Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study.

PubMed

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

2018-05-07

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 intubation success or peri-intubation adverse events. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications.

PubMed

Wilcox, Susan R; Bittner, Edward A; Elmer, Jonathan; Seigel, Todd A; Nguyen, Nicole Thuy P; Dhillon, Anahat; Eikermann, Matthias; Schmidt, Ulrich

2012-06-01

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 oxygenation (p = .07). The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

PubMed Central

Mutlak, Haitham; Rolle, Udo; Rosskopf, Willi; Schalk, Richard; Zacharowski, Kai; Meininger, Dirk; Byhahn, Christian

2014-01-01

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

Endotracheal intubation using the C-MAC® video laryngoscope or the Macintosh laryngoscope: A prospective, comparative study in the ICU

PubMed Central

2012-01-01

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

The Intubating Laryngeal Mask Airway Allows Tracheal Intubation When the Cervical Spine Is Immobilized by a Rigid Collar

PubMed Central

Komatsu, Ryu; Nagata, Osamu; Kamata, Kotoe; Yamagata, Katsuyuki; Sessler, Daniel I.; Ozaki, Makoto

2005-01-01

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 [25] vs. 22 [6] 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 [41] vs. 50 [30] 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

Encountering unexpected difficult airway: relationship with the intubation difficulty scale

PubMed Central

Koh, Wonuk; Kim, Hajung; Kim, Kyongsun; Ro, Young-Jin

2016-01-01

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

Comparison of the Laryngeal View during Tracheal Intubation Using Airtraq and Macintosh Laryngoscopes by Unskillful Anesthesiology Residents: A Clinical Study

PubMed Central

Ferrando, Carlos; Aguilar, Gerardo; Belda, F. Javier

2011-01-01

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

The effects of succinylcholine or low-dose rocuronium to aid endotracheal intubation of adult sows

PubMed Central

Duke-Novakovski, Tanya; Ambros, Barbara; Auckland, Crissie D.; Harding, John C.S.

2012-01-01

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

Conventional tracheal tubes for intubation through the intubating laryngeal mask airway.

PubMed

Kundra, Pankaj; Sujata, N; Ravishankar, M

2005-01-01

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.

Hands-Off Time for Endotracheal Intubation during CPR Is Not Altered by the Use of the C-MAC Video-Laryngoscope Compared to Conventional Direct Laryngoscopy. A Randomized Crossover Manikin Study.

PubMed

Schuerner, Philipp; Grande, Bastian; Piegeler, Tobias; Schlaepfer, Martin; Saager, Leif; Hutcherson, Matthew T; Spahn, Donat R; Ruetzler, Kurt

2016-01-01

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.

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

PubMed Central

Hindman, Bradley J.; From, Robert P.; Fontes, Ricardo B.; Traynelis, Vincent C.; Todd, Michael M.; Zimmerman, M. Bridget; Puttlitz, Christian M.; Santoni, Brandon G.

2015-01-01

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

Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway.

PubMed

Trevisan, P

2002-10-01

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.

Cost-effectiveness analysis of the use of high-flow oxygen through nasal cannula in intensive care units in NHS England.

PubMed

Eaton Turner, Emily; Jenks, Michelle

2018-06-01

To estimate the cost-effectiveness of Nasal High Flow (NHF) in the intensive care unit (ICU) compared with standard oxygen or non-invasive ventilation (NIV) from a UK NHS perspective. Three cost-effectiveness models were developed to reflect scenarios of NHF use: first-line therapy (pre-intubation model); post-extubation in low-risk, and high-risk patients. All models used randomized control trial data on the incidence of intubation/re-intubation, events leading to intubation/re-intubation, mortality and complications. NHS reference costs were primarily used. Sensitivity analyses were conducted. When used as first-line therapy, Optiflow™ NHF gives an estimated cost-saving of £469 per patient compared with standard oxygen and £611 versus NIV. NHF cost-savings for high severity sub-group were £727 versus standard oxygen, and £1,011 versus NIV. For low-risk post-intubation patients, NHF generates estimated cost-saving of £156 versus standard oxygen. NHF decreases the number of re-intubations required in these scenarios. Results were robust in most sensitivity analyses. For high-risk post-intubation patients, NHF cost-savings were £104 versus NIV. NHF results in a non-significant increase in re-intubations required. However, reduction in respiratory failure offsets this. For patients in ICU who are at risk of intubation or re-intubation, NHF cannula is likely to be cost-saving.

Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit.

PubMed

Khandelwal, Nita; Khorsand, Sarah; Mitchell, Steven H; Joffe, Aaron M

2016-04-01

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 primary endpoint during an emergency tracheal intubation in a back-up head-elevated position was 0.47 (95% confidence interval, 0.26-0.83; P = 0.01). Placing patients in a back-up head-elevated position, compared with supine position, during emergency tracheal intubation was associated with a reduced odds of airway-related complications.

Tracheal intubation by novice staff: the direct vision laryngoscope or the lighted stylet (Trachlight)?

PubMed Central

Soh, C; Kong, C; Kong, C; Ip-Yam, P; Chin, E; Goh, M

2002-01-01

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

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

PubMed

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

2018-05-16

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 in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. clinicaltrials.gov Identifier: NCT02902146.

A comparative study of effect of sevoflurane on intubating conditions with rocuronium in neurosurgical patients.

PubMed

Mitra, Saikat; Purohit, Shobha; Bhatia, Sonali; Kalra, Poonam; Sharma, Satya Prakash

2015-12-01

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.

