Dodd, Kenneth W; Kornas, Rebecca L; Prekker, Matthew E; Klein, Lauren R; Reardon, Robert F; Driver, Brian E
Removal of a functioning King laryngeal tube (LT) prior to establishing a definitive airway increases the risk of a "can't intubate, can't oxygenate" scenario. We previously described a technique utilizing video laryngoscopy (VL) and a bougie to intubate around a well-seated King LT with the balloons deflated; if necessary, the balloons can be rapidly re-inflated and ventilation resumed. Our objective is to provide preliminary validation of this technique. Emergency physicians performed all orotracheal intubations in this two-part study. Part 1 consisted of a historical analysis of VL recordings from emergency department (ED) patients intubated with the King LT in place over a two-year period at our institution. In Part 2, we analyzed VL recordings from paired attempts at intubating a cadaver, first with a King LT in place and then with the device removed, with each physician serving as his or her own control. The primary outcome for all analyses was first-pass success. There were 11 VL recordings of ED patients intubated with the King LT in place (Part 1) and 11 pairs of cadaveric VL recordings (Part 2). The first-pass success rate was 100% in both parts. In Part 1, the median time to intubation was 43 s (interquartile range [IQR] 36-60 s). In Part 2, the median time to intubation was 23 s (IQR 18-35 s) with the King LT in place and 17 s (IQR 14-18 s) with the King LT removed. Emergency physicians successfully intubated on the first attempt with the King LT in situ. The technique described in this proof-of-concept study seems promising and merits further validation. Copyright © 2016 Elsevier Inc. All rights reserved.
Elfgen, J; Buehler, P K; Thomas, J; Kemper, M; Imach, S; Weiss, M
Airway exchange catheters (AEC) and fiberoptic bronchoscopes (FOB) for tracheal intubation are selected so that there is only a minimal gap between their outer and inner diameter of endotracheal tube (ETT) to minimize the risk of impingement during airway instrumentation. This study aimed to test the ease of passage of FOBs and AECs through paediatric ETT of different sizes and from different manufacturers when using current recommendations for dimensional equipment compatibility taken from text books and manufacturers information. Twelve different brands of cuffed and uncuffed ETT sized ID 2.5 to 5.0 mm were evaluated in an in vitro set-up. Ease of device passage as well as the locations of an impaired passage within the ETT were assessed. Redundant samples were used for same sized ETT and all measurements were triple-checked in randomized order. In total, 51 paired samples of uncuffed as well as cuffed paediatric ETT were tested. There were substantial differences in the ease of ETT passage concordantly for FOBs and AECs among different manufacturers, but also among the product lines from the same manufacturer for a given ID size. Restriction to passage most frequently was found near the endotracheal tube tip or as a gradually increasing resistance along the ETT shaft. Current recommendations for dimensional equipment compatibility AECs and FOBs with ETTs do not appear to be completely accurate for all ETT brands available. We recommend that specific equipment combinations always must be tested carefully together before attempting to use them in a patient. © 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Koele-Schmidt, Lindsey; Vasquez, Margarita M
Competency rates in neonatal intubation among pediatric residents are low and currently not meeting ACGME/AAP standards. The aim of this study was to compare standard bedside teaching of neonatal endotracheal intubation to a computer module, as well as introduce residents to the emerging technology of videolaryngoscopy. The study population consisted of The University of Texas Health Science Center at San Antonio Pediatric interns/residents and PGY-1 Anesthesia interns rotating through the NICU. Prior to participating in the study, the residents completed a survey addressing past experiences with intubation, comfort level, and prior use of direct and videolaryngoscopy. Participants then performed timed trials of both direct and videolaryngoscopy on the SimNewB(®). They had up to three attempts to successfully intubate, with up to 30 s on each attempt. After randomization, participants received one of the following teaching interventions: standard, computer module, or both. This was followed by a second intubation trial and survey completion. Thirty residents were enrolled in the study. There was significant improvement in time to successful intubation in both methods after any teaching intervention (direct 22.0 ± 13.4 s vs 14.7 ± 5.9 s, P = 0.002 and videolaryngoscopy 42.2 ± 29.3 s vs 26.8 ± 18.6 s, P = 0.003). No differences were found between the types of teaching. Residents were faster at intubating with direct laryngoscopy compared to videolaryngoscopy before and after teaching. By the end of the study, only 33% of residents preferred using videolaryngoscopy over direct laryngoscopy, but 76% felt videolaryngoscopy was better to teach intubation. Both standard teaching and computer module teaching of neonatal intubation on a mannequin model results in improved time to successful intubation and overall improved resident confidence with intubation equipment and technique. Although intubation times were lower with direct laryngoscopy compared to
Techanivate, Anchalee; Leelanukrom, Ruenreong; Prapongsena, Prut; Terachinda, Danuchit
To evaluate the effectiveness of using mouthpiece nebulization and nasal swab stick packing for topical anesthesia in awake fiberoptic nasotracheal intubation. This was a prospective descriptive study of 30 patients with ASA I-II who underwent elective surgery and suspected of difficult intubation between March 2004 and June 2006. After 2% lidocaine 5 ml was nebulizated in a micronebulizer using oxygen 10 L/min as a driving gas through a standard mouthpiece and 10% cocaine 1 ml on cotton swab-stick was applied to the selected nostril for 15 min, fiberoptic nasotracheal intubation was done while the patient was awake. If the patient had severe gag or cough reflex, 1% lidocaine 5 ml per each time could be injected through the working channel of the fiberoptic bronchoscope. The descriptive statistics were calculated by using SPSS version 11.0. The success rate of awake fiberoptic nasotracheal was 100%. The mean duration of awake fiberoptic nasotracheal intubation was 119.0 +/- 76.8 sec. The responses of the patient to instrumentation during 4 periods, i.e.: passing the endotracheal tube into the nose, passing the bronchoscope into the pharynx-larynx, passing the bronchoscope into the trachea-carina and passing the endotracheal tube into the trachea were, as follows: no response in about 53.3%, 63.3%, 23.3%,and 13.3%; mild pain or reflex in about 46.7%, 10%, 70%, and 86.7%; moderate pain or reflex in about 0%, 3.3%, 6.7%, and 0%; and severe pain or reflex requiring more local anesthetic in about 0%, 23.3%, 0%, and 0%, respectively. Despite complete topical anesthesia in the majority of the patients, two patients required 5 ml more 1% lidocaine and five patients required 10 mL more of the drug through the fiberoptic bronchoscope. There was no serious complication such as hypoxemia, arrhythmia. Twenty-four patients (80%) were satisfied with mouthpiece nebulization and nasal swab packing because they felt safe, did not have pain, and were comfortable; only three patients
Introduction Endotracheal intubation in critically ill patients is associated with severe life-threatening complications in about 20%, mainly due to hypoxemia. We hypothesized that apneic oxygenation via a pharyngeal catheter during the endotracheal intubation procedure would prevent or increase the time to life-threatening hypoxemia and tested this hypothesis in an acute lung injury animal model. Methods Eight anesthetized piglets with collapse-prone lungs induced by lung lavage were ventilated with a fraction of inspired oxygen of 1.0 and a positive end-expiratory pressure of 5 cmH2O. The shunt fraction was calculated after obtaining arterial and mixed venous blood gases. The trachea was extubated, and in randomized order each animal received either 10 L oxygen per minute or no oxygen via a pharyngeal catheter, and the time to desaturation to pulse oximeter saturation (SpO2) 60% was measured. If SpO2 was maintained at over 60%, the experiment ended when 10 minutes had elapsed. Results Without pharyngeal oxygen, the animals desaturated after 103 (88-111) seconds (median and interquartile range), whereas with pharyngeal oxygen five animals had a SpO2 > 60% for the 10-minute experimental period, one animal desaturated after 7 minutes, and two animals desaturated within 90 seconds (P < 0.016, Wilcoxon signed rank test). The time to desaturation was related to shunt fraction (R2 = 0.81, P = 0.002, linear regression); the animals that desaturated within 90 seconds had shunt fractions >40%, whereas the others had shunt fractions <25%. Conclusions In this experimental acute lung injury model, pharyngeal oxygen administration markedly prolonged the time to severe desaturation during apnea, suggesting that this technique might be useful when intubating critically ill patients with acute respiratory failure. PMID:20497538
Akdogan, Ozlem; Ersoy, Yasemin; Kuzucu, Ciğdem; Gedik, Ender; Togal, Turkan; Yetkin, Funda
The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p<005). On average, VAP occurred 17.33±21.09 days in the case group and 10.43±7.83 days in the control group (p=0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP. Copyright © 2017 Sociedade Brasileira de Infectologia. Published by Elsevier Editora Ltda. All rights reserved.
Zhang, Bin; Gurnaney, Harshad G; Stricker, Paul A; Galvez, Jorge A; Isserman, Rebecca S; Fiadjoe, John E
The GlideScope Cobalt is one of the most commonly used videolaryngoscopes in pediatric anesthesia. Although visualization of the airway may be superior to direct laryngoscopy, users need to learn a new indirect way to insert the tracheal tube. Learning this indirect approach requires focused practice and instruction. Identifying the specific points during tube placement, during which clinicians struggle, would help with targeted education. We conducted this prospective observational study to determine the incidence and location of technical difficulties using the GlideScope, the success rates of various corrective maneuvers used, and the impact of technical difficulty on success rate. We conducted this observational study at our quaternary pediatric hospital between February 2014 and August 2014. We observed 200 GlideScope-guided intubations and documented key intubation-related outcomes. Inclusion criteria for patients were <6 years of age and elective surgery requiring endotracheal intubation. We documented the number of advancement maneuvers required to intubate the trachea, the location where technical difficulty occurred, the types of maneuvers used to address difficulties, and the tracheal intubation success rate. We used a bias-corrected bootstrapping method with 300 replicates to determine the 95% confidence interval (CI) around the rate of difficulty with an intubation attempt. After excluding attempts by inexperienced clinicians, there were 225 attempts in 187 patients, 58% (131 of 225; bootstrap CI, 51.6%-64.6%]) of the attempts had technical difficulties. Technical difficulty was most likely to occur when inserting the tracheal tube between the plane of the arytenoid cartilages to just beyond the vocal cords: "zone 3." Clockwise rotation of the tube was the most common successful corrective maneuver in zone 3. The overall tracheal intubation success rate was 98% (CI, 95%-99%); however, the first attempt success rate was only 80% (CI, 74%-86%). Patients
Noblett, K E; Meibalane, R
Respiratory care practitioners (RCPs) serve as the primary providers of neonatal endotracheal intubation (ETI) in our institution. ETIs are performed by registered respiratory therapists who have completed Pediatric Advanced Life Support and Neonatal Advanced Life Support training and have successfully completed 3 intubations under the direct supervision of a senior therapist. The purpose of this study was to (1) ascertain whether RCPs can successfully provide this type of service with acceptable complications rates and (2) survey the economic impact of this practice on patient charges in our hospital. An analysis of each intubation event in which an RCP participated was collected and compiled over a 5-month period (9-94 to 2-95). Calculations were made of the success rate and complications. A total of 38 ETIs were performed by the RCPs. Of these, 37 (97.4%) were performed with < or = 3 attempts; (73.7% with 1 attempt, 15.8% with 2 attempts, and 7.9% with 3 attempts). In only 1 event were more than 3 attempts required. There were no complications observed. RCPs can successfully serve as primary providers of neonatal ETI at a Level-II nursery in a community hospital, and this practice may result in a cost reduction.
Miyake, Fuyu; Suga, Rika; Akiyama, Takahiro; Namba, Fumihiko
Neonates, particularly premature babies, are often managed with endotracheal intubation and subsequent mechanical ventilation to maintain adequate pulmonary gas exchange. There is no consensus on the standard length of endotracheal tube. Although a short tube reduces resistance and respiratory dead space, it is believed to increase the risk of accidental extubation. There are not entirely coherent data regarding the effect of endotracheal tube length on work of breathing in infants. The aim of this study was to evaluate the impact of neonatal endotracheal tube diameter and length on the work of breathing using an infant in vitro lung model. We assessed the work of breathing index and mechanical ventilation settings with various endotracheal tube diameters and lengths using the JTR100 in vitro infant lung model. The basic parameters of the model were breathing frequency of 20 per minutes, inspiratory-expiratory ratio of 1:3, and positive end-expiratory pressure of 5 cmH 2 O. In addition, the diaphragm driving pressure to maintain the set tidal volume was measured as the work of breathing index. The JTR100 was connected to the Babylog 8000plus through the endotracheal tube. Finally, we monitored the peak inspiratory pressure generated during assist-control volume guarantee mode with a targeted tidal volume of 10-30 mL. The diaphragm driving pressure using a 2.0-mm inner diameter tube was twice as high as that using a 4.0-mm inner diameter tube. To maintain the targeted tidal volume, a shorter tube reduced both the diaphragm driving pressure and ventilator-generated peak inspiratory pressure. The difference in the generated peak inspiratory pressure between the shortest and longest tubes was 5 cmH 2 O. In our infant lung model, a shorter tube resulted in a lower work of breathing and lower ventilator-generated peak inspiratory pressure. © 2018 John Wiley & Sons Ltd.
Samosky, Joseph T; Baillargeon, Emma; Bregman, Russell; Brown, Andrew; Chaya, Amy; Enders, Leah; Nelson, Douglas A; Robinson, Evan; Sukits, Alison L; Weaver, Robert A
We have developed a prototype of a real-time, interactive projective overlay (IPO) system that creates augmented reality display of a medical procedure directly on the surface of a full-body mannequin human simulator. These images approximate the appearance of both anatomic structures and instrument activity occurring within the body. The key innovation of the current work is sensing the position and motion of an actual device (such as an endotracheal tube) inserted into the mannequin and using the sensed position to control projected video images portraying the internal appearance of the same devices and relevant anatomic structures. The images are projected in correct registration onto the surface of the simulated body. As an initial practical prototype to test this technique we have developed a system permitting real-time visualization of the intra-airway position of an endotracheal tube during simulated intubation training.
Honardar, Marzieh R; Posner, Karen L; Domino, Karen B
This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995 to 2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% confidence interval 34%-64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% confidence interval 20%).
Tracheoesophageal fistula most commonly occurs as a complication of prolonged tracheal intubation. The incidence decreased after the use of low pressure and high volume endotracheal cuffs, but the intensive care units continue to provide such cases. The abnormal tracheoesophageal communication causes pulmonary contamination (with severe suppuration) and impossibility to feed the patient. The prognosis is reserved, because most patients are debilitated and ventilator dependent, with severe neurological and cardiovascular diseases. The therapeutic options are elected based on respiratory, neurological and nutritional status. The aim of conservative treatment is to stop the contamination (drainage gastrostomy, feeding jejunostomy) and to treat the pulmonary infection and biological deficits. Endoscopic therapies can be tried in cases with surgical contraindication. Operation is addressed to selected cases and consists in the dissolution of the fistula, esophageal suture with or without segmental tracheal resection associated. Esophageal diversion is rarely required. The correct indication and timing of surgery, proper surgical technique and postoperative care are prerequisites for adequate results.
Tracheoesophageal fistula most commonly occurs as a complication of prolonged tracheal intubation. The incidence decreased after the use of low pressure and high volume endotracheal cuffs, but the intensive care units continue to provide such cases. The abnormal tracheoesophageal communication causes pulmonary contamination (with severe suppuration) and impossibility to feed the patient. The prognosis is reserved, because most patients are debilitated and ventilator dependent, with severe neurological and cardiovascular diseases. The therapeutic options are elected based on respiratory, neurological and nutritional status. The aim of conservative treatment is to stop the contamination (drainage gastrostomy, feeding jejunostomy) and to treat the pulmonary infection and biological deficits. Endoscopic therapies can be tried in cases with surgical contraindication. Operation is addressed to selected cases and consists in the dissolution of the fistula, esophageal suture with or without segmental tracheal resection associated. Esophageal diversion is rarely required. The correct indication and timing of surgery, proper surgical technique and postoperative care are prerequisites for adequate results. PMID:25713612
Rhode, Marianne Grønnebæk; Vandborg, Mads Partridge; Bladt, Vibeke; Rognås, Leif
Pre-hospital endotracheal intubation is challenging and repeated endotracheal intubation is associated with increased morbidity and mortality. We investigated whether the introduction of the McGrath MAC video laryngoscope as the primary device for pre-hospital endotracheal intubation could improve first-pass success rate in our anaesthesiologist-staffed pre-hospital critical care services. We also investigated the incidence of failed pre-hospital endotracheal intubation, the use of airway adjuncts and back-up devices and problems encountered using the McGrath MAC video laryngoscope. Prospective quality improvement study collecting data from all adult pre-hospital endotracheal intubation performed by four anaesthesiologist-staffed pre-hospital critical care teams between December 15(th) 2013 and December 15(th) 2014. We registered data from 273 consecutive patients. When using the McGrath MAC video laryngoscope the overall pre-hospital endotracheal intubation first-pass success rate was 80.8 %. Following rapid sequence intubation (RSI) it was 88.9 %. This was not significantly different from previously reported first-pass success rates in our system (p = 0.27 and p = 0.41). During the last nine months of the study period the overall first-pass success rate was 80.1 (p = 0.47) but the post-RSI first-pass success rate improved to 94.4 % (0.048). The overall pre-hospital endotracheal intubation success rate with the McGrath MAC video laryngoscope was 98.9 % (p = 0.17). Gastric content, blood or secretion in the airway resulted in reduced vision when using the McGrath MAC video laryngoscope. In this study of video laryngoscope implementation in a Scandinavian anaesthesiologist-staffed pre-hospital critical care service, overall pre-hospital endotracheal first pass success rate did not change. The post-RSI first-pass success rate was significantly higher during the last nine months of our 12-month study compared with our results from before
Panizza, Davide; Scaramuzzo, Rosa T; Moscuzza, Francesca; Vannozzi, Ilaria; Ciantelli, Massimiliano; Gentile, Marzia; Baldoli, Ilaria; Tognarelli, Selene; Boldrini, Antonio; Cuttano, Armando
In neonatal endotracheal intubation, excessive pressure on soft tissues during laryngoscopy can determine permanent injury. Low-fidelity skill trainers do not give valid feedback about this issue. This study describes the technical realization and validation of an active neonatal intubation skill trainer providing objective feedback. We studied expert health professionals' performances in neonatal intubation, underlining chance for procedure retraining. We identified the most critical points in epiglottis and dental arches and fixed commercial force sensors on chosen points on a ©Laerdal Neonatal Intubation Trainer. Our skill trainer was set up as a grade 3 on Cormack and Lehane's scale, i.e. a model of difficult intubation. An associated software provided real time sound feedback if pressure during laryngoscopy exceeded an established threshold. Pressure data were recorded in a database, for subsequent analysis with non-parametric statistical tests. We organized our study in two intubation sessions (5 attempts each one) for everyone of our participants, held 24 h apart. Between the two sessions, a debriefing phase took place. In addition, we gave our participants two interview, one at the beginning and one at the end of the study, to get information about our subjects and to have feedback about our design. We obtained statistical significant differences between consecutive attempts, with evidence of learning trends. Pressure on critical points was significantly lower during the second session (p < 0.0001). Epiglottis' sensor was the most stressed (p < 0.000001). We found a significant correlation between time spent for each attempt and pressures applied to the airways in the two sessions, more significant in the second one (shorter attempts with less pressure, r s = 0.603). Our skill trainer represents a reliable model of difficult intubation. Our results show its potential to optimize procedures related to the control of trauma risk and to improve
Tekin, Muhammet; Acar, Gul Ozbilen; Kaytaz, Asim; Savrun, Feray Karaali; Çelik, Melek; Cam, Osman Halit
Even endotracheal intubation could be considered safe in operations under general anesthesia; rarely, it could cause recurrent laryngeal nerve paralysis as a complication. As mentioned in the literature, as a possible reason for this, anterior branches of the recurrent laryngeal nerve in the larynx could suffer from compression between the posteromedial part of the thyroid cartilage and the cuff of the tube. In the literature, unilateral vocal cord paralysis due to endotracheal intubation occurs more frequently in comparison to bilateral vocal cord paralysis. These types of palsies usually totally improve in approximately 6 months. A patient who experienced bilateral vocal cord paralysis in the early postoperative period after undergoing an endotracheal intubation process for general anesthesia and primary partial lip resection and supraomohyoid neck dissection due to lower lip carcinoma is presented in our article. Although vocal cord paralysis occurring after head and neck surgery is first thought as a complication of the surgery, endotracheal intubation should be considered as a possible cause of this paralysis. In relation with this patient, causes, clinical symptoms, and treatment procedures of vocal cord paralysis due to endotracheal intubation are discussed under guidance of the literature.
Deem, Steven; Yanez, David; Sissons-Ross, Laura; Broeckel, Jo Ann Elrod; Daniel, Stephen; Treggiari, Miriam
Ventilator-associated pneumonia (VAP) is a prevalent and costly nosocomial infection related to instrumentation of the airway with an endotracheal tube (ETT), enabling microaspiration of contaminated secretions. Modification of the ETT design to reduce microaspiration and/or biofilm formation may play an important role in VAP prevention. However, there is insufficient evidence to provide strong recommendations regarding the use of modified ETT and unaddressed safety concerns. We performed a pilot randomized controlled trial comparing two modified ETTs designed specifically to prevent VAP, with the standard ETT, to test the feasibility of and inform planning for a large, pivotal, randomized trial. This study was conducted with institutional review board approval under exception from informed consent. We randomized in a blinded fashion patients undergoing emergency endotracheal intubation both out of and in hospital to receive one of three different ETT types: (1) a polyurethane-cuffed tube (PUC-ETT), (2) a polyurethane-cuffed tube equipped with a port for continuous aspiration of subglottic secretions (PUC-CASS-ETT), or a (3) standard polyvinylchloride-cuffed tube (PVC-ETT). In addition to investigating feasibility and safety, the study coprimary end points were tracheal bacterial colonization reaching a cfu count >10(6) cfu per milliliter and the incidence of invasively diagnosed VAP. A total of 102 subjects were randomized and met the eligibility criteria. Randomization procedures performed well and integrity of blinding at randomization was maintained. The majority of intubations occurred in the hospital setting (n = 77), and the remainder occurred out of hospital (n = 25). Compared with the PVC-ETT, there were no significant differences in tracheal colonization for PUC-ETT (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.31-3.09) or for PUC-CASS-ETT (OR, 1.26; 95% CI, 0.42-3.76). There were no differences in the risk of invasively diagnosed VAP
Yanez, David; Sissons-Ross, Laura; Elrod Broeckel, Jo Ann; Daniel, Stephen; Treggiari, Miriam
Rationale: Ventilator-associated pneumonia (VAP) is a prevalent and costly nosocomial infection related to instrumentation of the airway with an endotracheal tube (ETT), enabling microaspiration of contaminated secretions. Modification of the ETT design to reduce microaspiration and/or biofilm formation may play an important role in VAP prevention. However, there is insufficient evidence to provide strong recommendations regarding the use of modified ETT and unaddressed safety concerns. Objectives: We performed a pilot randomized controlled trial comparing two modified ETTs designed specifically to prevent VAP, with the standard ETT, to test the feasibility of and inform planning for a large, pivotal, randomized trial. Methods: This study was conducted with institutional review board approval under exception from informed consent. We randomized in a blinded fashion patients undergoing emergency endotracheal intubation both out of and in hospital to receive one of three different ETT types: (1) a polyurethane-cuffed tube (PUC-ETT), (2) a polyurethane-cuffed tube equipped with a port for continuous aspiration of subglottic secretions (PUC-CASS-ETT), or a (3) standard polyvinylchloride-cuffed tube (PVC-ETT). In addition to investigating feasibility and safety, the study coprimary end points were tracheal bacterial colonization reaching a cfu count >106 cfu per milliliter and the incidence of invasively diagnosed VAP. Measurements and Main Results: A total of 102 subjects were randomized and met the eligibility criteria. Randomization procedures performed well and integrity of blinding at randomization was maintained. The majority of intubations occurred in the hospital setting (n = 77), and the remainder occurred out of hospital (n = 25). Compared with the PVC-ETT, there were no significant differences in tracheal colonization for PUC-ETT (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.31–3.09) or for PUC-CASS-ETT (OR, 1.26; 95% CI, 0.42–3
McKay, William P; Klonarakis, Jim; Pelivanov, Vladko; O'Brien, Jennifer M; Plewes, Chris
Correct placement of the endotracheal tube (ETT) occurs when the distal tip is in mid-trachea. This study compares two techniques used to place the ETT at the correct depth during intubation: tracheal palpation vs placement at a fixed depth at the patient's teeth. With approval of the Research Ethics Board, we recruited American Society of Anesthesiologists physical status I-II patients scheduled for elective surgery with tracheal intubation. Clinicians performing the tracheal intubations were asked to "advance the tube slowly once the tip is through the cords". An investigator palpated the patient's trachea with three fingers spread over the trachea from the larynx to the sternal notch. When the ETT tip was felt in the sternal notch, the ETT was immobilized and its position was determined by fibreoptic bronchoscopy. The position of the ETT tip was compared with our hospital standard, which is a depth at the incisors or gums of 23 cm for men and 21 cm for women. The primary outcome was the incidence of correct placement. Correct placement of the ETT was defined as a tip > 2.5 cm from the carina and > 3.5 cm below the vocal cords. Movement of the ETT tip was readily palpable in 77 of 92 patients studied, and bronchoscopy was performed in 85 patients. Placement by tracheal palpation resulted in more correct placements (71 [77%]; 95% confidence interval [CI] 74 to 81) than hospital standard depth at the incisors or gums (57 [61%]; 95% CI 58 to 66) (P = 0.037). The mean (SD) placement of the ETT tip in palpable subjects was 4.1 (1.7) cm above the carina, 1.9 cm (1.5-2.3 cm) below the ideal mid-tracheal position. Tracheal palpation requires no special equipment, takes only a few seconds to perform, and may improve ETT placement at the correct depth. Further studies are warranted.
Cone, Sharon; Pickler, Rita H.; Grap, Mary Jo; McGrath, Jacqueline; Wiley, Paul M.
Objective To evaluate the effect of four-handed care on preterm infants’ physiologic and behavioral responses to and recovery from endotracheal suctioning versus routine endotracheal (ETT) suctioning. Design Randomized crossover design with infants as their own controls. Setting Single-family-room newborn intensive care unit in an academic health center. Participants Ten intubated infants on conventional ventilation with inline suctioning who were fewer than 37 weeks gestation at birth, and less than one week of age. Methods Each infant was observed twice on a single day. One observation involved routine ETT suctioning and one involved four-handed care. Physiologic and behavioral response data were collected. Results No differences were noted when comparing baseline heart rate (HR) or oxygen saturation (SpO2) data to those obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from preobservation 95.49 to during observation saturation 97.75 (p = .001). Salivary cortisol levels did not differ between groups at baseline or postsuctioning. No significant difference in behavior state was observed between the two conditions. More stress and defense behaviors occurred postsuctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care. No statistical difference was found in the number of monitor call-backs postsuctioning. Conclusions Four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. PMID:23316894
Bousarri, Mitra Payami; Shirvani, Yadolah; Agha-Hassan-Kashani, Saeed; Nasab, Nouredin Mousavi
In patients undergoing mechanical ventilation, mucus production and secretion is high as a result of the endotracheal tube. Because endotracheal suction in these patients is essential, chest physiotherapy techniques such as expiratory rib cage compression before endotracheal suctioning can be used as a means to facilitate mobilizing and removing airway secretion and improving alveolar ventilation. As one of the complications of mechanical ventilation and endotracheal suctioning is decrease of cardiac output, this study was carried out to determine the effect of expiratory rib cage compression before endotracheal suctioning on the vital signs in patients under mechanical ventilation. This study was a randomized clinical trial with a crossover design. The study subjects included 50 mechanically ventilated patients, hospitalized in intensive care wards of Valiasr and Mousavi hospitals in Zanjan, Iran. Subjects were selected by consecutive sampling and randomly allocated to groups 1 and 2. The patients received endotracheal suctioning with or without rib cage compression, with a minimum of 3 h interval between the two interventions. Expiratory rib cage compression was performed for 5 min before endotracheal suctioning. Vital signs were measured 5 min before and 15 and 25 min after endotracheal suctioning. Data were recorded on a data recording sheet. Data were analyzed using paired t-tests. There were statistically significant differences in the means of vital signs measured 5 min before with 15 and 25 min after endotracheal suctioning with rib cage compression (P < 0. 01). There was no significant difference in the means of diastolic pressure measured 25 min after with baseline in this stage). But on the reverse mode, there was a significant difference between the means of pulse and respiratory rate 15 min after endotracheal suctioning and the baseline values (P < 0.002). This effect continued up to 25 min after endotracheal suctioning just for respiratory rate (P = 0
O'Carroll, Darragh C; Barnes, Robert L; Aratani, Ashley K; Lee, Dane C; Lau, Christopher A; Morton, Paul N; Yamamoto, Loren G; Berg, Benjamin W
Tracheal Intubation is an important yet difficult skill to learn with many possible methods and techniques. Direct laryngoscopy is the standard method of tracheal intubation, but several instruments have been shown to be less difficult and have better performance characteristics than the traditional direct method. We compared 4 different intubation methods performed by novice intubators on manikins: conventional direct laryngoscopy, video laryngoscopy, Airtraq® laryngoscopy, and fiberoptic laryngoscopy. In addition, we attempted to find a correlation between playing videogames and intubation times in novice intubators. Video laryngoscopy had the best results for both our normal and difficult airway (cervical spine immobilization) manikin scenarios. When video was compared to direct in the normal airway scenario, it had a significantly higher success rate (100% vs 83% P=.02) and shorter intubation times (29.1 ± 27.4 sec vs 45.9 ± 39.5 sec, P=.03). In the difficult airway scenario video laryngoscopy maintained a significantly higher success rate (91% vs 71% P=0.04) and likelihood of success (3.2 ± 1.0 95%CI [2.9-3.5] vs 2.4 ± 0.9 95%CI [2.1-2.7]) when compared to direct laryngoscopy. Participants also reported significantly higher rates of self-confidence (3.5 ± 0.6 95%CI [3.3-3.7]) and ease of use (1.5 ± 0.7 95%CI [1.3-1.8]) with video laryngoscopy compared to all other methods. We found no correlation between videogame playing and intubation methods.
O'Carroll, Darragh C; Aratani, Ashley K; Lee, Dane C; Lau, Christopher A; Morton, Paul N; Yamamoto, Loren G; Berg, Benjamin W
Tracheal Intubation is an important yet difficult skill to learn with many possible methods and techniques. Direct laryngoscopy is the standard method of tracheal intubation, but several instruments have been shown to be less difficult and have better performance characteristics than the traditional direct method. We compared 4 different intubation methods performed by novice intubators on manikins: conventional direct laryngoscopy, video laryngoscopy, Airtraq® laryngoscopy, and fiberoptic laryngoscopy. In addition, we attempted to find a correlation between playing videogames and intubation times in novice intubators. Video laryngoscopy had the best results for both our normal and difficult airway (cervical spine immobilization) manikin scenarios. When video was compared to direct in the normal airway scenario, it had a significantly higher success rate (100% vs 83% P=.02) and shorter intubation times (29.1±27.4 sec vs 45.9±39.5 sec, P=.03). In the difficult airway scenario video laryngoscopy maintained a significantly higher success rate (91% vs 71% P=0.04) and likelihood of success (3.2±1.0 95%CI [2.9–3.5] vs 2.4±0.9 95%CI [2.1–2.7]) when compared to direct laryngoscopy. Participants also reported significantly higher rates of self-confidence (3.5±0.6 95%CI [3.3–3.7]) and ease of use (1.5±0.7 95%CI [1.3–1.8]) with video laryngoscopy compared to all other methods. We found no correlation between videogame playing and intubation methods. PMID:24167768
Kundra, Pankaj; Sujata, N; Ravishankar, M
The laryngeal mask airway (LMA)-Fastrach silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n=50), prewarmed PVCT (n=50), and LAT (n=50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P <0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P <0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P <0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.
Abdelgadir, Ibtihal S; Phillips, Robert S; Singh, Davinder; Moncreiff, Michael P; Lumsden, Joanne L
Direct laryngoscopy is the method currently used for tracheal intubation in children. It occasionally offers unexpectedly poor laryngeal views. Indirect laryngoscopy involves visualizing the vocal cords by means other than obtaining a direct sight, with the potential to improve outcomes. We reviewed the current available literature and performed a meta-analysis to compare direct versus indirect laryngoscopy, or videolaryngoscopy, with regards to efficacy and adverse effects. To assess the efficacy of indirect laryngoscopy, or videolaryngoscopy, versus direct laryngoscopy for intubation of children with regards to intubation time, number of attempts at intubation, and adverse haemodynamic responses to endotracheal intubation. We also assessed other adverse responses to intubation, such as trauma to oral, pharyngeal, and laryngeal structures, and we assessed vocal cord view scores. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and trial registers (www.clinicaltrials.gov and www.controlledtrials) in November 2015. We reran the search in January 2017. We added new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update. We performed reference checking and citation searching and contacted the authors of unpublished data to ask for more information. We applied no language restrictions. We included only randomized controlled trials. Participants were children aged 28 days to 18 years. Investigators performed intubations using any type of indirect laryngoscopes, or videolaryngoscopes, versus direct laryngoscopes. We used Cochrane standard methodological procedures. Two review authors independently reviewed titles, extracted data, and assessed risk of bias. We included 12 studies (803 children) in this review and meta-analysis. We identified three studies that
Stevens, Gregory J; Warfel, Joel W; Aden, James K; Blackwell, Scott D
Endotracheal intubation is a medical procedure that is often indicated in both the perioperative and critical care environments. Cuffed endotracheal tubes (ETT) allow for safer and more efficient delivery of positive pressure ventilation, as well as create a barrier to reduce the risk of micro-aspiration and anesthetic pollution in the operating room environment. Over-inflation of the endotracheal cuff can lead to serious and harmful sequelae. This study aimed to assess if departmental education paired with ready access to a manometer to assess cuff pressure would result in an improvement in the proportion of ETT cuff pressures in the goal range. A quality improvement study was conducted at the San Antonio Military Medical Center (SAMMC; Department of Defense hospital in San Antonio, TX). The initiative was divided into three key periods: pre-implementation, implementation, and post-implementation. During the pre-implementation period, ETT cuff pressures were obtained to assess the baseline state of ETT cuff pressures for patients in the operating room; the proportion of in-range (20-30 cmH2O) pressures was calculated. During the implementation phase, operating rooms were equipped with manometers and anesthesia departmental education was performed regarding the use of the manometers. Three months later, post-implementation cuff pressures were measured in the OR, and the proportion of in-range pressures was again calculated. The pre-implementation data showed an average cuff pressure of 48.92 cmH2O and a median of 38.5 cmH2O. Of the 100 pre-implementation pressures, 20 were in the goal range. Post-implementation data had an average cuff pressure of 41.96 cmH2O and a median of 30 cmH2O. A chi-squared test of pressures in the safe range from the pre-implementation versus post-implementation values yielded a highly significant p-value of 0.0003. The data from this study clearly demonstrated a statistically significant improvement in the proportion of in-range cuff
Qi, Le; Liu, Rong; Tang, Enhui; Li, Shouchun; Jin, Jun; He, Xihuan; Lyu, Shaojun; Weng, Hao
To evaluate the effect of auscultation, partial pressure of carbon dioxide in end-expiration (P(ET)CO2), transillumination technique to judge whether the endotracheal tube is misplaced into the esophagus. A blinded randomized controlled trial was conducted. Sixty patients with American Society of Anesthesiology (ASA) grade I - II undergoing endotracheal intubation in Fengxian Central Hospital admitted from September 2014 to February 2015 were enrolled. Two endotracheal tubes with the same size were respectively inserted into the trachea and esophagus for the same depth after general anesthesia by the same person. Two blinded anesthetists with different experience checked the tube position using three methods including auscultation, P(ET)CO2, and transillumination technique, respectively. The order of the tubes tested (trachea or esophagus) and the method used were randomized according to randomise numbers table. The experienced anesthetists conducted the test first, followed by an inexperienced anesthetist conducting the same methods. The numbers of right and wrong determinations with different methods by different anesthetists were recorded. Sixty patients underwent the procedures for 180 times, with intratracheal intubation for 90 times, and esophageal intubation for 90 times. It was shown that the results were not different in two groups [96.7% (174/180) vs. 92.2% (166/180), χ2 = 3.500, P = 0.057]. By using auscultation, the correct rate of experienced anesthetist was higher than that of inexperienced (95.0% vs. 78.3%, χ2 = 5.786, P = 0.013). Using P(ET)CO2, both anesthetists were correct in all cases, and the accuracy was 100%. Using transillumination, the experienced anesthetist was mistaken in 3 cases (accuracy was 95.0%), while the inexperienced mistook in 1 case (accuracy was 98.3%), and no significant difference was found between two groups χ2 = 0.500, P = 0.250). The correct rate of using transillumination was significantly higher than that of using
Özcan, Ayça Tuba Dumanlı; Döğer, Cihan; But, Abdülkadir; Kutlu, Işık; Aksoy, Şemsi Mustafa
It is recommended that endotracheal cuff (ETTc) pressure be between 20 and 30 cm H 2 O. In this present study, we intend to observe average cuff pressure values in our clinic and the change in these values after the training seminar. The cuff pressure values of 200 patients intubated following general anesthesia induction in the operating theatre were measured following intubation. One hundred patients whose values were measured before the training seminar held for all physician assistants, and 100 patients whose values were measured after the training seminar were regarded as Group 1 and Group 2, respectively. Cuff pressures of both groups were recorded, and the difference between them was shown. Moreover, cuff pressure values were explored according to the working period of the physician assistants. There was no significant difference between the groups in terms of age, gender and tube diameters. Statistically significant difference was found between cuff pressure values before and after the training (p < 0.001). Average pressure measure for Group I was 54 cm H 2 O, while average pressure in Group II declined to 33 cm H 2 O. It was observed that as the working period and experience of physician assistants increased, cuff pressure values decreased, however no statistically significant different was found (p < 0.375). We believe that clinical experience does not have significant effects on cuff pressure and that training seminars held at intervals would prevent high cuff pressure values and potential complications.