Protocol for rapid sequence intubation in pediatric patients -- a four-year study.

PubMed

Marvez-Valls, Eduardo; Houry, Debra; Ernst, Amy A; Weiss, Steven J; Killeen, James

2002-04-01

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.

A randomized controlled study to evaluate and compare Truview blade with Macintosh blade for laryngoscopy and intubation under general anesthesia.

PubMed

Timanaykar, Ramesh T; Anand, Lakesh K; Palta, Sanjeev

2011-04-01

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.

The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation

PubMed Central

Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D.

2016-01-01

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 simultaneous fashion. PMID:24589641

A Comparison Between the Conventional and the Laryngoscope-Assisted Lightwand Intubation Techniques in Patients With Cervical Immobilization: A Prospective Randomized Study.

PubMed

Kim, Eugene; Kim, Byung-Gun; Lim, Young-Jin; Jeon, Young-Tae; Hwang, Jung-Won; Lee, Seo-Yun; Park, Hee-Pyoung

2017-09-01

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.

Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry.

PubMed

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

2017-09-01

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.

Atraumatic intubation: experience using a 5.0 endotracheal tube without a stylet for laryngeal surgery.

PubMed

Moore, Jaime E; Hu, Amanda; Rutt, Amy; Green, Parmis; Hawkshaw, Mary; Sataloff, Robert T

2015-02-01

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.

The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.

PubMed

Prekker, Matthew E; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D

2014-06-01

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.

A randomized controlled study to evaluate and compare Truview blade with Macintosh blade for laryngoscopy and intubation under general anesthesia

PubMed Central

Timanaykar, Ramesh T; Anand, Lakesh K; Palta, Sanjeev

2011-01-01

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

Comparison of rocuronium at two different doses and succinylcholine for endotracheal intubation in adult patients for elective surgeries.

PubMed

Chavan, S G; Gangadharan, S; Gopakumar, A K

2016-01-01

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.

NewB for newbies: a randomized control trial training housestaff to perform neonatal intubation with direct and videolaryngoscopy.

PubMed

Koele-Schmidt, Lindsey; Vasquez, Margarita M

2016-04-01

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 videolaryngoscopy, the participating residents felt that videolaryngoscopy is an important educational tool. © 2015 John Wiley & Sons Ltd.

Tracheal intubation in the emergency department: the Scottish district hospital perspective.

PubMed

Stevenson, A G M; Graham, C A; Hall, R; Korsah, P; McGuffie, A C

2007-06-01

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.

Out-of-hospital tracheal intubation with single-use versus reusable metal laryngoscope blades: a multicenter randomized controlled trial.

PubMed

Jabre, Patricia; Galinski, Michel; Ricard-Hibon, Agnes; Devaud, Marie Laure; Ruscev, Mirko; Kulstad, Erik; Vicaut, Eric; Adnet, Fréderic; Margenet, Alain; Marty, Jean; Combes, Xavier

2011-03-01

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 blades was noninferior to first-pass success with reusable metal laryngoscope blades. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Endotracheal Intubation and In-Hospital Mortality after Intracerebral Hemorrhage.

PubMed

Lioutas, Vasileios-Arsenios; Marchina, Sarah; Caplan, Louis R; Selim, Magdy; Tarsia, Joseph; Catanese, Luciana; Edlow, Jonathan; Kumar, Sandeep

2018-06-13

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 2.5-7.49; p < 0.0001) with c-statistics of 0.79 and 0.89, in the intubated versus non-intubated patients, respectively. In this large hospital-based cohort of patients presenting with an acute spontaneous ICH, endotracheal intubation and MV were associated with increased odds of HAP and HM. These findings urge further examination of the practice of intubation in prospective studies. © 2018 S. Karger AG, Basel.

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.

PubMed

Kim, Tae Kyong; Son, Je-Do; Seo, Hyungseok; Lee, Yun-Seok; Bae, Jinyoung; Park, Hee-Pyoung

2017-08-01

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.

Tracheal intubation with rocuronium using a "modified timing principle".

PubMed

Kwon, Min A; Song, Jaegyok; Kim, Ju-Ri

2013-03-01

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.

A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient.

PubMed

Dronen, S C; Merigian, K S; Hedges, J R; Hoekstra, J W; Borron, S W

1987-06-01

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.

Influence of clinical experience of the Macintosh laryngoscope on performance with the Pentax-AWS Airway Scope(®), a rigid video-laryngoscope, by paramedics in Japan.

PubMed

Ota, Kohei; Sadamori, Takuma; Kusunoki, Shinji; Otani, Tadatsugu; Tamura, Tomoko; Une, Kazunobu; Kida, Yoshiko; Itai, Junji; Iwasaki, Yasumasa; Hirohashi, Nobuyuki; Nakao, Masakazu; Tanigawa, Koichi

2015-10-01

We sought to establish the clinical utility of the Pentax-AWS Airway Scope(®) (AWS) when used by paramedics to intubate the trachea, and to evaluate whether their performance was influenced by previous clinical experience with the Macintosh laryngoscope (ML). Twenty paramedics attempted tracheal intubation using the AWS in five patients each in the operating room. We recorded the success rate, the number of intubation attempts, and the time for intubation and adverse events, and compared these based on the paramedics' previous clinical experience with the ML. Ten paramedics had no prior clinical experience of the ML (group A) and 10 had used it on more than 30 occasions (group B). The intubation success rate was 99 % (99/100). Notably, 96 % (47/49) of intubations were achieved on the first attempt by the inexperienced paramedics in group A, compared with 64 % (32/50) by the experienced paramedics in group B (p = 0.0001). The time to intubation (mean ± SD) was significantly shorter in group A than in group B (37 ± 24 vs. 48 ± 21 s, p = 0.002). There were marked variations in the times taken to intubate, but no apparent improvement as the intubators gained experience between their first and fifth cases. No complications were encountered in either group. We found that paramedics could achieve a high tracheal intubation success rate using the AWS independent of previous airway management experience. Better intubation performance with the AWS was observed in paramedics without clinical experience with the ML.

[Tracheal Intubation by Paramedics in a Local Community: Current Situation and Future Challenges].

PubMed

Takinami, Yoshikazu

2016-03-01

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.

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital.

PubMed

Phillips, Luke; Orford, Neil; Ragg, Michael

2014-08-01

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.

Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students.

PubMed

Herbstreit, Frank; Fassbender, Philipp; Haberl, Helge; Kehren, Clemens; Peters, Jürgen

2011-09-01

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.

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature

PubMed Central

Xue, Fu-Shan; Li, Hui-Xian; Liu, Ya-Yang; Yang, Gui-Zhen

2017-01-01

The C-MAC videolaryngoscope is the first Macintosh-typed videolaryngoscope. Since the advent of its original version video Macintosh system in 1999, this device has been modified several times. A unique feature of C-MAC device is its ability to provide the 2 options of direct and video laryngoscopy with the same device. The available evidence shows that in patients with normal airways, C-MAC videolaryngoscope compared with direct laryngoscopy can provide comparable or better laryngeal views and exerts less force on maxillary incisors, but does not offer conclusive benefits with regard to intubation time, intubation success, number of intubation attempts, the use of adjuncts, and hemodynamic responses to intubation. In patients with predicted or known difficult airways, C-MAC videolaryngoscope can achieve a better laryngeal view, a higher intubation success rate and a shorter intubation time than direct laryngoscopy. Furthermore, the option to perform direct and video laryngoscopy with the same device makes C-MAC videolaryngoscope exceptionally useful for emergency intubation. In addition, the C-MAC videolaryngoscope is a very good tool for tracheal intubation teaching. However, tracheal intubation with C-MAC videolaryngoscope may occasionally fail and introduction of C-MAC videolaryngoscope in clinical practice must be accompanied by formal training programs in normal and difficult airway managements. PMID:28740393

Intubation methods by novice intubators in a manikin model.

PubMed

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

2013-10-01

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.

Outcomes following prehospital airway management in severe traumatic brain injury.

PubMed

Sobuwa, Simpiwe; Hartzenberg, Henry B; Geduld, Heike; Uys, Corrie

2013-07-29

Prevention of hypoxia and thus secondary brain injury in traumatic brain injury (TBI) is critical. However there is controversy regarding the role of endotracheal intubation in the prehospital management of TBI. To describe the outcome of TBI with various airway management methods employed in the prehospital setting in the Cape Town Metropole. The study was a cohort descriptive observational analysis of 124 consecutively injured adult patients who were admitted for severe TBI (Glasgow Coma Score ≤8) to Groote Schuur and Tygerberg hospitals between 1 January 2009 and 31 August 2011. Patients were categorised by their method of airway management: rapid sequence intubation (RSI), sedation-assisted intubation, failed intubation, basic airway management, and intubated without drugs. Good outcomes were defined by a Glasgow Outcome Score of 4 - 5. There was a statistically significant association between airway management and outcome (p=0.013). Patients who underwent basic airway management had a higher proportion of a good outcome (72.9%) than patients who were intubated in the prehospital setting. A good outcome was observed with 61.8% and 38.4% of patients who experienced sedation-assisted intubation and RSI, respectively. Patients intubated without drugs had the poorest outcome (88%), followed by rapid sequence intubation (61.5%) and by the sedation assisted group (38.2%). Prehospital intubation did not demonstrate improved outcomes over basic airway management in patients with severe TBI. A large prospective, randomised trial is warranted to yield some insight into how these airway interventions influence outcome in severe TBI.

Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation.

PubMed

Koh, Jae-Chul; Lee, Jong Seok; Lee, Youn-Woo; Chang, Chul Ho

2010-11-01

For patients suspicious of cervical spine injury, a Philadelphia cervical collar is usually applied. Application of Philadelphia cervical collar may cause difficult airway. The aim of this study was to evaluate the laryngeal view and the success rate at first intubation attempt of the Airtraq and conventional laryngoscopy in patients with simulated cervical spine injury after application of a Philadelphia cervical collar. Anesthesia was induced with propofol, remifentanil, and rocuronium. After a Philadelphia cervical collar applied, patients were randomly assigned to tracheal intubation with an Airtraq (Group A, n = 25) or with conventional laryngoscopy (Group L, n = 25). Measurements included intubation time, success rate of first intubation attempt, number of intubation attempts, and percentage of glottic opening (POGO) score. Mean blood pressure and heart rate were also recorded at baseline, just before and after intubation. The success rate of the first attempt in Group A (96%) was significantly greater than with the Group L (40%). POGO score was significantly greater in Group A (84 ± 20%) than in Group L (6 ± 11%). The duration of successful intubation at first tracheal intubation attempt and hemodynamic changes were not significantly different between the two groups. The Airtraq offers a better laryngeal view and higher success rate at first intubation attempt in patients who are applied with a Philadelphia cervical collar due to suspicion of cervical spine injury.