Yuce, Yucel; Uzun, Sennur; Aypar, Ulku
A 56-year-old man presented himself for an intracranial glioblastoma multiforme excision. After being routinely monitored, he was preoxygenated. We induced anesthesia and paralysis with 200 mg propofol, 50 μg fentanyl and 9 mg vecuronium. Direct laryngoscopy with a Macintosh 3 blade revealed a 2x2 cm cyst, pedunculated, arising from the right side of the vallecula preventing the endotracheal intubation. While the patient remained anesthetized, we urgently consulted an otolaryngologist and aspirated the cyst with a 22-gauge needle and syringe under direct laryngoscopy. We aspirated 10 cc of liquid content. This was followed by an uneventful tracheal intubation with a 9.0 enforced spiral cuffed tube. An alternative to fiberoptic intubation may be careful cyst aspiration to facilitate the intubation.
Rosero, Eric B; Ozayar, Esra; Eslava-Schmalbach, Javier; Minhajuddin, Abu; Joshi, Girish P
Tracheal tube cuff pressures exceeding the perfusion pressures of the tracheal mucosa have been associated with complications such as sore throat, tracheal mucosa ulcers, tracheal rupture, and subglottic stenosis. Despite appropriate inflation, many factors can increase the tracheal cuff pressure during mechanical ventilation. This prospective observational cohort study was designed to test the hypothesis that during a clinical model of decreasing respiratory compliance, the pressure within the endotracheal tube cuff will rise in direct relationship to increases in the airway pressures. Twenty-eight adult obese patients (BMI ≥30 kg/m) scheduled for elective laparoscopic gynecologic procedures were enrolled. All patients received general anesthesia utilizing endotracheal tubes with low-pressure high-volume cuffs. After baseline adjustment of the cuff pressure to 25 cm H2O, the airway pressures and endotracheal cuff pressures were continuously measured using pressure transducers connected to the anesthesia circuit and cuff pilot, respectively. Data on cuff and airway pressures, mechanical ventilation parameters, intraabdominal pressures, and degree of surgical table inclination were collected throughout the anesthetic procedure. General linear regression models with fixed and random effects were fit to assess the effect of increases in airway pressures on cuff pressure, after adjusting for covariates and the clustered structure of the data. The mean (standard deviation) age and body mass index were 42.2 (8.8) years and 37.7 (5.1) kg/m, respectively. After tracheal intubation, the cuffs were overinflated (ie, intracuff pressures >30 cm H2O) in 89% of patients. The cuff pressures significantly changed after concomitant variations in the airway pressures from a mean (standard error) value of 29.6 (1.30) cm H2O before peritoneal insufflations, to 35.6 (0.68) cm H2O after peritoneal insufflation, and to 27.8 (0.79) cm H2O after peritoneal deflation (P < .0001). The
Miller, Joel A; Levsky, Marc E; Givens, Melissa L; Miller, Michael A
Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation. Nineteen emergency medicine residents and attending physicians, who were participants in a cadaveric airway course, placed and inflated a size 4 LMA (The Laryngeal Mask Company Ltd., San Diego, CA) on each of six unembalmed human cadavers in the usual fashion. They then attempted to pass a lubricated, 15 Fr, reusable, coude-tipped ETTI (Portex, Smiths Medical, Keene, NH)) through the airspace/handle of the inflated LMA. The LMA was then deflated and removed while the ETTI was held in place. Investigators then determined the location of the ETTI by laryngoscopy. Of 114 attempts at the rescue procedure, 59 resulted in placement of the bougie into the trachea, yielding an overall success rate of 52% (95% CI 48%-56%). There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.
Hamilton, Nigel D; Hegarty, Mary; Calder, Alyson; Erb, Thomas O; von Ungern-Sternberg, Britta S
The use of topical lidocaine, applied to the airways with various administration techniques, is common practice in pediatric anesthesia in many institutions. However, it remains unclear whether these practices achieve their intended goal of reducing the risk of perioperative respiratory adverse events (PRAE) in children undergoing elective endotracheal intubation without neuromuscular blockade (NMB). The relative frequency of PRAE (laryngospasm, coughing, desaturation <95%) associated with no use of topical airway lidocaine (TAL), with TAL sprayed directly onto the vocal cords, and TAL administered blindly into the pharynx was assessed. This prospective audit involved 1000 patients undergoing general anesthesia with elective endotracheal intubation without NMB. Patients with suspected difficult airways or undergoing airway surgery were excluded. The use of TAL and the mode of administration were recorded. Respiratory adverse events were recorded in the perioperative period. Two hundred and fifty-four patients had the vocal cords sprayed under direct vision, 236 had lidocaine blindly dripped into the pharynx, and 510 received no TAL. The mean age and known risk factors for PRAE (asthma, recent upper respiratory tract infection (≤2 weeks), passive smoking, hayfever, past or present eczema, nocturnal dry cough) were similar among the groups. The proportion of patients with desaturation (<95%) between induction of anesthesia and discharge from the recovery room was higher in the two groups who received TAL (data combined for all patients receiving lidocaine regardless of administration method, P = 0.01) compared to those who received no TAL. No difference in the rates of laryngospasm (P = 0.13) or cough (P = 0.07) was observed among the groups. There was no difference in the rates of PRAE between the groups given TAL directly onto the vocal cords and in those whom received TAL blindly. The incidence of desaturation was higher in patients receiving TAL compared with
Szarpak, Łukasz; Czyżewski, Łukasz; Truszewski, Zenon; Kurowski, Andrzej; Gaszyński, Tomasz
The aim of the study was to compare the intubation times and success rates of various laryngoscopes during resuscitation in pediatric emergency intubation with uninterrupted chest compression on a standardized pediatric manikin model. This was a randomized crossover study with 107 paramedic participants. We compared times to successful intubation, intubation success rates, and glottic visibility using a Cormack-Lehane grade for Macintosh, Intubrite®, Coopdech®, and Copilot® laryngoscopes. One hundred seven paramedics (mean age 31.2 ± 7.5 years) routinely involved in the management of prehospital care participated in this study. Intubation success rates (overall effectiveness), which was the primary study endpoint, were highest for the Coopdech® and CoPilot® devices (100 %) and were lowest for Intubrite® (89.7 %, p < 0.001) and Macintosh (80.4 %, p < 0.001). The secondary study endpoint, time to first effective ventilation, was achieved fastest when using the Coopdech® laryngoscope (21.6 ± 6.2 s) and was significantly slower with all other devices (Intubrite® 25.4 ± 10.5 s, p = 0.006; CoPilot® 25.6 ± 7.4 s, p = 0.007; Macintosh 29.4 ± 8.2 s, p < 0.001). We conclude that in child simulations managed by paramedics, the Coopdech® and Copilot® video laryngoscopes performed better than the standard Macintosh or Intubrite® laryngoscopes for endotracheal intubation during child chest compression.
Colwell, Christopher B; McVaney, Kevin E; Haukoos, Jason S; Wiebe, David P; Gravitz, Craig S; Dunn, Will W; Bryan, Tamara
To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. Reasonable success and complication rates of endotracheal intubation in the out-of-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications.
Amini, Nazanin; Rezaei, Korosh; Yazdannik, Ahmadreza
Background: Formation of biofilm and bacterial colonization within the endotracheal tube (ETT) are significant sources of airway contamination and play a role in the development of ventilator-associated pneumonia (VAP). This study was conducted to examine the effect of nebulized eucalyptus (NE) on bacterial colonization of ETT biofilm. Materials and Methods: We performed a randomized clinical trial in three intensive care units (ICUs) of an educational hospital. Seventy intubated patients were selected and randomly divided into intervention (n = 35) and control (n = 35) groups. The intervention group received 4 ml (5%) of eucalyptus in 6 ml normal saline every 8 h. The placebo group received only 10 ml of normal saline in the same way. On extubation, the interior of the tube was immediately sampled using a sterile swab for standard microbiological analysis. Chi-square and Fisher's exact tests were used for statistical analysis in SPSS. P values less than 0.05 were considered statistically significant. Results: In both samples, Klebsiella pneumoniae and Acinetobacter baumannii were the most frequently isolated bacteria. In the control group, heavy colonization was greater than in the intervention group (P = 0.002). The frequency of isolation of K. pneumoniae in the intervention group was lower than in the control group (P < 0.001). However, there was no difference between the two groups in other isolated bacteria. Conclusions: NE can reduce microbial contamination of the endotracheal tube biofilm in ventilated patients. Moreover, K. pneumoniae was the most sensitive to NE. PMID:27095990
Dat, Vu Quoc; Geskus, Ronald B; Wolbers, Marcel; Loan, Huynh Thi; Yen, Lam Minh; Binh, Nguyen Thien; Chien, Le Thanh; Mai, Nguyen Thi Hoang; Phu, Nguyen Hoan; Lan, Nguyen Phu Huong; Hao, Nguyen Van; Long, Hoang Bao; Thuy, Tran Phuong; Kinh, Nguyen Van; Trung, Nguyen Vu; Phu, Vu Dinh; Cap, Nguyen Trung; Trinh, Dao Tuyet; Campbell, James; Kestelyn, Evelyne; Wertheim, Heiman F L; Wyncoll, Duncan; Thwaites, Guy Edward; van Doorn, H Rogier; Thwaites, C Louise; Nadjm, Behzad
Ventilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam. This is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital
Gamble, Jonathan J; McKay, William P; Wang, Andrew F; Yip, Kinsha A; O'Brien, Jennifer M; Plewes, Christopher E
Accurate endotracheal tube (ETT) depth is critical, especially in children. The current tools used to guide appropriate ETT depth have significant limitations. To evaluate the utility of tracheal palpation in the neck to guide appropriate ETT placement in children. A prospective observational study with a convenience sample of 50 children was conducted. During intubation, an investigator palpated the trachea with three fingertips side-by-side extending upward from the suprasternal notch. The anesthesiologist advanced the ETT slowly until palpated at the sternal notch. The investigator stated ETT palpation certainty as 'strongly felt', 'weakly felt', or 'not felt.' Final ETT position was determined by bronchoscopy and categorized as 'ETT too shallow' (tip in proximal ¼ of trachea), 'ETT too deep' (tip in distal ¼ of trachea), or 'ETT placement satisfactory' (between those extremes). Thirty boys and 20 girls undergoing dental surgery with nasal intubation were recruited (median age 4.4 years; range 2.0-10.8). The ETT (all ≥4 mm ID) was palpable at the sternal notch in all patients: 46 of 50 strongly palpable and 4 of 50 weakly palpable. The experimental methods led to satisfactory ETT placement in 49 of 50 patients, too deep in 1 of 50 patients. Compared with the Pediatrics Advanced Life Support (PALS) predictive formula, satisfactory placement would have been 41 of 50 patients (P < 0.008). Number needed to treat is 6.3 for improvement over the PALS method. The use of tracheal palpation to guide ETT placement has excellent clinical performance and better guides appropriate ETT depth than the PALS formula in our study population. © 2014 John Wiley & Sons Ltd.
Yang, Tao; Hou, Jiong; Li, Jinbao; Zhang, Xu; Zhu, Xiaoyan; Ni, Wen; Mao, Yanfei; Deng, Xiaoming
Tracheal intubation with conventional laryngoscopy requires many trials until beginners are sufficiently skilled in intubating patients safely. To facilitate intubation, the authors used retrograde light-guided laryngoscopy (RLGL) and compared its feasibility with conventional direct laryngoscopy (DL). Twenty operators participated in a prospective, randomized, open-label, parallel-arm study. These operators intubated 205 patients randomly according to a computer-generated procedure by using either DL or RLGL (five intubations with each technique). The primary outcome was the success rate of tracheal intubation. The authors evaluated the success rate of tracheal intubation, the time to glottic exposure and tracheal intubation, and the Cormack and Lehane grades. Compared with DL, the success rate was greater in the RLGL group for all five intubations (72% vs. 47%; rate difference, 25%; 95% CI [11.84-38.16%], P < 0.001). This was associated with a shorter time to glottic exposure (median [25th and 75th percentile]; 27 [15; 42] vs. 45 [30; 73] s, P < 0.001), shorter intubation time (66 [44; 120] vs. 120 [69; 120] s, P < 0.001), and decreased throat soreness (mean ± SD; visual analog scale, 2.1 ± 0.9 vs. 3.7 ± 1.0 cm, P = 0.001) in the RLGL group compared to the DL group. RLGL is an alternative intubation technique. In our study, it enables beginners to intubate patients more successfully and quickly than conventional DL.
Xu, Xuan; Yang, Xianxian; Li, Shangyingying; Luo, Mei; Qing, Ying; Zhou, Xipeng; Xue, Jian; Qiu, Jingfu; Li, Yingli
Lower respiratory tract infection (LRTI) after tracheal intubation under general anesthesia poses a serious threat to worldwide health care systems, especially those in developing countries. However, a significant number of studies have found inconsistent results in their investigation of the corresponding risk factors. Relevant articles published up to September 2015 were retrieved from PubMed, Ovid, Embase, China National Knowledge Infrastructure, Chinese Biological Medical Database, China Science and Technology Journal Database, and Wanfang Data. The z test was used to determine the significance of the pooled odds ratio (OR). ORs and 95% confidence intervals were used to compare the risk factors of LRTI after intubation under general anesthesia. Fifteen case-control studies that included 27,304 participants were identified. We identified the following variables as independent risk factors: duration of general anesthesia >3 hours (OR, 2.45), age >60 years (OR, 2.35), normal endotracheal tube (OR, 1.63), deep intubation (OR, 2.66), unpracticed intubation (OR, 2.61), postoperative extubation time >2 hours (OR, 3.76), smoking history (OR, 3.02), chronic respiratory disease history (OR, 2.30), incomplete extubation indication (OR, 3.54), thoracic or craniocerebral surgery (OR, 1.90), and emergent surgery (OR, 2.54). Eleven risk factors, including surgery, anesthesia, and health condition, were related to LRTI after intubation under general anesthesia. Given the limitations of this study, well-designed epidemiologic studies with a large sample size should be performed in the future. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Brodsky, Martin B; Huang, Minxuan; Shanholtz, Carl; Mendez-Tellez, Pedro A; Palmer, Jeffrey B; Colantuoni, Elizabeth; Needham, Dale M
Nearly 60% of patients who are intubated in intensive care units (ICUs) experience dysphagia after extubation, and approximately 50% of them aspirate. Little is known about dysphagia recovery time after patients are discharged from the hospital. To determine factors associated with recovery from dysphagia symptoms after hospital discharge for acute respiratory distress syndrome (ARDS) survivors who received oral intubation with mechanical ventilation. This is a prospective, 5-year longitudinal cohort study involving 13 ICUs at four teaching hospitals in Baltimore, Maryland. The Sydney Swallowing Questionnaire (SSQ), a 17-item visual analog scale (range, 0-1,700), was used to quantify patient-perceived dysphagia symptoms at hospital discharge, and at 3, 6, 12, 24, 36, 48, and 60 months after ARDS. An SSQ score greater than or equal to 200 was used to indicate clinically important dysphagia symptoms at the time of hospital discharge. Recovery was defined as an SSQ score less than 200, with a decrease from hospital discharge greater than or equal to 119, the reliable change index for SSQ score. Fine and Gray proportional subdistribution hazards regression analysis was used to evaluate patient and ICU variables associated with time to recovery accounting for the competing risk of death. Thirty-seven (32%) of 115 patients had an SSQ score greater than or equal to 200 at hospital discharge; 3 died before recovery. All 34 remaining survivors recovered from dysphagia symptoms by 5-year follow-up, 7 (23%) after 6 months. ICU length of stay was independently associated with time to recovery, with a hazard ratio (95% confidence interval) of 0.96 (0.93-1.00) per day. One-third of orally intubated ARDS survivors have dysphagia symptoms that persist beyond hospital discharge. Patients with a longer ICU length of stay have slower recovery from dysphagia symptoms and should be carefully considered for swallowing assessment to help prevent complications related to dysphagia.
Needham, Dale M.
Rationale: Nearly 60% of patients who are intubated in intensive care units (ICUs) experience dysphagia after extubation, and approximately 50% of them aspirate. Little is known about dysphagia recovery time after patients are discharged from the hospital. Objectives: To determine factors associated with recovery from dysphagia symptoms after hospital discharge for acute respiratory distress syndrome (ARDS) survivors who received oral intubation with mechanical ventilation. Methods: This is a prospective, 5-year longitudinal cohort study involving 13 ICUs at four teaching hospitals in Baltimore, Maryland. The Sydney Swallowing Questionnaire (SSQ), a 17-item visual analog scale (range, 0–1,700), was used to quantify patient-perceived dysphagia symptoms at hospital discharge, and at 3, 6, 12, 24, 36, 48, and 60 months after ARDS. An SSQ score greater than or equal to 200 was used to indicate clinically important dysphagia symptoms at the time of hospital discharge. Recovery was defined as an SSQ score less than 200, with a decrease from hospital discharge greater than or equal to 119, the reliable change index for SSQ score. Fine and Gray proportional subdistribution hazards regression analysis was used to evaluate patient and ICU variables associated with time to recovery accounting for the competing risk of death. Measurements and Main Results: Thirty-seven (32%) of 115 patients had an SSQ score greater than or equal to 200 at hospital discharge; 3 died before recovery. All 34 remaining survivors recovered from dysphagia symptoms by 5-year follow-up, 7 (23%) after 6 months. ICU length of stay was independently associated with time to recovery, with a hazard ratio (95% confidence interval) of 0.96 (0.93–1.00) per day. Conclusions: One-third of orally intubated ARDS survivors have dysphagia symptoms that persist beyond hospital discharge. Patients with a longer ICU length of stay have slower recovery from dysphagia symptoms and should be carefully considered for
Introduction Endotracheal intubation in the ICU is associated with a high incidence of complications. Etomidate use is debated in septic shock because it increases the risk of critical illness-related corticosteroid insufficiency, which may impact outcome. We hypothesized that hydrocortisone, administered in all septic shock cases in our ICU, may counteract some negative effects of etomidate. The aim of our study was to compare septic shock patients who received etomidate versus another induction drug both for short-term safety and for long-term outcomes. Methods A single-center observational study was carried out in septic shock patients, treated with hydrocortisone and intubated within the first 48 hours of septic shock. Co-primary end points were life-threatening complications incidence occurring within the first hour after intubation and mortality during the ICU stay. Statistical analyses included unmatched and matched cohorts using a propensity score analysis. P < 0.05 was considered significant. Results Sixty patients in the etomidate cohort and 42 patients in the non-etomidate cohort were included. Critical illness-related corticosteroid insufficiency was 79% in the etomidate cohort and 52% in the non-etomidate cohort (P = 0.01). After intubation, life-threatening complications occurred in 36% of the patients whatever the cohort. After adjustment with propensity score analysis, etomidate was a protective factor for death in the ICU both in unmatched (hazard ratio, 0.33 (0.15 to 0.75); P < 0.01)) and matched cohorts (hazard ratio, 0.33 (0.112 to 0.988); P = 0.04). Conclusion In septic shock patients treated with hydrocortisone, etomidate did not decrease life-threatening complications following intubation, but when associated with hydrocortisone it also did not impair outcome. PMID:23171852
Sakles, John C.; Mosier, Jarrod; Chiu, Stephen; Cosentino, Mari; Kalin, Leah
Study objective We determine the proportion of successful intubations with the C-MAC video laryngoscope (C-MAC) compared with the direct laryngoscope in emergency department (ED) intubations. Methods This was a retrospective analysis of prospectively collected data entered into a continuous quality improvement database during a 28-month period in an academic ED. After each intubation, the operator completed a standardized data form evaluating multiple aspects of the intubation, including patient demographics, indication for intubation, device(s) used, reason for device selection, difficult airway characteristics, number of attempts, and outcome of each attempt. Intubation was considered ultimately successful if the endotracheal tube was correctly inserted into the trachea with the initial device. An attempt was defined as insertion of the device into the mouth regardless of whether there was an attempt to pass the tube. The primary outcome measure was ultimate success. Secondary outcome measures were first-attempt success, Cormack-Lehane view, and esophageal intubation. Multivariate logistic regression analyses, with the inclusion of a propensity score, were performed for the outcome variables ultimate success and first-attempt success. Results During the 28-month study period, 750 intubations were performed with either the C-MAC with a size 3 or 4 blade or a direct laryngoscope with a Macintosh size 3 or 4 blade. Of these, 255 were performed with the C-MAC as the initial device and 495 with a Macintosh direct laryngoscope as the initial device. The C-MAC resulted in successful intubation in 248 of 255 cases (97.3%; 95% confidence interval [CI] 94.4% to 98.9%). A direct laryngoscope resulted in successful intubation in 418 of 495 cases (84.4%; 95% CI 81.0% to 87.5%). In the multivariate regression model, with a propensity score included, the C-MAC was positively predictive of ultimate success (odds ratio 12.7; 95% CI 4.1 to 38.8) and first-attempt success (odds
De Pascale, Gennaro; Pennisi, Mariano Alberto; Vallecoccia, Maria Sole; Bello, Giuseppe; Maviglia, Riccardo; Montini, Luca; Di Gravio, Valentina; Cutuli, Salvatore Lucio; Conti, Giorgio; Antonelli, Massimo
To determine the safety and clinical efficacy of an innovative integrated airway system (AnapnoGuard™ 100 system) that continuously monitors and controls the cuff pressure (Pcuff), while facilitating the aspiration of subglottic secretions (SS). This was a prospective, single centre, open-label, randomized, controlled feasibility and safety trial. The primary endpoint of the study was the rate of device related adverse events (AE) and serious AE (SAE) as a result of using AnapnoGuard (AG) 100 during mechanical ventilation. Secondary endpoints were: (1) mechanical complications rate (2) ICU staff satisfaction; (3) VAP occurrence; (4) length of mechanical ventilation; (5) length of Intensive Care Unit stay and mortality; (6) volume of evacuated subglottic secretions. Sixty patients were randomized to be intubated with the AG endotracheal-tube (ETT) and connected to the AG 100 system allowing Pcuff adjustment and SS aspiration; or with an ETT combined with SS drainage and Pcuff controlled manually. No difference in adverse events rate was identified between the groups. The use of AG system was associated with a significantly higher incidence of Pcuff determinations in the safety range (97.3% vs. 71%; p<0.01) and a trend to a greater volume of aspirated SS secretions: (192.0[64-413] ml vs. 150[50-200], p = 0.19 (total)); (57.8[20-88.7] ml vs. 50[18.7-62] ml, p = 0.11 (daily)). No inter-group difference was detected using AG system vs. controls in terms of post-extubation throat pain level (0 [0-2] vs. 0 [0-3]; p = 0.7), hoarseness (42.9% vs. 75%; p = 0.55) and tracheal mucosa oedema (16.7% vs. 10%; p = 0.65). Patients enrolled in the AG group had a trend to reduced VAP risk of ventilator-associated pneumonia(VAP) (14.8% vs. 40%; p = 0.06), which were more frequently monomicrobial (25% vs. 70%; p = 0.03). No statistically significant difference was observed in duration of mechanical ventilation, ICU stay, and mortality. The use AG 100 system and AG tube in critically
Lama, P; Shrestha, B R
Inserting a retrograde wire into the pharynx through a cricothyroid puncture can facilitate tracheal intubation in difficult situations where either a flexible fiber-optic bronchoscope or an expert user of such a device is not available. Even in cases when fibropric can not be negotiated for the purpose, this method has been claimed to be useful to manage the airway. Some mouth opening is essential for the oral or nasal retrieval of the wire from the pharynx. Here, a case of post mandibular reconstructed wound infection required surgical debridement and plate removal from reconstructed lower mandible under general anesthesia. We retrieved the guide wire passed through a cricothyroid puncture and subsequently accomplished wire-guided oro-tracheal intubation. In the absence of a flexible fiber-optic bronchoscope, this technique is a very useful aid to intubate patients with limited mouth opening.
Krishna, Senthil G; Hakim, Mumin; Sebastian, Roby; Dellinger, Heather L; Tumin, Dmitry; Tobias, Joseph D
In children, the size of the cuffed endotracheal tube is based on various age-based formulas. However, such formulas may over or underestimate the size of the cuffed endotracheal tube. There are no data on the impact of different-sized cuffed endotracheal tubes (ETT) on the intracuff pressure in children. The current study measures intracuff pressure with different-sized cuffed ETT. The study was conducted in an in vitro and in vivo phase. For the in vitro phase, 10 cuffed ETT of size 4.0, 4.5, and 5 mm internal diameter (ID) each were randomly placed inside a 1.0 cm ID plastic tube (mimicking the trachea), which was in turn connected to a 1 l test lung. After inflation of the cuff using the air leak test at a continuous positive airway pressure of 20 cmH 2 O, the intracuff pressure was measured. The in vivo phase was conducted in 100 children (4-8 years) and were randomly divided into two groups to receive either a cuffed endotracheal tube based on the Khine formula (Group R) or a cuffed endotracheal tube that was a half-size (0.5 mm ID) smaller (Group S). Following the inflation of the cuff to seal the trachea, the intracuff pressure was measured. In the in vitro phase, the intracuff pressure was 45 ± 6, 23 ± 1, and 14 ± 6 cmH 2 O with size 4.0, 4.5, and 5 mm ID cuffed ETT, respectively (F-test P < 0.001 for difference among three groups). In the in vivo phase, the mean intracuff pressure in Group R was 25 ± 19 cmH 2 O vs 37 ± 35 cmH 2 O in Group S (95% CI of difference: 1, 23; P = 0.039). If the cuffed endotracheal tube is too small, the trachea can still be sealed by inflating the cuff with additional air. However, this transforms the cuff from the intended high-volume, low-pressure cuff to an undesirable high-volume, high-pressure cuff. © 2017 John Wiley & Sons Ltd.
Blot, Stijn I; Poelaert, Jan; Kollef, Marin
Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH2O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5-8 cmH2O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of
Ji, Fanceng; Nie, Peihe; Yi, Fuxia; Zhang, Limin
Although the placement of esophageal self-expandable stents (SES) can effectively relieve dysphagia after radiotherapy in patients with esophageal cancer (EC), it may induce severe esophageal complications. This article reports a case of emergency endotracheal intubation in an EC patient who suddenly developed severe dyspnea two months after SES placement. Electronic bronchoscopy of the patient's airway confirmed the diagnosis of esophagotracheal fistula, tracheal stenosis and tracheal rupture. Endotracheal intubation was successfully performed under the guidance of electronic bronchoscopy. Dyspnea due to tracheal stenosis was relieved effectively by inserting the tracheal catheter to a proper place under the guidance of electronic bronchoscopy. Bronchoscopic examination is strongly recommended in EC patients who are highly suspected as having airway stenosis associated with esophageal stenting, for which endotracheal intubation under the guidance of bronchoscopy is suggested.
A comparison of direct versus indirect laryngoscopic visualization during endotracheal intubation of lightly embalmed cadavers utilizing the GlideScope®, Storz Medi Pack Mobile Imaging System™ and the New Storz CMAC™ videolaryngoscope.
Boedeker, Ben H; Nicholsal, Thomas A; Carpenter, Jennifer; Singh, Leighton; Bernhagen, Mary A; Murray, W Bosseau; Wadman, Michael C
Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging System™, the Storz CMAC® VL System and the GlideScope®. After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected. N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization. Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation. 2011.
Bakshi, Sumitra G; Vanjari, Vinayak S; Divatia, Jigeeshu V
Video laryngoscopy has been recommended as an alternative during difficult conventional direct laryngoscopy using the Macintosh blade (MAC). However, successful visualisation of the larynx and tracheal intubation using some of the indirect laryngoscopes or video laryngoscopes (VL) requires hand-eye coordination. We conducted this study to determine whether non-channel VLs are easy to use for novices and whether there is any association between expertise with MAC and ease of tracheal intubation with VLs. Anaesthesiologists participating in the study were divided into three groups: Group novice to intubation (NTI), Group novice to videoscope (NVL)- experienced with MAC, novice to VLs and Group expert (EXP) experienced in all. Group NTI, NVL received prior mannequin training. VLs- Truview(®) and McGrath series 5 (MGR) were compared with MAC. One hundred and twenty six adult patients with normal airway were randomised to both, the intubating anaesthesiologist and laryngoscope. The time taken to intubate (TTI) and participants' rating of the ease of use was recorded on a scale of 1-10 (10-most difficult). In Group NTI, there was no difference in mean TTI with the three scopes (P = 0.938). In Group NVL, TTI was longer with the VLs than MAC (P < 0.001). In Group EXP, TTI with VL took 20 s more (P < 0.001). There was significant difference in participants' rating of ease of use of laryngoscope in Group NVL (P = 0.001) but not in the NTI (P = 0.205), EXP (P = 0.529) groups. A high failure was seen with MGR in Group NTI and NVL. In Group NTI, TTI and the ease of use were similar for all scopes. Expertise with standard direct laryngoscopy does not translate to expertise with VLs. Separate training and experience with VLs is required.
Bakshi, Sumitra G; Vanjari, Vinayak S; Divatia, Jigeeshu V
Background and Aims: Video laryngoscopy has been recommended as an alternative during difficult conventional direct laryngoscopy using the Macintosh blade (MAC). However, successful visualisation of the larynx and tracheal intubation using some of the indirect laryngoscopes or video laryngoscopes (VL) requires hand-eye coordination. We conducted this study to determine whether non-channel VLs are easy to use for novices and whether there is any association between expertise with MAC and ease of tracheal intubation with VLs. Methods: Anaesthesiologists participating in the study were divided into three groups: Group novice to intubation (NTI), Group novice to videoscope (NVL)- experienced with MAC, novice to VLs and Group expert (EXP) experienced in all. Group NTI, NVL received prior mannequin training. VLs- Truview® and McGrath series 5 (MGR) were compared with MAC. One hundred and twenty six adult patients with normal airway were randomised to both, the intubating anaesthesiologist and laryngoscope. The time taken to intubate (TTI) and participants’ rating of the ease of use was recorded on a scale of 1–10 (10-most difficult). Results: In Group NTI, there was no difference in mean TTI with the three scopes (P = 0.938). In Group NVL, TTI was longer with the VLs than MAC (P < 0.001). In Group EXP, TTI with VL took 20 s more (P < 0.001). There was significant difference in participants’ rating of ease of use of laryngoscope in Group NVL (P = 0.001) but not in the NTI (P = 0.205), EXP (P = 0.529) groups. A high failure was seen with MGR in Group NTI and NVL. Conclusion: In Group NTI, TTI and the ease of use were similar for all scopes. Expertise with standard direct laryngoscopy does not translate to expertise with VLs. Separate training and experience with VLs is required. PMID:26257415
Bruder, Eric A; Ball, Ian M; Ridi, Stacy; Pickett, William; Hohl, Corinne
trials in patients undergoing emergency endotracheal intubation for critical illness, including but not limited to trauma, stroke, myocardial infarction, arrhythmia, septic shock, hypovolaemic or haemorrhagic shock, and undifferentiated shock states. We included single (bolus) dose etomidate for emergency airway intervention compared to any other rapid-acting intravenous bolus single-dose induction agent. Refinement of our initial search results by title review, and then by abstract review was carried out by three review authors. Full-text review of potential studies was based on their adherence to our inclusion and exclusion criteria. This was decided by three independent review authors. We reported the decisions regarding inclusion and exclusion in accordance with the PRISMA statement.Electronic database searching yielded 1635 potential titles, and our grey literature search yielded an additional 31 potential titles. Duplicate titles were filtered leaving 1395 titles which underwent review of their titles and abstracts by three review authors. Sixty seven titles were judged to be relevant to our review, however only eight met our inclusion criteria and seven were included in our analysis. We included eight studies in the review and seven in the meta-analysis. Of those seven studies, only two were judged to be at low risk of bias. Overall, no strong evidence exists that etomidate increases mortality in critically ill patients when compared to other bolus dose induction agents (odds ratio (OR) 1.17; 95% confidence interval (CI) 0.86 to 1.60, 6 studies, 772 participants, moderate quality evidence). Due to a large number of participants lost to follow-up, we performed a post hoc sensitivity analysis. This gave a similar result (OR 1.15; 95% CI 0.86 to 1.53). There was evidence that the use of etomidate in critically ill patients was associated with a positive adrenocorticotropic hormone (ACTH) stimulation test, and this difference was more pronounced at between 4 to 6
Anaegbu, Nc; Olatosi, Oj; Tobi, Ku
Heat Moisture Exchangers (HMEs) conserve heat and moisture during expiration and make this available to inspired gases during subsequent inspiration. We sought to evaluate the effectiveness of HMEs in the prevention of perioperative hypothermia in patients scheduled for abdominal surgery under general anaesthesia relaxant technique with endotrachael intubation (GART.) Lagos University Teaching Hospital, in Modular theatre, Anaesthesia unit. The study was a randomized, controlled, longitudinal, interventional study Methods: 100 ASA I, II and III patients aged 18 to 65 years scheduled for abdominal surgery under GART were randomly assigned to 2 groups, groups H and C. Group H had HMEs, while group C served as controls. Core temperature measured using tympanic probe was every 10 minutes till end of anaesthesia Data from total 99 patients, 49 in group H and 50 in group C were eventually analysed. Although patients in both groups developed hypothermia in the course of anaesthesia, core temperature was significantly lower p< 0.05 after one hour in the control group than the intervention group. The use of HMEs during general anaesthesia with endotrachael intubation did not prevent hypothermia but resulted in higher core temperature and should be part of a multimodal approach in the prevention of perioperative hypothermia. Heat Moisture Exchangers, General endotracheal anaesthesia, Hypothermia, abdominal surgery.
Sosis, M B
To determine whether saline soaked pledgets would protect the cuffs of polyvinylchloride (PVC) endotracheal tubes from carbon dioxide (CO2) laser-induced combustion. 12 PVC endotracheal tubes were studied. The cuffed end of each was placed in a graduated cylinder and flushed with 5 L/min of oxygen for 5 minutes. The endotracheal tube's cuff was then inflated with air and the system pressure set to 20 cm H2O. Research laboratory of a university hospital. Six of the endotracheal tube cuffs were protected with 1 inch by 3 inch saline soaked pledgets and six were left unprotected. A CO2 laser set to 40 watts was then fired at the cuffs. All six unprotected cuffs were ignited in less than 1 second. No significant combustion occurred at the six pledget protected endotracheal tube cuffs after 1 minute of laser fire. Under the conditions of this experiment, saline soaked pledgets protected PVC endotracheal tube cuffs from the CO2 laser.
Goto, Tadahiro; Gibo, Koichiro; Hagiwara, Yusuke; Okubo, Masashi; Brown, David F M; Brown, Calvin A; Hasegawa, Kohei
The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED). We analyzed the data from two multicenter prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient's age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and intubator's level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children <10 years. A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the analysis. The overall first-pass success rate was 60% (95%CI [54%-66%]). In the multivariable model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23-4.87]), use of RSI (aOR, 2.17; 95% CI [1.31-3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78-5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63-5.70]), and intubation attempt by an emergency physician (aOR, 4.08; 95% CI [1.92-8.63]) were significantly associated with a higher chance of first-pass success. Based on two large multicenter prospective studies of ED airway management, we found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher chance of first-pass success in children. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.
Shaker, M H; Konchigeri, H N; Andrews, A H; Holinger, P H
Fifty-one patients underwent 71 carbon dioxide laser procedures under general anesthesia for various intralaryngeal pathology. Anesthesia was induced with thiopental sodium, followed by succinylcholine to facilitate endotracheal intubation. For maintenance of anesthesia, 70% nitrous oxide was supplemented with halothane, enflurane or small doses of fentanyl. Succinylcholine, d-tubocurare or pancuronium were used to maintain muscular relaxation of jaw, pharyngeal and laryngeal muscles for a smooth lasing procedure. Small diameter (16-22 Fr.), red rubber, cuffed endotracheal tubes provided maximum working space, facilitated the controlled ventilation and reduced the explosion hazard of the anesthetic gases. Safely eyeglasses were used by all the personnel in the operating room against accidental injury to the cornea by the laser beam. Anesthetic management provided excellent operative conditions with maximum safety to the patient and the personnel in the operating room.
Fouche, Pieter F; Stein, Christopher; Simpson, Paul; Carlson, Jestin N; Zverinova, Kristina M; Doi, Suhail A
Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96-98) vs. 98% (95% CI 91-100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73-89) vs. 82% (95% CI 70-93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98-100) vs. 96% (95% CI 94-97) and first-pass success 89% (95% CI 77-98) vs. 71% (95% CI 57-84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88-100) vs. 98% (95% CI 95-100), but no analysis for physician ground first pass was possible. Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.
Noguchi, Akiko; Kuga, Kumiko; Tashiro, Naoki; Shimakawa, Yusuke; Shono, Takeshi; Hirakawa, Naomi; Sakaguchi, Yoshiro
The present study was conducted to investigate changes in uncuffed endotracheal tube (ETT) leak during laparoscopic surgery. The study included 31 patients aged between 1 and 6 years scheduled for elective laparoscopic inguinal herniorrhaphy. Inspiratory and expiratory tidal volumes (TVi and TVe) were measured during mechanical ventilation, and ETT leak was calculated using the formula-ETT leak = (TVi - TVe)/TVi × 100 (%), assessed at the following time-points-5 min after the start of mechanical ventilation (T1, baseline), just before the start of surgery (T2), 5 min after the induction of pneumoperitoneum with 15° Trendelenburg tilt (T3), and at the end of surgery (T4). Additionally, leak pressure was assessed after successful tracheal intubation (T0, baseline) at T2, T3 and T4. Uncuffed ETT leak significantly decreased at T3 compared with T1 (baseline). Leak pressure significantly increased at T3 and T4 compared with T0 (baseline). Further studies are needed in order to determine whether the results are universal and associated with clinically significant outcomes.