Dose of rocuronium for rapid tracheal intubation following remifentanil 2 μg kg-1 and propofol 2 mg kg-1.

PubMed

Oh, Ah-Young; Cho, Suk-Ju; Seo, Kwang-Suk; Ryu, Jung-Hee; Han, Sung-Hee; Hwang, Jung-Won

2013-09-01

Full relaxation is not mandatory for successful tracheal intubation. We tried to find the dose of rocuronium that gave acceptable intubation conditions in a rapid sequence intubation with remifentanil and propofol. A dose-finding study of rocuronium using a modified Dixon's up-and-down method. A single tertiary care teaching hospital. Patients undergoing elective surgery under general anaesthesia. After premedication with midazolam and glycopyrrolate, anaesthesia was induced using remifentanil 2 μg kg and propofol 2 mg kg, and a predetermined dose of rocuronium was administered. The dose of rocuronium was determined by a modified Dixon's up-and-down method starting from 0.8 mg kg with an interval of 0.1 or 0.05 mg kg. Intubation was performed 60 s after the start of the rocuronium injection. Intubation conditions were graded as excellent, good or poor. Excellent or good were regarded as clinically acceptable. A dose of rocuronium needed for acceptable intubation condition in 50% of patients (ED50) during rapid tracheal intubation after induction of anaesthesia with remifentanil and propofol. Twenty-eight patients were enrolled to obtain six crossovers. The ED50 of rocuronium was 0.20 mg kg (95% confidence interval, CI 0.17 to 0.23 mg kg) by a modified Dixon's up-and-down method. After induction of anaesthesia with remifentanil 2 μg kg and propofol 2 mg kg, the ED50 of rocuronium for acceptable intubation condition was 0.20 mg kg (95% CI, 0.17 to 0.23 mg kg) for rapid sequence intubation. Thus, we recommend that the intubation dose should be 0.8 mg kg. Clinical trial registration KCT0000094.

Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults: A Retrospective Comparative Analysis from the Multicenter Perioperative Outcomes Group.

PubMed

Aziz, Michael F; Brambrink, Ansgar M; Healy, David W; Willett, Amy Wen; Shanks, Amy; Tremper, Tyler; Jameson, Leslie; Ragheb, Jacqueline; Biggs, Daniel A; Paganelli, William C; Rao, Janavi; Epps, Jerry L; Colquhoun, Douglas A; Bakke, Patrick; Kheterpal, Sachin

2016-10-01

Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques. Using a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet. A total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period. Video laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

An evaluation of out-of-hospital advanced airway management in an urban setting.

PubMed

Colwell, Christopher B; McVaney, Kevin E; Haukoos, Jason S; Wiebe, David P; Gravitz, Craig S; Dunn, Will W; Bryan, Tamara

2005-05-01

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.

A 12-month descriptive analysis of emergency intubations at Brooke Army Medical Center: a National Emergency Airway Registry study.

PubMed

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

2017-01-01

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.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway

PubMed Central

Vivek, Bangaru; Sripriya, R.; Mishra, Gayatri; Ravishankar, M.; Parthasarathy, S.

2017-01-01

Background and Aims: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. Material and Methods: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. Results: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26–80) s and 49 (range 28–83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. Conclusion: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt. PMID:28413282

High levels of IGF-1 predict difficult intubation of patients with acromegaly.

PubMed

Zhang, Yu; Guo, Xiaopeng; Pei, Lijian; Zhang, Zhuhua; Tan, Gang; Xing, Bing

2017-08-01

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 intubation in acromegalic patients.

Ventilator-associated pneumonia, like real estate: location really matters.

PubMed

Eckert, Matthew J; Davis, Kimberly A; Reed, R Lawrence; Esposito, Thomas J; Santaniello, John M; Poulakidas, Stathis; Gamelli, Richard L; Luchette, Fred A

2006-01-01

Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma. A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed. In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP. Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.

The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea.

PubMed

Brain, A I; Verghese, C; Addy, E V; Kapila, A; Brimacombe, J

1997-12-01

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 airway patients not at risk of gastric aspiration.

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

PubMed

Hulme, G J; Blues, C M

1999-08-01

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.

Intubation conditions in young infants after propofol and remifentanil induction with and without low-dose rocuronium.

PubMed

Gelberg, J; Kongstad, L; Werner, O

2014-08-01

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.

Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit

PubMed Central

Grubb, Peter H.; Lea, Amanda S.; Walsh, William F.; Markham, Melinda H.; Maynord, Patrick O.; Whitney, Gina M.; Stark, Ann R.; Ely, E. Wesley

2016-01-01

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

Intubation Methods by Novice Intubators in a Manikin Model

PubMed Central

O'Carroll, Darragh C; Aratani, Ashley K; Lee, Dane C; Lau, Christopher A; Morton, Paul N; Yamamoto, Loren G; Berg, Benjamin W

2013-01-01

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

Evaluation of chest compression effect on airway management with air-Q, aura-i, i-gel, and Fastrack intubating supraglottic devices by novice physicians: a randomized crossover simulation study.