Evanina, Eileen Youshock; Hanisak, Jill L
The electromyographic endotracheal tube (EMG-ETT) is a relatively new tool used to measure integrity of the vocal cord structures during surgery. We describe a case in which an EMG-ETT was inserted for the operative period but not replaced with an ETT during the immediate postoperative period. Intensive care unit nurses had difficulty suctioning the EMG-ETT. The patient was not provided the pulmonary toilet necessary until the EMG-ETT was removed and replaced with a regular ETT. The purpose of this article is to make anesthesia providers aware that when mechanical ventilation is required during the postoperative period, the EMG-ETT should be removed and replaced with a regular ETT to facilitate pulmonary toilet.
Calenda, Emile; Baste, Jean Marc; Hajjej, Ridha; Rezig, Najiba; Moriceau, Jerome; Diallo, Yaya; Sghaeir, Slim; Danielou, Eric; Peillon, Christophe
The aim of this study was to assess the right placement of the double lumen endotracheal tube with fluoroscopic guidance, which is used in first intention prior to the fiberscope in our institution. This was a prospective observational study. The study was conducted in vascular and thoracic operating rooms. We enrolled 205 patients scheduled for thoracic surgery, with ASA physical statuses of I (n = 37), II (n = 84), III (n = 80), and IV (n = 4). Thoracic procedures were biopsy (n = 20), wedge (n = 34), culminectomy (n = 6), lobectomy (n = 82), pneumonectomy (n = 4), sympathectomy (n = 9), symphysis (n = 47), and thymectomy (n = 3). The intubation with a double lumen tube was performed with the help of a laryngoscope. Tracheal and bronchial balloons were inflated and auscultation was performed after right and left exclusions. One shot was performed to locate the position of the bronchial tube and the hook. Fluoroscopic guidance was used to relocate the tube in case of a wrong position. When the fluoroscopic guidance failed to position the tube, a fiberscope was used. Perioperative collapse of the lung was assessed by the surgeon during the surgery. Correct fluoroscopic image was obtained after the first attempt in 58.5% of patients therefore a misplaced position was encountered in 41.5%. The fluoroscopic guidance allowed an exact repositioning in 99.5% of cases, and the mean duration of the procedure was 8 minutes. A fiberscope was required to move the hook for one patient. We did not notice a moving of the double lumen endotracheal tube during the surgery. The surgeon satisfaction was 100%. The fluoroscopy evidenced the right position of the double lumen tube and allowed a right repositioning in 99.5% of patients with a very simple implementation. Copyright © 2014. Published by Elsevier B.V.
Sosis, M B; Braverman, B; Caldarelli, D D
The risk of an endotracheal tube's combustion during laser airway surgery necessitates the use of special anesthetic techniques and equipment to prevent this complication. This study was designed to evaluate the Laser-Trach(TM), a new laser-resistant rubber endotracheal tube for use during laser airway surgery. The Laser-Trach endotracheal tubes that were evaluated were size 6.0 mm internal diameter (ID) red rubber endotracheal tubes which had been commercially wrapped by Kendall-Sheridan (Mansfield, Mass.) with copper foil tape and overwrapped with fabric. The fabric layer was saturated with water prior to our tests, as recommended by the manufacturer. The Laser-Trach endotracheal tubes were compared with plain (bare) size 6.0 mm ID Rusch red rubber endotracheal tubes. The tubes under study were positioned horizontally on wet towels in air and had 5 L x min(-1) of oxygen flowing through them. They were subjected to continuous laser radiation at 40 W from either a CO2 or an Nd-YAG laser. The Nd-YAG laser was propagated via a 600-micron fiber bundle. Each laser was directed perpendicularly at the shaft of the endotracheal tube being studied, and its output was continued until a blowtorch fire occurred or 60 seconds had elapsed. Sixty seconds of CO2 laser fire did not ignite any of the eight Laser-Trach endotracheal tubes tested. However, blowtorch ignition of all eight bare rubber tubes tested occurred after 0.87 +/- 0.21 (mean +/- SD) seconds of CO2 laser fire. Nd-YAG laser contact with the Laser-Trach endotracheal tubes caused the perforation and blowtorch ignition of all eight tubes tested after 18.79 +/- 7.83 seconds. This was a significantly (P<.05) longer time than the 5.45 +/- 4.75 seconds required for the blowtorch ignition of all eight plain rubber endotracheal tubes tested with the Nd-YAG laser. Our results show that under the conditions of this study, the shafts of the Kendall-Sheridan Laser-Trach endotracheal tubes were resistant to the C02 laser
Wong, David T; Yee, Amanda J; Leong, Siaw May; Chung, Frances
During the process of tracheal intubation, patients are apneic or hypoventilating and are at risk of becoming hypoxemic. This risk is especially high in patients with acute or chronic respiratory failure and accompanying compromised respiratory reserve. To address this concern, apneic oxygenation can be administered during tracheal intubation to aid in maintaining arterial oxygen saturation. The objective of this narrative review is to examine the utilization of apneic oxygenation within the operating room, intensive care unit (ICU), emergency department, and pre-hospital settings and to determine its efficacy compared with controls. For this narrative review, we obtained pertinent articles using MEDLINE ® (1946 to April 2016), EMBASE™ (1974 to April 2016), Google Scholar, and manual searches. Apneic oxygenation was administered using various techniques, including the use of nasal prongs, nasopharyngeal or endotracheal catheters, or laryngoscopes. First, all 12 operating room studies showed that apneic oxygenation significantly prolonged the duration to, and incidence of, desaturation. Second, two of the five ICU studies showed a significantly smaller decline in oxygen saturation with apneic oxygenation, with three studies showing no statistically significant difference vs controls. Lastly, two emergency department or pre-hospital studies showed that the use of apneic oxygenation resulted in a significantly lower incidence of desaturation and smaller declines in oxygen saturation. Sixteen of the 19 studies showed that apneic oxygenation prolongs safe apneic time and reduces the incidence of arterial oxygen desaturation. Overall, studies in this review show that apneic oxygenation prolongs the time to oxygen desaturation during tracheal intubation. Nevertheless, the majority of the studies were small in size, and they neither measured nor were adequately powered to detect adverse respiratory events or other serious rare complications. Prolonged apneic oxygenation
Hayden, S R; Sciammarella, J; Viccellio, P; Thode, H; Delagi, R
To evaluate the ability of a disposable, colorimetric end-tidal CO2 detector to verify proper endotracheal (ET) tube placement in out-of-hospital cardiac arrest, and to correlate semiquantitative CO2 measurements with the rate of return of spontaneous circulation (ROSC). Prospective, observational study using a convenience sample of intubated out-of-hospital cardiac arrest patients. A disposable, colorimetric end-tidal CO2 detector was attached to the ET tube after intubation. In the absence of a colorimetric change, the paramedics reassessed the tube placement and could reintubate the patient. Tube placement was verified at the hospital. Paramedics were instructed to contact the base station and report the colorimetric change upon hospital arrival. ROSC was defined as restoration of a self-sustaining pulse until hospital arrival. Between December 1990 and May 1993, ET tubes were placed in 566 victims of out-of-hospital cardiac arrest. 541 of the 566 intubations (95.6%) were associated with a color change. In one case with a color change and out-of-hospital clinical evidence of proper tube placement, the tube was determined to be in the esophagus at the hospital. Correct placement of the remaining 565 of 566 (99.8%) tubes was verified. Of the 566 patients who had a colorimetric change, 91 (16%) had ROSC vs one of 25 (4%) patients who did not have a color change. In one subgroup (n = 179), the degree of color change was highly associated with ROSC (p = 0.004). A disposable, colorimetric end-tidal CO2 detector appears reliable in verifying proper ET tube placement in victims of out-of-hospital cardiac arrest. The degree of color change correlates with the probability of ROSC.
Kohan, Mahmoud; Rezaei-Adaryani, Morteza; Najaf-Yarandi, Akram; Hoseini, Fatemeh; Mohammad-Taheri, Nahid
To investigate the effects of expiratory ribcage compression (ERCC) before endotracheal suctioning on the arterial blood gases (ABG) in patients receiving mechanical ventilation. Endotracheal suctioning is one of the most frequently used methods for airway clearance in patients receiving mechanical ventilation. Chest physiotherapy techniques such as ERCC before endotracheal suctioning can be used as a means to facilitate mobilizing and removing airway secretions and improving alveolar ventilation. A prospective, randomized, controlled cross-over design. A randomized controlled cross-over trial with a convenience sample of 70 mechanically ventilated patients was conducted from 2006 to 2007. The patients received endotracheal suctioning with (experiment-period) or without (control-period) an antecedent 5-min expiratory ribcage. All the patients experienced both periods with at least a 3-h washed-out interval between the two periods. ABG were measured 5 min before and 25 min after endotracheal suctioning. The statistical tests showed that the levels of partial pressure of oxygen (PaO2 )/fraction of inspired oxygen (FiO2 ), partial pressure of carbon dioxide (PaCO2 ) and arterial oxygen saturation (SaO2 ) in the experimental period at 25 min after the intervention were significantly different from the control period. The tests also revealed that the levels of these variables at 25 min after suctioning were also significantly different from baseline values. However, these differences were clinically significant only for PaO2 /FiO2 . By improving the levels of PaO2 /FiO2 , ERCC can reduce the patients' need for oxygen and hence it can at least reduce the side effects of oxygen therapy. Improving PaO2 /FiO2 levels means less need for oxygen therapy. Hence, by applying ERCC we can at least minimize the side effects of oxygen therapy. © 2014 British Association of Critical Care Nurses.
Wilcox, Susan R; Bittner, Edward A; Elmer, Jonathan; Seigel, Todd A; Nguyen, Nicole Thuy P; Dhillon, Anahat; Eikermann, Matthias; Schmidt, Ulrich
Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications. Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation. The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of
Akbarzadeh, Seyed Reza; Taghavi Gillani, Maryar; Tabari, Masoumeh; Morovatdar, Negar
Background Difficult intubation is dangerous and sometimes fatal, especially in patients with obesity. In difficult intubation cases the best device should be applied to decrease the risk of complications. The current study aimed at comparing laryngoscopes, Macintosh, McCoy, GlideScope® and devices for intubation purposes. Methods A total of 102 patients with obesity and ASA (American society of anesthesiologists) class I or II, and body mass index (BMI) of > 30 kg/m2 were selected. After obtaining the informed consent, the patients were divided into 3 groups based on the 3 laryngoscope types. Preoperative airway assessment including the Mallampati score, thyromental distance (TMD), and neck circumference was performed and all the patients were anesthetized based on the same protocol. Subsequently, all of the patients were intubated using a Macintosh, McCoy, or GlideScope® laryngoscope. Laryngoscopy time, Cormack-Lehane score (1 - 4), and the percentage of glottic opening (POGO; 1 - 100) were evaluated. Data were analyzed using SPSS version 16, and results were considered statistically significant at P ≤ 0.05. Results There was no significant difference between demographic characteristics and preoperative airway evaluations. The shortest and longest laryngoscopy time were obtained in the GlideScope® and McCoy laryngoscope groups, respectively (P = 0.001). The highest Cormack-Lehane score was obtained using the GlideScope® method (P = 0.04). The POGO was higher and, therefore, more appropriate in the McCoy laryngoscope group (P = 0.009). A direct relationship was observed between neck circumference (P = 0.008), BMI (P = 0.023), Mallampati score (P = 0.000), and laryngoscopy. Conclusions In the current study, the shortest and longest intubation time in patients with obesity was observed in the GlideScope® and the McCoy laryngoscope groups, respectively. Moreover, the direct relationships of BMI and neck circumference with laryngoscopy time were observed in all
White, Donna M; Redondo, José I; Mair, Alastair R; Martinez-Taboada, Fernando
The effect of user experience and inflation technique on endotracheal tube cuff pressure using a feline airway simulator. Prospective, experimental clinical study. Participants included veterinary students at the beginning (group S1) and end (group S2) of their 2-week anaesthesia rotation and veterinary anaesthetists (group A). The feline airway simulator was designed to simulate an average size feline trachea, intubated with a 4.5 mm low-pressure, high-volume cuffed endotracheal tube, connected to a Bain breathing system with oxygen flow of 2 L minute -1 . Participants inflated the on-endotracheal tube cuff by pilot balloon palpation and by instilling the minimum occlusive volume (MOV) required for loss of airway leaks during manual ventilation. Intracuff pressures were measured by manometers obscured to participants and ideally were 20-30 cm H 2 O. Student t, Fisher exact, and Chi-squared tests were used where appropriate to analyse data (p < 0.05). Participants were 12 students and eight anaesthetists. Measured intracuff pressures for palpation and MOV, respectively, were 19 ± 12 and 29 ± 19 cm H 2 O for group S1, 10 ± 5 and 20 ± 11 cm H 2 O for group S2 and 13 ± 6 and 29 ± 18 cm H 2 O for group A. All groups performed poorly at achieving intracuff pressures within the ideal range. There was no significant difference in intracuff pressures between techniques. Students administered lower (p = 0.02) intracuff pressures using palpation after their training. When using palpation and MOV for cuff inflation operators rarely achieved optimal intracuff pressures. Experience had no effect on this skill and, as such, a cuff manometer is recommended. Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.
Nikolla, Dhimitri; Lewandowski, Tyler; Carlson, Jestin
Although multiple airway management and ventilation strategies have been proposed during cardiac arrest, the ideal strategy is unknown. Current strategies call for advanced airways, such as endotracheal intubation and supraglottic airways. These may facilitate hyperventilation which is known to adversely affect cardiopulmonary physiology. We provide a summary of conceptual models linking hyperventilation to patient outcomes and identify methods for mitigating hyperventilation during cardiac arrest. Copyright © 2015 Elsevier Inc. All rights reserved.
Chan, Fuan Chiang; Kawamoto, Henry K; Bradley, James P
A self-retaining Dingman mouth retractor is widely used to keep the mouth open during cleft palate and intraoral surgery. The airway is at risk of being crushed or occluded as the gag (tongue plate) of the Dingman mouth retractor is being pushed against the endotracheal tube.Kinking of the endotracheal tube between the teeth and Dingman mouth retractor has been reported even with the oral Ring-Adair-Elwyn or flexometallic or armored endotracheal tubes. To minimize kinking of the endotracheal tube and its consequent complications, we routinely insert an 18-gauge needle cap at the potential space between the teeth and the tongue plate (gag) of the Dingman mouth retractor, which is situated lateral to the endotracheal tube. In our experience of approximately 5000 intraoral cases using a Dingman mouth retractor and 18-gauge needle cap, we have not had any tooth avulsion or aspiration of the 18-gauge foreign body while maintaining a consistent and secured airway during cleft palate and intraoral surgery.
Brain, A I; Verghese, C; Addy, E V; Kapila, A; Brimacombe, J
We have assessed the efficacy of a new laryngeal mask prototype, the intubating laryngeal mask airway (ILMA), as a ventilatory device and blind intubation guide. The ILMA consists of an anatomically curved, short, wide bore, stainless steel tube sheathed in silicone which is bonded to a laryngeal mask and a guiding handle. It has a single moveable aperture bar, a guiding ramp and can accommodate an 8 mm tracheal tube (TT). After induction of anaesthesia with propofol 2.5 mg kg-1 and fentanyl 2.5 micrograms kg-1, the device was inserted successfully at the first attempt in all 150 (100%) patients and adequate ventilation achieved in all, with minor adjustments required in four patients. Placement did not require movement of the head and neck or insertion of the fingers in the patient's mouth. Blind tracheal intubation using a straight silicone cuffed TT was attempted after administration of atracurium 0.5 mg kg-1. If resistance was felt during intubation, a sequence of adjusting manoeuvres was used based on the depth at which resistance occurred. Tracheal intubation was possible in 149 of 150 (99.3%) patients. In 75 (50%) patients no resistance was encountered and the trachea was intubated at the first attempt, 28 (19%) patients required one adjusting manoeuvre and 46 (31%) patients required 2-4 adjusting manoeuvres before intubation was successful. There were 13 patients with potential or known airway problems. The lungs of all of these patients were ventilated easily and the trachea intubated using the ILMA. In 10 of 13 (77%) of these patients, no resistance was encountered and the trachea was intubated at the first attempt; three of 13 (23%) patients required one adjusting manoeuvre. Tracheal intubation required significantly fewer adjusting manoeuvres in patients with a predicted or known difficult airway (P < 0.05). We conclude that the ILMA appeared on initial assessment to be an effective ventilatory device and intubation guide for routine and difficult
Arora, Suman; Rattan, Vidya; Bhardwaj, Neerja
The eruption of the first and second permanent molar teeth may influence the size of the retromolar space. In this study we evaluated the adequacy of the retromolar space for retromolar intubation and any effect of eruption of the first and second permanent molar teeth on this space in children. Children 3-15 yr of age, undergoing surgery other than facial surgery were included for evaluation of the retromolar space. After standard oral tracheal intubation, the endotracheal tube was shifted to the retromolar space and the mandible was slowly closed to achieve centric occlusion. At the same time, any increase in airway resistance or decrease in oxygen saturation was noted. In the second part of the study, the feasibility of retromolar intubation in pediatric patients undergoing maxillofacial surgery with intraoperative maxillomandibular fixation was assessed. There was enough space for endotracheal tube placement in the retromolar region. The eruption of the first and second permanent molar teeth did not affect intubation. It was possible to achieve centric occlusion in 79 of 80 children with the endotracheal tube positioned in the retromolar space. Retromolar intubation was successfully accomplished in six pediatric patients undergoing maxillomandibular fixation and maxillofacial surgery. The retromolar space can be safely used for intubation in children when intraoperative maxillomandibular fixation, and simultaneous access to the nose and oral cavity are needed.
Ferrando, Carlos; Aguilar, Gerardo; Belda, F. Javier
Background and Objective. The Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) is a novel tracheal intubation device. Studies, performed until now, have compared the Airtraq with the Macintosh laryngoscope, concluding that it reduces the intubation times and increase the success rate at first intubation attempt, decreasing the Cormack-Lehane score. The aim of the study was to evaluate if, in unskillful anesthesiology residents during the laryngoscopy, the Airtraq compared with the Macintosh laryngoscope improves the laryngeal view, decreasing the Cormack-Lehane score. Methods. A prospective, randomized, crossed-over trial was carried out on 60 patients. Each one of the patients were intubated using both devices by unskillful (less than two hundred intubations with the Macintosh laryngoscope and 10 intubations using the Airtraq) anesthesiology residents. The Cormack-Lehane score, the success rate at first intubation attempt, and the laryngoscopy and intubation times were compared. Results. The Airtraq significantly decreased the Cormack-Lehane score (P = 0.04). On the other hand, there were no differences in times of laryngoscopy (P = 0.645; IC 95% 3.1, +4.8) and intubation (P = 0.62; C95% −6.1, +10.0) between the two devices. No relevant complications were found during the maneuvers of intubation using both devices. Conclusions. The Airtraq is a useful laryngoscope in unskillful anesthesiology residents improving the laryngeal view and, therefore, facilitating the tracheal intubation. PMID:22162683
Davies, Kylie; Bulsara, Max K; Ramelet, Anne-Sylvie; Monterosso, Leanne
To establish criterion-related construct validity and test-retest reliability for the Endotracheal Suction Assessment Tool© (ESAT©). Endotracheal tube suction performed in children can significantly affect clinical stability. Previously identified clinical indicators for endotracheal tube suction were used as criteria when designing the ESAT©. Content validity was reported previously. The final stages of psychometric testing are presented. Observational testing was used to measure construct validity and determine whether the ESAT© could guide "inexperienced" paediatric intensive care nurses' decision-making regarding endotracheal tube suction. Test-retest reliability of the ESAT© was performed at two time points. The researchers and paediatric intensive care nurse "experts" developed 10 hypothetical clinical scenarios with predetermined endotracheal tube suction outcomes. "Experienced" (n = 12) and "inexperienced" (n = 14) paediatric intensive care nurses were presented with the scenarios and the ESAT© guiding decision-making about whether to perform endotracheal tube suction for each scenario. Outcomes were compared with those predetermined by the "experts" (n = 9). Test-retest reliability of the ESAT© was measured at two consecutive time points (4 weeks apart) with "experienced" and "inexperienced" paediatric intensive care nurses using the same scenarios and tool to guide decision-making. No differences were observed between endotracheal tube suction decisions made by "experts" (n = 9), "inexperienced" (n = 14) and "experienced" (n = 12) nurses confirming the tool's construct validity. No differences were observed between groups for endotracheal tube suction decisions at T1 and T2. Criterion-related construct validity and test-retest reliability of the ESAT© were demonstrated. Further testing is recommended to confirm reliability in the clinical setting with the "inexperienced" nurse to guide decision-making related to endotracheal tube
Perrotta, V J; Stern, J D; Lo, A K; Mitra, A
Endotracheal tube stabilization in children with facial burns can be difficult. Several methods rely on straps or complex devices that apply undesirable pressure to the face, potentially destroying skin grafts and making wound care difficult. Techniques that rely on a single wire or suture can be unreliable. Presented here is the arch bar method of endotracheal tube stabilization, which appears to be free of these problems. This method employs a standard dental arch bar secured to four maxillary teeth with 24-gauge stainless steel wire. The endotracheal tube is anchored to the arch bar with two pieces of wire or suture material. The arch bar method of endotracheal tube stabilization was used on three patients in the burn center at St. Christopher's Hospital for Children. Wound care and successful skin grafting were performed without difficulty. No complications related to the arch bars occurred.
Chacur, Fernando Hauaji; Vilella Felipe, Luis Marcelo; Fernandes, Cintia Gonçalves; Lazzarini, Luiz Claudio Oliveira
Noninvasive positive-pressure ventilation (NPPV) is commonly used to improve ventilation and oxygenation and avoid endotracheal intubation and mechanical ventilation. Although clinically indicated, most patients fail to use NPPV due to mask intolerance. A total face mask was designed to increase compliance, but whether this translates into better outcome (improvement in clinical and blood gas parameters and less intubation) is unknown. We compared the evolution of the clinical parameters, blood gases, levels of ventilatory support and rate of endotracheal intubation using the total face mask or the traditional oronasal mask during NPPV. A total of 60 patients were randomized to use either mask during NPPV. The clinical and laboratory parameters, as well as the level of ventilatory support were recorded at different intervals in both groups for up to 6 h. In addition, the tolerance for each mask and the need for endotracheal intubation were compared. Patients tolerated the total face mask significantly better (p = 0.0010) and used NPPV for a longer time (p = 0.0017) when compared with the oronasal mask. Just 1 patient switched to the total face mask because of intolerance. Although better tolerated, the rate of endotracheal intubation was similar in both groups (p = 0.4376), as was the clinical and laboratory evolution. The total face mask was more comfortable, allowing the patients to tolerate NPPV longer; however, these accomplishments did not translate into a better outcome. Due to its comfort, the total face mask should be available, at least as an option, in units where NPPVs are routinely applied. Copyright © 2011 S. Karger AG, Basel.
Döcker, Dennis; Walther, Andreas
The use of muscle relaxants facilitates endotracheal intubation and ameliorates the conditions of surgery. But, their use should be controlled - otherwise there will be postoperative residual curarisation which can lead to patient discomfort up to severe medical complications. Therefore, an appropriate surveillance via objective neuromuscular monitoring is essential. This article gives a review of the basic principles of muscle relaxants, their clinical application and the surveillance of their effects and degradation. © Georg Thieme Verlag Stuttgart · New York.
Andronis, Lazaros; Oppong, Raymond A; Manga, Na'ngono; Senanayake, Eshan; Gopal, Shameer; Charman, Susan; Giri, Ramesh; Luckraz, Heyman
Ventilator-associated pneumonia (VAP) is common and costly. In a recent randomized controlled trial, the Venner-PneuX (VPX) endotracheal tube system was found to be superior to standard endotracheal tubes (SET) in preventing VAP. However, VPX is considerably more expensive. We evaluated the costs and benefits of VPX to determine whether replacing SET with VPX is a cost-effective option for intensive care units. We developed a decision analytic model to compare intubation with VPX or SET for patients requiring mechanical ventilation post cardiac surgery. The model was populated with existing evidence on costs, effectiveness and quality of life. Cost-effectiveness and cost-utility analyses were conducted from an NHS hospital perspective. Uncertainty was assessed through deterministic and probabilistic sensitivity analyses. Compared to SET, VPX is associated with an expected cost saving of £738 per patient. VPX led to a small increase in quality-adjusted life years (QALYs), indicating that the device is overall less costly and more effective than SET. The probability of VPX being cost-effective at £30,000 per QALY is 97%. VPX would cease to be cost-effective if (i) it led to a risk reduction smaller than 0.02 compared to SET, (ii) the acquisition cost of VPX was as high as £890 or, (iii) the cost of treating a case of VAP was lower than £1,450. VPX resulted in improved outcomes and savings which far offset the cost of the device, suggesting that replacing SET with VPX is overall beneficial. Findings were robust to extreme values of key parameters. Copyright © 2018. Published by Elsevier Inc.
Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the Trauma Registry of the German Society of Trauma Surgery.
Kulla, Martin; Helm, Matthias; Lefering, Rolf; Walcher, Felix
The aim of this study was to determine whether prehospital endotracheal intubation (ETI) and chest tube placement is unnecessarily time consuming in severely injured patients. A retrospective, multicentre study including all adult patients (ISS ≥9; 2002-7) of the Trauma Registry of the German Society of Trauma Surgery who were not secondarily transferred to a trauma centre and received a definitive airway and a chest tube. Creating four groups: AA (n=963) receiving ETI and chest tube on scene, AB (n=1547) ETI performed in the prehospital setting but chest tubing later in the emergency department (ED) and BB (n=640) receiving both procedures in the ED. The BA collective (ETI performed in the ED, but chest tubing on scene) was excluded from the study because of the small sample size (n=41). The trauma resuscitation time (TRT), demographic data, injuries, treatment and outcome of the remaining three collectives were compared. The prehospital TRT of the AA collective was longer than the AB and BB subgroups (80±37 min vs 77±44 min 65±46 min; p<0.01). Although the AA and AB subgroups were more severely injured (ISS 35±15 vs 38±15 vs 31±12; p<0.01) and showed poorer vital parameters on scene, the overall TRT (accident until end of ED treatment) were equal for all three groups (152±59 min vs 151±62 min vs 148±68 min; p=0.07). The TRISS adjusted mortality was also equal in all three groups. In a physician-based emergency medical service, prehospital ETI and chest tube placement do not prolong the total TRT of severely injured patients.
Mohr, Rebecca; Thomas, Jörg; Cannizzaro, Vincenzo; Weiss, Markus; Schmidt, Alexander R
Work of breathing accounts for a significant proportion of total oxygen consumption in neonates and infants. Endotracheal tube inner diameter and length significantly affect airflow resistance and thus work of breathing. While endotracheal tube shortening reduces endotracheal tube resistance, the impact on work of breathing in mechanically ventilated neonates and infants remains unknown. The objective of this in vitro study was to quantify the effect of endotracheal tube shortening on work of breathing in simulated pediatric lung settings. We hypothesized that endotracheal tube shortening significantly reduces work of breathing. We used the Active-Servo-Lung 5000 to simulate different clinical scenarios in mechanically ventilated infants and neonates under spontaneous breathing with and without pressure support. Endotracheal tube size, lung resistance, and compliance, as well as respiratory settings such as respiratory rate and tidal volume were weight and age adapted for each lung model. Work of breathing was measured before and after maximal endotracheal tube shortening and the reduction of the daily energy demand calculated. Tube shortening with and without pressure support decreased work of breathing to a maximum of 10.1% and 8.1%, respectively. As a result, the calculated reduction of total daily energy demand by endotracheal tube shortening was between 0.002% and 0.02%. In this in vitro lung model, endotracheal tube shortening had minimal effects on work of breathing. Moreover, the calculated percentage reduction of the total daily energy demand after endotracheal tube shortening was minimal. © 2017 John Wiley & Sons Ltd.
Huang, Ling; Xie, Chen; Zhang, Lifeng; Meng, Liying; Li, Guizheng; Li, Yang; Huang, Bing; Pan, Linghui; Tang, Zhanhong
endotracheal intubation cuff was approximately equal to the value of the pressure loss caused by the pressure gauge self-structure and the pressure loss when the indicated cuff was connected and disconnected [normal pressure group: (10.19±0.45) cmH 2 O ≍ (8.77±0.53) cmH 2 O + (1.33±0.49) cmH 2 O, high pressure group: (15.10±0.43) cmH 2 O ≍ (13.91±0.48) cmH 2 O + (1.23±0.55) cmH 2 O]. The intermittently monitoring on endotracheal tube cuff pressure is the main cause of the pressure loss. The total pressure loss consists of the pressure leak from the cuff to the gauge and the pressure leak when connecting and disconnecting the gauge and the indicated cuff during each test. When the pressure in the cuff is increased, it will cause more pressure loss.
Nava, Stefano; Navalesi, Paolo; Conti, Giorgio
Non-invasive ventilation (NIV) is a safe, versatile and effective technique that can avert side effects and complications associated with endotracheal intubation. The success of NIV relies on several factors, including the type and severity of acute respiratory failure, the underlying disease, the location of treatment, and the experience of the team. The time factor is also important. NIV is primarily used to avert the need for endotracheal intubation in patients with early-stage acute respiratory failure and post-extubation respiratory failure. It can also be used as an alternative to invasive ventilation at a more advanced stage of acute respiratory failure or to facilitate the process of weaning from mechanical ventilation. NIV has been used to prevent development of acute respiratory failure or post-extubation respiratory failure. The number of days of NIV and hours of daily use differ, depending on the severity and course of the acute respiratory failure and the timing of application. In this review article, we analyse, compare and discuss the results of studies in which NIV was applied at various times during the evolution of acute respiratory failure.
... invention embodied in: HHS Ref. No. E-061-2004/0 ``Mucus Shaving Apparatus for Endotracheal Tubes''; U.S... endotracheal tube cleaning apparatus which is inserted into the inside of an endotracheal tube to shave away... apparatus with a flexible central tube and an inflatable balloon at its distal end. Affixed to the...
Harvie, D A; Darvall, J N; Dodd, M; De La Cruz, A; Tacey, M; D'Costa, R L; Ward, D
Endotracheal tube (ETT) cuff pressure management is an essential part of airway management in intubated and mechanically ventilated patients. Both under- and over-inflation of the ETT cuff can lead to patient complications, with an ideal pressure range of 20-30 cmH 2 O defined. A range of techniques are employed to ensure adequate ETT cuff inflation, with little comparative data. We performed an observational cross-sectional study in a tertiary metropolitan ICU, assessing the relationship between the minimal leak test and cuff manometry. Forty-five mechanically ventilated patients, over a three-month period, had ETT cuff manometry performed at the same time as their routine cuff maintenance (minimal leak test). Bedside nurse measurements were compared with investigator measurements. At the endpoint of cuff inflation, 20 of 45 patients (44%) had cuff pressures between 20 and 30 cmH 2 O; 11 of 45 patients (24%) had cuff pressures <20 cmH 2 O; 14 of 45 patients (31%) had cuff pressures ≥30 cmH 2 O. Univariate analysis demonstrated an association between both patient obesity and female gender requiring less ETT cuff volume ( P =0.008 and P <0.001 respectively), though this association was lost on multivariate analysis. No association was demonstrated between any measured variables and cuff pressures. Inter-operator reliability in performing the minimal leak test showed no evidence of bias between nurse and investigators (Pearson coefficient = 0.897). We conclude the minimal leak test for maintenance of ETT cuffs leads to both over- and under-inflation, and alternative techniques, such as cuff manometry, should be employed.
Ari, Arzu; Harwood, Robert J; Sheard, Meryl M; Fink, James B
Previous research reporting factors influencing aerosol delivery in intubated patients has been largely focused on the endotracheal tube (ETT) during mechanical ventilation, with little comparative analysis of effect of types of artificial airways and their interfaces on aerosol delivery during spontaneous breathing. The purpose of this study was to compare aerosol delivery via tracheostomy tube (TT) and ETT, using interfaces such as T-piece, tracheostomy collar, and manual resuscitation bag. A teaching manikin was intubated with either an ETT (8.0 mm inner diameter) and TT (8 mm inner diameter). Both bronchi were connected to a collecting filter, attached to a sinusoidal pump simulating the breathing pattern of a spontaneously breathing adult (tidal volume 450 mL, respiratory rate 20 breaths/min, inspiratory-expiratory ratio 1:2). Albuterol sulfate (2.5 mg/3 mL) was nebulized through a jet nebulizer, using each airway and interface as appropriate (n = 3). Drug on the filter was eluted and analyzed with spectrophotometry, and expressed as mean percent of loaded dose delivered. Descriptive statistics, the Student t test, and one-way analysis of variance were applied. A greater percentage of nominal dose was delivered via TT than ETT with both T-piece (13.79 ± 2.59% vs 9.05 ± 0.70%) and manual resuscitation bag (45.75 ± 1.8% vs 27.23 ± 8.98%, P = .038 and P = .025, respectively). Use of manual resuscitation bag with both TT and ETT increased lung dose more than 3-fold. Inhaled dose with tracheostomy collar was (6.92 ± 0.81%) less than T-piece with TT (P = .01). In this adult model of spontaneous ventilation, aerosol therapy through ETT was less efficient than TT, while the manual resuscitation bag was more efficient than T-piece or tracheostomy collar.
Timanaykar, Ramesh T; Anand, Lakesh K; Palta, Sanjeev
The Truview EVO2™ laryngoscope is a recently introduced device with a unique blade that provides a magnified laryngeal view at 42° anterior reflected view. It facilitates visualization of the glottis without alignment of oral, pharyngeal, and tracheal axes. We compared the view obtained at laryngoscopy, intubating conditions and hemodynamic parameters of Truview with Macintosh blade. In prospective, randomized and controlled manner, 200 patients of ASA I and II of either sex (20-50 years), presenting for surgery requiring tracheal intubation, were assigned to undergo intubation using a Truview or Macintosh laryngoscope. Visualization of the vocal cord, ease of intubation, time taken for intubation, number of attempts, and hemodynamic parameters were evaluated. Truview provided better results for the laryngeal view using Cormack and Lehane grading, particularly in patients with higher airway Mallampati grading (P < 0.05). The time taken for intubation (33.06±5.6 vs. 23.11±57 seconds) was more with Truview than with Macintosh blade (P < 0.01). The Percentage of Glottic Opening (POGO) score was significantly higher (97.26±8) in Truview as that observed with Macintosh blade (83.70±21.5). Hemodynamic parameters increased after tracheal intubation from pre-intubation value (P < 0.05) in both the groups, but they were comparable amongst the groups. No postoperative adverse events were noted. Tracheal intubation using Truview blade provided consistently improved laryngeal view as compared to Macintosh blade without the need to align the oral, pharyngeal and tracheal axes, with equal attempts for successful intubation and similar changes in hemodynamics. However, the time taken for intubation was more with Truview.
Timanaykar, Ramesh T; Anand, Lakesh K; Palta, Sanjeev
Background: The Truview EVO2™ laryngoscope is a recently introduced device with a unique blade that provides a magnified laryngeal view at 42° anterior reflected view. It facilitates visualization of the glottis without alignment of oral, pharyngeal, and tracheal axes. We compared the view obtained at laryngoscopy, intubating conditions and hemodynamic parameters of Truview with Macintosh blade. Materials and Methods: In prospective, randomized and controlled manner, 200 patients of ASA I and II of either sex (20–50 years), presenting for surgery requiring tracheal intubation, were assigned to undergo intubation using a Truview or Macintosh laryngoscope. Visualization of the vocal cord, ease of intubation, time taken for intubation, number of attempts, and hemodynamic parameters were evaluated. Results: Truview provided better results for the laryngeal view using Cormack and Lehane grading, particularly in patients with higher airway Mallampati grading (P < 0.05). The time taken for intubation (33.06±5.6 vs. 23.11±57 seconds) was more with Truview than with Macintosh blade (P < 0.01). The Percentage of Glottic Opening (POGO) score was significantly higher (97.26±8) in Truview as that observed with Macintosh blade (83.70±21.5). Hemodynamic parameters increased after tracheal intubation from pre-intubation value (P < 0.05) in both the groups, but they were comparable amongst the groups. No postoperative adverse events were noted. Conclusion: Tracheal intubation using Truview blade provided consistently improved laryngeal view as compared to Macintosh blade without the need to align the oral, pharyngeal and tracheal axes, with equal attempts for successful intubation and similar changes in hemodynamics. However, the time taken for intubation was more with Truview. PMID:21772680
Sakai, Daniel M; Zornow, Kailee Anne; Campoy, Luis; Cable, Christina; Appel, Leslie D; Putnam, Holly J; Martin-Flores, Manuel
Objectives We evaluated the use of rocuronium 0.3 mg/kg intravenously (IV) to facilitate tracheal intubation in cats anesthetized for elective ovariohysterectomy. Methods Thirty female cats were randomly allocated to receive rocuronium 0.3 mg/kg IV or an equal volume of normal saline, following induction of anesthesia with ketamine and midazolam. Thirty seconds after induction, a single investigator, unaware of treatment allocation, attempted tracheal intubation. The number of attempts and the time to complete intubation were measured. Intubating conditions were assessed as acceptable or unacceptable based on a composite score consisting of five different components. Duration of apnea after induction was measured and cases of hemoglobin desaturation (SpO 2 <90%) were identified. Results Intubation was completed faster (rocuronium 12 s [range 8-75 s]; saline 60 s [range 9-120 s]) and with fewer attempts (rocuronium 1 [range 1-2]; saline 2 [range 1-3], both P = 0.006) in cats receiving rocuronium. Unacceptable intubating conditions on the first attempt occurred in 3/15 cats with rocuronium and in 10/15 with saline ( P = 0.01). Apnea lasted 4 ± 1.6 mins with rocuronium and 2.3 ± 0.5 mins with saline ( P = 0.0007). No cases of desaturation were observed. Conclusions and relevance Rocuronium 0.3 mg/kg IV improves intubating conditions compared with saline and reduces the time and number of attempts to intubate with only a short period of apnea in cats.
Gulabani, Michell; Gupta, Akhilesh; Bannerjee, Neerja Gaur; Sood, Rajesh; Dass, Prashant
An 11-year-old male child, known case of down's syndrome with congenital oesophageal stricture was posted for oesophageal dilatation. Preoperative airway assessment revealed a high arched palate, receding mandible and Mallampati Score of 2. During surgery, after loss of consciousness which was described as loss of eyelash reflex and adequate jaw relaxation, direct laryngoscopy and endotracheal intubation was attempted with a cuffed endotracheal tube number 5.0mm ID (internal diameter). The endotracheal tube could not be negotiated smoothly, so 5.0mm ID uncuffed endotracheal tube was used which passed through easily, but on auscultation revealed a significant leak. Later, intubation via a Micro Laryngeal Surgery (MLS) cuffed tube 4.0mm ID was attempted. The MLS tube advanced smoothly and there was no associated leak on positive pressure ventilation. Thus by innovative thinking and avant-garde reasoning, a definitive airway device could be positioned with no other suitable alternative at hand.
Sosis, M B; Dillon, F
To determine how well Laser-Guard protects polyvinyl chloride (PVC) endotracheal tubes from the carbon dioxide (CO2) laser. Bare and Laser-Guard-protected PVC endotracheal tubes were tested with 5 L/min of oxygen (O2) passing through them. Research laboratory of a university-affiliated metropolitan medical center. After moistening the Laser-Guard-protected endotracheal tubes, we subjected the tubes to CO2 laser radiation at 10 and 70 watts until combustion occurred or 60 seconds had elapsed. The bare PVC tube ignited and a "blowtorch" fire occurred after 3 seconds of CO2 laser use at 70 watts. The moistened Laser-Guard-protected PVC endotracheal tubes were not significantly damaged by 1 minute of laser use at 70 watts. Laser-Guard protects the shafts of combustible PVC endotracheal tubes from direct, high-power, continuous CO2 laser radiation.
Acute exacerbations of asthma can lead to respiratory failure requiring ventilatory assistance. Noninvasive ventilation may prevent the need for endotracheal intubation in selected patients. For patients who are intubated and undergo mechanical ventilation, a strategy that prioritizes avoidance of ventilator-related complications over correction of hypercapnia was first proposed 30 years ago and has become the preferred approach. Excessive pulmonary hyperinflation is a major cause of hypotension and barotrauma. An appreciation of the key determinants of hyperinflation is essential to rational ventilator management. Standard therapy for patients with asthma undergoing mechanical ventilation consists of inhaled bronchodilators, corticosteroids, and drugs used to facilitate controlled hypoventilation. Nonconventional interventions such as heliox, general anesthesia, bronchoscopy, and extracorporeal life support have also been advocated for patients with fulminant asthma but are rarely necessary. Immediate mortality for patients who are mechanically ventilated for acute severe asthma is very low and is often associated with out-of-hospital cardiorespiratory arrest before intubation. However, patients who have been intubated for severe asthma are at increased risk for death from subsequent exacerbations and must be managed accordingly in the outpatient setting.
Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers—Cadavers vs. Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion
Hindman, Bradley J.; From, Robert P.; Fontes, Ricardo B.; Traynelis, Vincent C.; Todd, Michael M.; Zimmerman, M. Bridget; Puttlitz, Christian M.; Santoni, Brandon G.
Introduction The aims of this study were to characterize: 1) cadaver intubation biomechanics, including the effect of repeated intubations; and 2) the relationship between intubation force and the motion of an injured cervical segment. Methods Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (Type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations. Results Cadaver intubation biomechanics were comparable to those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (Set 2/Set1 force ratio = 0.61 [95% CI: 0.46, 0.81]; P=0.002) and Oc-C5 extension (Set 2 –Set 1 difference = −6.1 degrees [95% CI: −11.4, −0.9]; P=0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ: 1) between intact and injured states; or 2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm [95% CI: 0.7, 4.9 mm]; P=0.004). Discussion With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a Type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression. PMID:26288267
Tandon, Navin; McCarthy, Matthew; Forehand, Brett; Carlson, Jestin N
Interruptions in chest compressions during cardiopulmonary resuscitation can negatively impact survival. Several new endotracheal intubation (ETI) techniques including video laryngoscopy may allow for ETI with minimal or no interruptions in chest compressions. We sought to determine the impact of three different ETI techniques upon time to intubation (TTI) in a simulated cardiac arrest during uninterrupted chest compression. We performed a randomised crossover study with a convenience sample of emergency physicians using three different ETI techniques: direct laryngoscopy (DL), GlideScope video laryngoscopy (GVL) and GlideScope video laryngoscopy with bougie (GVL-B). Providers performed ETI on a manikin on a hospital bed with concurrent chest compressions. Our primary outcome, TTI, was defined as the time from insertion of the laryngoscope blade until first breath. Given the correlated nature of the data, we used the paired t test to assess the differences in mean TTIs between GVL minus DL and GVL-B minus DL. We also ran the analysis stratified by provider experience. We enrolled 20 providers with a median TTI (IQR) by device of: DL 27 s (20.3, 35.4), GVL 20.6 s (17.7, 27.1) and GVL-B 60.1 s (39.1, 99). The mean GVL-DL difference was -10.1 s (-17.9-2.3) while the mean GVL-B-DL difference was 45.6 s (19.8-71.4) (p<0.001). The GVL-B required the greatest TTI across providers of varying experience levels. In this simulated model of cardiac arrest with uninterrupted chest compressions, TTI was shorter for GVL than DL while use of the GVL with bougie resulted in longer TTI. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Wong, David T; Mehta, Arpan; Tam, Amanda D; Yau, Brian; Wong, Jean
The purpose of this survey was to determine the equipment that anesthesiologists prefer in difficult tracheal intubation and "cannot intubate, cannot ventilate" (CICV) situations. A questionnaire was e-mailed to members of the Canadian Anesthesiologists' Society to ascertain their preferences, experience, and comfort level with regard to their use of airway equipment in difficult intubation and CICV situations in adult patients. A Chi square test was used to analyse the data. All reported P values are two-sided. Nine hundred ninety-seven of 2,532 questionnaires (39%) were returned. In an unanticipated difficult direct laryngoscopic intubation situation, 893 of 997 (90%) respondents chose a video laryngoscope as the first-choice rescue technique, while 41 (4%) and 21 (2%) of respondents chose a flexible bronchoscope and an intubating laryngeal mask airway device, respectively. The majority of anesthesiologists had experience and were comfortable with using a flexible bronchoscope or a video laryngoscope. Regarding CICV, 294 of 955 (31%) respondents stated that they had never encountered it. Wire-guided cricothyroidotomy was chosen as the first-choice surgical airway by 375 of 955 (39%) respondents, while intravenous catheter cricothyroidotomy and "defer to tracheostomy by surgeon" were selected by 266 (28%) and 215 (23%) respondents, respectively. Seven hundred eighty-five of 997 (78%) respondents were familiar with the exact steps of the American Society of Anesthesiologists' difficult airway algorithm, while 448 (47%) had attended an airway workshop within the past five years. In a difficult intubation situation, the most frequently selected first-choice airway device was a video laryngoscope, followed by a flexible bronchoscope. In a CICV situation, the most frequently selected first-choice surgical airway technique was a wire-guided cricothyroidotomy, followed by an intravenous catheter cricothyroidotomy.
Biniwale, Manoj; Wertheimer, Fiona
The literature supports minimizing duration of invasive ventilation to decrease lung injury in premature infants. Neonatal Resuscitation Program recommended use of non-invasive ventilation (NIV) in delivery room for infants requiring prolonged respiratory support. To evaluate the impact of implementation of non-invasive ventilation (NIV) using nasal intermittent positive pressure ventilation (NIPPV) for resuscitation in very low birth infants. Retrospective study was performed after NIPPV was introduced in the delivery room and compared with infants receiving face mask to provide positive pressure ventilation for resuscitation of very low birth weight infants prior to its use. Data collected from 119 infants resuscitated using NIPPV and 102 infants resuscitated with a face mask in a single institution. The primary outcome was the need for endotracheal intubation in the delivery room. Data was analyzed using IBM SPSS Statistics software version 24. A total of 31% of infants were intubated in the delivery room in the NIPPV group compared to 85% in the Face mask group (p=<0.001). Chest compression rates were 11% in the NIPPV group and 31% in the Face mask group (p<0.001). Epinephrine administration was also lower in NIPPV group (2% vs. 8%; P=0.03). Only 38% infants remained intubated at 24hours of age in the NIPPV group compared to 66% in the Face mask group (p<0.001). Median duration of invasive ventilation in the NIPPV group was shorter (2days) compared to the Face mask group (11days) (p=0.01). The incidence of air-leaks was not significant between the two groups. NIPPV was safely and effectively used in the delivery room settings to provide respiratory support for VLBW infants with less need for intubation, chest compressions, epinephrine administration and subsequent invasive ventilation. Copyright © 2017 Elsevier B.V. All rights reserved.
Baker, Katherine; Tremblay, Eric; Karp, Jason; Ford, Joseph; Finer, Neil; Rich, Wade
Extremely low birth weight (ELBW) infants frequently require endotracheal intubation for assisted ventilation or as a route for administration of drugs or exogenous surfactant. In adults and less premature infants, the risks of this intubation can be greatly reduced using video laryngoscopy, but current products are too large and incorrectly shaped to visualize an ELBW infant's airway anatomy. We design and prototype a video laryngoscope using a miniature camera set in a curved acrylic blade with a 3×6-mm cross section at the tip. The blade provides a mechanical structure for stabilizing the tongue and acts as a light guide for an LED light source, located remotely to avoid excessive local heating at the tip. The prototype is tested on an infant manikin and found to provide sufficient image quality and mechanical properties to facilitate intubation. Finally, we show a design for a neonate laryngoscope incorporating a wafer-level microcamera that further reduces the tip cross section and offers the potential for low cost manufacture.
Michalek, P; Donaldson, W; Graham, C; Hinds, J D
Insertion of a supraglottic airway and tracheal intubation through it may be indicated in resuscitation scenarios where conventional laryngoscopy fails. Various supraglottic devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), the Ctrach laryngeal mask and the I-gel supraglottic airway. A prospective study with 25 participants evaluated the success rate of blind intubation (using a gum-elastic bougie, an Aintree intubating catheter (AIC) and designated tracheal tube) and fibrescope-guided tracheal intubation (through the intubating laryngeal mask airway and the I-gel supraglottic airway) on three different airway manikins. Twenty-five anaesthetists performed three intubations with each method on each of three manikins. The success rate of the fibrescope-guided technique was significantly higher than blind attempts (P<0.0001) with both devices. For fibreoptic techniques, there was no difference found between the ILMA and I-gel (P>0.05). All blind techniques were significantly more successful in the ILMA group compared to the I-gel (P<0.0001 for bougie, Aintree catheter and tracheal tube, respectively). The results of this study show that, in manikins, fibreoptic intubation through both ILMA and I-gel is a highly successful technique. Blind intubation through the I-gel showed a low success rate and should not be attempted. Copyright 2009 Elsevier Ireland Ltd. All rights reserved.
Gaszynska, Ewelina; Gaszynski, Tomasz
The aim of this study was to compare the performance of the Truview EVO2 laryngoscope in manikin-simulated cardiopulmonary resuscitation (CPR) and no-CPR scenarios with standard intubation technique. Participants performed 4 scenarios in random order: endotracheal intubation (ETI) using Macintosh laryngoscope (MCL), Truview EVO2 laryngoscope in no-CPR patient scenario, and intubation during uninterrupted chest compressions using both laryngoscopes. The participants were directed to make 3 attempts in each scenario. Primary outcomes were time to tracheal intubation (TTI) and intubation success, whereas secondary outcomes were cumulative success ratio and the number of esophageal intubation (EI). TTI and success ratios were reported per attempt. Thirty paramedics completed the study. Median TTI with Truview EVO2 with CPR was 36 (interquartile range [IQR] 29.00-52.00), 22.5 (IQR 18.33-35.00), and 18 (IQR 11.00-23.00) seconds; MCL with CPR was 23 (IQR 18.92-36.90), 16.8 (IQR 14.00-22.31), and 14.5 (IQR 11.12-16.36) seconds; Truview EVO2 without CPR was 28.6 (IQR 24.02-38.34), 21.7 (IQR 17.00-25.00), and 13 (IQR 11.90-17.79) seconds; MCL without CPR was 17 (IQR 13.23-22.29), 13 (IQR 12.09-15.26), and 12.4 (IQR 10.08-19.84) seconds for first, second, and third attempts, respectively. The P values for differences in TTI between Truview EVO2 and MCL were P < 0.0001, P = 0.0540, and P = 0.7550 in CPR scenario and P = 0.0080, P = 0.1570, and P = 0.7652 in no-CPR scenario for first, second, and third attempts, respectively. The success ratios for each of the scenarios were as follows: in CPR scenario it was 0.73 versus 0.53 (P = 0.0558), 0.83 versus 0.76 (P = 0.2633), and 1 versus 0.8 (P = 0.0058); in no-CPR scenario it was 0.63 versus 0.73 (P = 0.2068), 0.86 versus 0.86, and 0.97 versus 1 (P = 0.1637) for Truview EVO2 vs MCL in first, second, and third attempts, respectively. The cumulative success ratio related to the time of ETI
Ong, Jimmy; Lee, Chia-Ling; Huang, Shen-Jer; Shyr, Ming-Hwang
Objectives: It remains to be determined whether the TVI-4000 Trachway video intubating (TVI) stylet (Markstein Sichtec Medical Corp, Taichung, Taiwan), an airway device for novices, improves airway management practice by experienced anesthesiologists. The aim of this study was to evaluate the feasibility of using the TVI stylet in difficult tracheal intubation situations compared with that of using the Macintosh laryngoscope on an airway manikin. Materials and Methods: Ten anesthesiologists (with 3–21 years’ experience), including three senior residents, participated. We compared tracheal intubation in four airway scenarios: normal airway, tongue edema, cervical spine immobilization, and tongue edema combined with cervical spine immobilization. The time of tracheal intubation (TTI), success rate, and perceived difficulty of intubation for each scenario were compared and analyzed. Results: The TTI was significantly shorter in both the tongue edema and combined scenarios with the TVI stylet compared with the Macintosh laryngoscope (21.60 ± 1.45 seconds vs. 24.07 ± 1.58 seconds and 23.73 ± 2.05 seconds vs. 26.6 ± 2.77 seconds, respectively). Success rates for both devices were 100%. Concomitantly, participants rated using the TVI stylet in these two scenarios as being less difficult. Conclusion: The learning time for tracheal intubation using the TVI stylet in difficult airway scenarios was short. Use of the TVI stylet was easier and required a shorter TTI for tracheal intubation in the tongue edema and combined scenarios. PMID:28757736
Sakles, John C; Mosier, Jarrod M; Chiu, Stephen; Keim, Samuel M
Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy. To compare the success rates of GlideScope(®) (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations. This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope(®) standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure. There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005. The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management. Published by Elsevier Inc.
Björling, Gunilla; Johansson, Dorota; Bergström, Linda; Jalal, Shah; Kohn, Ivar; Frostell, Claes; Kalman, Sigridur
Hospital acquired infections worsen the outcome of patients treated in intensive care units and are costly. Coatings with silver or metal alloys may reduce or alter the formation of biofilm on invasive medical devices. An endotracheal tube (ETT) is used to connect the patient to a ventilator and coated tubes have been tested in relation to bacterial colonization and respiratory infection. In the present study, we aimed to evaluate and compare a coated and uncoated ETT for patient symptoms and local tracheal tolerability during short term clinical use. Degree of bacterial colonization was also described. A silver-palladium-gold alloy coating ('Bactiguard®'Infection Protection, BIP) has been extensively used on urinary tract catheters and lately also on central venous catheters. We performed a randomised, single-blinded, controlled, first in man, post Conformité Européenne (EC) certification and CE marking study, focused on Bactiguard® coated ETTs (BIP ETT). Thirty patients at a tertiary university hospital scheduled for upper abdominal elective surgery with an expected duration of anaesthesia of at least 3 h were randomised; BIP ETT (n = 20) or standard ETT (n = 10). The tolerability was assessed with a modified version of Quality of Life Head and Neck Module, QLQ-H&N35 and by inspection of the tracheal mucosa with a fibre-optic bronchoscope before intubation and at extubation. Adverse Events (AE) and bacterial adherence were also studied. Statistical evaluations were carried out with the Fisher's Exact Test, the Clopper-Pearson method, as well as a Proportional Odds Model. Differences between groups were identified in 2 of 8 patient related symptoms with regard to tolerability by QLQ-H&N35 (cough, p = 0.022 and dry mouth, p = 0.014 in the treatment group.). No mucosal damage was identified with bronchoscopy. A low level of bacterial colonization with normal flora, equal between groups, was seen after short-term of intubation (median 5 h). No
Orsborn, Jonathan; Graham, James; Moss, Michele; Melguizo, Maria; Nick, Todd; Stroud, Michael
Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport. Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL. Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL. The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.
Cooper, Joel D
Respiratory care advances such as the introduction of ventilatory assistance have been associated with postintubation airway stenosis resulting from tracheal injury at the site of the inflatable cuff on endotracheal or tracheostomy tubes. Low-pressure cuffs have significantly reduced this occurrence. Loss of airway stability at the site of a tracheostomy stoma may result in tracheal stenosis. Subglottic stenosis may result from a high tracheostomy site at, or just inferior to, the cricoid arch, or to malposition of an endotracheal tube cuff. Awareness of these complications and their causes is essential to prevent their occurrence. Copyright © 2018 Elsevier Inc. All rights reserved.
Kwon, Min A; Song, Jaegyok; Kim, Ju-Ri
Rapid sequence induction (RSI) is indicated in various situations. Succinylcholine has been the muscle relaxant of choice for RSI, and rocuronium has become an alternative medicine for patients who cannot be administered succinylcholine for various reasons. Although rocuronium has the most rapid onset time among non-depolarizing muscle relaxants, the standard dose of rocuronium (0.6 mg/kg) takes 60 seconds to achieve appropriate muscle relaxation. We evaluated intubating conditions using the "modified timing principle" with rocuronium and succinylcholine. In this prospective controlled blinded study, all patients received 1.5 µg/kg fentanyl intravenously with preoxygenation for 2 minutes and were randomized to receive 0.6 mg/kg rocuronium followed by 1.5 mg/kg propofol or 1.5 mg/kg propofol and 1.5 mg/kg succinylcholine. The rocuronium group was intubated just after confirming loss of consciousness, and the succinylcholine group was intubated 1 minute after injecting succinylcholine. Intubation condition, timing of events, and complications were recorded. All patients were successfully intubated in both groups. Apnea time of the rocuronium group (38.5 seconds) was significantly shorter than that in the succinylcholine group (100.7 seconds). No significant differences were observed in loss of consciousness time or intubation time. The succinylcholine group tended to show better intubation conditions, but no significant difference was observed. None of the patients complained awareness of the intubation procedure or had respiratory difficulty during a postoperative interview. The modified RSI with rocuronium showed shorter intubation sequence, acceptable intubation conditions, and a similar level of complications compared to those of conventional RSI with succinylcholine.
Velasco Sanz, T R; Ronda Delgado de la Fuente, M; Sánchez de la Ventana, A B; Reyes Merino Martínez, M
To analyze proper control of endotracheal cuff pressure in an intensive care unit. The specific objective is to verify whether training of nursing professionals improves monitoring endotracheal cuff pressure. the study type is descriptive, observational and retrospective. All patients were admitted to the Critical Unit II of the Clínico San Carlos Hospital between May 2010-November 2011, requiring either a tracheal tube or tracheal cannula. Studied variables were: number of in range measures, number of intubated patients, or with tracheal cannula and register. Four cuts were made on all admitted patients admitted during the study period in order to measure endotracheal cuff pressure. Two cuts were performed before the professional nurses training and the other two cuts after a specific training with respect to endotracheal cuff pressure and Zero pneumonia. There were 74 measurements. The first cut obtained 40.74% of measures in range. In the second cut 61.90% of measures were identified in range. In the third cut, it was found that 85.7% of measures were in range and in the fourth court, it was noted the 89.47% of measures were in range. Monitoring of the endotracheal cuff pressure was inadequate before specific training of professionals. Nursing professionals training facilitates the correct measurement of the endotracheal cuff pressure, which improves patient safety. Copyright © 2013 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
Koh, Wonuk; Kim, Hajung; Kim, Kyongsun; Ro, Young-Jin
Background An unexpected difficult intubation can be very challenging and if it is not managed properly, it may expose the encountered patient to significant risks. The intubation difficulty scale (IDS) has been used as a validated method to evaluate a global degree of intubation difficulty. The aims of this study were to evaluate the prevalence and characteristics of unexpected difficult intubation using the IDS. Methods We retrospectively reviewed 951 patients undergoing elective surgery in a single medical center. Patients expected to have a difficult intubation or who had history of difficult intubation were excluded. Each patient was assessed by the IDS scoring system with seven variables. Total prevalence of difficult intubation and the contributing individual factors were further analyzed. Results For the 951 patients, the difficult intubation cases presenting IDS > 5 was 5.8% of total cases (n = 55). The prevalence of Cormack-Lehane Grade 3 or 4 was 16.2% (n = 154). Most of the difficult intubation cases were managed by simple additional maneuvers and techniques such as stylet application, additional lifting force and laryngeal pressure. Conclusions Unexpected difficult airway was present in 5.8% of patients and most was managed effectively. Among the components of IDS, the Cormack-Lehane grade was most sensitive for predicting difficult intubation. PMID:27274369
Jabre, Patricia; Penaloza, Andrea; Pinero, David; Duchateau, Francois-Xavier; Borron, Stephen W; Javaudin, Francois; Richard, Olivier; de Longueville, Diane; Bouilleau, Guillem; Devaud, Marie-Laure; Heidet, Matthieu; Lejeune, Caroline; Fauroux, Sophie; Greingor, Jean-Luc; Manara, Alessandro; Hubert, Jean-Christophe; Guihard, Bertrand; Vermylen, Olivier; Lievens, Pascale; Auffret, Yannick; Maisondieu, Celine; Huet, Stephanie; Claessens, Benoît; Lapostolle, Frederic; Javaud, Nicolas; Reuter, Paul-Georges; Baker, Elinor; Vicaut, Eric; Adnet, Frédéric
Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival. To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28. Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017. Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023). The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure. Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7
Cha, Dong Guk; Jeong, Ji Seon; Kwon, Hye Mee
Background The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration. Methods A total of 140 adult patients were randomized into 4 groups to receive either 30 µg/kg ephedrine (Group 30, n = 35), 70 µg/kg ephedrine (Group 70, n = 35), 110 µg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration. Results An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 ± 44.7 s, Group 70: 152.6 ± 40.3 s, Group 110: 151.2 ± 51.6 s) compared to Group C (224.6 ± 56.9 s) after 0.15 mg/kg of cisatracurium (P < 0.001). Ephedrine doses of either 70 or 110 µg/kg for pretreatment significantly improved intubating conditions (P < 0.05). Systolic and diastolic blood pressure and heart rate at 1 min after tracheal intubation were significantly increased than other times in all groups (P < 0.001), with no differences among the groups. However, 5 patients in Group 110 experienced marked hypertension (systolic/diastolic blood pressure: > 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups. Conclusions We conclude that pre-treatment with ephedrine 70 µg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects. PMID:25097735
Introduction Succinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI. Methods This was a prospective randomized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel. Participants were 401 critically ill patients requiring emergent RSI. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade. The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ≥ 5%, assessed by continuous pulse oxymetry, at any time between the start of the induction sequence and two minutes after the completion of the intubation. A severe oxygen desaturation was defined as a decrease in oxygen saturation ≥ 5% leading to a saturation value of ≤ 80%. Results There was no difference between succinylcholine and rocuronium regarding oxygen desaturations (succinylcholine 73/196; rocuronium 66/195; P = 0.67); severe oxygen desaturations (succinylcholine 20/196; rocuronium 20/195; P = 1.0); and extent of oxygen desaturations (succinylcholine -14 ± 12%; rocuronium -16 ± 13%; P = 0.77). The duration of the intubation sequence was shorter after succinycholine than after rocuronium (81 ± 38 sec versus 95 ± 48 sec; P = 0.002). Intubation conditions (succinylcholine 8.3 ± 0.8; rocuronium 8.2 ± 0.9; P = 0.7) and failed first intubation attempts (succinylcholine 32/200; rocuronium 36/201; P = 1.0) did not differ between the groups. Conclusions In critically ill
el-Ebiary, M; Torres, A; González, J; de la Bellacasa, J P; García, C; Jiménez de Anta, M T; Ferrer, M; Rodriguez-Roisin, R
Bronchoalveolar lavage (BAL) and protected specimen brushing (PSB) are the most commonly used methods for diagnosing ventilator-associated (VA) pneumonia although they require bronchoscopy. Endotracheal aspiration (EA) is a simple and less costly technique than PSB or BAL. The purpose of our study was to investigate the diagnostic value of EA quantitative cultures and to compare the results obtained using EA with those obtained using PSB and BAL in mechanically ventilated patients with or without pneumonia. We prospectively studied 102 intubated patients divided into three diagnostic categories: Group I (definite pneumonia, n = 26), Group II (uncertain status, n = 48), and Group III (control group, n = 28). All patients received prior antibiotic treatment. EA, PSB, and BAL were obtained sequentially in all patients. When comparing Group I with Group III and using 10(5) cfu/ml as a threshold, we found that EA quantitative cultures represented a relatively sensitive (70%) and relatively specific (72%) method to diagnose VA pneumonia. The specificity of BAL and PSB (87% and 93%, respectively) was better than that of EA. The negative predictive value of EA cultures was higher (72%) when compared with that obtained using PSB (34%) (p < 0.05). EA quantitative cultures correlated with PSB and BAL quantitative cultures in patients with definite pneumonia. Although EA quantitative cultures are less specific than PSB and BAL for diagnosing VA pneumonia, our results suggest that the former approach may be used to treat these patients when bronchoscopic procedures are not available.
Paix, A D; Williamson, J A; Runciman, W B
Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. To examine the role of a specific sub-algorithm for the management of difficult intubation. The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors. The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.
Kurien, M; Raviraj, R; Mathew, J; Kaliaperumal, I; Ninan, S
In an emergency, the non-availability of a conventional paediatric tracheostomy tube is a therapeutic challenge for the attending surgeon. To describe a simple alternative to a paediatric tracheostomy tube for use in an emergency situation. Case report of a 14-year-old boy who developed tracheomalacia following partial cricotracheal resection for subglottic stenosis. As a suitably sized tracheostomy tube (with a long narrow segment) was not available, an endotracheal tube was modified and used successfully. Details of the modification, and a relevant literature review, are also discussed. In the paediatric age group, when an appropriately sized tracheostomy tube is not available, a modified endotracheal tube is a simple temporary alternative; this may be especially useful in an emergency.
Johnson, Angela M; Hill, James L; Zagorski, Dave J; McClain, Joseph M; Maronian, Nicole C
Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.
Johnson, Angela M; Hill, James L; Zagorski, Dave J; McClain, Joseph M; Maronian, Nicole C
Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.
Burjek, Nicholas E; Nishisaki, Akira; Fiadjoe, John E; Adams, H Daniel; Peeples, Kenneth N; Raman, Vidya T; Olomu, Patrick N; Kovatsis, Pete G; Jagannathan, Narasimhan; Hunyady, Agnes; Bosenberg, Adrian; Tham, See; Low, Daniel; Hopkins, Paul; Glover, Chris; Olutoye, Olutoyin; Szmuk, Peter; McCloskey, John; Dalesio, Nicholas; Koka, Rahul; Greenberg, Robert; Watkins, Scott; Patel, Vikram; Reynolds, Paul; Matuszczak, Maria; Jain, Ranu; Khalil, Samia; Polaner, David; Zieg, Jennifer; Szolnoki, Judit; Sathyamoorthy, Kumar; Taicher, Brad; Riveros Perez, N Ricardo; Bhattacharya, Solmaletha; Bhalla, Tarun; Stricker, Paul; Lockman, Justin; Galvez, Jorge; Rehman, Mohamed; Von Ungern-Sternberg, Britta; Sommerfield, David; Soneru, Codruta; Chiao, Franklin; Richtsfeld, Martina; Belani, Kumar; Sarmiento, Lina; Mireles, Sam; Bilen Rosas, Guelay; Park, Raymond; Peyton, James
The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.
Background The most important action in the resuscitation of a newborn in the delivery room is to establish effective assisted ventilation. The face mask and endotracheal tube are the devices used to achieve this goal. Laryngeal mask airways that fit over the laryngeal inlet have been shown to be effective for ventilating newborns at birth and should be considered as an alternative to facemask ventilation or endotracheal intubation among newborns weighing >2,000 g or delivered ≥34 weeks’ gestation. A recent systematic review and meta-analysis of supraglottic airways in neonatal resuscitation reported the results of four randomized controlled trials (RCTs) stating that fewer infants in the group using laryngeal mask airways required endotracheal intubation (1.5%) compared to the group using face masks (12.0%). However, there were methodological concerns over all the RCTs including the fact that the majority of the operators in the trials were anesthesiologists. Our hypothesis is based on the assumption that ventilating newborns needing positive pressure ventilation with a laryngeal mask airway will be more effective than ventilating with a face mask in a setting where neonatal resuscitation is performed by midwives, nurses, and pediatricians. The primary aim of this study will be to assess the effectiveness of the laryngeal mask airway over the face mask in preventing the need for endotracheal intubation. Methods/design This will be an open, prospective, randomized, single center, clinical trial. In this study, 142 newborns weighing >1,500 g or delivered ≥34 weeks gestation needing positive pressure ventilation at birth will be randomized to be ventilated with a laryngeal mask airway (LMA SupremeTM, LMA Company, UK - intervention group) or with a face mask (control group). Primary outcome: Proportion of newborns needing endotracheal intubation. Secondary outcomes: Apgar score at 5 minutes, time to first breath, onset of the first cry, duration of
Clukey, Lory; Weyant, Ruth A; Roberts, Melanie; Henderson, Ann
The perceptions of patients who are restrained and sedated while being treated with mechanical ventilation in the intensive care unit are not well understood. The effectiveness of sedation used to aid in recovery and enhance comfort during intubation is unknown. To explore the perceptions of patients who were intubated and receiving pain medication while sedated and restrained in the intensive care unit, in particular, their experience and their memories of the experience. In a phenomenological study, 14 patients who were intubated and receiving pain medication while sedated and restrained were interviewed at the bedside. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. Three major themes were identified from the data: lack of memory of being restrained; a perception of being intubated as horrific; nursing behaviors that were helpful and comforting. An unexpected discovery was that sedation may be interfering with pain assessment and management. Being intubated can be painful and traumatic despite administration of sedatives and analgesics. Sedation may mask uncontrolled pain for intubated patients and prevent them from communicating this condition to a nurse. Nurses may need to evaluate current interventions in order to provide maximum comfort and promote optimal positive outcomes for intensive care patients who are intubated.
Fisher, Daniel F; Chenelle, Christopher T; Marchese, Andrew D; Kratohvil, Joseph P; Kacmarek, Robert M
Tracheal intubation is used to establish a secure airway in patients who require mechanical ventilation. Unexpected extubation can have serious complications, including airway trauma and death. Various methods and devices have been developed to maintain endotracheal tube (ETT) security. Associated complications include pressure ulcers due to decreased tissue perfusion. Device consideration includes ease of use, rapid application, and low exerted pressure around the airway. Sixteen ETT holders were evaluated under a series of simulated clinical conditions. ETT security was tested by measuring distance displaced after a tug. Nine of the 16 methods could be evaluated for speed of moving the ETT to the opposite side of the mouth. Sensors located on a mannequin measured applied forces when the head was rotated vertically or horizontally. Data were analyzed using multivariate analysis of variance, with P < .05. Median displacement of the ETT by the tug test was 0 cm (interquartile range of 0.0-0.10 cm, P < .001). The mean time to move the ETT from one side of the mouth to the other ranged from 1.25 ± 0.2 s to 34.4 ± 3.4 s (P < .001). Forces applied to the face with a vertical head lift ranged from < 0.2 newtons (N) to a maximum of 3.52 N (P < .001). Forces applied to the face with a horizontal rotation ranged from < 0.2 N to 3.52 N (P < .001). Commercial devices produced greater force than noncommercial devices. Noncommercial airway holders exert less force on a patient's face than commercial devices. Airway stability is affected by the type of securing method. Many commercial holders allow for rapid but secure movement of the artificial airway from one side of the mouth to the other. Copyright © 2014 by Daedalus Enterprises.
Li Bassi, Gianluigi; Fernandez-Barat, Laia; Saucedo, Lina; Giunta, Valeria; Marti, Joan Daniel; Tavares Ranzani, Otavio; Aguilera Xiol, Eli; Rigol, Montserrat; Roca, Ignasi; Muñoz, Laura; Luque, Nestor; Esperatti, Mariano; Saco, Maria Adela; Ramirez, Jose; Vila, Jordi; Ferrer, Miguel; Torres, Antoni
Laboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections. We assessed whether the LTP could also prevent pulmonary colonization and infections caused by an endotracheal tube (ETT) biofilm. Eighteen pigs were intubated with ETTs colonized by Pseudomonas aeruginosa biofilm. Pigs were positioned in LTP and randomized to be on mechanical ventilatin (MV) up to 24 hour, 48 hour, 48 hour with acute lung injury (ALI) by oleic acid and 72 hour. Bacteriologic and microscopy studies confirmed presence of biofilm within the ETT. Upon autopsy, samples from the proximal and distal airways were excised for P.aeruginosa quantification. Ventilator-associated tracheobronchitis (VAT) was confirmed by bronchial tissue culture ≥3 log colony forming units per gram (cfu/g). In pulmonary lobes with gross findings of pneumonia, ventilator-associated pneumonia (VAP) was confirmed by lung tissue culture ≥3 log cfu/g. P.aeruginosa colonized the internal lumen of 16 out of 18 ETTs (88.89%), and a mature biofilm was consistently present. P.aeruginosa colonization did not differ among groups, and was found in 23.6% of samples from the proximal airways, and in 7.1% from the distal bronchi (P = 0.001). Animals of the 24 hour group never developed respiratory infections, whereas 20%, 60% and 25% of the animals in group 48 hour, 48 hour-ALI and 72 hour developed P.aeruginosa VAT, respectively (P = 0.327). Nevertheless, VAP never developed. Our findings imply that during the course of invasive MV up to 72 hour, an ETT P.aeruginosa biofilm hastily colonizes the respiratory tract. Yet, the LTP compartmentalizes colonization and infection within the proximal airways and VAP never develops.
Comparative analysis of efficacy of lignocaine 1.5 mg/kg and two different doses of dexmedetomidine (0.5 μg/kg and 1 μg/kg) in attenuating the hemodynamic pressure response to laryngoscopy and intubation
Gulabani, Michell; Gurha, Pavan; Dass, Prashant; Kulshreshtha, Nishi
Context: Laryngoscopy and intubation cause an intense reflex increase in heart rate, blood pressure, due to an increased sympathoadrenal pressor response. Lignoocaine has shown blunting of pressor response to intubation. Dexmedetomidine has sympatholytic effects. Aims: To the best of our knowledge there is no study comparing the efficacy of lignocaine with two different doses of dexmedetomidine for attenuating the pressor response. With this idea, we planned to conduct the present study. Materials and Methods: After approval by the Hospital Ethics committee, 90 consenting adults aged 18-65 years of age of either sex of non-hypertensive ASA Grade I or II were randomly allocated into three groups. Group D1- IV Dexmedetomidine 0.5μg/kg over 10 minutes Group D2- IV Dexmedetomidine 1μg/kg over 10 minutes Group X- IV Lignocaine 1.5mg/kg in 10 ml normal saline Statistical Analysis Used: ANOVA and Student's t test used for analysis. Results: Dexmedetomidine 1µg/kg was more effective than 0.5µg/kg and lignocaine 1.5mg/kg in attenuating the pressor response. Conclusions: We conclude that dexmedetomidine 1μg/kg adequately attenuates the hemodynamic response to laryngoscopy and endotracheal intubation when compared with dexmedetomidine 0.5μg/kg and lignocaine 1.5mg/kg. PMID:25886414
Durga, Padmaja; Sahu, Barada Prasad
Anaesthesiologists are often involved in the management of patients with cervical spine disorders. Airway management is often implicated in the deterioration of spinal cord function. Most evidence on neurological deterioration resulting from intubation is from case reports which suggest only association, but not causation. Most anaesthesiologists and surgeons probably believe that the risk of spinal cord injury (SCI) during intubation is largely due to mechanical compression produced by movement of the cervical spine. But it is questionable that the small and brief deformations produced during intubation can produce SCI. Difficult intubation, more frequently encountered in patients with cervical spine disorders, is likely to produce greater movement of spine. Several alternative intubation techniques are shown to improve ease and success, and reduce cervical spine movement but their role in limiting SCI is not studied. The current opinion is that most neurological injuries during anaesthesia are the result of prolonged deformation, impaired perfusion of the cord, or both. To prevent further neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and positioning for surgery are essential. The features that diagnose laryngoscopy induced SCI are myelopathy present on recovery, short period of unconsciousness, autonomic disturbances following laryngoscopy, cranio-cervical junction disease or gross instability below C3. It is difficult to accept or refute the claim that neurological deterioration was induced by intubation. Hence, a record of adequate care at laryngoscopy and also perioperative period are important in the event of later medico-legal proceedings. PMID:25624530
Gürgün, Alev; Korkmaz Ekren, Pervin; Bacakoğlu, Feza; Başoğlu, Ozen Kaçmaz; Dirican, Nigar; Aydemir, Şöhret; Nart, Deniz; Sayıner, Abdullah
Ventilator associated pneumonia (VAP) is one of the most important causes of mortality in patients treated with invasive mechanical ventilation (IMV) in intensive care unit (ICU). Microbiological examinations are required as clinical and radiological findings are usually insufficient in the diagnosis. Twenty four patients who were receiving IMV because of respiratory failure, had a Clinical Pulmonary Infection Score (CPIS) of ≥ 6 in the follow-up and died with the suspicion of VAP were enrolled in our study. Six patients were excluded as post-mortem biopsy could not be performed. The patients who had pre-mortem CPIS ≥ 6, in whom a causative organism was identified from the culture of post-mortem lung biopsy and/or histopathological examination of lung biopsy was compatible with pneumonia were diagnosed as VAP. In the 18 patients in whom a post-mortem lung biopsy was performed, quantitative culture results of endotracheal aspirate performed 48 hours prior to death were compared with microbiological and histopathological results of post-mortem lung biopsy specimens, and the role of endotracheal aspirate in the diagnosis of VAP was evaluated retrospectively. Out of 18 patients (12 men, mean age 67.0 ± 13.0 years) included in the study, 11 (61.1%) were diagnosed as VAP. The quantitative culture of endotracheal aspirate was positive in 9 (81.8%) out of 11 patients diagnosed as VAP. The sensitivity, specificity, positive and negative predictive values of endotracheal aspirate culture for identifying VAP were found to be 81.8%, 14.3%, 60.0% and 33.3%, respectively. Our study shown that quantitative culture of endotracheal aspirate is a practical and reliable method that can be used for the diagnosis of VAP in patients receiving IMV in ICU and having CPIS ≥ 6.