PubMed

Komasawa, Nobuyasu; Ueki, Ryusuke; Kaminoh, Yoshiroh; Nishi, Shin-Ichi

2014-10-01

In the 2010 American Heart Association guidelines, supraglottic devices (SGDs) such as the laryngeal mask are proposed as alternatives to tracheal intubation for cardiopulmonary resuscitation. Some SGDs can also serve as a means for tracheal intubation after successful ventilation. The purpose of this study was to evaluate the effect of chest compression on airway management with four intubating SGDs, aura-i (aura-i), air-Q (air-Q), i-gel (i-gel), and Fastrack (Fastrack), during cardiopulmonary resuscitation using a manikin. Twenty novice physicians inserted the four intubating SGDs into a manikin with or without chest compression. Insertion time and successful ventilation rate were measured. For cases of successful ventilation, blind tracheal intubation via the intubating SGD was performed with chest compression and success or failure within 30 s was recorded. Chest compression did not decrease the ventilation success rate of the four intubating SGDs (without chest compression (success/total): air-Q, 19/20; aura-i, 19/20; i-gel, 18/20; Fastrack, 19/20; with chest compression: air-Q, 19/20; aura-i, 19/20; i-gel, 16/20; Fastrack, 18/20). Insertion time was significantly lengthened by chest compression in the i-gel trial (P < 0.05), but not with the other three devices. The blind intubation success rate with chest compression was the highest in the air-Q trial (air-Q, 15/19; aura-i, 14/19; i-gel, 12/16; Fastrack, 10/18). This simulation study revealed the utility of intubating SGDs for airway management during chest compression.

Practice of Intubation of the Critically Ill at Mayo Clinic.

PubMed

Smischney, Nathan J; Seisa, Mohamed O; Heise, Katherine J; Busack, Kyle D; Loftsgard, Theodore O; Schroeder, Darrell R; Diedrich, Daniel A

2017-01-01

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.

[Inductions and intubating conditions with sevoflurane and different doses of remifentanil without muscle relaxant in children].

PubMed

Wei, Ling-Xin; Deng, Xiao-Ming; Liu, Ju-Hui; Luo, Mao-Ping; Tong, Shi-Yi; Zhang, Yan-Ming; Liao, Xu; Xu, Kun-Lin

2008-12-01

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.

Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study.

PubMed

Van Oeveren, Lucas; Donner, Julie; Fantegrossi, Andrea; Mohr, Nicholas M; Brown, Calvin A

2017-04-01

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.

Failed Endotracheal Intubation and Adverse Outcomes Among Extremely Low Birth Weight Infants

PubMed Central

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.

2015-01-01

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

Airway management of patients with traumatic brain injury/C-spine injury

PubMed Central

2015-01-01

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 opening and lead to a poor laryngoscopic view. The newly introduced video laryngoscope can manage these problems. The AirWay Scope® (AWS) and AirTraq laryngoscope decreased the extension movement of C-spines at the occiput-C1 and C2-C4 levels, improving intubation conditions and shortening the time to complete tracheal intubation compared with a direct laryngoscope. The Glidescope® also decreased cervical movement in the C2-C5 levels during intubation and improved vocal cord visualization, but a longer duration was required to complete intubation compared with other devices. A lightwand also reduced cervical motion across all segments. A fiberoptic bronchoscope-guided nasal intubation is the best method to reduce cervical movement, but a skilled operator is required. In conclusion, a video laryngoscope assists airway management in TBI patients with C-spine injury. PMID:26045922

A comparison of GlideScope(®) videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children.

PubMed

Kim, Hyun-Jung; Kim, Jin-Tae; Kim, Hee-Soo; Kim, Chong-Sung; Kim, Seong-Deok

2011-04-01

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.

Evaluation of alternative airway management strategies in surgical repair of severe cranio-maxillofacial trauma.

PubMed

Zhang, Xinpei; Wang, Xing; Gu, Qianping; Zhang, Jie; Wu, Ruihan; Zhuang, Qianwei; Na, Li; Meng, Jian

2016-12-01

Severe cranio-maxillofacial trauma requires the utilization of alternative airway management techniques when oral and nasal routes of tracheal intubation are either not possible or contraindicated. This retrospective study evaluated the techniques of submental intubation, retromolar intubation and tracheostomy in terms of their frequency of use, time required, costs involved and associated complications in a total of 200 patients. Frequency of utilization of alternative airway management techniques was 3.63%. Tracheostomy was associated with the most severe complications, took the most time to establish and was the most expensive technique. Although retromolar intubation was not associated with any complications, it was not suitable in adults with erupted third molars and interfered with the surgical field. Submental intubation was associated with minor complications, was suitable in all cases and did not interfere with surgical access. Retromolar intubation must be considered as a first choice alternative in patients with unerupted third molars provided the surgeon is adept at working in the presence of an oral tube. Submental intubation is a good second choice when retromolar intubation is not possible or is not acceptable to the surgeon. Tracheostomy is only indicated in patients who require long term control of the airway.

[Usefullness of bronchofiberscopy for difficult intubation in patients with severe motor and intellectual disabilities].

PubMed

Mizuno, Yuji; Ukaji, Koutarou

2005-11-01

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.

Ventilation-associated pneumonia after intubation in the prehospital or the emergency unit.

PubMed

Decelle, Lydie; Thys, Frédéric; Zech, Francis; Verschuren, Franck

2013-02-01

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.

Comparison of Macintosh and Intubrite laryngoscopes for intubation performed by novice physicians in a difficult airway scenario.