Background The Pentax Airway Scope (AWS) is a video laryngoscope designed to facilitate tracheal intubation with a high-resolution image. The Pentax AWS has been reported to cause less hemodynamic stress than the Macintosh laryngoscope. The aims of this study are to investigate the differences in hemodynamic responses and norepinephrine concentrations to tracheal intubation between procedures using he Pentax AWS and the Macintosh laryngoscope. Methods Forty patients (American Society of Anesthesiologists class I-II, age range: 18-60 years) were randomly assigned to be intubated with either the Pentax AWS or the Macintosh laryngoscope while under general anesthesia. Routine monitoring, including invasive arterial blood pressure and bispectral index, were applied. Thiopental (4 mg/kg), fentanyl (1 µg/kg), midazolam (0.05 mg/kg), and rocuronium (0.6 mg/kg) were administered for anesthetic induction. Systolic, diastolic, and mean blood pressures and heart rates were recorded pre-intubation, immediately post-intubation (T0), and over the following 10 minutes at one minute intervals (T1, T2, T3, T4, T5…T10). Patient blood was sampled for norepinephrine concentrations pre-intubation (baseline) and post-intubation (T1). Evidence of sore throat was evaluated 30 min and 24 hr after extubation. Data were transformed to % basal and expressed as mean ± SD. Results The systolic, diastolic, and mean blood pressure, and heart rate at T0 and T4 were significantly different between the two groups. There was no significant difference in plasma norepinephrine between the two groups. The difference in incidence of sore throat was not significant between the two groups. Conclusions Pentax-AWS for tracheal intubation has greater hemodynamic stability than the Macintosh blade laryngoscope. PMID:23646240
Stevenson, A G M; Graham, C A; Hall, R; Korsah, P; McGuffie, A C
Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs. To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006. Crosshouse Hospital, a 450-bed district general hospital serving a mixed urban and rural population; annual ED census 58,000 patients. Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid-sequence induction (RSI) was defined as the co-administration of an induction agent and suxamethonium. 234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non-RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties. Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.
Dasgupta, Sugata; Singh, Shipti Shradha; Chaudhuri, Arunima; Bhattacharya, Dipasri; Choudhury, Sourav Das
Background: Although tracheal tubes are essential devices to control and protect airway in a critical care unit (CCU), they are not free from complications. Aims: To document the incidence and nature of airway accidents in the CCU of a government teaching hospital in Eastern India. Methods: Retrospective analysis of all airway accidents in a 5-bedded (medical and surgical) CCU. The number, types, timing, and severity of airway accidents were analyzed. Results: The total accident rate was 19 in 233 intubated and/or tracheostomized patients over 1657 tube days (TDs) during 3 years. Fourteen occurred in 232 endotracheally intubated patients over 1075 endotracheal tube (ETT) days, and five occurred in 44 tracheostomized patients over 580 tracheostomy TDs. Fifteen accidents were due to blocked tubes. Rest four were unplanned extubations (UEs), all being accidental extubations. All blockages occurred during night shifts and all UEs during day shifts. Five accidents were mild, the rest moderate. No major accident led to cardiorespiratory arrest or death. All blockages occurred after 7th day of intubation. The outcome of accidents were more favorable in tracheostomy group compared to ETT group (P = 0.001). Conclusions: The prevalence of airway accidents was 8.2 accidents per 100 patients. Blockages were the most common accidents followed by UEs. Ten out of the 15 blockages and all 4 UEs were in endotracheally intubated patients. Tracheostomized patients had 5 blockages and no UEs. PMID:27076709
Bhutada, A; Sahni, R; Rastogi, S; Wung, J
AIMS—To determine the effects of premedication with thiopental on heart rate, blood pressure, and oxygen saturation during semi-elective nasotracheal intubation in neonates. METHODS—A randomised, placebo controlled, non-blinded study design was used to study 30 neonates (mean birthweight 3.27 kg) requiring semi-elective nasotracheal intubation. The babies were randomly allocated to receive either 6 mg/kg of thiopental (study group) or an equivalent volume of physiological saline (control group) one minute before the start of the procedure. Six infants were intubated primarily and 24 were changed from orotracheal to a nasotracheal tube. The electrocardiogram, arterial pressure wave, and transcutaneous oxygen saturation were recorded continuously 10 minutes before, during, and 20 minutes after intubation. Minute by minute measurements of heart rate, heart rate variability, mean blood pressure (MBP) and transcutaneous oxygen saturation (SpO2) were computed. The differences for all of these between the baseline measurements and those made during and after intubation were determined. Differences in the measurements made in the study and the control groups were compared using Student's t test. RESULTS—During intubation, heart rate increased to a greater degree (12.0 vs−0.5 beats per minute, p < 0.03) and MBP increased to a lesser degree (−2.9 vs 4.4 mm Hg; p < 0.002) in the infants who were premedicated with thiopental. After intubation only the changes in MBP differed significantly between the two groups (−3.8 vs 4.6 mm Hg; p < 0.001). There were no significant changes in the oxygen saturation between the two groups during or after intubation. The time taken for intubation was significantly shorter in the study group (p < 0.04). CONCLUSIONS—The heart rate and blood pressure of infants who are premedicated with thiopental are maintained nearer to baseline values than those of similar infants who receive no premedication. Whether this lessening of the
Sivasankar, Chitra; Schlichter, Rolf A; Baranov, Dimitry; Kofke, W Andrew
Awake craniotomies have been performed regularly at the University of Pennsylvania since 2004. Varying approaches to airway management are described for this procedure, including intubation with an endotracheal tube and use of a laryngeal mask airway, simple facemask, or nasal cannula. In this case series, we describe the successful use (i.e., no need for endotracheal intubation related to inadequate gas exchange) of bilateral nasopharyngeal airways in 90 patients undergoing awake craniotomies. The use of nasopharyngeal airways can ease the transition between the asleep and awake phases of the craniotomy without the need to stimulate the airway. Our purpose was to describe our experience and report adverse events related to this technique.
Wetsch, Wolfgang A; Hellmich, Martin; Spelten, Oliver; Schier, Robert; Böttiger, Bernd W; Hinkelbein, Jochen
Tracheal intubation in nonstandardised positions is associated with a higher risk of tube misplacement and may have deleterious consequences for patients. Video laryngoscopes for tracheal intubation facilitate both glottic view and success rates. However, their use in the ice-pick position has not been evaluated. To evaluate the role of video laryngoscopes for tracheal intubation in the ice-pick position. A randomised, controlled manikin trial. A standardised airway manikin was placed in the corner of a room. Tracheal intubation was only possible from the lower right side of the manikin. In randomised order, participants used a standard Macintosh laryngoscope and GlideScope Ranger, Storz C-MAC, Pentax AWS, Airtraq and McGrath Series5 video laryngoscopes. Statistical analysis was performed using the Wilcoxon signed-rank and McNemar's tests; A P value of less than 0.05 was deemed statistically significant. Twenty anaesthesiologists, all emergency medicine board-certified. Time to first ventilation (primary); time to glottic view and confirmation of tube position (secondary). Successful ventilation was achieved most rapidly with the Macintosh laryngoscope (36.1 ± 13.4 s; reference method), followed by the Airtraq (38.4 ± 36.3 s; P = n.s.), Pentax AWS (51.6 ± 43.3 s; P = n.s.) and Storz C-Mac (62.7 ± 49.7 s; P = n.s.). The use of the GlideScope Ranger (79.8 ± 61.9 s, P = 0.01) and McGrath series5 (79.8 ± 58.5 s, P = 0.023) resulted in significantly longer times. When comparing overall intubation success, the rate of successful tracheal intubation was higher with the Airtraq than with the McGrath Series5 (P = 0.031; all others n.s.). The use of video laryngoscopes did not result in higher success rates or faster tracheal intubation in the ice-pick position when compared with conventional laryngoscopy in this manikin study. www.clinicaltrials.gov, NCT01210105.
Aghamohammadi, H; Massoudi, N; Fathi, M; Jaffari, A; Gharaei, B; Moshki, A
Background: Direct laryngoscopy (DL) is considered the most common method of tracheal intubation. On the other hand, evidence shows the growing role of video laryngoscopy in danger airway administration. Objectives: Due to the importance of a proper training to accomplish an accurate and fast intubation by the student of anesthesia, this research was conducted to assess the effects of DL and video laryngoscopy (Glidescope VL) training on the success rate of tracheal intubation by low-skill students. Materials/Patients and styles: 50 undergraduate students of anesthesiology took part in this randomized control educational intervention. Having no considerable experience in intubation, they were selected and divided randomly into two equal groups (n = 25); video-laryngoscopy via GlideScope VL and direct laryngoscopy (DL) via a Macintosh blade were prepared by the same experienced anesthesiologist. All the participants practiced intubation six times on the same mannequin within a routine airway situation. The maximum acceptable time for each intubation was 3 minutes and three times of successful intubation was considered as an appropriate intubation skill. The required time for laryngoscopy and intubation at each stage, the grade of glottis view, the reasons for an unsuccessful intubation and the amount of successful intubations were recorded and compared between groups. Results: There was a clear variation between the 2 teams, in all the steps, based on the required time for laryngoscopy and intubation (p = 0.0001). Data analysis was performed by using repeated measures data which demonstrated that the necessary time for laryngoscopy and intubation during the study was clearly lower in the GlideScope VL team (p = .0001). In first five rounds of training, the glottis view in the DL group was significantly better than in the VL group (p < 0.05). Conclusion: Based on the result of today' study, routine airway intubation by using GlideScope VL is significantly faster than
Tvede, M F; Kristensen, M S; Nyhus-Andreasen, M
Intubation using a flexible optical scope (FOS) is a cornerstone technique for managing the predicted and unpredicted difficult airway. The term FOS covers both fibre-optic scopes and videoscopes. The total costs of using flexible scopes for intubation are unknown. The recent introduction of a disposable flexible scope for intubation merits closer scrutiny of the total costs associated with both modalities. The costs incurred during intubations using FOSs at a large anaesthesia department were identified, and a series of intubations using a disposable scope were analyzed for comparison. Recognized health-economic methodology was applied. During a 1-year period, 360 FOS intubations were performed. In this clinical setting, the average cost of an intubation using a reusable FOS was €177.7. When using the disposable Ambu(®) aScope (Ambu A/S, Ballerup, Denmark), the cost was €204.4. The break-even point, i.e. the number of intubations per month where the cost of using disposable and non-disposable equipment is identical, was 22.5/month. A subgroup analysis looking solely at intubations performed with flexible videoscopes revealed that the cost per intubation was equal for disposable and reusable videoscopes. At our institution, the total cost of an intubation is greater when using disposable compared with reusable equipment (€204.4 vs. €177.7). If video equipment with an external monitor is considered mandatory, the expenses are of equal magnitude. The cost analysis is particularly sensitive to the actual number of flexible optic intubations performed; with fewer intubations, the total cost will begin to favour disposable equipment. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.
Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C
The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the ‘can't intubate, can't oxygenate’ situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how
Scott, J Brady; Dubosky, Meagan N; Vines, David L; Sulaiman, Adewunmi S; Jendral, Kyle R; Singh, Gagan; Patel, Ankeet; Kaplan, Carl A; Gurka, David P; Balk, Robert A
Spontaneous breathing trials (SBTs) are used to assess the readiness for discontinuation of mechanical ventilation. When airway resistance (R aw ) is elevated, the imposed work of breathing can lead to prolongation of mechanical ventilation. Biofilm and mucus build-up within the endotracheal tube (ETT) can increase R aw . Scraping the ETT can remove the biofilm build-up and decrease mechanical R aw . The primary aim of this study was to evaluate the impact of ETT scraping on R aw . The secondary aim was to determine whether decreasing R aw would impact subsequent SBT success. Intubated, mechanically ventilated subjects were enrolled if they failed an SBT and had an R aw of > 10 cm H 2 O/L/s. SBT failure was based on institutional guidelines, and R aw was calculated by subtracting the difference between the measured peak and plateau pressures using a square flow waveform with an inspiratory flow set at 60 L/min. The endOclear device was inserted into the ETT and withdrawn per manufacturer's guidelines. Scraping was repeated until the ETT was cleared. Change in R aw was compared pre- and post-ETT scraping using a paired t test. A Mann-Whitney U test evaluated the difference in percentage change in R aw between SBT groups. Twenty-nine subjects completed the study. The mean pre- and post-ETT scraping R aw values were 15.17 ± 3.83 and 12.05 ± 3.19 cm H 2 O/L/s, respectively ( P < .001). Subsequent SBT success was 48%; however, there was no difference in percentage change in R aw between subsequent passed SBT (18.61% [interquartile range 8.90-33.93%]) and failed SBT (23.88% [interquartile range 0.00-34.80%]), U = 78.5, z = -0.284, P = .78. No adverse events were noted with ETT scraping. This study demonstrated that ETT scraping can reduce R aw . The decrease in R aw post-ETT scraping did not affect subsequent SBT success. Copyright © 2017 by Daedalus Enterprises.
to hypoxia and causes expansion of gas trapped in closed spaces. In the latter case, gas trapped in the body ( pneumothorax , bowel gas) or in devices... pneumothorax , bowel gas) or in devices (endotracheal tube (ETT) cuffs, pneumatic tourniquets) expands during ascent and contracts on descent. We designed a...hypoxia and causes expansion of gas trapped in closed spaces . In the latter case, gas trapped in the body ( pneumothorax , bowel gas) or in
Hasegawa, Kohei; Hiraide, Atsushi; Chang, Yuchiao; Brown, David F M
It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation. To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA. Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010. Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2. Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for
The placement of a tube into a patient's trachea "the intubation" as we call is not as simple as it looks. It is a very tricky and tedious maneuver that entails skills to assess and perform. Nevertheless, often this is left to the chores of inefficient hands due to a paucity of the availability of experts. They seldom are able to complete the task and often wind up calling the attention of the unit. The present review is an attempt to describe the need to undertake intubation, the procedures and techniques, the complications, including morbidity and mortality and airway management. This overview includes explicit descriptions of the difficult airway which represents multifaceted interface amid patient factors, clinical setting, and skills of the practitioner. To accomplish the target, peer-reviewed English language articles published during third millennium up to 2013 were selected from Pub Med, Pub Med Central, Science Direct, Up-to-date, Med Line, comprehensive databases, Cochrane library, and the Internet (Google, Yahoo). The review constituted a systematic search of literature on the requirements that necessitate the practice of intubation, different techniques that facilitate easy conduct of procedure, the complications, including, morbidity and mortality, and the airway management. Recording every single detail has been beyond the scope of this review, however; some aspects have been wrapped up in nutshell. Some areas of the review are too basic which the medics are well aware of and knowledgeable. Nevertheless, these are difficult to be dispensed with in consideration of their source to the awareness of a common man and a great majority of the patients.
Igarashi, Ayuko; Amagasa, Sumio; Oda, Shinya; Yokoo, Noriko
A 31-year-old man underwent general anesthesia for sinus surgery. Anesthesia was induced with midazolam and butorphanol, and an endotracheal tube was orally placed with a bronchoscope, due to difficulty with temporomandibular joint opening. Ventilation difficulty and increased peak inspiratory pressure were noticed shortly after tracheal intubation, and bronchoscopy was performed for diagnosis. The bronchi were filled with a clear mucous secretion. Removal of the secretion improved respiration and decreased the peak inspiratory pressure. A chest roentgenogram taken prior to extubation showed right upper lobe atelectasis. A diagnosis of sinobronchial syndrome was made postoperatively. The etiology of the acutely developed atelectasis was unclear. However, the latent syndrome may have induced excessive airway secretion with stimuli such as endotracheal intubation.
Sands, Kirsty M; Wilson, Melanie J; Lewis, Michael A O; Wise, Matt P; Palmer, Nicki; Hayes, Anthony J; Barnes, Rosemary A; Williams, David W
In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients. Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay. A "microbial shift" occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms. To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens. Copyright © 2016 Elsevier Inc. All rights reserved.
Lee, Delice Weishan; Thampi, Swapna; Yap, Eric Peng Huat; Liu, Eugene Hern Choon
Using three-dimensional printing, we produced adaptors to attach a smartphone with camera to the eyepiece of the Airtraq(®) laryngoscope. This low-cost system enabled a team to simultaneously view the laryngoscopy process on the smartphone screen, and also enabled image transmission. We compared the Airtraq(®) with the smartphone Airtraq(®) system in a crossover study of trainee anesthesiologists performing tracheal intubation in a manikin. We also evaluated the smartphone Airtraq(®) system for laryngoscopy and tracheal intubation in 30 patients, including image transmission to and communication with a remote instructor. In the manikin study, the smartphone Airtraq(®) system enabled instruction where both trainee and instructor could view the larynx simultaneously, and did not substantially increase the time required for intubation. In the patient study, we were able to view the larynx in all 30 patients, and the remote instructor was able to receive the images and to respond on correctness of laryngoscopy and tracheal tube placement. Tracheal intubation was successful within 90s in 19 (63 %) patients. In conclusion, use of a smartphone with the Airtraq(®) may facilitate instruction and communication of laryngoscopy with the Airtraq(®), overcoming some of its limitations.
Marvez-Valls, Eduardo; Houry, Debra; Ernst, Amy A; Weiss, Steven J; Killeen, James
To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center. Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups. Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p<0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p<0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications. This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.
Zhang, Yu; Guo, Xiaopeng; Pei, Lijian; Zhang, Zhuhua; Tan, Gang; Xing, Bing
To investigate the characteristics of difficult intubation and identify novel efficient predictors in patients with acromegaly. Patients with either untreated acromegaly or non-functional pituitary adenomas were enrolled. Patients with acromegaly underwent hormone assays, upper airway computed tomography and magnetic resonance imaging examinations and preoperative overnight polysomnography. The modified Mallampati classification, mouth opening, neck circumference, and neck extension were assessed, and the Cormack-Lehane grades and the time of tracheal intubation were recorded. Patients with acromegaly had a higher incidence of difficult intubation (62.5%). The time of tracheal intubation was prolonged, the neck circumference was enlarged, and the neck extension was confined. In patients with acromegaly and difficult intubation, the insulin-like growth factor 1 levels and apnea/hypoxia index were significantly higher compared to patients without difficult intubation (1115.40 ± 253.73 vs. 791.67 ± 206.62 ng/ml, P = 0.020; 22.17 ± 23.25 vs. 2.47 ± 2.84, P = 0.026, respectively). The bilateral regression analysis revealed that high levels of insulin-like growth factor 1 were an independent risk factor for developing difficult intubation (p = 0.042, Exp B = 1.006). The modified Mallampati classification was positively correlated with apnea/hypoxia index and could be calculated using the following logarithmic equation: MMC = 0.2982 * ln (AHI) + 2.1836. In patients with acromegaly, neck movement is confined, the time of tracheal intubation is prolonged, and the neck circumference is enlarged, and these patients suffer from an increased incidence of difficult intubation (62.5%) during anesthesia induction. The apnea/hypoxia index and insulin-like growth factor 1 levels are both increased in acromegalic patients with difficult intubation, and elevated insulin-like growth factor 1 levels are an independent risk factor of difficult
Evans, Heather L; Zonies, David H; Warner, Keir J; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph
In an emergency medical system with established rapid-sequence intubation protocols, prehospital (PH) intubation of patients with trauma is not associated with a higher rate of ventilator-associated pneumonia (VAP) than emergency department (ED) intubation. Retrospective observational cohort. Level I trauma center. Adult patients with trauma intubated in a PH or an ED setting from July 1, 2007, through July 31, 2008. Diagnosis of VAP by means of bronchoscopic alveolar lavage or clinical assessment when bronchoscopic alveolar lavage was impossible. Secondary outcomes included time to VAP, length of hospitalization, and in-hospital mortality. Of 572 patients, 412 (72.0%) underwent PH intubation. The ED group was older than the PH group (mean ages, 46.4 vs 39.1 years; P < .001) and had a higher incidence of blunt injury (142 [88.8%] vs 322 [78.2%]; P = .002). The mean (SD) lowest recorded ED systolic blood pressure was lower in the ED group (102.8 [1.9] vs 111.4 [1.2] mm Hg; P < .001), despite similar mean injury severity scores in both groups (27.2 [0.7] vs 27.0 [1.1]; P = .94). There was no difference in the mean rate of VAP (30 [18.8%] vs 71 [17.2%]; P = .66) or mean time to diagnosis (8.1 [1.2] vs 7.8 [1.0] days; P = .89). Logistic regression analysis identified history of drug abuse, lowest recorded ED systolic blood pressure, and injury severity score as 3 independent factors predictive of VAP. Prehospital intubation of patients with trauma is not associated with higher risk of VAP. Further investigation of intubation factors and the incidence and timing of aspiration is required to identify potentially modifiable factors to prevent VAP.
Gosavi, Kundan S; Mundada, Surbhi D
Gorlin-Goltz syndrome is a rare autosomal-dominant syndrome related to mutation in "Patched" tumour suppressor gene on chromosome 9. Basocellular carcinomas, odontogenic keratocysts, palmar and/or plantar pits and ectopic calcifications of the falx cerebri are its major features, along with more than 100 minor features. Odontogenic cysts, notorious for recurrence, can make endotracheal intubation difficult, requiring modification of the standard intubation technique. We report such a case managed successfully by awake fibreoptic intubation. Direct laryngoscopy under anaesthesia later confirmed that it was a good decision.
Hilton, Michael T; Wayne, Max; Martin-Gill, Christian
Orotracheal intubation is a key component of prehospital airway management and success rates are dependent on procedural experience. Supraglottic airway devices are increasingly being used in the prehospital setting. As a result, paramedics may have fewer opportunities for performing intubation, limiting their proficiency in the procedure. We aimed to determine the trends in intubation versus supraglottic airway use over an 8 year period. We also aimed to determine the association between system-wide introduction of King LT guidelines and ETI success rates. We performed a retrospective observational study of 37 Emergency Medical Services (EMS) agencies in a 10 county region of Southwestern Pennsylvania. Cases between January 1, 2005 and December 31, 2012 were included if an advanced airway procedure was performed. We determined trends in advanced airway placement and compared the proportion of cases with first pass intubation success before and after the King LT was introduced and promoted by statewide protocol starting in 2007. Use of airway devices before and after King LT implementation were presented using descriptive statistics and compared using Pearson's Chi-square or Fishers Exact test as appropriate. We compared first pass success rate of orotracheal intubation between study periods using multivariable logistic regression, controlling for other factors that may impact success of orotracheal intubation (year, EMS agency, age category, traumatic injury, and cardiac arrest). There were 712 cases of orotracheal intubation before and 2,835 cases after introduction of the King LT. The proportion of cases ultimately managed with orotracheal intubation before and after 2007 decreased from 72.3% (95% CI 68.9-75.6%) to 67.1% (95% CI 65.3-68.8%) (p = 0.007). In the multivariable analysis, success of orotracheal intubation was not associated with implementation of the King LT airway (OR 1.02, 95% CI 0.74-1.41). Fewer patients with advanced airway management received
Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C
The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to
Romano, Michael J; Lee, Jacques S; Chenkin, Jordan
Ultrasound has been shown to be a highly accurate adjunct for confirming endotracheal tube (ETT) placement, however there is no universally accepted scanning technique. The objective of this study was to determine which ultrasound technique provides the highest rate of adequate airway visualisation in a sample of stable emergency department (ED) patients. We conducted a prospective observational study using a convenience sample of ED patients. Airway imaging was performed using the following five techniques: 1) transcricothryoid membrane (TCM), 2) suprasternal notch (SSN) without transducer pressure, 3) SSN with pressure, 4) SSN with pressure to the left of the trachea and 5) SSN with pressure to the right of the trachea. A blinded reviewer scored the adequacy of airway visualisation for each technique. A total of 100 patients were enrolled in the study. SSN to the left of the trachea with pressure had the highest rate of adequate airway visualisation (93.0%, 95% CI 86.1-97.1%), followed by 82.0% (95% CI 73.1-89.0%) for SSN with pressure, 74.0% (95% CI 64.3-82.3%) for TCM, 44.0% (95% CI 34.1-54.3%) for SSN without pressure, and 1.0% (95% CI 0.0-5.4%) for SSN to the right of the trachea. In 76.0% (95% CI 66.4-84.0%) of patients, the SSN view was improved by moving the probe off the midline towards the patient's left. In a sample of ED patients, the airway anatomy relevant for use in endotracheal intubation is best visualised at the SSN to the left of the trachea with transducer pressure applied. Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
Thomas, Frank; Carpenter, Judi; Rhoades, Carol; Holleran, Renee; Snow, Gregory
This exploratory study examined novice intubators and the effect difficult airway factors have on pre- and posttraining oral-tracheal simulation intubation success rates. Using a two-level, full-factorial design of experimentation (DOE) involving a combination of six airway factors (curved vs. straight laryngoscope blade, trismus, tongue edema, laryngeal spasm, pharyngeal obstruction, or cervical immobilization), 64 airway scenarios were prospectively randomized to 12 critical care nurses to evaluate pre- and posttraining first-pass intubation success rates on a simulator. Scenario variables and intubation outcomes were analyzed using a generalized linear mixed-effects model to determine two-way main and interactive effects. Interactive effects between the six study factors were nonsignificant (p = 0.69). For both pre- and posttraining, main effects showed the straight blade (p = 0.006), tongue edema (p = 0.0001), and laryngeal spasm (p = 0.004) significantly reduced success rates, while trismus (p = 0.358), pharyngeal obstruction (p = 0.078), and cervical immobilization did not significantly change the success rate. First-pass intubation success rate on the simulator significantly improved (p = 0.005) from pre- (19%) to posttraining (36%). Design of experimentation is useful in analyzing the effect difficult airway factors and training have on simulator intubation success rates. Future quality improvement DOE simulator research studies should be performed to help clarify the relationship between simulator factors and patient intubation rates.
Morley, Colin J
Stabilisation and resuscitation of babies at birth is one of the most frequently performed procedures and requires considerable skill. If it is not done well, the baby may suffer prolonged hypoxia and bradycardia. Over the last few years there has been a growing interest in carefully evaluating an infant's condition at birth and the details of what is happening during resuscitation. Clinical assessment of an infant at this time is difficult and often inaccurate. Assessments of heart rate, colour, chest excursions, mask leak, tidal volume, inflation and expiration times, endotracheal intubation, and spontaneous breathing are imprecise. Detailed monitoring of gas flow in and out of the baby, integrated to tidal volume and used to calculate the leak around the face mask or endotracheal tube, together with ventilation pressures, pulse oximetry, ECG, and capnography add objectivity to the clinical assessments. These physiological parameters can be used directly to guide care but are also very useful for debriefing, feedback, audit, teaching, and research. With simultaneous video recording of the resuscitation it is possible to see exactly what is happening during the procedure. Endotracheal intubation is a difficult skill to learn and teach. However, this is now much easier with video laryngoscopy showing the intubator and supervisors exactly what is happening at the larynx. © 2018 S. Karger AG, Basel.
Background Out-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath® Series 5 and GlideScope® Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics. Methods Thirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated. Results Time until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath® compared to the GlideScope® and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath® device (p < 0.001) compared to using the Macintosh blade. Conclusions The learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath® and GlideScope® devices by paramedics. PMID:21241469
Thomas, Frank; Rhoades, Carol; Carpenter, Judi; Holleran, Renee; Handrahan, Diana
This study was undertaken to evaluate difficult airway simulator intubation success rates using Commission on Accreditation of Medical Transport Systems (CAMTS) initial and maintenance intubation training standards on transport-RN novice intubators over a 1-year period. Twelve transport nurses were blinded to and randomly assigned five or six of 64 different difficult airway simulator scenarios. Intubation success rates were measured 1 month before training, 1 month after training, and 1 year later, following CAMTS initial and maintenance intubation standards. Outcome measurements included first attempt intubation rate, overall intubation success rate, number of attempts to intubation, time per attempt, time to intubation, and time between attempts. During the study, participants received no additional training or opportunities to intubate. First-attempt intubation rates significantly improved (P 5 .022) from 19% 1 month before training to 36% 1 month after training, but did not significantly change (P > .999) 1 year later following CAMTS maintenance standards (34%). Mean cumulative success rates did not significantly improve after four attempts or after 3.5 minutes. The overall mean time per attempt and time between attempts declined with subsequent intubation attempts. Using initial and maintenance CAMTS standards, simulator difficult airway intubation success rates are low in novice intubators. Our results suggest that one intubation/quarter may be enough to maintain difficult airway intubation success rates. Training significantly improves intubation rates. Little advantage occurs in intubation rates after four attempts or 3.5 minutes. Copyright © 2011 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Portillo, Augusto L; Poling, Mikaela I; McCormick, Rodger J
The authors describe the surgical approach, findings, and 8-year follow-up in a 29-year-old woman, with severe Freeman-Sheldon syndrome, presenting with congenital blepharophimosis of both upper eyelids resulting in near-complete functional visual obstruction. To avoid possible Freeman-Sheldon syndrome-associated complications of malignant hyperthermia, difficult vascular access, and challenging endotracheal intubation, the surgery was completed under local anesthesia without sedation, and anatomical and functional correction was immediate and remained stable at 8-year follow-up. Unlike many congenital craniofacial syndromes, which frequently involve life-long impairments, important implications exist for plastic surgeons to facilitate opportunities for patients to overcome functional limitations.
Keseg, David; Cortez, Eric; Rund, Douglas; Caterino, Jeffrey
Abstract Introduction. Prehospital personnel frequently encounter agitated, combative, and intoxicated patients in the field. In recent years, ketamine has been described as an effective sedative agent to treat such patients; however, a paucity of research exists describing the use of prehospital ketamine. The objective of this study was to provide a descriptive analysis of the Columbus Division of Fire's experience with utilizing ketamine in the prehospital setting. We hypothesized that ketamine administration improves patient condition, is effective at sedating patients, and does not result in endotracheal intubation in the prehospital setting or in the emergency department (ED). Methods. We conducted a retrospective cohort chart review of Columbus Division of Fire patient care reports and hospital records from destination hospitals in the central Ohio region between October 2010 and October 2012. All patients receiving ketamine administered by Columbus Division of Fire personnel for sedation were included. Patients 17 years and younger were excluded. The primary outcome was the percentage of patients noted to have an "improved" condition recorded in the data field of the patient care report. The secondary outcomes were the effectiveness of sedation and the performance of endotracheal intubation. Results. A total of 36 patients met inclusion criteria over the study period. Data were available on 35 patients for analysis. The mean IV dose of ketamine was 138 mg (SD = 59.5, 100-200). The mean IM dose of ketamine was 324 mg (SD = 120, 100-500). Prehospital records noted an improvement in patient condition after ketamine administration in 32 cases (91%, 95% CI 77-98%). Six patients required sedation post-ketamine administration either by EMS (2) or in the ED (4) (17%, 95% CI 6.5-34%). Endotracheal intubation was performed in eight (23%, 95% CI 10-40%) patients post-ketamine administration. Conclusion. We found that in a cohort of patients administered ketamine
Abdel-Aziz, Samer; Hashmi, Nazish; Khan, Sabina; Ismaeil, Mohamed
We report a case in which the use of benzocaine spray to facilitate awake fiber optic intubation (FOI) in a patient with a difficult airway caused methemoglobinemia intraoperatively. Local benzocaine was sprayed to numb the patient's airway for a total time of one second, fifteen minutes later SpO2 decreased to 85% on the pulse oximeter. Arterial blood gas (ABG) showed a MetHb of 24.6% of total Hemoglobin. The patient was successfully treated with methylene blue intravenously and recovered uneventfully. Small amounts of local benzocaine sprayed to numb the airway can cause significant methemoglobinemia that requires immediate recognition and appropriate management.
Gosavi, Kundan S; Mundada, Surbhi D
Gorlin-Goltz syndrome is a rare autosomal-dominant syndrome related to mutation in “Patched” tumour suppressor gene on chromosome 9. Basocellular carcinomas, odontogenic keratocysts, palmar and/or plantar pits and ectopic calcifications of the falx cerebri are its major features, along with more than 100 minor features. Odontogenic cysts, notorious for recurrence, can make endotracheal intubation difficult, requiring modification of the standard intubation technique. We report such a case managed successfully by awake fibreoptic intubation. Direct laryngoscopy under anaesthesia later confirmed that it was a good decision. PMID:23087465
Nawn, Corinne D.; Souhan, Brian E.; Carter, Robert; Kneapler, Caitlin; Fell, Nicholas; Ye, Jing Yong
During emergency medical situations where the patient has an obstructed airway or necessitates respiratory support, endotracheal intubation (ETI) is the medical technique of placing a tube into the trachea in order to facilitate adequate ventilation of the lungs. In particular, the anatomical, visual and time-sensitive challenges presented in these scenarios, such as in trauma, require a skilled provider in order to successfully place the tube into the trachea. Complications during ETI such as repeated attempts, failed intubation or accidental intubation of the esophagus can lead to severe consequences or ultimately death. Consequently, a need exists for a feedback mechanism to aid providers in performing successful ETI. To investigate potential characteristics to exploit as a feedback mechanism, our study examined the spectral properties of the trachea tissue to determine whether a unique spectral profile exists. In this work, hyperspectral cameras and fiber optic sensors were used to capture and analyze the reflectance profiles of tracheal and esophageal tissues illuminated with UV and white light. Our results show consistent and specific spectral characteristics of the trachea, providing foundational support for using spectral properties to detect features of the trachea.
Decelle, Lydie; Thys, Frédéric; Zech, Francis; Verschuren, Franck
The aim of the study was to evaluate the prevalence and the risk factors of ventilation-associated pneumonia (VAP) for out-of-hospital or in the emergency department intubated patients. This was a retrospective descriptive study. All intubated adults subsequently admitted to the ICU over 1-year period were included. Among 75 patients, 15 patients developed VAP (20%; 95% CI 12-31%). A multivariate analysis revealed three variables independently associated with VAP: cardiorespiratory arrest as the reason of intubation (P=0.001), out-of-hospital as the location of intubation (P=0.011), and clinical macroaspiration as clinical characteristic at the time of intubation (P=0.024). Death rate was 17% and was not significantly higher for patients with VAP (P=0.9; 95% CI 0.32-4.95%). Emergency care workers should be aware of the potential 20% occurrence of VAP when they intubate and ventilate a patient. Preventive strategies, which have been proven effective in ICUs, should be implemented in the emergency setting.
Dronen, S C; Merigian, K S; Hedges, J R; Hoekstra, J W; Borron, S W
In the patient obtunded by drug intoxication, the optimal method of airway protection prior to gastric emptying is not clear. We report a prospective randomized trial of two methods of intubation in this patient population. Fifty-two overdose patients with Glascow Coma Scale scores of 12 or less were intubated either orotracheally after succinylcholine administration or nasotracheally. Success rate, time to intubate, difficulty, and complications of intubation were compared for the two groups. We found a success rate of 100% (23 of 23) for succinylcholine assisted intubation (SAI) versus 65% (19 of 29) success with blind nasotracheal intubation (BNI). Mean time to intubate was 64 seconds and 276 seconds in the SAI and BNI groups, respectively. Eighty-six percent (19 of 22) of patients were intubated successfully in less than 120 seconds in the SAI group versus 37% (10 of 27) in the BNI group (P less than .005). In the SAI group, the mean number of attempts was 1.3 per patient, (range, one to three) with 96% (22 of 23) having two or fewer attempts. No complications were identified. In the BNI group, the mean number of attempts was 3.7 per patient, (range, one to 13) with 45% (13 of 29) having two or fewer attempts (P less than .005). Sixty-nine percent of the BNI group experienced epistaxis, 17% had vomiting, and 10% aspirated. We conclude that SAI is a safe and effective method of airway protection in the obtunded poisoned patient. Complications and difficulty in intubation were significantly less with SAI than with blind nasotracheal intubation.
Hulme, G J; Blues, C M
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.
Prekker, Matthew E; Delgado, Fernanda; Shin, Jenny; Kwok, Heemun; Johnson, Nicholas J; Carlbom, David; Grabinsky, Andreas; Brogan, Thomas V; King, Mary A; Rea, Thomas D
Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific
Fernandez, Juan F; Levine, Stephanie M; Restrepo, Marcos I
Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs. Interventions to prevent VAP are a high priority in the care of critically ill patients requiring mechanical ventilation (MV). Multiple interventions are recommended by evidence-based practice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal tube (ETT) as the main target linked to VAP. Microaspiration and biofilm formation are the two most important mechanisms implicated in the colonization of the tracheal bronchial tree and the development of VAP. Microaspiration occurs when there is distal migration of microorganisms present in the secretions accumulated above the ETT cuff. Biofilm formation has been described as the development of a network of secretions and attached microorganisms that migrate along the ETT cuff polymer and inside the lumen, facilitating the transfer to the sterile bronchial tree. Therefore, our objective was to review the literature related to recent advances in ETT technologies regarding their impact on the control of microaspiration and biofilm formation in patients on MV, and the subsequent impact on VAP.
AFRL-SA-WP-SR-2017-0004 Correlation Between Endotracheal Tube Cuff Pressure and Tracheal Wall Pressure Using Air- and Saline -Filled...Correlation Between Endotracheal Tube Cuff Pressure and Tracheal Wall Pressure Using Air- and Saline -Filled Cuffs 5a. CONTRACT NUMBER FA8650-14...descending from altitude. When using saline in the ETT cuff, TW pressure differences with the 7.5 high-volume, low-pressure cuff and 8.0 TaperGuard
As of April 2013, 164 paramedics are certified to perform tracheal intubation in Fukui Prefecture. This study investigated the current situation surrounding tracheal intubation performed by paramedics in prehospital care. Subjects were 58 paramedics who completed practical training at our hospital. Post-training duration, number of tracheal intubation cases, number of attempts before successful tracheal intubation, disease involved, rate of return of spontaneous circulation, and prognosis were examined. Tracheal intubation was successful on the first attempt in 92% of cases. Rate of return of spontaneous circulation was high in paramedics whose post-training duration was short. No return of spontaneous circulation occurred after a second attempt. Four patients survived asphyxia or aspiration. It is important to perform successful tracheal intubation on the first attempt, to recognize the probability of successful resuscitation in patients with exogenous disease, and to strengthen the medical control system.
Randolph, Adrienne G; Agan, Anna A; Flanagan, Ryan F; Meece, Jennifer K; Fitzgerald, Julie C; Loftis, Laura L; Truemper, Edward J; Li, Simon; Ferdinands, Jill M
Multiplex rapid viral tests and nasopharyngeal flocked swabs are increasingly used for viral testing in PICUs. This study aimed at evaluating how the sampling site and the type of diagnostic test influence test results in children with suspected severe viral infection. Prospective cohort study. PICUs at 21 tertiary pediatric referral centers in the United States. During the 2010-2011 and 2011-2012 influenza seasons, we enrolled children (6 mo to 17 yr old) who were suspected to have severe viral infection. We collected samples by using a standardized protocol for nasopharyngeal aspirate and nasopharyngeal flocked swabs in nonintubated patients and for endotracheal tube aspirate and nasopharyngeal flocked swabs in intubated patients. Viral testing included a single reverse transcription-polymerase chain reaction influenza test and the GenMark Respiratory Viral Panel (20 viruses). We enrolled 90 endotracheally intubated and 133 nonintubated children. We identified influenza in 45 patients with reverse transcription-polymerase chain reaction testing; the multiplex panel was falsely negative for influenza in two patients (4.4%). Six patients (13.3%) had not been diagnosed with influenza in the PICU. Non-influenza viruses were identified in 172 of 223 children (77.1%). In nonintubated children, the same virus was identified by nasopharyngeal flocked swabs and nasopharyngeal aspirate in 133 of 183 paired samples (72.7%), with +nasopharyngeal aspirate/-nasopharyngeal flocked swabs in 32 of 183 paired samples (17.4%). In intubated children, the same virus was identified by nasopharyngeal flocked swabs and endotracheal tube aspirate in 67 of 94 paired samples (71.3%), with +nasopharyngeal flocked swabs/- endotracheal tube aspirate in 22 of 94 paired samples (23.4%). Most discrepancies were either adenovirus or rhinovirus in both groups. Standardized specimen collection and sensitive diagnostic testing with a reverse transcription-polymerase chain reaction increased the
Naito, Hiromichi; Guyette, Francis X; Martin-Gill, Christian; Callaway, Clifton W
Video laryngoscopy (VL) is a technical adjunct to facilitate endotracheal intubation (ETI). VL also provides objective data for training and quality improvement, allowing evaluation of the technique and airway conditions during ETI. Previous studies of factors associated with ETI success or failure are limited by insufficient nomenclature, individual recall bias and self-report. We tested whether the covariates in prehospital VL recorded data were associated with ETI success. We also measured association between time and clinical variables. Retrospective review was conducted in a non-physician staffed helicopter emergency medical service system. ETI was typically performed using sedation and neuromuscular-blockade under protocolized orders. We obtained process and outcome variables from digitally recorded VL data. Patient characteristics data were also obtained from the emergency medical service record and linked to the VL recorded data. The primary outcome was to identify VL covariates associated with successful ETI attempts. Among 304 VL recorded ETI attempts in 268 patients, ETI succeeded for 244 attempts and failed for 60 attempts (first-pass success rate, 82% and overall success rate, 94%). Laryngoscope blade tip usually moved from a shallow position in the oropharynx to the vallecula. In the multivariable logistic regression analysis, attempt time (p = 0.02; odds ratio [OR] 0.99), Cormack-Lehane view (p < 0.001; OR 0.23), bodily fluids obstructing the view (p = 0.01; OR 0.29), and VL equipment failure (p < 0.001; OR 0.14) were negatively associated with successful attempts. Bodily fluids obstructing the view (p < 0.001; hazard ratio [HR] 0.51), VL equipment failure (p = 0.003; HR 0.42), shallow placement of blade tip within 4 seconds (p < 0.001; HR 0.40), number of forward movements (p < 0.001; HR 0.84), trauma (p = 0.04; HR 0.65), and neurological diagnosis (p = 0.04; HR 0.60) were associated with longer ETI attempt time. Bodily fluids obstructing the view
Soh, C; Kong, C; Kong, C; Ip-Yam, P; Chin, E; Goh, M
Objective: To compare the ease of use of the direct vision laryngoscope and the lighted stylet (Trachlight) by novice staff. Methods: Ten novice medical officers (MOs) performed orotracheal intubations using either the conventional direct vision laryngoscope (DL) or a lighted stylet device (Trachlight). They performed their DL intubations during the first phase of the study, followed by the Trachlight intubations in the subsequent phase. Results: 51 of 54 (94%) of the DL intubation attempts were successful compared with 36 of 54 (67%) of the Trachlight intubations (p<0.001). The mean (SEM) time for intubation was 44 (7) seconds in the DL group and 66 (13) seconds in the Trachlight group (p=0.004). In addition 45 of 54 (83%) of the DL intubations were successful at the first attempt versus 15 of 54 (28%) in the Trachlight group (p<0.001). Conclusion: The results show that the use of the conventional direct vision laryngoscope in novices is associated with significantly shorter mean intubation times and higher success rates on the first attempt compared with the Trachlight. PMID:12101133
Vanlinthout, L E H; Mesfin, S H; Hens, N; Vanacker, B F; Robertson, E N; Booij, L H D J
We systematically reviewed factors associated with intubation conditions in randomised controlled trials of mivacurium, using random-effects meta-regression analysis. We included 29 studies of 1050 healthy participants. Four factors explained 72.9% of the variation in the probability of excellent intubation conditions: mivacurium dose, 24.4%; opioid use, 29.9%; time to intubation and age together, 18.6%. The odds ratio (95% CI) for excellent intubation was 3.14 (1.65-5.73) for doubling the mivacurium dose, 5.99 (2.14-15.18) for adding opioids to the intubation sequence, and 6.55 (6.01-7.74) for increasing the delay between mivacurium injection and airway insertion from 1 to 2 min in subjects aged 25 years and 2.17 (2.01-2.69) for subjects aged 70 years, p < 0.001 for all. We conclude that good conditions for tracheal intubation are more likely by delaying laryngoscopy after injecting a higher dose of mivacurium with an opioid, particularly in older people. © 2014 The Association of Anaesthetists of Great Britain and Ireland.
Heidari, Andrew E.; Moghaddam, Samer; Troung, Kimberly K.; Chou, Lidek; Genberg, Carl; Brenner, Matthew; Chen, Zhongping
Biofilm formation has been linked to ventilator-associated pneumonia, which is a prevalent infection in hospital intensive care units. Currently, there is no rapid diagnostic tool to assess the degree of biofilm formation or cellular biofilm composition. Optical coherence tomography (OCT) is a minimally invasive, nonionizing imaging modality that can be used to provide high-resolution cross-sectional images. Biofilm deposited in critical care patients' endotracheal tubes was analyzed in vitro. This study demonstrates that OCT could potentially be used as a diagnostic tool to analyze and assess the degree of biofilm formation and extent of airway obstruction caused by biofilm in endotracheal tubes.
Anaesthetic management of a parturient with predicted difficult airway presenting for caesarean section (CS) is not a straightforward decision: general anaesthesia should be avoided because intubation can be impossible and a "cannot intubate, cannot ventilate" scenario might ensue, on the other hand regional techniques can be unsuccessful or, though rarely, have complications that require emergency intubation. The case is presented of a primigravida admitted to hospital at 37 weeks' gestation with hypertension, intrauterine growth retardation and oligohydramnios. After a few days' observation, it was decided to proceed with an elective CS. The preoperative airway examination revealed a poor mouth opening with an interdental distance of 20 mm and a Mallampati class IV. The patient was classified as a case of difficult intubation and the following anaesthetic options were considered: epidural anaesthesia, spinal anaesthesia and awake fibreoptic intubation followed by general anaesthesia. The pros and the cons of these techniques were explained to the patient and it was suggested that awake fibreoptic intubation was the safest option. The patient gave her consent, so an uneventful nasal awake fibreoptic intubation was carried out under local anaesthesia. This case report offers the opportunity to underline the risk to perform a central blockade in a parturient with predicted difficult intubation, arguing that the safest course of action is an awake fibrescopic intubation, besides some controversial points to safely perform awake fibreoptic intubation in obstetric patients are discussed.
Warner, Keir; Bulger, Eileen M.; Sharar, Sam R.; Maier, Ronald V.; Cuschieri, Joseph
Abstract Background We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP. Methods The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007–July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥104 colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis. Results Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003). Conclusion Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease
Evans, Heather L; Warner, Keir; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph
We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP. The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007-July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥ 10⁴ colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis. Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003). Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration.
Grubb, Peter H.; Lea, Amanda S.; Walsh, William F.; Markham, Melinda H.; Maynord, Patrick O.; Whitney, Gina M.; Stark, Ann R.; Ely, E. Wesley
OBJECTIVE: To improve patient safety in our NICU by decreasing the incidence of intubation-associated adverse events (AEs). METHODS: We sequentially implemented and tested 3 interventions: standardized checklist for intubation, premedication algorithm, and computerized provider order entry set for intubation. We compared baseline data collected over 10 months (period 1) with data collected over a 10-month intervention and sustainment period (period 2). Outcomes were the percentage of intubations containing any prospectively defined AE and intubations with bradycardia or hypoxemia. We followed process measures for each intervention. We used risk ratios (RRs) and statistical process control methods in a times series design to assess differences between the 2 periods. RESULTS: AEs occurred in 126/273 (46%) intubations during period 1 and 85/236 (36%) intubations during period 2 (RR = 0.78; 95% confidence interval [CI], 0.63–0.97). Significantly fewer intubations with bradycardia (24.2% vs 9.3%, RR = 0.39; 95% CI, 0.25–0.61) and hypoxemia (44.3% vs 33.1%, RR = 0.75, 95% CI 0.6–0.93) occurred during period 2. Using statistical process control methods, we identified 2 cases of special cause variation with a sustained decrease in AEs and bradycardia after implementation of our checklist. All process measures increased reflecting sustained improvement throughout data collection. CONCLUSIONS: Our interventions resulted in a 10% absolute reduction in AEs that was sustained. Implementation of a standardized checklist for intubation made the greatest impact, with reductions in both AEs and bradycardia. PMID:27694281
TBI), hemorrhagic shock and burns by enhanced delivery of oxygen . A class-based side effect of PFC (day 2-5 after infusion in 30-50%) may be...anesthesia level assessment. Animals were transported to the laboratory. Then, the animals were intubated and ventilated with 70% nitrogen/30% oxygen ...intubated with an endotracheal tube (ID= 9~10 mm with cuff), an orogastric tube placed to expel vomit, and ventilated with mixed nitrogen/ oxygen (80:20
Trevisanuto, Daniele; Cavallin, Francesco; Nguyen, Loi Ngoc; Nguyen, Tien Viet; Tran, Linh Dieu; Tran, Chien Dinh; Doglioni, Nicoletta; Micaglio, Massimo; Moccia, Luciano
To assess the effectiveness of supreme laryngeal mask airway (SLMA) over face mask ventilation for preventing need for endotracheal intubation at birth. We report a prospective, randomized, parallel 1:1, unblinded, controlled trial. After a short-term educational intervention on SLMA use, infants ≥34-week gestation and/or expected birth weight ≥1500 g requiring positive pressure ventilation (PPV) at birth were randomized to resuscitation by SLMA or face mask. The primary outcome was the success rate of the resuscitation devices (SLMA or face mask) defined as the achievement of an effective PPV preventing the need for endotracheal intubation. We enrolled 142 patients (71 in SLMA and 71 in face mask group, respectively). Successful resuscitation rate was significantly higher with the SLMA compared with face mask ventilation (91.5% vs 78.9%; P = .03). Apgar score at 5 minutes was significantly higher in SLMA than in face mask group (P = .02). Neonatal intensive care unit admission rate was significantly lower in SLMA than in face mask group (P = .02). No complications related to the procedure occurred. In newborns with gestational age ≥34 weeks and/or expected birth weight ≥1500 g needing PPV at birth, the SLMA is more effective than face mask to prevent endotracheal intubation. The SLMA is effective in clinical practice after a short-term educational intervention. Registered with ClinicalTrials.gov: NCT01963936. Copyright © 2015 Elsevier Inc. All rights reserved.
Musk, Gabrielle C; Collins, Teresa; Hosgood, Giselle
In veterinary medical education, reduction, replacement, and refinement (the three Rs) must be considered. Three clinical skills in anesthesia were identified as challenging to students: endotracheal intubation, intravenous catheterization, and drug dose calculations. The aims of this project were to evaluate students' perception of their level of confidence in performing these three clinical skills in veterinary anesthesia, to document the extent of students' previous experience in performing these three tasks, and to describe students' emotional states during this training. Veterinary students completed a series of four surveys over the period of their pre-clinical training to evaluate the usefulness of high-fidelity models for skill acquisition in endotracheal intubation and intravenous catheterization. In addition, practice and ongoing assessment in drug dose calculations were performed. The curriculum during this period of training progressed from lectures and non-animal training, to anesthesia of pigs undergoing surgery from which they did not recover, and finally to anesthesia of dogs and cats in a neutering clinic. The level of confidence for each of the three clinical skills increased over the study period. For each skill, the number of students with no confidence decreased to zero and the proportion of students with higher levels of confidence increased. The high-fidelity models for endotracheal intubation and intravenous catheterization used to complement the live-animal teaching were considered a useful adjunct to the teaching of clinical skills in veterinary anesthesia. With practice, students became more confident performing drug dose calculations.
Rialp Cervera, G; del Castillo Blanco, A; Pérez Aizcorreta, O; Parra Morais, L
Noninvasive ventilation (NIV) with conventional therapy improves the outcome of patients with acute respiratory failure due to hypercapnic decompensation of chronic obstructive pulmonary disease (COPD) or acute cardiogenic pulmonary edema (ACPE). This review summarizes the main effects of NIV in these pathologies. In COPD, NIV improves gas exchange and symptoms, reducing the need for endotracheal intubation, hospital mortality and hospital stay compared with conventional oxygen therapy. NIV may also avoid reintubation and may decrease the length of invasive mechanical ventilation. In ACPE, NIV accelerates the remission of symptoms and the normalization of blood gas parameters, reduces the need for endotracheal intubation, and is associated with a trend towards lesser mortality, without increasing the incidence of myocardial infarction. The ventilation modality used in ACPE does not affect the patient prognosis. Copyright © 2012 Elsevier España, S.L. y SEMICYUC. All rights reserved.
Gonzalez-Rivas, Diego; Bonome, Cesar; Fieira, Eva; Aymerich, Humberto; Fernandez, Ricardo; Delgado, Maria; Mendez, Lucia; de la Torre, Mercedes
Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated
Caratto, Valentina; Ball, Lorenzo; Sanguineti, Elisa; Insorsi, Angelo; Firpo, Iacopo; Alberti, Stefano; Ferretti, Maurizio; Pelosi, Paolo
Objective The aim of this study was to assess the antibacterial activity against Staphylococcus aureus and Pseudomonas aeruginosa of two nanoparticle endotracheal tube coatings with visible light-induced photocatalysis. Methods Two types of titanium dioxide nanoparticles were tested: standard anatase (TiO2) and N-doped TiO2 (N-TiO2). Nanoparticles were placed on the internal surface of a segment of commercial endotracheal tubes, which were loaded on a cellulose acetate filter; control endotracheal tubes were left without a nanoparticle coating. A bacterial inoculum of 150 colony forming units was placed in the endotracheal tubes and then exposed to a fluorescent light source (3700 lux, 300-700 nm wavelength) for 5, 10, 20, 40, 60 and 80 minutes. Colony forming units were counted after 24 hours of incubation at 37°C. Bacterial inactivation was calculated as the percentage reduction of bacterial growth compared to endotracheal tubes not exposed to light. Results In the absence of light, no relevant antibacterial activity was shown against neither strain. For P. aeruginosa, both coatings had a higher bacterial inactivation than controls at any time point (p < 0.001), and no difference was observed between TiO2 and N-TiO2. For S. aureus, inactivation was higher than for controls starting at 5 minutes for N-TiO2 (p = 0.018) and 10 minutes for TiO2 (p = 0.014); inactivation with N-TiO2 was higher than that with TiO2 at 20 minutes (p < 0.001), 40 minutes (p < 0.001) and 60 minutes (p < 0.001). Conclusions Nanosized commercial and N-doped TiO2 inhibit bacterial growth under visible fluorescent light. N-TiO2 has higher antibacterial activity against S. aureus compared to TiO2. PMID:28444073
Slater, E A; Weiss, S J; Ernst, A A; Haynes, M
Maintenance of an airway in the air medically transported patient is of paramount importance. The purpose of this study is to compare preflight versus en route rapid sequence intubation (RSI)-assisted intubations and to determine the value of air medical use of RSI. This study is a 31-month retrospective review of all patients intubated and transported by a large city air medical service. Subgroup analysis was based on whether patients were transported from a hospital or a scene and whether they were intubated preflight or en route. Information on age, Glasgow Coma Scale score, type of scene, ground time, and previous attempts at intubation was recorded. Complications included failures, multiple attempts at intubation, arrhythmias, and need for repeated paralytic agents. Comparisons were made using a confidence interval analysis. An alpha of 0.05 was considered significant; Bonferroni correction was used for multiple comparisons. Three hundred twenty-five patients were intubated and transported by Lifeflight during the study period. Two hundred eighty-eight patients were intubated using RSI (89%). The success rate was 97%. Preflight intubations were performed on 100 hospital calls and 86 scene calls. En route intubations were performed on 40 hospital cases and 62 scene calls. Patients who underwent preflight intubations were significantly younger than those who underwent en route intubations for both the hospital group (34 +/- 11 vs. 44 +/- 24 years, p < 0.05) and the scene group (27 +/- 13 vs. 32 +/- 16 years,p < 0.05). Otherwise, the demographic characteristics of the four groups were similar. Trauma accounted for 60 to 70% of hospital transfers and almost 95 to 100% of scene calls. Compared with preflight intubations, there was a significant decrease in ground time for hospital patients who were intubated en route (26 +/- 10 vs. 34 +/- 11 minutes, p < 0.05) and for scene patients who were intubated en route (11 +/- 8 vs. 18 +/- 9 minutes, p < 0.05). There were
Kulkarni, Atul P; Tirmanwar, Amar S
Literature suggests glottic view is better with straight blades while tracheal intubation is easier with curved blades. To compare glottic view and ease of intubation with Macintosh, Miller, McCoy blades and the Trueview(®) laryngoscope. This prospective randomised study was undertaken in operation theatres of a 550 bedded tertiary referral cancer centre after approval from the Institutional Review Board. We compared the Macintosh, Miller, McCoy blades and the Trueview(®) laryngoscope for glottic visualisation and ease of tracheal intubation; in 120 patients undergoing elective cancer surgery; randomly divided into four groups. After induction of anaesthesia laryngoscopy was performed and trachea intubated. We recorded: Visualisation of glottis (Cormack Lehane grade), ease of intubation, number of attempts; need to change the blade and need for external laryngeal manipulation. Demographic data, Mallampati classification were compared using the Chi-square test. A P<0.05 was considered significant. Grade 1 view was obtained most often (87% patients) with Trueview(®) laryngoscope. Intubation was easier (Grade 1) with Trueview(®) and McCoy blades (93% each). Seven patients needed two attempts; one patient in Miller group needed three attempts. No patient in McCoy and Trueview(®) Groups required external laryngeal manipulation. We found that in patients with normal airway glottis was best visualised with Miller blade and Trueview(®) laryngoscope however, the trachea was more easily intubated with McCoy and Macintosh blades and Trueview(®) laryngoscope.
Harbrecht, Brian G; Franklin, Glen A; Smith, Jason W; Benns, Matthew V; Miller, Keith R; Nash, Nicholas A; Bozeman, Matthew C; Coleman, Royce; O'Brien, Dan; Richardson, J David
Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n = 513), compared with intubated level 1 patients (n = 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc
Davies, Kylie; Bulsara, Max K; Ramelet, Anne-Sylvie; Monterosso, Leanne
We report outcomes of a clinical audit examining criteria used in clinical practice to rationalize endotracheal tube (ETT) suction, and the extent these matched criteria in the Endotracheal Suction Assessment Tool(ESAT)©. A retrospective audit of patient notes ( N = 292) and analyses of criteria documented by pediatric intensive care nurses to rationalize ETT suction were undertaken. The median number of documented respiratory and ventilation status criteria per ETT suction event that matched the ESAT© criteria was 2 [Interquartile Range (IQR) 1-6]. All criteria listed within the ESAT© were documented within the reviewed notes. A direct link was established between criteria used for current clinical practice of ETT suction and the ESAT©. The ESAT©, therefore, reflects documented clinical decision making and could be used as both a clinical and educational guide for inexperienced pediatric critical care nurses. Modification to the ESAT © requires "preparation for extubation" to be added.
Aissaoui, Younes; Qamous, Youssef; Serghini, Issam; Zoubir, Mohammed; Salim, Jaafar Lalaoui; Boughalem, Mohammed
Tracheal intubation without administration of a neuromuscular blocking drug is used frequently in anaesthesia. Several techniques and adjuvants have been tried to improve intubating conditions. Magnesium sulphate is an agent with analgesic, anaesthetic and muscle relaxant effects. To assess the effect of magnesium sulphate on intubating conditions after induction of anaesthesia without a neuromuscular blocking drug. Double-blinded randomised study. Sixty patients with American Society of Anesthesiologists physical status 1/2 scheduled for elective surgery under general anaesthesia were included. Avicenna Military Hospital between June 2010 and March 2011. Before induction of general anaesthesia, patients were assigned to receive either a 10-min infusion of magnesium sulphate 45 mg kg(-1) in 100 ml of isotonic saline (magnesium group, n = 30) or the same volume of saline (control group, n = 30). Anaesthesia was induced with fentanyl 3 μg kg(-1) followed 3 min later by propofol 2.5 mg kg(-1). Intubating conditions were evaluated by a blinded anaesthesiologist using the criteria of the Copenhagen consensus conference: ease of laryngoscopy, vocal cord position and/or movement and response to intubation or cuff inflation (cough or diaphragmatic movement). Intubating conditions were considered as acceptable (excellent or good) or unacceptable (poor). Mean arterial pressure and heart rate were also recorded during the study period. The two groups were comparable in their demographic profiles. Clinically acceptable intubating conditions were observed more frequently in the magnesium group than in the control group: 25 (83%) vs. 18 patients (60%) (P = 0.042). There was no failed intubation. There were no differences between the groups with regard to haemodynamic variables. Addition of magnesium sulphate to propofol and fentanyl at induction of anaesthesia significantly improved intubating conditions without administration of a neuromuscular blocking drug.
Lin, Li-Ching; Chao, Yann-Fen C; Lin, Pi-Chu
Patients with endotracheal intubation often experience anxiety because they are unable to express their needs freely. However, the family members of these patients are able to provide encouragement, comfort, and substantive support. The aims of the present study were: (1) to compare the anxiety scores, vital signs, and incidence of unplanned extubation (UE) between the two comparison groups; (2) to compare the differences in vital signs before and after the intervention in the experimental group; and (3) to explore the satisfaction of patients in the experimental group with the intervention. A quasi-experimental, pretest-posttest design was carried out. A convenience sampling was adopted to recruit patients with endotracheal intubation in intensive care units (ICUs). The experimental group listened to the UE-prevention reminders of their family members for three times a day for 4 days. The control group was provided with usual care. (1) No significant difference was observed in the anxiety scores between the two groups (t = -1.282, p = .205). (2) A repeated-measures analysis found no significant difference in vital signs, taken nightly at 10 p.m., between the experimental and control groups (p > .05). (3) The experimental group registered significantly lower heart rates, systolic blood pressure, diastolic blood pressure, and mean arterial pressure after the conclusion of the intervention (p < .05). However, no significant pre-test / posttest difference in breathing rate was observed for this group. (4) A large majority (89%) of the experimental group expressed satisfaction with the intervention treatment program. The present study, which used a DVD of family reminders encouraging and reminding patients about intubation safety, achieved a very high level of patient satisfaction and reduced their anxiety-related vital signs. The results may serve as a reference for providing intervention treatment to patients with endotracheal intubation in ICUs.
Mitra, Saikat; Purohit, Shobha; Bhatia, Sonali; Kalra, Poonam; Sharma, Satya Prakash
Rocuronium may not always be the preferred relaxant for rapid sequence intubation. When 2% sevoflurane is used in conjunction with rocuronium, it may reduce the time required for achieving complete skeletal muscle relaxation with the intubating dose of rocuronium. This study was prospective, randomised, double-blind in nature and compared the effect of sevoflurane on intubation time and intubating conditions when used along with rocuronium. Thirty adult patients belonging to American Society of Anesthesiologists physical status Grades 1 and 2, of either gender aged between 30 and 65 years undergoing neurosurgical operations were randomly allocated into two equal groups: Group R received 0.8 mg/kg rocuronium, and Group RS received 0.8 mg/kg of rocuronium with 2% sevoflurane. Onset time of intubation was assessed using train-of-four stimuli. The intubating conditions were compared using the Cooper scoring system and the haemodynamic responses were compared between the two groups. The onset time of intubation was 101.73 ± 10.28 s in Group R and 60.4 ± 4.1 s in Group RS (P < 0.001), with excellent intubating conditions in both groups and without any adverse effects. Significant differences in heart rate and mean arterial pressure were seen immediately after intubation, at 1 and 3 min (P < 0.05) between the two groups. Rocuronium 0.8 mg/kg along with 2% sevoflurane provides excellent intubating conditions within 60-66 s from its administration.
Rhee, Chi-Hyoung; Kang, Chul Won; Lee, Chang Ha
We present an intubation simulation with deformable objects and a cross-sectional visual guidance using a general haptic device. Our method deforms the tube model when it collides with the human model. Mass-Spring model with the Euler integration is used for the tube deformation. For the trainee's more effective understanding of the intubation process, we provide a cross-sectional view of the oral cavity and the tube. Our system also applies a stereoscopic rendering to improve the depth perception and the reality of the simulation.
Efrati, Shai; Bolotin, Gil; Levi, Leon; Zaaroor, Menashe; Guralnik, Ludmila; Weksler, Natan; Levinger, Uriel; Soroksky, Arie; Denman, William T; Gurman, Gabriel M
Many of the complications of mechanical ventilation are related to inappropriate endotracheal tube (ETT) cuff pressure. The aim of the current study was to evaluate the effectiveness of automatic cuff pressure closed-loop control in patients under prolonged intubation, where presence of carbon dioxide (CO2) in the subglottic space is used as an indicator for leaks. The primary outcome of the study is leakage around the cuff quantified using the area under the curve (AUC) of CO2 leakage over time. This was a multicenter, prospective, randomized controlled, noninferiority trial including intensive care unit patients. All patients were intubated with the AnapnoGuard ETT, which has an extra lumen used to monitor CO2 levels in the subglottic space.The study group was connected to the AnapnoGuard system operating with cuff control adjusted automatically based on subglottic CO2 (automatic group). The control group was connected to the AnapnoGuard system, while cuff pressure was managed manually using a manometer 3 times/d (manual group). The system recorded around cuff CO2 leakage in both groups. Seventy-two patients were recruited and 64 included in the final analysis. The mean hourly around cuff CO2 leak (mm Hg AUC/h) was 0.22 ± 0.32 in the manual group and 0.09 ± 0.04 in the automatic group (P = .01) where the lower bound of the 1-sided 95% confidence interval was 0.05, demonstrating noninferiority (>-0.033). Additionally, the 2-sided 95% confidence interval was 0.010 to 0.196, showing superiority (>0.0) as well. Significant CO2 leakage (CO2 >2 mm Hg) was 0.027 ± 0.057 (mm Hg AUC/h) in the automatic group versus 0.296 ± 0.784 (mm Hg AUC/h) in the manual group (P = .025). In addition, cuff pressures were in the predefined safety range 97.6% of the time in the automatic group compared to 48.2% in the automatic group (P < .001). This study shows that the automatic cuff pressure group is not only noninferior but also superior compared to the manual cuff pressure group
Romagna, Alexander; Rachinger, Walter; Schwartz, Christoph; Mehrkens, Jan-Hinnerk; Betz, Christian; Briegel, Josef; Schnell, Oliver; Tonn, Jörg-Christian; Schichor, Christian; Thon, Niklas
The 10th cranial nerve (CN X) is at risk during surgery in the lower cerebellopontine angle (CPA). To evaluate endotracheal surface electrodes for assessment of CN X motor function during CPA surgery. Twenty patients were enrolled. Electrophysiological recordings were analyzed and retrospectively correlated with clinical, imaging, and intraoperative data. Recordings from endotracheal surface electrodes were reliable and eligible for analyses in 17 patients; in 3 patients, no surface electrode compound motor action potentials (CMAPs) could be obtained. Those patients with sufficient recordings underwent surgery in the CPA for tumors in 14 patients and for nontumor pathologies in 3 patients. In 12 patients, bipolar stimulation of motor rootlets in the CPA resulted in simultaneous CMAPs recorded from both surface electrodes and needle electrodes placed in the soft palate. Coactivation was particularly seen in patients with an intricate relationship between lower cranial nerves and tumor formations (n = 9/10). Amplitudes and latencies of vocal cord CMAPs showed high interindividual but low intraindividual variability. Parameters were not well correlated with the type of surgery (tumor vs nontumor surgery) and lower CN anatomy (displaced vs undisplaced). In 2 patients, vocal cord CMAPs were lost during tumor surgery, which was associated with postoperative dysphagia and hoarseness in 1 patient. Endotracheal surface electrodes allow identification of vocal cord motor rootlets in the CPA. Worsening of CMAP parameters might indicate functional impairment. These aspects support the use of endotracheal surface electrodes in selected patients in whom the vagus nerve might be at risk during CPA surgery.
Costa, D L; Lehmann, J R; Harold, W M; Drew, R T
A fiberoptic laryngoscope which allows direct visualization of the deep pharynx and epiglottis has been developed for transoral tracheal intubation of small laboratory mammals. The device has been employed in the intubation and instillation of a variety of substances into the lungs of rats, and with minor modification, has had similar application in mice, hamsters, and guinea pigs. The simplicity and ease of handling of the laryngoscope permits one person to intubate large numbers of enflurane anesthetized animals either on an open counter top or in a glove-box, as may be required for administration of carcinogenic materials. Instillation of 7Be-labeled carbon particles into the lungs of mice, hamsters, rats, and guinea pigs resulted in reasonably consistent interlobal distribution of particles for each test animal species with minimal tracheal deposition. However, actual lung tissue doses of carbon exhibited some species dependence.
Siegel, Bianca; Bent, John P; Ward, Robert F
To reflect on lessons learned placing endotracheal nitinol stents in children. Case series with chart review. Tertiary care children's hospital. All children who underwent nitinol cervical tracheal stenting were included. Records were carefully reviewed for intraoperative and postoperative complications, management choices, outcomes, and factors that influenced results. Between 1999 and 2011, 7 children underwent 13 stent placements. Median follow-up was 5 years (range, 1-12 years). Six patients underwent stenting as a salvage procedure following open attempts at airway reconstruction. Four patients remain decannulated with their stent in place (median follow-up 7 years). The fifth patient had his stent removed endoscopically after 50 days because it became apparent that his obstruction was primarily laryngeal. The sixth child had his stent removed via a tracheal fissure after 14 months because of recalcitrant subglottic inflammation at the superior stent border. The seventh patient was decannulated for over 2 years but ultimately required tracheotomy replacement because of stenosis with the stent lumen. Complications included stent migration (23%), restenosis (29%), edema (29%), and granulation (57%). Endotracheal nitinol stents provide a realistic opportunity for decannulation in children for whom other options have failed but should be reserved only as a salvage procedure in severely complicated airways. Our experience has taught valuable lessons about stent indications, sizing, characteristics, and deployment, as well as means to avoid and manage their complications.
Thapa, Dennis B; Greene, Nathaniel H; Udani, Andrea G
Intraoperative ventilatory failure is not an uncommon complication; however, acute endotracheal obstruction by a foreign body or blood clot can be difficult to quickly discriminate from other causes. Once the diagnosis is made, quick action is needed to restore ventilation. The ultimate solution is to exchange the endotracheal tube; however, there can be other ways of resolving this in situations where reintubation would be difficult or unsafe. This case report discusses such an event in an infant with multiple airway challenges including a retropharyngeal and anterior mediastinal abscess. We have also formulated a pathway based on various case reports involving complete ETT obstruction.
Longari, F; Dehgani Mobaraki, P; Ricci, A L; Lapenna, R; Cagini, C; Ricci, G
The objective of this study is to assess different outcomes between endoscopic dacryocystorhinostomy (En-DCR) with and without silicone intubation. We retrospectively analyzed 84 patients (89 procedures), suffering from chronic epiphora for primary acquired nasolacrimal duct obstruction, treated with En-DCR and divided into two groups depending on silicone stent intubation. The surgical outcomes were evaluated at 7 post-operative controls using Munk's score criteria. Functional success was defined as absence of epiphora, no further episodes of dacryocystitis, and a patent ostium after fluorescein irrigation. 45 En-DCR with stent and 44 En-DCR without stent were performed. Success rate after 18 months follow-up were, respectively, 82.2 % in the stent group and 88.6 % in the non-stent group (OR 0.59) with no statistical differences. The ostial size reduction has been reported in higher percentage in the stent group, mainly due to peristomal granuloma (OR 3.64), scar tissue formation (OR 2.25), and turbinoseptal synaechia (OR 1.76). The benefits of non-intubation are less patient discomfort, reduced surgical time and costs, simpler follow-up regimen and less intubation-associated complications. En-DCR without silicone stent intubation should be the first choice of procedure, stent intubation should be reserved in selected cases with poor local conditions pre and intra-operatively assessed.
Nawn, Corinne D.; Souhan, Brian E.; Carter, Robert, III; Kneapler, Caitlin; Fell, Nicholas; Ye, Jing Yong
During emergency medical situations, where the patient has an obstructed airway or necessitates respiratory support, endotracheal intubation (ETI) is the medical technique of placing a tube into the trachea in order to facilitate adequate ventilation of the lungs. Complications during ETI, such as repeated attempts, failed intubation, or accidental intubation of the esophagus, can lead to severe consequences or ultimately death. Consequently, a need exists for a feedback mechanism to aid providers in performing successful ETI. Our study examined the spectral reflectance properties of the tracheal and esophageal tissue to determine whether a unique spectral profile exists for either tissue for the purpose of detection. The study began by using a hyperspectral camera to image excised pig tissue samples exposed to white and UV light in order to capture the spectral reflectance properties with high fidelity. After identifying a unique spectral characteristic of the trachea that significantly differed from esophageal tissue, a follow-up investigation used a fiber optic probe to confirm the detectability and consistency of the different reflectance characteristics in a pig model. Our results characterize the unique and consistent spectral reflectance characteristic of tracheal tissue, thereby providing foundational support for exploiting spectral properties to detect the trachea during medical procedures.
el-Beheiry, H; Kim, J; Milne, B; Seegobin, R
The objective of this study was to determine the effectiveness of two prophylactic approaches against the anticipated hypotension induced by propofol during rapid-sequence intubation. Thirty-six male or female nonpremedicated ASA class I-II patients aged 21-60 yr undergoing elective outpatient surgery were included in the study. Patients were randomly allocated to receive pre-induction ephedrine sulphate (70 micrograms x kg(-1)iv), pre-induction volume loading (12 ml x kg(-1) Ringer's lactate) or no treatment. Rapid-sequence intubation with cricoid pressure was then performed with propofol (2.5 mg. x kg(-1)) and succinylcholine (1.5 mg x kg(-1). The lungs were subsequently ventilated with 0.25-0.5% isoflurane in a 2:1 N2O/O2 mixture. Vecuronium was given once neuromuscular function had recovered from the succinylcholine. Heart rate and systemic arterial blood pressure were measured non-invasively before induction, after propofol administration and every minute for ten minutes after intubation. Pre-induction volume loading prevented the hypotension observed before surgical stimulation in control and ephedrine groups. Moreover, pre-induction volume loading was not associated with increases in heart rate after intubation as was ephedrine administration. The intubating conditions were excellent to satisfactory in most patients and the overall incidence of adverse events during intubation was mainly due to pain during injection of propofol. The present study showed that preoperative volume loading is more efficacious than pre-induction administration of ephedrine sulphate in maintaining haemodynamic stability during rapid-sequence induction with propofol and succinylcholine. In addition, propofol in combination with succinylcholine provides excellent conditions for rapid-sequence intubation.