PubMed

Szarpak, Lukasz; Smereka, Jacek; Ladny, Jerzy R

2017-05-01

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 device. The effectiveness of the first intubation attempt using MAC and INT was 63.6% and 53.4%, respectively (p=0.023), and the total percentage of intubation was 100% for both methods. The median time to intubation was 29.5 (interquartile range [IQR], 27-35.5) s with MAC, and 229 (IQR, 25.5-37) s with INT. The total of 24 physicians out of all study participants would choose MAC as a device to intubate with in real terms, while only 6 physicians would choose INT. During the simulation study, the novice physicians were able to perform endotracheal intubation at the same time using both the Macintosh and Intubrite videolaryngoscope. However, the efficacy of the first intubation attempt was higher for MAC. Further studies are needed to confirm the results. Copyright © 2017 Elsevier Inc. All rights reserved.

Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies.

PubMed

Wang, Henry E; Donnelly, John P; Barton, Dustin; Jarvis, Jeffrey L

2018-05-01

Although often the focus of quality improvement efforts, emergency medical services (EMS) advanced airway management performance has few national comparisons, nor are there many assessments with benchmarks accounting for differences in agency volume or patient mix. We seek to assess variations in advanced airway management and conventional intubation performance in a national cohort of EMS agencies. We used EMS data from ESO Solutions, a national EMS electronic health record system. We identified EMS emergency responses with attempted advanced airway management (conventional intubation, rapid sequence intubation, sedation-assisted intubation, supraglottic airway insertion, and cricothyroidotomy). We also separately examined cases with initial conventional intubation. We determined EMS agency risk-standardized advanced airway management and initial conventional intubation success rates by using mixed-effects regression models, fitting agency as a random intercept, adjusting for patient age, sex, race, cardiac arrest, or trauma status, and use of rapid sequence or sedation-assisted intubation, and accounting for reliability variations from EMS agency airway volume. We assessed changes in agency advanced airway management and initial conventional intubation performance rank after risk and reliability adjustment. We also identified high and low performers (reliability-adjusted and risk-standardized success confidence intervals falling outside the mean). During 2011 to 2015, 550 EMS agencies performed 57,209 advanced airway management procedures. Among 401 EMS agencies with greater than or equal to 10 advanced airway management procedures, there were a total of 56,636 procedures. Median reliability-adjusted and risk-standardized EMS agency advanced airway management success was 92.9% (interquartile range 90.1% to 94.8%; minimum 58.2%; maximum 99.0%). There were 56 advanced airway management low-performing and 38 high-performing EMS agencies. Among 342 agencies with greater than or equal to 10 initial conventional intubations, there were a total of 37,360 initial conventional intubations. Median reliability-adjusted and risk-standardized EMS agency initial conventional intubation success was 77.3% (interquartile range 70.9% to 83.6%; minimum 47.1%; maximum 95.8%). There were 64 initial conventional intubation low-performing and 45 high-performing EMS agencies. In this national series, EMS advanced airway management and initial conventional intubation performance varied widely. Reliability adjustment and risk standardization may influence EMS airway management performance assessments. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Critical Analyses and Development of Training Mechanisms: Cholinergic Crisis and Pediatric/Neonatal Intubation

DTIC Science & Technology

2015-02-01

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 [5]Calderwood -Medical students -Anesthetized cats -Success -PM [6]Falck -449 intubation...optic intubation – realism and effectiveness -Pig -Mannequin -Secretions -Anatomy -Appearance Technique - [8]Hall -36 paramedic students

Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation.

PubMed

Hilton, Michael T; Wayne, Max; Martin-Gill, Christian

2016-01-01

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 orotracheal intubation since introduction of the King LT. In spite of this modest change in airway management, there has not been a change in orotracheal intubation success rate since introduction of this supraglottic device as a primary or rescue airway in this regional EMS setting.

Effects of nicardipine on the onset time and intubation conditions of rocuronium-induced neuromuscular blockade.

PubMed

Lee, Sun-Yeul; Kim, Yoon-Hee; Ko, Young-Kwon; Park, Sang-Il; Lee, Jung-Un; Chung, Woo-Suk; Lim, Chae-Seong

2016-08-01

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.

Comparison of the Pentax AirwayScope and McGrath MAC videolaryngoscope for endotracheal intubation in patients with a normal airway

PubMed Central

Lee, Jiyoung; Kwak, Hyun Jeong; Lee, Ji Yeon; Chang, Min Young; Lee, Sook Young; Kim, Jong Yeop

2017-01-01

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

The effects of nicardipine or esmolol on the onset time of rocuronium and intubation conditions during rapid sequence induction: a randomized double-blind trial.

PubMed

Lee, Ji Heui; Kim, Yunkwang; Lee, Kye Hyeok; Rim, Sung Kyu; Lee, Ji Yeon; Lee, Cheong

2015-06-01

The main aims of rapid sequence induction (RSI) are prompt and adequate muscle relaxation for tracheal intubation and hemodynamic stability during and after intubation. The purpose of the present study was to investigate the effects of nicardipine and esmolol on the action of rocuronium and intubation conditions during RSI. Adult patients (n = 82) were randomly allocated to one of three groups. One minute prior to the induction of sevoflurane-based general anesthesia, patients received 20 μg/kg of nicardipine (N group; n = 27) or 0.5 mg/kg of esmolol (E group; n = 27), or 5 ml of saline (C group; n = 28). Patients were assessed according to intubation conditions, the onset time of rocuronium, mean arterial pressure (MAP), and heart rate (HR) during RSI. The intubation conditions and score were significantly better in the C and N groups than in the E group (P < 0.001). The onset time of rocuronium was shortened in the N group and prolonged in the E group when compared to the C group (P < 0.001). A significant attenuation in the increase of MAP immediately after intubation was observed in the N group as compared with the C and E groups (P < 0.008). HR was significantly lower in the E group than in the N and C groups (P < 0.01). Pretreatment with nicardipine for RSI improved intubation conditions and shortened the onset time of rocuronium and attenuated changes in MAP after intubation. Esmolol may disturb intubation conditions and the onset of action of rocuronium, despite being effective in alleviating responses of HR after RSI.

Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department.

PubMed

Goto, Tadahiro; Gibo, Koichiro; Hagiwara, Yusuke; Okubo, Masashi; Brown, David F M; Brown, Calvin A; Hasegawa, Kohei

2016-03-01

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.

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.

PubMed

Boedeker, Ben H; Nicholsal, Thomas A; Carpenter, Jennifer; Singh, Leighton; Bernhagen, Mary A; Murray, W Bosseau; Wadman, Michael C

2011-01-01

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.

Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations.

PubMed

Sakles, John C; Mosier, Jarrod M; Chiu, Stephen; Keim, Samuel M

2012-04-01

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.

Comparison of Effect of Ephedrine and Priming on the Onset Time of Vecuronium.

PubMed

Anandan, Krishnadas; Suseela, Indu; Purayil, Harish Valiya

2017-01-01

Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO 4 pretreatment is good options. To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium. A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital. After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18-60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40-70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted. Chi-square test and independent t -test were done with PASW statistics 18 to analyze data. The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s ( P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups ( P = 0.791). Hemodynamic parameters were comparable between groups at all time frames ( P > 0.05). Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation.

Estimating 'lost heart beats' rather than reductions in heart rate during the intubation of critically-ill children.

PubMed

Jones, Peter; Ovenden, Nick; Dauger, Stéphane; Peters, Mark J

2014-01-01

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 [1]-[32] 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.

A Randomized Study Comparing the Sniffing Position with Simple Head Extension for Glottis Visualization and Difficulty in Intubation during Direct Laryngoscopy.

PubMed

Akhtar, Mehmooda; Ali, Zulfiqar; Hassan, Nelofar; Mehdi, Saqib; Wani, Gh Mohammad; Mir, Aabid Hussain

2017-01-01

Proper positioning of the head and neck is important for an optimal laryngeal visualization. Traditionally, sniffing position (SP) is recommended to provide a superior glottic visualization, during direct laryngoscopy, enhancing the ease of intubation. Various studies in the last decade of this belief have challenged the need for sniffing position during intubation. We conducted a prospective study comparing the sniffing head position with simple head extension to study the laryngoscopic view and intubation difficulty during direct laryngoscopy. Five-hundred patients were included in this study and randomly distributed to SP or simple head extension. In the sniffing group, an incompressible head ring was placed under the head to raise its height by 7 cm from the neutral plane followed by maximal extension of the head. In the simple extension group, no headrest was placed under the head; however, maximal head extension was given at the time of laryngoscopy. Various factors as ability to mask ventilate, laryngoscopic visualization, intubation difficulty, and posture of the anesthesiologist during laryngoscopy and tracheal intubation were noted. In the incidence of difficult laryngoscopy (Cormack Grade III and IV), Intubation Difficulty Scale (IDS score) was compared between the two groups. There was no significant difference between two groups in Cormack grades. The IDS score differed significantly between sniffing group and simple extension group ( P = 0.000) with an increased difficulty during intubation in the simple head extension. Patients with simple head extension needed more lifting force, increased use of external laryngeal manipulation, and an increased use of alternate techniques during intubation when compared to SP. We conclude that compared to the simple head extension position, the SP should be used as a standard head position for intubation attempts under general anesthesia.

High flow nasal cannula oxygen versus noninvasive ventilation in adult acute respiratory failure: a systematic review of randomized-controlled trials.

PubMed

Beng Leong, Lim; Wei Ming, Ng; Wei Feng, Lee

2018-06-19

We reviewed the use of noninvasive ventilation (NIV) versus high flow nasal cannula (HFNC) oxygen in adult acute respiratory failure (ARF). We searched major databases and included randomized trials comparing at least NIV with HFNC or NIV+HFNC with NIV in ARF. Primary outcomes included intubation/re-intubation rates. Secondary outcomes were ICU mortality and morbidities. Five trials were included; three compared HFNC with NIV, one compared HFNC, NIV and oxygen whereas one compared HFNC+NIV with NIV. Patients had hypoxaemic ARF (PaO2/FiO2≤300 mmHg). Heterogeneity prevented result pooling. Three and two studies had superiority and noninferiority design, respectively. Patients were postcardiothoracic surgery, mixed medical/surgical patients and those with pneumonia. Two trials were conducted after extubation, two before intubation and one during intubation. Three trials reported intubation/re-intubation rates as the primary outcomes. The other two trials reported the lowest peripheral capillary oxygen saturation readings during bronchoscopy or intubation. In the former three trials, the odds ratio for intubation/re-intubation rates between HFNC versus the NIV group ranged from 0.80 (95% confidence interval: 0.54-1.19) to 1.65 (95% confidence interval: 0.96-2.84). In the latter two trials, only one reported a difference in the lowest peripheral capillary oxygen saturation between NIV+HFNC versus the NIV group during intubation [100% (interquartile range: 95-100) vs. 96% (interquartile range: 92-99); P=0.029]. The secondary outcomes included differences in ICU mortality and patient tolerability, favouring HFNC, were conflicting, but highlighted future research directions. These include patients with hypercapneic ARF, more severe hypoxaemia (PaO2/FiO2≤200 mmHg), a superiority design, an oxygen arm and patient-centred outcomes.