Cabrini, Luca; Landoni, Giovanni; Baiardo Radaelli, Martina; Saleh, Omar; Votta, Carmine D; Fominskiy, Evgeny; Putzu, Alessandro; Snak de Souza, Cézar Daniel; Antonelli, Massimo; Bellomo, Rinaldo; Pelosi, Paolo; Zangrillo, Alberto
We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool. We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation , while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials. The limited available
Mizuno, Yuji; Ukaji, Koutarou
In 21 patients with severe motor and intellectual disabilities, bronchofiberoptic intubation was performed because of difficulty in tracheal intubation by direct laryngoscopy. The patients ranged from 3 to 35 years old (mean age: 20.2 years). Twenty patients (95.2%) were bedridden. Among the 21 patients, 15 had cerebral palsy and 20 had hypertonia. The reason for intubation were acute respiratory failure due to pneumonia in 17 cases, suffocation after aspiration of food in 2 cases, hypovolemic shock in 1 case, and laryngotracheomalacia in 1 case. Intubation was done pernasally in 15 patients and perorally in 10. It was successful in 20 cases without any significant complications. The Cormack score ranged from 3rd degree in 4 cases to 4th in 17 cases. The 20 cases of successful fiberoptic intubation were divided into 7 patients with and 13 without tracheostomy. The mortality rate was 14.3% in patients with tracheostomy and 30.8% in those without tracheostomy. When more than 4 intubation trials were needed, there was a significantly higher mortality rate. In neurologically handicapped patients with deformity or hypertonia of the oral, cervical, or airway structures, a bronchofiberoptic procedure may be recommended when there is difficulty with intubation.
Gupta, Deepak; Wang, Hong
To calculate the costs per intubation of reusable fiberoptic scopes versus single-use intubation scopes. Open-label retrospective study. University-affiliated hospital. The one-year intubation records of intubations performed with reusable intubation scopes, the one-year maintenance costs of these scopes, and their three-year repair cost records were analyzed. A total of 166 intubations were performed with reusable fiberoptic scopes in 2009. Calculations to assess the costs per intubation based on the documented records at our institution were made. The total cost of an intubation, the repair-to-intubation ratio, and the repair cost per intubation were determined. The total cost of an intubation at our institution in 2009, using reusable scopes, was $119.75 [US dollars (USD)], which included $20.15 (purchasing), $53.48 (repair), $33.16 (maintenance), and $12.96 (labor). The repair-to-intubation ratio was 1:55. Repair costs were $53.48 per intubation and $2,959.44 per instance of repair. The Ambu aScope, a single-use intubation scope, is a new addition to video laryngoscopy. The price should range within 10% of our intubation cost ($120.00 to $132.00 per single-use intubation scope). Copyright © 2011 Elsevier Inc. All rights reserved.
Ould-Ahmed, M; Mas, B; Paris, A; Caroff, P; Segalen, F
We report the failure of a reintubation under direct laryngoscopy, during a percutaneous tracheostomy by Fantoni method. After the accidental per-procedural extubation and in front of an unpredicted difficult conventional endotracheal intubation, a laryngeal mask was used as an airway intubator conduit for the blind passage of the set's ventilation tube. This ventilation tube is a 40 cm long, 4 mm internal diameter special catheter with low pressure cuff, included into the TLT kit. The end of the procedure was uneventful.
Mair, E A; Parsons, D S; Lally, K P; Van Dellen, A F
Present surgical alternatives for pediatric tracheobronchomalacia are limited and associated with many potentially undesirable complications. The feasibility of different intraluminal expandable endotracheal stents for the treatment of surgically induced tracheomalacia was analyzed in 27 piglets. A potentially fatal tracheomalacia was surgically created. Either a stainless steel "zig-zag" stent or a woven polymeric stent was then implanted. Tracheal patency, mucosal function, histopathologic respiratory tract changes, and effects of the stent on esophageal motility were evaluated over a 16-week period. Piglets with steel stents uniformly experienced intense inflammation leading to tracheal dysfunction and death. Piglets with polymeric stents experienced minimal respiratory symptoms. Expandable polymeric endotracheal stents alleviate surgically induced piglet tracheomalacia, were easy to insert, allowed for tracheal growth, and reduced the need for high-risk surgical procedures with prolonged ventilatory support.
Perkins, Michael W; Pierre, Zdenka; Rezk, Peter; Song, Jian; Marshall, Seema; Oguntayo, Samuel; Morthole, Venee; Sciuto, Alfred M; Doctor, Bhupendra P; Nambiar, Madhusoodana P
The efficacy of endotracheal aerosolization of atropine sulfate for protection against soman (GD)-induced respiratory toxicity was investigated using microinstillation technique in guinea pigs. GD (841 mg/m(3), 1.3 LCt(50) or 1121 mg/m(3), 1.7 LCt(50)) was aerosolized endotracheally to anesthetized male guinea pigs that were treated with atropine sulfate (5.0 mg/kg) 30 s postexposure by endotracheal microinstillation. Animals exposed to 841 mg/m(3) and 1121 mg/m(3)GD resulted in 31 and 13% while treatment with atropine sulfate resulted in 100 and 50% survival, respectively. Cholinergic symptoms and increased body weight loss were reduced in atropine-treated animals compared to GD controls. Diminished pulse rate and blood O(2) saturation in GD-exposed animals returned to normal levels after atropine treatment. Increased cell death, total cell count and protein in the bronchoalveolar fluid (BALF) in GD-exposed animals returned to normal levels following atropine treatment. GD exposure increased glutathione and superoxide dismutase levels in BALF and that were reduced in animals treated with atropine. Respiratory parameters measured by whole-body barometric plethysmography revealed that treatment with atropine sulfate resulted in normalization of respiratory frequency, tidal volume, time of expiration, time of inspiration, end expiratory pause, pseudo lung resistance (Penh) and pause at 4 and 24 h post 841 mg/m(3) GD exposure. Lung histopathology showed that atropine treatment reduced bronchial epithelial subepithelial inflammation and multifocal alveolar septal edema. These results suggest that endotracheal aerosolization of atropine sulfate protects against respiratory toxicity and lung injury induced by microinstillation inhalation exposure to lethal doses of GD.
Metterlein, Thomas; Dintenfelder, Anna; Plank, Christoph; Graf, Bernhard; Roth, Gabriel
Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anaesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical
Metterlein, Thomas; Dintenfelder, Anna; Plank, Christoph; Graf, Bernhard; Roth, Gabriel
Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical
Baldoli, Ilaria; Tognarelli, Selene; Vangi, Ferdinando; Panizza, Davide; Scaramuzzo, Rosa T; Cuttano, Armando; Laschi, Cecilia; Menciassi, Arianna
This study describes the technical realization and the pre-clinical validation of a instrumented neonatal intubation skill trainer able to provide objective feedback for the improvement of clinical competences required for such a delicate procedure. The Laerdal ® Neonatal Intubation Trainer was modified by applying pressure sensors on areas that are mainly subject to stress and potential injuries. Punctual Force Sensing Resistors (FSRs) were characterized and fixed on the external side of the airway structure on the dental arches and epiglottis. A custom silicone tongue was designed and developed to integrate a matrix textile sensor for mapping the pressure applied on its whole surface. The assessment of the developed tool was performed by nine clinical experts who were asked to practice three intubation procedures apiece. Median and maximum forces, over threshold events (i.e. 2N for gingival arch sensors and 7N for epiglottis and tongue sensors respectively) and execution time were measured for each trainee. Data analysis from training sessions revealed that the epiglottis is the point mainly stressed during an intubation procedure (maximum value: 16.69N, median value: 3.11N), while the analysis carried out on the pressure distribution on the instrumented tongue provided information on both force values and distribution, according to clinicians' performance. The debriefing phase was used to enhance the clinicians' awareness of applied force and gestures performed, confirming that the present study is an adequate starting point for achieving and optimizing neonatal intubation skills for both residents and expert clinicians. Copyright © 2016 IPEM. Published by Elsevier Ltd. All rights reserved.
Greene, Nathaniel H.
Intraoperative ventilatory failure is not an uncommon complication; however, acute endotracheal obstruction by a foreign body or blood clot can be difficult to quickly discriminate from other causes. Once the diagnosis is made, quick action is needed to restore ventilation. The ultimate solution is to exchange the endotracheal tube; however, there can be other ways of resolving this in situations where reintubation would be difficult or unsafe. This case report discusses such an event in an infant with multiple airway challenges including a retropharyngeal and anterior mediastinal abscess. We have also formulated a pathway based on various case reports involving complete ETT obstruction. PMID:28299222
Khandelwal, Nita; Khorsand, Sarah; Mitchell, Steven H; Joffe, Aaron M
Based on the data from elective surgical patients, positioning patients in a back-up head-elevated position for preoxygenation and tracheal intubation can improve patient safety. However, data specific to the emergent setting are lacking. We hypothesized that back-up head-elevated positioning would be associated with a decrease in complications related to tracheal intubation in the emergency room environment. This retrospective study was approved by the University of Washington Human Subjects Division (Seattle, WA). Eligible patients included all adults undergoing emergent tracheal intubation outside of the operating room by the anesthesiology-based airway service at 2 university-affiliated teaching hospitals. All intubations were through direct laryngoscopy for an indication other than full cardiopulmonary arrest. Patient characteristics and details of the intubation procedure were derived from the medical record. The primary study endpoint was the occurrence of a composite of any intubation-related complication: difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration. Multivariable logistic regression was used to estimate the odds of the primary endpoint in the supine versus back-up head-elevated positions with adjustment for a priori-defined potential confounders (body mass index and a difficult intubation prediction score [Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score]). Five hundred twenty-eight patients were analyzed. Overall, at least 1 intubation-related complication occurred in 76 of 336 (22.6%) patients managed in the supine position compared with 18 of 192 (9.3%) patients managed in the back-up head-elevated position. After adjusting for body mass index and the Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score, the odds of encountering the
Kim, Hyun-Jung; Kim, Jin-Tae; Kim, Hee-Soo; Kim, Chong-Sung; Kim, Seong-Deok
The relative effectiveness of GlideScope(®) videolaryngoscopy (GV) for nasotracheal intubation in pediatric patients is unclear. The purpose of this study is to evaluate the usefulness of GV for nasotracheal intubation compared with direct laryngoscopy (DL) in pediatric patients. Our patient cohort consisted of 80 children <10 years of age who required nasotracheal intubation for elective dental or facial surgery. The patients were randomly allocated to GV (n = 40) or DL (n = 40) group. The time to intubation (TTI), glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation were evaluated. The median TTI was similar between the groups. The TTI of the former 20 patients was faster in the DL group (53.3 s, interquartile range: 42.0-64.3) than GV group (65.9 s, interquartile range: 56.0-93.9) (P = 0.007), whereas the TTI of the latter 20 patients was comparable between the groups. There were no significant differences in glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation between the two groups. GV can provide similar intubation performance characteristics compared with DL when used for nasotracheal intubation in pediatric patients. However, experience is needed to be skillful in the GV to acquire comparable TTI with DL. © 2011 Blackwell Publishing Ltd.
Tekelioğlu, Ümit Yaşar; Karabekmez, Furkan Erol; Demirhan, Abdullah; Akkaya, Akcan; Bayır, Hakan; Koçoğlu, Hasan
Two patients, aged 18 and 28 years, with maxillofacial trauma due to motor vehicle accident, were operated upon by a team of plastic surgeons. In this report we aimed to present our experience with submental intubation procedure in these cases, in which orotracheal or nasotracheal intubation was impossible due to panfacial fracture. PMID:27366379
Lee, Christopher H; Wira, Charles R
Myxedema coma is the most lethal manifestation of hypothyroidism. It is a true medical emergency and can result in profound hemodynamic instability and airway compromise. Myxedema coma currently remains a diagnostic challenge due to the rarity of cases seen today, and failure to promptly initiate therapy with replacement thyroid hormone can be fatal. As thyroid hormone therapy can take days or weeks to reverse the manifestations of myxedema coma, interim supportive therapy is critical while awaiting clinical improvement. Some patients will require endotracheal intubation in the emergency department (ED), and physicians should be aware that unanticipated posterior pharyngeal edema in myxedema coma could severely complicate airway management. Although mechanical ventilation is a well-described adjunctive therapy for myxedema coma, reports of the potential difficulty in securing a definitive airway in these patients are rare. We describe a case of an unidentified woman who presented to the ED with myxedema coma requiring urgent endotracheal intubation and was found to have extensive posterior pharyngeal angioedema inconsistent with her relatively benign external examination. This case highlights the typical features of myxedema coma and discusses our necessity for a rescue device in definitive endotracheal tube placement. Emergency physicians should anticipate a potentially difficult airway in all myxedema coma patients regardless of the degree of external facial edema present.
Philippart, François; Gaudry, Stéphane; Quinquis, Laurent; Lau, Nicolas; Ouanes, Islem; Touati, Samia; Nguyen, Jean Claude; Branger, Catherine; Faibis, Frédéric; Mastouri, Maha; Forceville, Xavier; Abroug, Fekri; Ricard, Jean Damien; Grabar, Sophie; Misset, Benoît
The occurrence of ventilator-associated pneumonia (VAP) is linked to the aspiration of contaminated pharyngeal secretions around the endotracheal tube. Tubes with cuffs made of polyurethane rather than polyvinyl chloride or with a conical rather than a cylindrical shape increase tracheal sealing. To test whether using polyurethane and/or conical cuffs reduces tracheal colonization and VAP in patients with acute respiratory failure. We conducted a multicenter, prospective, open-label, randomized study in four parallel groups in four intensive care units between 2010 and 2012. A cohort of 621 patients with expected ventilation longer than 2 days was included at intubation with a cuff composed of cylindrical polyvinyl chloride (n = 148), cylindrical polyurethane (n = 143), conical polyvinyl chloride (n = 150), or conical polyurethane (n = 162). We used Kaplan-Meier estimates and log-rank tests to compare times to events. After excluding 17 patients who secondarily refused participation or had met an exclusion criterion, 604 were included in the intention-to-treat analysis. Cumulative tracheal colonization greater than 10(3) cfu/ml at Day 2 was as follows (median [interquartile range]): cylindrical polyvinyl chloride, 0.66 (0.58-0.74); cylindrical polyurethane, 0.61 (0.53-0.70); conical polyvinyl chloride, 0.67 (0.60-0.76); and conical polyurethane, 0.62 (0.55-0.70) (P = 0.55). VAP developed in 77 patients (14.4%), and postextubational stridor developed in 28 patients (6.4%) (P = 0.20 and 0.28 between groups, respectively). Among patients requiring mechanical ventilation, polyurethane and/or conically shaped cuffs were not superior to conventional cuffs in preventing tracheal colonization and VAP. Clinical trial registered with clinicaltrials.gov (NCT01114022).
Salata, R A; Lederman, M M; Shlaes, D M; Jacobs, M R; Eckstein, E; Tweardy, D; Toossi, Z; Chmielewski, R; Marino, J; King, C H
The clinical distinction between bacterial colonization of the tracheobronchial tree and nosocomial pneumonia is difficult, especially in intubated patients. We studied 51 intubated, intensive care unit patients prospectively by serial examinations of tracheal aspirates for elastin fibers, graded Gram's stains, and quantitative bacterial cultures in conjunction with clinical and radiologic observations in an attempt to develop criteria for the early detection of pulmonary infection. Patients with infection had new or progressive pulmonary infiltrates plus 1 of the following: positive blood culture results, radiographic evidence of cavitation, or histologic evidence of pneumonia, or 2 or more of the following: new fever, new leukocytosis, or grossly purulent tracheal aspirates. Twenty-one patients developed infection, 22 remained colonized, and 8 had an uncertain status. Infiltrates developed in 34 patients (21 infected, 8 colonized, 5 uncertain status). Gram-negative bacilli were most commonly isolated and were more frequent in infected patients (81 versus 47%, p less than 0.05); Pseudomonas aeruginosa and Serratia marcescens were most often associated with infection. No differences were observed between infected and colonized patients in demographic features, smoking history, underlying disease, previous antibiotic therapy, days in hospital before intubation, preexisting pneumonia upon intubation, or highest temperature or leukocyte count during course. By univariate analysis, infected patients had a longer duration of intubation (p less than 0.05), higher Gram's stain grading for neutrophils (p less than 0.05) or bacteria (p less than 0.005), higher bacterial colony counts (p less than 0.05), and more frequent detection of elastin fibers in tracheal aspirates (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
Gamble, John F; Kurian, Dinesh J; Udani, Andrea G; Greene, Nathaniel H
We present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general anesthesia for laparoscopic gastrostomy tube placement with a focus on airway management. WHS is a rare 4p microdeletion syndrome resulting in multiple congenital abnormalities, including craniofacial deformities. Microcephaly, micrognathia, and glossoptosis are common features in WHS patients and risk factors for a pediatric airway that is potentially difficult to intubate. We discuss anesthesia strategies for airway preparation and management in a WHS patient requiring general anesthesia with endotracheal intubation.
Sharma, Anoop; Dwivedi, Deepak; Sharma, Ram Murti
Intubating a pediatric patient with temporomandibular joint ankylosis is a daunting task, and it becomes more challenging with limited mouth opening. Fiberoptic nasotracheal intubation technique is considered a gold standard. We describe an improvised technique of securing airway in the absence of appropriate-sized fiberoptic scope. The endotracheal tube inserted in the left nostril for maintaining depth of anesthesia was advanced under vision by the fiberoptic scope inserted into the right nostril, and with external laryngeal manipulation, the airway was secured with no complications.
Bentazone is classified as a moderately hazardous (class II) herbicide by the World Health Organization. A 53-year-old Korean woman was transferred to the emergency department after a suicide attempt using approximately 500 mL of bentazone one hour prior to admission. Upon admission, she was alert and tachycardia of 125/min was observed. She was treated with gastric lavage and activated charcoal, during which she experienced diarrhea. Two hours after bentazone ingestion, cardiac arrest and muscle rigidity throughout the body occurred. Cardiopulmonary resuscitation was immediately started. Endotracheal intubation after administration of a muscle relaxant (succinylcholine) was unsuccessful because of temporomandibular joint muscle rigidity. Surgical cricothyroidotomy was performed by the emergency physician, but the patient was not resuscitated. For cardiac arrest patients with muscle rigidity caused by bentazone overdose, endotracheal intubation may be challenging because of muscle rigidity, despite appropriate use of muscle relaxants. Early surgical cricothyroidotomy may be the preferred method of airway management in these patients. PMID:29055963
Oliveira, J; Zagalo, C; Cavaco-Silva, P
Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways. Copyright © 2013 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.
El-Seify, Zeinab A; Khattab, Ahmed Metwally; Shaaban, Ashraf; Radojevic, Dobrila; Jankovic, Ivanka
Background Low flow anesthesia can lead to reduction of anesthetic gas and vapor consumption. Laryngeal mask airway (LMA) has proved to be an effective and safe airway device. The aim of this study is to assess the feasibility of laryngeal mask airway during controlled ventilation using low fresh gas flow (1.0 L/min) as compared to endotracheal tube (ETT). Patients and Methods Fifty nine non-smoking adult patients; ASA I or II, being scheduled for elective surgical procedures, with an expected duration of anesthesia 60 minutes or more, were randomly allocated into two groups - Group I (29 patients) had been ventilated using LMA size 4 for females and 5 for males respectively; and Group II (30 patients) were intubated using ETT. After 10 minutes of high fresh gas flow, the flow was reduced to 1 L/min. Patients were monitored for airway leakage, end-tidal CO2(ETCO2), inspiratory and expiratory isoflurane and nitrous oxide fraction concentrations, and postoperative airway-related complications. Results Two patients in the LMA-group developed initial airway leakage (6.9%) versus no patient in ETT-group. Cough and sore throat were significantly higher in ETT patients. There were no evidences of differences between both groups regarding ETCO2, uptake of gases, nor difficulty in swallowing. Conclusion: The laryngeal mask airway proved to be effective and safe in establishing an airtight seal during controlled ventilation under low fresh gas flow of 1 L/min, inducing less coughing and sore throat during the immediate postoperative period than did the ETT, with continuous measurement and readjustment of the tube cuff pressure. PMID:20668559
Orandi, Amirali; Orandi, Amirhossein; Najafi, Atabak; Hajimohammadi, Fatemeh; Soleimani, Sara; Zahabi, Somayeh
Postoperative sore throat is one of the most common complications of general anesthesia and intubation with prevalence of 18%-65% in different studies. Several risk factors including female gender, postoperative nausea and vomiting and so on have been mentioned. The aim of this study was to evaluate the incidence of postoperative sore throat in females and its association with menstrual cycles. One hundred females between 18-45 years old with ASA class I or II without predicted difficult airway that were candidate for operation in supine position were enrolled in study. Patients who had pulmonary disease, smoking, common cold within two weeks prior to the operation, previous traumatic intubation history, removable dentures, any congenital or acquired deformity in face, neck, mouth and airway, any known pathology in mouth like aphthous and mouth ulcer,pregnant women, and patients with irregular cycles, and those taking oral contraceptive pills were excluded. By the same protocol general anesthesia was provided and the patients were asked to fill out a three-point scale questionnaire (Low, High, None) 1,6 and 24 hours following intubation to study and record the incidence and severity of sore throat, dysphagia and hoarseness. The date of last menstrual period had been recorded as well. Of 100 patients, in the first six hours, 51 patients had sore throat and 49 had no pain. During the first 6 hours, 33 patients (33%) had dysphagia and 13 patients had hoarseness at 6th postoperative hour. Age, weight, LMP, intubation time, operation and extubation time and coughing were compared to sore throat, dysphagia and hoarseness. The association between the incidence of coughing and bucking and sore throat was significant (P = 0.03). None of the parameters had a statistically meaningful association with dysphagia. According to our results, by omitting probable risk factors of incidence of sore throat and evaluation of role of hormonal changes in women represented in menstrual
Jiang, Hai; Miao, Hai-Sheng; Jin, San-Qing; Chen, Li-Hong; Tian, Jing-Ling
Difficult airway remains not only a challenge to the anesthesiologists, but also a life-threatening event to the patients. Awake intubation is the principal choice to deal with difficult airway, and a key point for awake intubation is airway topical anesthesia. Yet, so far there is no ideal topical anesthesia approach for awake intubation. This study aimed at evaluating the effect of pressure-driven (by 10 L/min oxygen flow) lidocaine spray on airway topical anesthesia in order to find a powerful and convenient method for airway topical anesthesia for conscious sedation intubation. Thirty adult patients referred for elective surgery under general anesthesia, aged 18 - C60 years and Mallampati class I or II, were recruited for the study. Before topical anesthesia, the observer's assessment of alert and sedation (OAA/S) scale was controlled between 3 and 4 by intravenous midazolam (0.03 mg/kg), propofol (2 mg×kg(-1)×h(-1)) and remifentanil (0.05 µg×kg(-1)×min(-1)). Ten minutes after sedation, topical anesthesia was performed with the pressure-driven lidocaine spray; the driving pressure was achieved by an oxygen flow of 10 L/min. After topical anesthesia, tracheal intubation was performed and the intubation condition was assessed with modified the Erhan's intubation condition score by an experienced anesthesiologist, and a score of less than 10 was considered to be satisfactory. Attempts to intubate the patient were recorded, and the complications such as local anesthetic toxicity, mucosa injury, and respiration depression were also recorded. The mean arterial blood pressure (MAP), heart rate (HR) and pulse oxygen saturation (SpO2) were recorded at different time points before and after intubation. Patients were asked 24 hours after the operation whether they could recall the events during intubation. All patients were intubated at the first attempt, the average intubation condition score was 7.0 ± 1.1, from 6 to 10, satisfied intubation condition. MAP and HR
Degerli, Semih; Acar, Baran; Sahap, Mehmet; Horasanlı, Eyup
The procedure of laryngoscopic orotracheal intubation (LOTI) has many impacts on several parts of the body. But its effect on middle ear pressure (MEP) is not known well. The purpose of this study is to evaluate the MEP changes subsequent to insertion of endotracheal tube with laryngoscope. 44 patients were included in this study with a normal physical examination of ear, nose and throat. A standard general anaesthesia induction without any inhaler agent was performed to the all patients. The MEP measurements for both ears were applied under 1 minute; before induction (BI) and after intubation (AI) with a middle ear analyzer. Also hemodynamic parameters were recorded before induction and after intubation. Of the 44 patients were 25 women and 19 men with a 43.5±15.1 mean age. A statistically significant rise in MEP was seen in all patients subsequent to insertion of endotracheal tube (P<0.05). Mean right MEPs were BI: -9.5 and AI: 18.5 daPa. Also mean left MEPs were BI: -21.7 and AI: 29.1 daPa. The amount of increases in left and right MEPs were 50 daPa and 27 daPa, respectively. 20% increase in systolic blood pressure and 19% increase in diastolic blood pressure were determined after intubation. The mean heart rate was 76/min before intubation, whereas it was 102/min after intubation with a 34% increase. In this study bilateral significant increases in MEP were determined subsequent to LOTI. Possible factors affecting MEP may be auditory tube, size and type of the blades, drugs and face masking time. But on the other hand in our opinion cardiovascular and haemodynamic response to LOTI has the most impact over the middle ear mucosa with mucosal venous congestion.
Gelberg, J; Kongstad, L; Werner, O
Bolus injections of intravenous propofol and remifentanil can be used in the tracheal intubation of infants and children, but relatively large doses are needed. We hypothesised that addition of a small bolus of rocuronium would ensure good intubation conditions when modest propofol and remifentanil doses were used. Seventy infants between 3 weeks and 4 months of age were randomised to receive either placebo or rocuronium. Anaesthesia was induced with IV propofol, 3 (3-5) mg/kg [median (range)]. Rocuronium (0.2 mg/kg) or placebo was then injected, followed 15 s later by 2 μg/kg remifentanil. One anaesthetist attempted tracheal intubation 1 min after the rocuronium/placebo injection and used the 'Copenhagen scoring system' to assess intubation conditions. The neuromuscular effect of 0.2 mg/kg rocuronium was recorded in another eight, already intubated, infants using thumb accelerometry during train-of-four stimulation of the ulnar nerve. Intubation conditions were classified as 'poor' in 14 of 34 (41%) patients given placebo and in 10 of 36 (28%) patients given rocuronium (P = 0.32). There were four failed first attempts at intubation in the placebo group and none in the rocuronium group (P = 0.051). Maximum neuromuscular depression occurred 4 (3-8) after injection of 0.2 mg/kg rocuronium. Intubation conditions were poor in almost one third of the patients receiving propofol-remifentanil. Adding a low-dose rocuronium did not significantly improve intubation conditions. © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Wei, Ling-Xin; Deng, Xiao-Ming; Liu, Ju-Hui; Luo, Mao-Ping; Tong, Shi-Yi; Zhang, Yan-Ming; Liao, Xu; Xu, Kun-Lin
To observe the clinical effectiveness of inductions and tracheal intubating conditions with 3% sevoflurane and different doses of remifentanil without muscle relaxant in children. Totally 120 peadiatric patients (aged 4-10 years, American Society of Anesthesiologists grade I for inhalational induction) were randomly allocated into group I (remifentanil 1 microg/kg), group II (remifentanil 2 microg/kg), group III (remifentanil 3 microg/kg), and control group (vecuronium bromide 0.1 mg/kg). After inhalational induction with 3% sevoflurane and 60% nitrous oxide in 40% oxygen for 2 minutes, remifentanil 1 microg/kg, 2 microg/ kg, and 3 microg/kg were intravenously injected over 1 minute into patients in group I , group II, and group III, respectively. After remifentanil administration and manual ventilation for 1 minute, the trachea was intubated. In the control group, 2 minutes after intravenous administration of vecuronium bromide 0.1 mg/kg, tracheal intubation was attempted. Agitation, intubating satisfactoriness, and the circulation changes after tracheal intubation and anesthesia induction were observed. In these four groups, agitation occurred in 37.5% of patients during sevoflurane induction. Satisfactory intubation rate was 70.0% in group I, 86.7% in group II, 90.0% in group III, and 93.3% in the control group. Compared with the control group, the impact of tracheal intubation on the circulatory system was smaller in group I , II , and III. Induction with 3% sevoflurane combined with remifentanil can be smoothly performed, followed by the successful tracheal intubation. The intubating conditions are more satisfactory with 3% sevoflurane combined with remifentanil 2 microg/kg or 3 microg/kg.
Liu, Jin-Jen; Chou, Fan-Hao; Yeh, Shu-Hui
This study was conducted to investigate the basic needs and communication difficulties of intubated patients in surgical intensive care units (ICUs) and to identify predictors of the basic needs from the patient characteristics and communication difficulties. In this descriptive correlational study, 80 surgical ICU patients were recruited and interviewed using 3 structured questionnaires: demographic information, scale of basic needs, and scale of communication difficulties. The intubated patients were found to have moderate communication difficulties. The sense of being loved and belonging was the most common need in the intubated patients studied (56.00 standardized scores). A significantly positive correlation was found between communication difficulties and general level of basic needs (r = .53, P < .01), and another positive correlation was found between the length of stay in ICUs and the need for love and belonging (r = .25, P < .05). The basic needs of intubated patients could be significantly predicted by communication difficulties (P = .002), use of physical restraints (P = .010), lack of intubation history (P = .005), and lower educational level (P = .005). These 4 predictors accounted for 47% of the total variance in basic needs. The intubated patients in surgical ICUs had moderate basic needs and communication difficulties. The fact that the basic needs could be predicted by communication difficulties, physical restraints, and educational level suggests that nurses in surgical ICUs need to improve skills of communication and limit the use of physical restraints, especially in patients with a lower educational level.
Wu, R S; Wu, K C; Wong, T K; Tsai, Y H; Cheng, R K; Bishop, M J; Tan, P P
We have studied the effects of a beta-agonist, fenoterol, and a cholinergic antagonist, ipratropium, on post-intubation total respiratory system resistance (Rrs) in asthmatics who developed increased Rrs after tracheal intubation. Sixteen stable asthmatics in whom Rrs increased after intubation were allocated randomly to receive either 10 puffs of fenoterol (group F) or 10 puffs of ipratropium (group IB) via a metered dose inhaler 5 min after intubation. Anaesthesia was induced and maintained with propofol i.v. Rrs was recorded before treatment and again 5, 15 and 30 min after treatment. Rrs decreased significantly from pretreatment values by mean 53 (SD 8)%, 53 (7)% and 58 (6)% at 5, 15 and 30 min, respectively, in group F, but declined by only 12 (6)%, 15 (4)% and 17 (5)% in group IB. At all times after treatment, patients in the fenoterol group had significantly lower Rrs values than those in the ipratropium group. We conclude that increased Rrs after tracheal intubation in asthmatics can be reduced effectively by treatment with fenoterol. A secondary finding of our study was that even after induction of anaesthesia with propofol, patients with a history of asthma may develop high Rrs.
Albertos, Raquel; Caralt, Berta; Rello, Jordi
Ventilator-associated pneumonia (VAP) is a frequent adverse event in the intensive care unit.We review recent publications about the management and prevention of VAP. The latest care bundles introduced standard interventions to facilitate implementation of evidence-based clinical guidelines and to improve the outcome of patients. Recent studies find that prevention management of ventilated patients decreases the risk of VAP. Enteral feeding, considered a risk factor for VAP, currently has been recommended, with appropriate administration, for all critical ill patients if no contraindications exist. In view of the recently available data, it can be concluded that the implementation of care bundles on the general management of ventilated patients in daily practice has reduced the VAP rates. The main pharmacological measures to prevent VAP are proper hands hygiene, high nurse-to-patient ratio, avoid unnecessary transfer of ventilated patients, use of noninvasive mechanical ventilation, shortening weaning period, avoid the use of nasal intubation, prevent bio-film deposition in endotracheal tube, aspiration of subglottic secretions, maintenance of adequate pressure of endotracheal cuffs, avoid manipulation of ventilator circuits, semi-recumbent position and adequate enteral feeding.In addition, updated guidelines incorporate more comprehensive diagnostic protocols to the evidence-based management of VAP.
of a FDA approved device, the CONMED endotracheal cardiac output monitor (ECOM) ™ apparatus, by comparing it to the Edwards Vig ilance II monitor...and Use Committee (FWH 20140100A). Results Using GraphPad Prism® to conduct non-linear fit analyses comparing the slopes of the curves for ECOM
endotracheal intubation was then accomplished and medullary cavity to control bleeding and to produce anesthesia maintained with N,0/O,/Forane (ANA- some...Dis 122:410, 1970 experimental animal in dental research. Arch Oral Biol 7:17, 5. Norden CW, Shinners E, Niederriter K: Clindamycin treatment 1962 of
ABRAHAMSON, STEPHEN; DENSON, JUDSON S.
IN THIS STUDY, A COMPUTER-CONTROLLED PATIENT SIMULATOR (SIM ONE) WAS DESIGNED, CONSTRUCTED, AND TESTED FOR THE TRAINING OF ANESTHESIOLOGY RESIDENTS AT THE UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE. THE TRAINING INVOLVED THE DEVELOPMENT OF SKILL IN ENDOTRACHEAL INTUBATION. THE EXPERIMENT INVOLVED 10 ANESTHESIOLOGY RESIDENTS. FIVE WERE…
Jabre, Patricia; Galinski, Michel; Ricard-Hibon, Agnes; Devaud, Marie Laure; Ruscev, Mirko; Kulstad, Erik; Vicaut, Eric; Adnet, Fréderic; Margenet, Alain; Marty, Jean; Combes, Xavier
Emergency tracheal intubation is reported to be more difficult with single-use plastic than with reusable metal laryngoscope blades in both inhospital and out-of-hospital settings. Single-use metal blades have been developed but have not been compared with conventional metal blades. This controlled trial compares the efficacy and safety of single-use metal blades with reusable metal blades in out-of-hospital emergency tracheal intubation. This randomized controlled trial was carried out in France with out-of-hospital emergency medical units (Services de Médecine d'Urgence et de Réanimation). This was a multicenter prospective noninferiority randomized controlled trial in adult out-of-hospital patients requiring emergency tracheal intubation. Patients were randomly assigned to either single-use or reusable metal laryngoscope blades and intubated by a senior physician or a nurse anesthetist. The primary outcome was first-pass intubation success. Secondary outcomes were incidence of difficult intubation, need for alternate airway devices, and early intubation-related complications (esophageal intubation, mainstem intubation, vomiting, pulmonary aspiration, dental trauma, bronchospasm or laryngospasm, ventricular tachycardia, arterial desaturation, hypotension, or cardiac arrest). The study included 817 patients, including 409 intubated with single-use blades and 408 with a reusable blade. First-pass intubation success was similar in both groups: 292 (71.4%) for single-use blades, 290 (71.1%) for reusable blades. The 95% confidence interval (CI) for the difference in treatments (0.3%; 95% CI -5.9% to 6.5%) did not include the prespecified inferiority margin of -7%. There was no difference in rate of difficult intubation (difference 3%; 95% CI -7% to 2%), need for alternate airway (difference 4%; 95% CI -8% to 1%), or early complication rate (difference 3%; 95% CI -3% to 8%). First-pass out-of-hospital tracheal intubation success with single-use metal laryngoscopy
Udani, Andrea G.
We present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general anesthesia for laparoscopic gastrostomy tube placement with a focus on airway management. WHS is a rare 4p microdeletion syndrome resulting in multiple congenital abnormalities, including craniofacial deformities. Microcephaly, micrognathia, and glossoptosis are common features in WHS patients and risk factors for a pediatric airway that is potentially difficult to intubate. We discuss anesthesia strategies for airway preparation and management in a WHS patient requiring general anesthesia with endotracheal intubation. PMID:27752382
Objective To prospectively assess the association between impoverished sensorimotor integration of the tongue and lips and post-extubation dysphagia (PED). Methods This cross-sectional study included non-neurologic critically ill adult patients who required endotracheal intubation and underwent videofluoroscopic swallowing study (VFSS) between October and December 2016. Participants underwent evaluation for tongue and lip performance, and oral somatosensory function. Demographic and clinical data were retrieved from medical records. Results Nineteen patients without a definite cause of dysphagia were divided into the non-dysphagia (n=6) and the PED (n=13) groups based on VFSS findings. Patients with PED exhibited greater mean duration of intubation (11.85±3.72 days) and length of stay in the intensive care unit (LOS-ICU; 13.69±3.40 days) than those without PED (6.83±5.12 days and 9.50±5.96 days; p=0.02 and p=0.04, respectively). The PED group exhibited greater incidence of pneumonia, higher videofluoroscopy swallow study dysphagia scale score, higher oral transit time, and lower tongue power and endurance and lip strength than the non-dysphagia groups. The differences in two-point discrimination and sensations of light touch and taste among the two groups were insignificant. Patients intubated for more than 7 days exhibited lower maximal tongue power and tongue endurance than those intubated for less than a week. Conclusion Duration of endotracheal intubation, LOS-ICU, and oromotor degradation were associated with PED development. Oromotor degradation was associated with the severity of dysphagia. Bedside oral performance evaluation might help identify patients who might experience post-extubation swallowing difficulty. PMID:29354572
Galvez, Carlos; Navarro-Martinez, Jose; Bolufer, Sergio; Sesma, Julio; Lirio, Francisco; Galiana, Maria; Rivera, Maria Jesus
Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures.
How, K L; Reens, N; Stokhof, A A; Hellebrekers, L J
This article reviews the present state of the art of resuscitation of dogs and cats. The purpose of resuscitation is to revive animals so that the vital functions resume together with a normal brain function. Resuscitation must be started as soon as the cardiopulmonary arrest has been confirmed. Adequate ventilation and effective circulation to the most vital body organs, the heart and the brain, have the highest priority. They can be achieved by endotracheal intubation, artificial ventilation with 100% oxygen and rhythmic compression of the closed chest or direct cardiac massage following thoracotomy. Medical therapy is an important part of resuscitation. In the absence of a central venous route, deep endotracheal administration is the preferred method of administration. Most medications can be administered through the endotracheal tube in this fashion.
Frerk, C.; Mitchell, V. S.; McNarry, A. F.; Mendonca, C.; Bhagrath, R.; Patel, A.; O'Sullivan, E. P.; Woodall, N. M.; Ahmad, I.
These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team. PMID:26556848
Baek, Ji Sun; Lee, Saem; Lee, Jung Hye; Choi, Hye Sun; Jang, Jae Woo; Kim, Sung Joo
To evaluate prognostic factors affecting silicone tube intubation outcomes in Asian patients with lacrimal drainage system stenosis. A retrospective review was conducted on the medical records of 822 patients (1,118 eyes) who had undergone silicone tube intubation to treat lacrimal drainage system stenosis between January 2011 and December 2012. Patients were divided into two groups: a success group and a failure group. Success was defined as the disappearance of epiphora symptoms, normalization of tear meniscus height, and the easy passage of fluid without resistance on the postoperative syringing test. Patient and ocular parameters were compared between the success and failure groups. A total of 994 eyes of 727 patients were included in analyses. Patients had a mean follow-up period of 34.11 ± 18.70 weeks. Silicone tube intubation was successful in 67.2% of participants. Significant differences between the success and failure groups were found for age (p < 0.001), history of ipsilateral facial palsy (p = 0.028), follow-up period (p < 0.001), and degree of passage on the preoperative syringing test (p = 0.001). Only age (p < 0.001) and degree of passage on the preoperative syringing test (p = 0.002) remained significantly associated with silicone tube intubation success in multivariate analysis. Age was negatively associated with silicone tube intubation success in patients with lacrimal drainage system stenosis. The success rate was higher in patients who showed easy passage of fluid without resistance on the preoperative syringing test. These factors should be considered by surgeons planning silicone tube intubation in patients with lacrimal drainage system stenosis.
Lasocki, Sigismond; Lu, Qin; Sartorius, Alfonso; Fouillat, Dominique; Remerand, Francis; Rouby, Jean-Jacques
Closed-circuit endotracheal suctioning (CES) is advocated for preventing hypoxemia caused by the loss of lung volume resulting from open endotracheal suctioning (OES). However, the efficiency of CES and OES on tracheal secretion removal has never been compared in patients with acute lung injury. The authors designed a two-part study aimed at comparing gas exchange and efficiency between OES and CES performed at two levels of negative pressure. Among 18 patients with acute lung injury, 9 underwent CES and OES at 3-h intervals in a random order using a negative pressure of -200 mmHg. Nine other patients underwent CES twice using two levels of negative pressure (-200 and -400 mmHg) applied in a random order. After each CES, a recruitment maneuver was performed using 20 consecutive hyperinflations. Tracheal aspirates were weighed after each suctioning procedure. Arterial blood gases were continuously recorded using an intravascular sensor. Open endotracheal suctioning induced a significant 18% decrease in arterial oxygen tension (Pa(O2)) (range, +13 to -71%) and an 8% increase in arterial carbon dioxide tension (Pa(CO2)) (range, -2 to +16%) that persisted 15 min after the end of the procedure. CES using -200 cm H2O did not change Pa(O2), but tracheal aspirate mass was lower compared with OES (0.6 +/- 1.0 vs. 3.2 +/- 5.1 g; P = 0.03). Increasing negative pressure to -400 cm H2O during CES did not change Pa(O2) but increased the tracheal aspirate mass (1.7 +/- 1.6 vs. 1.0 +/- 1.3 g; P = 0.02). Closed-circuit endotracheal suctioning followed by a recruitment maneuver prevents hypoxemia resulting from OES but decreases secretion removal. Increasing suctioning pressure enhances suctioning efficiency without impairing gas exchange.
El-Jawahri, Areej; Mitchell, Susan L; Paasche-Orlow, Michael K; Temel, Jennifer S; Jackson, Vicki A; Rutledge, Renee R; Parikh, Mihir; Davis, Aretha D; Gillick, Muriel R; Barry, Michael J; Lopez, Lenny; Walker-Corkery, Elizabeth S; Chang, Yuchiao; Finn, Kathleen; Coley, Christopher; Volandes, Angelo E
Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51% were women. Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75). The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). Intervention participants (vs. controls) were more likely not to want CPR (64% vs. 32%, p <0.0001) and intubation (72% vs. 43%, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57% vs. 19%, p < 0.0001) and intubation (64% vs.19%, p < 0.0001) by hospital discharge, documented discussions about their preferences (81% vs. 43%, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001). Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers
Bowton, David L; Hite, R Duncan; Martin, R Shayn; Sherertz, Robert
Aspiration of colonized oropharyngeal secretions is a major factor in the pathogenesis of ventilator-associated pneumonia (VAP). A tapered-cuff endotracheal tube (ETT) has been demonstrated to reduce aspiration around the cuff. Whether these properties are efficacious in reducing VAP is not known. This 2-period, investigator-initiated observational study was designed to assess the efficacy of a tapered-cuff ETT to reduce the VAP rate. All intubated, mechanically ventilated patients over the age of 18 were included. During the baseline period a standard, barrel-shaped-cuff ETT (Mallinckrodt Hi-Lo) was used. All ETTs throughout the hospital were then replaced with a tapered-cuff ETT (TaperGuard). The primary outcome variable was the incidence of VAP per 1,000 ventilator days. We included 2,849 subjects, encompassing 15,250 ventilator days. The mean ± SD monthly VAP rate was 3.29 ± 1.79/1,000 ventilator days in the standard-cuff group and 2.77 ± 2.00/1,000 ventilator days in the tapered-cuff group (P = .65). While adherence to the VAP prevention bundle was high throughout the study, bundle adherence was significantly higher during the standard-cuff period (96.5 ± 2.7%) than in the tapered-cuff period (90.3 ± 3.5%, P = .01). In the setting of a VAP rate very near the average of ICUs in the United States, and where there was high adherence to a VAP prevention bundle, the use of a tapered-cuff ETT was not associated with a reduction in the VAP rate.
Zhou, Qing-he; Xiao, Wang-pin; Zhou, Hong-mei
It is challenging for anesthetists to determine the optimal tracheal intubation depth in children. We hypothesize that a measure three times the length of the middle finger can be used for predicting tracheal tube depth in children. Eighty-six children (4-14 years of age) were included in this study. After the children were anesthetized, a fiberoptic bronchoscope (FOB) was inserted into the trachea, the lengths from the upper incisor teeth to carina and vocal cords were measured, and a suitably sized cuffed tracheal tube was inserted into the trachea. Age-based and middle finger length-based formulas were used to determine the tracheal intubation depth. All 86 children enrolled were included in this study. Compared with the age-based intubation, the rate of appropriate tube placement was higher for middle finger length-based intubation (88.37% vs 66.28%, P = 0.001). The proximal intubation rate was lower in middle finger length-based intubation (4.65% vs 32.56%, P < 0.001). There was only weak evidence for a difference in the distal intubation rate between the two methods (6.97% vs 1.16%, P = 0.054). The correlation coefficient between middle finger length and optimal tracheal tube depth was larger than that between age and optimal tracheal tube depth (0.883 vs 0.845). Our data indicate that the appropriate tube placement rate can be improved by using three times the middle finger length as the tracheal intubation depth in children. © 2015 John Wiley & Sons Ltd.
Day, T; Wainwright, S P; Wilson-Barnett, J
Endotracheal suctioning is a frequently performed procedure that has many associated risks and complications. It is imperative that nurses are aware of these risks and are able to practise according to current research recommendations. This study was designed to examine to what extent intensive care nurses' knowledge and practice of endotracheal suctioning is based on research evidence, to investigate the relationships between knowledge and practice, and to evaluate the effectiveness of a research-based teaching programme. This quasi-experimental study was a randomized, controlled, single-blinded comparison of two research-based teaching programmes, with 16 intensive care nurses, using non-participant observation and a self-report questionnaire. Initial baseline data revealed a low level of knowledge for many participants, which was also reflected in practice, as suctioning was performed against many of the research recommendations. Following teaching, significant improvements were seen in both knowledge and practice. Four weeks later these differences were generally sustained, and provide evidence of the effectiveness of the educational intervention. The study raised concern about all aspects of endotracheal suctioning and highlighted the need for changes in nursing practice, with clinical guidelines and focused practice-based education.
Valori, Roland M; Damery, Sarah; Gavin, Daniel R; Anderson, John T; Donnelly, Mark T; Williams, J Graham; Swarbrick, Edwin T
Cecal intubation rate (CIR) is an established performance indicator of colonoscopy. In some patients, cecal intubation with acceptable tolerance is only achieved with additional sedation. This study proposes a composite Performance Indicator of Colonic Intubation (PICI), which combines CIR, comfort, and sedation. METHODS : Data from 20 085 colonoscopies reported in the 2011 UK national audit were analyzed. PICI was defined as the percentage of procedures achieving cecal intubation with median dose (2 mg) of midazolam or less, and nurse-assessed comfort score of 1 - 3/5. Multivariate logistic regression analysis evaluated possible associations between PICI and patient, unit, colonoscopist, and diagnostic factors. RESULTS : PICI was achieved in 54.1 % of procedures. PICI identified factors affecting performance more frequently than single measures such as CIR and polyp detection, or CIR + comfort alone. Older age, male sex, adequate bowel preparation, and a positive fecal occult blood test as indication were associated with a higher PICI. Unit accreditation, the presence of magnetic imagers in the unit, greater annual volume, fewer years' experience, and higher training/trainer status were associated with higher PICI rates. Procedures in which PICI was achieved were associated with significantly higher polyp detection rates than when PICI was not achieved. CONCLUSIONS : PICI provides a simpler picture of performance of colonoscopic intubation than separate measures of CIR, comfort, and sedation. It is associated with more factors that are amenable to change that might improve performance and with higher likelihood of polyp detection. It is proposed that PICI becomes the key performance indicator for intubation of the colon in colonoscopy quality improvement initiatives. © Georg Thieme Verlag KG Stuttgart · New York.
Background: The placement of a tube into a patient's trachea “the intubation” as we call is not as simple as it looks. It is a very tricky and tedious maneuver that entails skills to assess and perform. Nevertheless, often this is left to the chores of inefficient hands due to a paucity of the availability of experts. They seldom are able to complete the task and often wind up calling the attention of the unit. The present review is an attempt to describe the need to undertake intubation, the procedures and techniques, the complications, including morbidity and mortality and airway management. This overview includes explicit descriptions of the difficult airway which represents multifaceted interface amid patient factors, clinical setting, and skills of the practitioner. Materials and Methods: To accomplish the target, peer-reviewed English language articles published during third millennium up to 2013 were selected from Pub Med, Pub Med Central, Science Direct, Up-to-date, Med Line, comprehensive databases, Cochrane library, and the Internet (Google, Yahoo). Review of Literature: The review constituted a systematic search of literature on the requirements that necessitate the practice of intubation, different techniques that facilitate easy conduct of procedure, the complications, including, morbidity and mortality, and the airway management. Conclusion: Recording every single detail has been beyond the scope of this review, however; some aspects have been wrapped up in nutshell. Some areas of the review are too basic which the medics are well aware of and knowledgeable. Nevertheless, these are difficult to be dispensed with in consideration of their source to the awareness of a common man and a great majority of the patients. PMID:25949040
Kahane, Nili; Segev, Gilad
This report describes a successful dilation of tracheal stenosis in a 16-year-old dog using a conventional endotracheal tube balloon. This technique should be considered as palliative treatment when owners decline other therapeutic options.
Patients with trauma may have airways that are difficult to manage. Patients with blunt trauma are at increased risk of unrecognized cervical spine injury, especially patients with head trauma. Manual in-line stabilization reduces cervical motion and should be applied whenever a cervical collar is removed. All airway interventions cause some degree of cervical spine motion. Flexible fiberoptic intubation causes the least cervical motion of all intubation approaches, and rigid video laryngoscopy provides a good laryngeal view and eases intubation difficulty. In emergency medicine departments, video laryngoscopy use is growing and observational data suggest an improved success rate compared with direct laryngoscopy. Copyright © 2013 Elsevier Inc. All rights reserved.
Tamura, Jun; Hatakeyama, Naohiro; Ishizuka, Tomohito; Itami, Takaharu; Fukui, Sho; Miyoshi, Kenjiro; Sano, Tadashi; Pasloske, Kirby; Yamashita, Kazuto
The pharmacological effects of intramuscular (IM) administration of alfaxalone combined with medetomidine and butorphanol were evaluated in 6 healthy beagle dogs. Each dog received three treatments with a minimum 10-day interval between treatments. The dogs received an IM injection of alfaxalone 2.5 mg/kg (ALFX), medetomidine 2.5 µg/kg and butorphanol 0.25 mg/kg (MB), or their combination (MBA) 1 hr after the recovery from their instrumentation. Endotracheal intubation was attempted, and dogs were allowed to breath room air. Neuro-depressive effects (behavior changes and subjective scores) and cardiorespiratory parameters (rectal temperature, heart rate, respiratory rate, direct blood pressure, central venous pressure and blood gases) were evaluated before and at 2 to 120 min after IM treatment. Each dog became lateral recumbency, except for two dogs administered the MB treatment. The duration was longer in the MBA treatment compared with the ALFX treatment (100 ± 48 min vs 46 ± 13 min). Maintenance of the endotracheal tube lasted for 60 ± 24 min in five dogs administered the MBA treatment and for 20 min in one dog administered the ALFX treatment. Cardiorespiratory variables were maintained within clinically acceptable ranges, although decreases in heart and respiratory rates, and increases in central venous pressure occurred after the MBA and MB treatments. The MBA treatment provided an anesthetic effect that permitted endotracheal intubation without severe cardiorespiratory depression in healthy dogs.
Akkaya, Akcan; Yıldız, İsa; Demirhan, Abdullah; Tekelioğlu, Ümit Yaşar; Koçoğlu, Hasan
A 23-year-old male patient with occipitocervical fixator was scheduled for surgery due to injury to the right forearm. The patient’s thyromental distance was 5 cm, mouth opening grade II, sternomental distance 10 cm and Mallampati score 4. Loss of extension and rotation movements of the head was assessed as difficult intubation criteria. Anaesthetic procedures are almost always difficult in patients with occipitocervical fixation; the limited cervical extension complicated both intubation and ventilation. In this report, application of general anaesthesia using awake fibreoptic bronchoscopic intubation (FOB) is described. After routine monitoring of vital signs and premedication, hypopharyngeal topical anaesthesia was accomplished by instilling 10% lidocaine spray twice via the appropriate nostril. Superior laryngeal nerve block was performed with local anaesthetic infiltration of tissues 1 cm below the greater horns of the hyoid bone. Lingual and pharyngeal branches of the glossopharyngeal nerve were blocked. Transtracheal block was performed. Following completion of local anaesthesia, the patient was intubated using the awake FOB technique, on 5 L min−1 of 100% O2. After muscle relaxation, the patient underwent a microsurgical operation to repair eight tendons, one artery, and one nerve. Surgery lasted for 5 hours. When the extubation criteria were met, the patient was extubated. In cases of occipitocervical fixation, which causes severe limitation of neck movements, the use of awake fibreoptic intubation should be considered. PMID:27366367
Navarro-Martinez, Jose; Bolufer, Sergio; Sesma, Julio; Lirio, Francisco; Galiana, Maria; Rivera, Maria Jesus
Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures. PMID:29078611
Krishnan, L; Nasruddin; Prabhakar, P; Bhaskaranand, N
A retrospective analysis was performed on 215 babies to evaluate the incidence of septicemia in babies intubated at birth for aspirating meconium from the trachea. Only term, appropriate for gestational age babies were included. Babies with any known perinatal risk factor for infection were excluded from the study and none of the babies had been put on "prophylactic antibiotics." There were 88 babies in the intubated group in a one year period from January 1991 to December 1991. One hundred and twenty seven babies were taken as controls. There was no significant difference in the incidence of early septicemia in the two groups. There were no deaths in either group. It is concluded that well term babies who are intubated for aspirating meconium need not be put on routine antibiotic cover.
Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review.
Ali, Husain Shabbir; Hassan, Ibrahim Fawzy; George, Saibu
Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO). A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients' pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support. ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.
Jones, Peter; Ovenden, Nick; Dauger, Stéphane; Peters, Mark J
Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication. Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats. 333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0-1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15-83]). During intubation the median number of lost beats was 8 - when atropine was not used compared to 0 [0-0] when atropine was used (p<0.001). A reduction in heart rate during intubation of <50 bpm reliably predicted a minimal loss of beats. When the reduction in heart rate was >50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range.
Kim, Young-Min; Kim, Ji-Hoon; Kang, Hyung-Goo; Chung, Hyun Soo; Yim, Hyeon-Woo; Jeong, Seung-Hee
The aim of the study was to compare the time taken for intubation (TTI) using the Macintosh and 2 video laryngoscopes (VLs) (GlideScope [GVL]; Saturn Biomedical System, Burnaby, British Columbia, Canada, and Airway Scope [AWS]; Pentax, Tokyo, Japan) with and without chest compressions by experienced intubators in a mannequin model. This was a randomized crossover study. Twenty-two experienced physicians who have limited experience in the VLs participated in the study. The TTI using 3 laryngoscopes with and without compressions were compared. Median TTI difference between 2 conditions was only significant in the AWS (1.64 seconds; P = .01). There were no significant differences in the TTI between the Macintosh and the GVL or the AWS during compressions. In a mannequin model, the Macintosh or the GVL was not affected by chest compressions. The TTI using the AWS was delayed by compressions but not clinically significant. Considering the lack of experience, 2 VLs may be useful adjuncts for intubation by experienced intubators during chest compressions. Copyright © 2011 Elsevier Inc. All rights reserved.
Habre, W; Scalfaro, P; Sims, C; Tiller, K; Sly, P D
We studied lung function in children with and without asthma receiving anesthesia with sevoflurane. Fifty-two children had anesthesia induced with sevoflurane (up to 8%) in a mixture of 50% nitrous oxide in oxygen and then maintained at 3% with children breathing spontaneously via face mask and Jackson-Rees modification of the T-piece. Airway opening pressure and flow were then measured. After insertion of an oral endotracheal tube under 5% sevoflurane, measurements were repeated at 3%, as well as after increasing to 4.2%. Respiratory system resistance (Rrs) and compliance during expiration were calculated using multilinear regression analysis of airway opening pressure and flow, assuming a single-compartment model. Data from 44 children were analyzed (22 asthmatics and 22 normal children). The two groups were comparable with respect to age, weight, ventilation variables, and baseline respiratory mechanics. Intubation was associated with a significant increase in Rrs in asthmatics (17% +/- 49%), whereas in normal children, Rrs slightly decreased (-4% +/- 39%). At 4.2%, Rrs decreased slightly in both groups with almost no change in compliance system resistance. We concluded that in children with mild to moderate asthma, endotracheal intubation during sevoflurane anesthesia was associated with increase in Rrs that was not seen in nonasthmatic children. Tracheal intubation using sevoflurane as sole anesthetic is possible and its frequency is increasing. When comparing children with and without asthma, tracheal intubation under sevoflurane was associated with an increase in respiratory system resistance in asthmatic children. However, no apparent clinical adverse event was observed.
airway obstruction: chin lift or jaw thrust, nasopharyngeal airway, place casualty in recovery position Surgical cricothyroidotomy (with lidocaine ...laryngeal mask airway /ILMA or Combitube or endotracheal intubation or surgical cricothyroidotomy (with lidocaine if conscious) Spinal immobilization is...surgical cricothyroidotomy (with lidocaine If conscious) 3. Breathing Consider tension pneumothorax and decompress with needle thoracostomy if
Smereka, Jacek; Ladny, Jerzy R; Naylor, Amanda; Ruetzler, Kurt; Szarpak, Lukasz
The aim of this study was to compare C-MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. The study was designed as a prospective randomized crossover manikin trial. 70 paramedics with <5years of medical experience participated in the study. The paramedics attempted to intubate manikins in 3 airway scenarios: normal airway without cervical immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). Scenario A: Nearly all participants performed successful intubations with both MAC and C-MAC on the first attempt (95.7% MAC vs. 100% C-MAC), with similar intubation times (16.5s MAC vs. 18s C-MAC). Scenario B: The results with C-MAC were significantly better than those with MAC (p<0.05) for the time of intubation (23 s MAC vs. 19 s C-MAC), success of the first intubation attempt (88.6% MAC vs. 100% C-MAC), Cormack-Lehane grade, POGO score, severity of dental compression, device difficulty score, and preferred airway device. Scenario C: The results with C-MAC were significantly better than those with MAC (p<0.05) for all the analysed variables: success of the first attempt (51.4% MAC vs. 100% C-MAC), overall success rate, intubation time (27 s MAC vs. 20.5 s C-MAC), Cormack-Lehane grade, POGO score, dental compression, device difficulty score and the preferred airway device. The C-MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization. Copyright © 2017 Elsevier Inc. All rights reserved.
Rezoagli, Emanuele; Zanella, Alberto; Cressoni, Massimo; De Marchi, Lorenzo; Kolobow, Theodor; Berra, Lorenzo
The presence of an endotracheal tube is the main cause for developing ventilator-associated pneumonia (VAP), but pneumonia can still develop in hospitalized patients after endotracheal tube removal (postextubation pneumonia [PEP]). We hypothesized that short-term intubation (24 hours) can play a role in the pathogenesis of PEP. To test such hypothesis, we initially evaluated the occurrence of lung colonization and VAP in sheep that were intubated and mechanically ventilated for 24 hours. Subsequently, we assessed the incidence of lung colonization and PEP at 48 hours after extubation in sheep previously ventilated for 24 hours. To simulate intubated intensive care unit patients placed in semirecumbent position, 14 sheep were intubated and mechanically ventilated with the head elevated 30° above horizontal. Seven of them were euthanized after 24 hours (Control Group), whereas the remaining were euthanized after being awaken, extubated, and left spontaneously breathing for 48 hours after extubation (Awake Group). Criteria of clinical diagnosis of pneumonia were tested. Microbiological evaluation was performed on autopsy in all sheep. Only 1 sheep in the Control Group met the criteria of VAP after 24 hours of mechanical ventilation. However, heavy pathogenic bacteria colonization of trachea, bronchi, and lungs (range, 10-10 colony-forming unit [CFU]/g) was reported in 4 of 7 sheep (57%). In the Awake Group, 1 sheep was diagnosed with VAP and 3 developed PEP within 48 hours after extubation (42%), with 1 euthanized at 30 hours because of respiratory failure. On autopsy, 5 sheep (71%) confirmed pathogenic bacterial growth in the lower respiratory tract (range, 10-10 CFU/g). Twenty-four hours of intubation and mechanical ventilation in semirecumbent position leads to significant pathogenic colonization of the lower airways, which can promote the development of PEP. Strategies directed to prevent pathogenic microbiological colonization before and after mechanical
Uncuffed Endotracheal Tube Size, the Diameter of the Distal Digit of the Little Finger and the Penlington Formula 12. PERSONAL AUTHOR(S) Roy H. Fukuoka 13a...BETWEEN ACTUAL UNCUFFED ENDOTRACHEAL TUBE SIZE, THE DIAMETER OF THE DISTAL DIGIT OF THE LITTLE FINGER AND THE PENLINGTON FORMULA By Roy H. Fukuoka May... PENLINGTON FORMULA A THESIS PROPOSAL Presented to the Department of Nursing California State University, Long Beach In Partial Fulfillment of the
Ekeoduru, Rhashedah A; Greives, Matthew R; Nesrsta, Eric A
A former 25-week-old neonate presented at 34 weeks postconceptual age with necrotizing fasciitis and purpura fulminans because of Group B Streptococcus infection. He was septic and coagulopathic when he was intubated, and the endotracheal tube was secured with adhesives. When he subsequently developed large purpuric, bullous lesions on the face and neck, he presented to the operating room for excision and debridement of his facial lesions. No change was made in how the endotracheal tube was secured. Midprocedure, an unintentional extubation occurred. We describe how we subsequently secured the airway and make recommendations on how to avoid this problem in the future and for rescue preparation before the procedure.
Carlisle, H R; Kamlin, C O F; Owen, L S; Davis, P G; Morley, C J
Non-invasive respiratory support is increasingly popular but is associated with complications including nasal trauma. The present report describes a novel method of oral continuous positive airway pressure (CPAP) delivery in an extremely premature infant with severe nasal septum erosion. The distal end of a cut down endotracheal tube was passed through a small hole made in the teat of a dummy (infant pacifier) and sutured in place. The dummy was secured in the infant's mouth and CPAP was delivered to the pharynx. The device was well tolerated and the infant was successfully managed using this technique for 48 days, avoiding endotracheal intubation and ventilation.
Levitan, R M; Goldman, T S; Bryan, D A; Shofer, F; Herlich, A
Video imaging of intubation as seen by the laryngoscopist has not been a part of traditional instruction methods, and its potential impact on novice intubation success rates has not been evaluated. We prospectively tracked the success rates of novice intubators in paramedic classes who were required to watch a 26-minute instructional videotape made with a direct laryngoscopy imaging system (video group). We compared the prospectively obtained intubation success rate of the video group against retrospectively collected data from prior classes of paramedic students (traditional group) in the same training program. All classes received the same didactic airway instruction, same mannequin practice time, same paramedic textbook, and were trained in the same operating room with the same teaching staff. The traditional group (n=113, total attempts 783) had a mean individual intubation success rate of 46.7% (95% confidence interval 42.2% to 51.3%). The video group (n=36, total attempts 102) had a mean individual intubation success rate of 88.1% (95% confidence interval 79.6% to 96.5%). The difference in mean intubation success rates between the 2 groups was 41.4% (95% confidence interval 31.1% to 50.7%, P <.0001). The 2 groups did not differ in respect to age, male sex, or level of education. An instructional videotape made with the direct laryngoscopy video system significantly improved the initial success rates of novice intubators in an operating room setting.
Jean, Yuel-Kai; Potnuru, Paul; Diez, Christian
We present an approach to airway management in a patient with machete injuries culminating in near-complete cricotracheal transection, in addition to a gunshot wound to the neck. Initial airway was established by direct intubation through the cricotracheal wound. Once the airway was secured, a bronchoscopy-guided orotracheal intubation was performed with simultaneous retraction of the cricotracheal airway to optimize the surgical field. This case offers insight into a rarely performed approach to airway management. Furthermore, our case report demonstrates that, in select airway injuries, performing through-the-wound intubation engenders a multitude of benefits.
Koh, Shizuka; Inoue, Yasushi; Ochi, Shintaro; Takai, Yoshihiro; Maeda, Naoyuki; Nishida, Kohji
To investigate visual function and optical quality in eyes with epiphora undergoing lacrimal passage intubation. Prospective case series. Thirty-four eyes of 30 patients with lacrimal passage obstruction were enrolled. Before and 1 month after lacrimal passage intubation, functional visual acuity (FVA), higher-order aberrations (HOAs), lower tear meniscus, and tear clearance were assessed. An FVA measurement system was used to examine changes in continuous visual acuity (VA) over time, and visual function parameters such as FVA, visual maintenance ratio, and blink frequency were obtained. Sequential ocular HOAs were measured for 10 seconds after the blink using a wavefront sensor. Aberration data were analyzed in the central 4 mm for coma-like, spherical-like, and total HOAs. Fluctuation and stability indices of the total HOAs over time were calculated. Lower tear meniscus was assessed by anterior segment optical coherence tomography. After lacrimal passage intubation, visual function significantly improved, as indicated by improved FVA (P = .003) and visual maintenance ratio (P < .001). Blink frequency decreased significantly after treatment (P = .01). Optical quality significantly improved, as indicated by a decrease in coma-like aberrations (P = .003), spherical-like aberrations (P = .018), and total HOAs (P = .001). Stability index increased (P < .001) and fluctuation index decreased (P = .019), and tear meniscus dimension decreased (P < .001). Lacrimal passage intubation for eyes with epiphora significantly improved visual function and optical quality via patency of the lacrimal passage. Copyright © 2017 Elsevier Inc. All rights reserved.
Hodd, Jack A R; Doyle, D John; Gupta, Shipra; Dalton, Jarrod E; Cata, Juan P; Brewer, Edward J; James, Monyulona; Sessler, Daniel I
The AP Advance (APA) is a videolaryngoscope with interchangeable blades: intubators can choose standard Macintosh blades or a difficult-airway blade with increased curvature and a channel to guide the tube to the larynx. The APA may therefore be comparably effective in both normal and difficult airways. We tested the hypotheses that intubation with the APA is no slower than Macintosh laryngoscopy for normal mannequin airways, and that it is no slower than videolaryngoscopy using a GlideScope Ranger in difficult mannequin airways. Medical professionals whose roles potentially include tracheal intubation were trained with each device. Participants intubated simulated (Laerdal SimMan) normal and difficult airways with the APA, GlideScope, and a conventional Macintosh blade. Speed of intubation was compared using Cox proportional hazards regression, with a hazard ratio >0.8 considered noninferior. We also compared laryngeal visualization, failures, and participant preferences. Unadjusted intubation times in the normal airway with the APA and Macintosh were virtually identical (median, 22 vs 23 seconds); after adjustment for effects of experience, order, and period, the hazard ratio (95% confidence interval) comparing APA with Macintosh laryngoscopy was 0.87 (0.65, 1.17), which was not significantly more than our predefined noninferiority boundary of 0.8 (P = 0.26). Intubation with the APA was faster than with the GlideScope in difficult airways (hazard ratio = 7.6 [5.0, 11.3], P < 0.001; median, 20 vs 59 seconds). All participants intubated the difficult airway mannequin with the APA, whereas 33% and 37% failed with the GlideScope and Macintosh, respectively. In the difficult airway, 99% of participants achieved a Cormack and Lehane grade I to II view with the APA, versus 85% and 33% with the GlideScope and Macintosh, respectively. When asked to choose 1 device overall, 82% chose the APA. Intubation times were similar with the APA and Macintosh laryngoscopes in
Andreatta, Pamela B; Klotz, Jessica J; Dooley-Hash, Suzanne L; Hauptman, Joe G; Biddinger, Bea; House, Joseph B
The purpose of this article was to establish psychometric validity evidence for competency assessment instruments and to evaluate the impact of 2 forms of training on the abilities of clinicians to perform neonatal intubation. To inform the development of assessment instruments, we conducted comprehensive task analyses including each performance domain associated with neonatal intubation. Expert review confirmed content validity. Construct validity was established using the instruments to differentiate between the intubation performance abilities of practitioners (N = 294) with variable experience (novice through expert). Training outcomes were evaluated using a quasi-experimental design to evaluate performance differences between 294 subjects randomly assigned to 1 of 2 training groups. The training intervention followed American Heart Association Pediatric Advanced Life Support and Neonatal Resuscitation Program protocols with hands-on practice using either (1) live feline or (2) simulated feline models. Performance assessment data were captured before and directly following the training. All data were analyzed using analysis of variance with repeated measures and statistical significance set at P < .05. Content validity, reliability, and consistency evidence were established for each assessment instrument. Construct validity for each assessment instrument was supported by significantly higher scores for subjects with greater levels of experience, as compared with those with less experience (P = .000). Overall, subjects performed significantly better in each assessment domain, following the training intervention (P = .000). After controlling for experience level, there were no significant differences among the cognitive, performance, and self-efficacy outcomes between clinicians trained with live animal model or simulator model. Analysis of retention scores showed that simulator trained subjects had significantly higher performance scores after 18 weeks (P = .01
Yue, Hui; Han, Jinyu; Liu, Ling; Wang, Kaiyuan; Li, Jincheng
The aim of the present study was to investigate the effect of various doses of rocuronium on bispectral index (BIS) responses to propofol induction and tracheal intubation, as well as the role of the non-depolarization muscle relaxant rocuronium on the depth of sedation. A total of 72 patients (American Society of Anesthesiologists physical status I-II) were anaesthetized with propofol using a target-controlled infusion, and randomly divided into two sedation level groups (n=36). The patients were divided into 2 groups according to the BIS value: A normal sedation group (group 1), with a stable BIS value at 40-60, and a deep sedation group (group 2), with a BIS value <20 or with burst suppression. Each group was randomly divided into 4 subgroups A-D (n=9) according to the various doses of rocuronium (0.3, 0.6, 0.9 and 1.2 mg/kg). Tracheal intubation was performed after 2 min of rocuronium administration. BIS, electromyography (EMG), heart rate (HR) and mean arterial pressure (MAP) were recorded continuously and averaged over 1 min during baseline (T1), steady state (T2), 2 min after rocuronium infusion (T3), and 0, 2 and 5 min after tracheal intubation. The results demonstrated that HR and MAP decreased significantly at T2 and T3 compared with T1. Following tracheal intubation (L0), HR and MAP significantly increased compared with T2 and T3, and returned to levels similar to those prior to intubation after 5 min. In group 1C and 1D, BIS was significantly decreased at T3 compared with T2; BIS was significantly increased at L0 compared with T3 in group 1A and 1B. EMG at earlier stages of anesthesia was significantly higher compared with other points, and was significantly increased at L0 compared with T3 in group 1A and 1B. These results demonstrated that BIS response may be associated with the dosage of rocuronium in the normal sedation group, although no association was observed with the deep sedation group. Tracheal intubation resulted in marked hemodynamic
MacNab, A J; MacPhail, I; MacNab, M K; Noble, R; O'Flaherty, D
We conducted a prospective randomized study of success rate and time to intubation using Trachlight and Surch-Lite lighted stylets versus a regular tracheal tube stylet, in a training setting. Participants, 18 paediatric transport paramedics, performed two intubations with each of the three devices, using an airway management trainer. There was no significant difference in mean time for intubation between the three devices. The times for external confirmation of correct tube placement were comparable using the two lighted stylets. External confirmation of the tube placement using the lighted stylets was quicker than laryngoscopic visualization. In darkness, with a nonfunctioning laryngoscope, intubations were successfully performed 100% of the time with the lighted stylet, but only 11% of the time with the regular stylet. All paramedics felt that a lighted stylet would be a useful airway management adjunct for the transport environment for complicated intubations or for use in very high or low levels of ambient light.
Alter, Scott M; Haim, Eithan D; Sullivan, Alex H; Clayton, Lisa M
Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades. Design: retrospective chart review. hospital-based suburban ALS service with 20,000 annual calls. prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated. 2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7). Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success. Copyright © 2018 Elsevier Inc. All rights reserved.
The goal of this study is to evaluate the efficacy of deep convolutional neural networks (DCNNs) in differentiating subtle, intermediate, and more obvious image differences in radiography. Three different datasets were created, which included presence/absence of the endotracheal (ET) tube (n = 300), low/normal position of the ET tube (n = 300), and chest/abdominal radiographs (n = 120). The datasets were split into training, validation, and test. Both untrained and pre-trained deep neural networks were employed, including AlexNet and GoogLeNet classifiers, using the Caffe framework. Data augmentation was performed for the presence/absence and low/normal ET tube datasets. Receiver operating characteristic (ROC), area under the curves (AUC), and 95% confidence intervals were calculated. Statistical differences of the AUCs were determined using a non-parametric approach. The pre-trained AlexNet and GoogLeNet classifiers had perfect accuracy (AUC 1.00) in differentiating chest vs. abdominal radiographs, using only 45 training cases. For more difficult datasets, including the presence/absence and low/normal position endotracheal tubes, more training cases, pre-trained networks, and data-augmentation approaches were helpful to increase accuracy. The best-performing network for classifying presence vs. absence of an ET tube was still very accurate with an AUC of 0.99. However, for the most difficult dataset, such as low vs. normal position of the endotracheal tube, DCNNs did not perform as well, but achieved a reasonable AUC of 0.81.
Kedarisetty, Suraj; Johnson, Jennifer Moitoza; Glaser, Dale; Delson, Nathan
Background: The goal of this study was to determine whether motion parameters during laryngoscopy in a manikin differed with experienced operators versus novice trainees and whether motion measurements would predict trainee outcomes when intubating patients. Methods: Motion, force, and duration of laryngoscopy on a manikin were compared in two separate experiments between beginning anesthesiology residents (CA1) and anesthesiologists with more than 24 months of anesthesiology training (CA3 or attendings). In one experiment, CA1 residents were also evaluated for the percentage of their laryngoscope path that followed the route used by attending anesthesiologists. The residents were then observed for patient intubation outcomes for 4 weeks after manikin testing. The relationship between manikin test metrics and patient intubation outcomes was analyzed by multilevel modeling. Results: CA1 residents positioned the laryngoscope blade farther right and with less lift than did experienced anesthesiologists. Endpoint position was 0.6 ± 0.3 cm left of midline for residents (n = 10) versus 2.7 ± 0.3 cm for advanced anesthesiologists (n = 8; P = .0003), and 15.6 ± 0.8 versus 17.7 ± 0.2 cm above the table surface, respectively (P = .033). On average, only 74 ± 6% of the CA1 laryngoscopy trajectory coincided with the Attending Route (P < .001 versus 100%). For each percentage point increase in Attending Route match, residents' odds of intubating a patient's trachea improved by a factor of 1.033 (95% confidence interval [CI] 1.007–1.059, P = .040), and their rate of failed laryngoscopy attempts decreased by a factor of 0.982 (0.969–0.996, P = .045). Discussion: Laryngoscopy motion in manikins may predict which trainees can complete a patient intubation successfully in a few attempts. The assessment could help determine readiness for intubating patients with indirect supervision.
Sakata, Shinichiro; Hallett, Kerrod B; Brandon, Matthew S; McBride, Craig A
Endotracheal tube stabilization in patients with facial burns is crucial and often challenging. We present a simple method of securing an endotracheal tube using two orthodontic brackets bonded to the maxillary central incisor teeth and a 0.08'' stainless steel ligature wire. Our technique is less traumatic, and is easier to maintain oral hygiene than with previously described methods. This anchorage system takes 5 min to apply and can be removed on the ward without the need for a general anaesthetic.
Traumatic brain injury (TBI) is usually combined with cervical spine (C-spine) injury. The possibility of C-spine injury is always considered when performing endotracheal intubation in these patients. Rapid sequence intubation is recommended with adequate sedative or analgesics and a muscle relaxant to prevent an increase in intracranial pressure during intubation in TBI patients. Normocapnia and mild hyperoxemia should be maintained to prevent secondary brain injury. The manual-in-line-stabilization (MILS) technique effectively lessens C-spine movement during intubation. However, the MILS technique can reduce mouth op