Magnesium sulphate: an adjuvant to tracheal intubation without muscle relaxation--a randomised study.

PubMed

Aissaoui, Younes; Qamous, Youssef; Serghini, Issam; Zoubir, Mohammed; Salim, Jaafar Lalaoui; Boughalem, Mohammed

2012-08-01

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.

Intubation Biomechanics: Laryngoscope force and cervical spine motion during intubation with Macintosh and Airtraq laryngoscopes

PubMed Central

Hindman, Bradley J.; Santoni, Brandon G.; Puttlitz, Christian M.; From, Robert P.; Todd, Michael M.

2014-01-01

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

Air-Q intubating laryngeal airway: A study of the second generation supraglottic airway device.

PubMed

Attarde, Viren Bhaskar; Kotekar, Nalini; Shetty, Sarika M

2016-05-01

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.

Intravenous rocuronium 0.3 mg/kg improves the conditions for tracheal intubation in cats: a randomized, placebo-controlled trial.

PubMed

Sakai, Daniel M; Zornow, Kailee Anne; Campoy, Luis; Cable, Christina; Appel, Leslie D; Putnam, Holly J; Martin-Flores, Manuel

2018-01-01

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.

The usefulness of design of experimentation in defining the effect difficult airway factors and training have on simulator oral-tracheal intubation success rates in novice intubators.

PubMed

Thomas, Frank; Carpenter, Judi; Rhoades, Carol; Holleran, Renee; Snow, Gregory

2010-04-01

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.

Training with video imaging improves the initial intubation success rates of paramedic trainees in an operating room setting.

PubMed

Levitan, R M; Goldman, T S; Bryan, D A; Shofer, F; Herlich, A

2001-01-01

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.

Comparison between the Trachway video intubating stylet and Macintosh laryngoscope in four simulated difficult tracheal intubations: A manikin study

PubMed Central

Ong, Jimmy; Lee, Chia-Ling; Huang, Shen-Jer; Shyr, Ming-Hwang

2016-01-01

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

Discovery of unexpected pain in intubated and sedated patients.

PubMed

Clukey, Lory; Weyant, Ruth A; Roberts, Melanie; Henderson, Ann

2014-05-01

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.

Effects of tung oil on salivary viscosity and extent and incidence of dental caries in rats.

PubMed

Biesbrock, A R; Dirksen, T; Schuster, G

1992-01-01

Increased salivary viscosity may be associated with an increase in dental caries. In order to examine this relationship, the caries level in rats was monitored following gastric intubation with tung oil which has been shown to significantly increase salivary viscosity. Tung oil intubation over an 8-week period significantly increased the salivary viscosity in rats as compared with deoinized water and corn oil intubation. The total number of carious lesions was significantly increased (p less than 0.05) in the tung oil intubated rats as compared with the two other groups. This increase in carious lesions was primarily associated with the smooth surfaces of the teeth. There was also a significant increase (p less than 0.05) in the extent of enamel and dentin involvement of the tung oil intubated rats as compared with the other two groups. Histologic examination of the submandibular glands revealed an increase in the amount of glycoprotein material in the convoluted granular tubules of the tung oil intubated rats as compared with the deionized water and corn oil intubated animals. Collectively, these results suggest that tung oil intubation is correlated with both increased salivary viscosity and increased smooth-surface dental caries, suggesting that the viscosity may be related to dental caries progression.

A systematic review and meta-regression analysis of mivacurium for tracheal intubation.

PubMed

Vanlinthout, L E H; Mesfin, S H; Hens, N; Vanacker, B F; Robertson, E N; Booij, L H D J

2014-12-01

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.

A Comparison of the C-MAC Video Laryngoscope to the Macintosh Direct Laryngoscope for Intubation in the Emergency Department

PubMed Central

Sakles, John C.; Mosier, Jarrod; Chiu, Stephen; Cosentino, Mari; Kalin, Leah

2015-01-01

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 ratio 2.2; 95% CI 1.2 to 3.8). When the C-MAC was used as a video laryngoscope, a Cormack-Lehane grade I or II view (video) was obtained in 117 of 125 cases (93.6%; 95% CI 87.8% to 97.2%), whereas when a direct laryngoscope was used, a grade I or II view was obtained in 410 of 495 cases (82.8%; 95% CI 79.2% to 86.1%). The C-MAC was associated with immediately recognized esophageal intubation in 4 of 255 cases (1.6%; 95% CI 0.4% to 4.0%), whereas a direct laryngoscope was associated with immediately recognized esophageal intubation in 24 of 495 cases (4.8%; 95% CI 3.1% to 7.1%). Conclusion When used for emergency intubations in the ED, the C-MAC was associated with a greater proportion of successful intubations and a greater proportion of Cormack-Lehane grade I or II views compared with a direct laryngoscope. PMID:22560464

Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway.

PubMed

Monclus, Enric; Garcés, Antonio; Artés, David; Mabrock, Maged

2008-07-01

For a predicted difficult airway, oral intubation techniques are well established in pediatric anesthesia, but nasotracheal intubation remains a problem. There are many reports concerning this, but the risk of bleeding, added to the lack of cooperation make this procedure difficult and hazardous. We describe a modification of the nasal intubation technique in two stages. First an oral intubation and then exchanging the oral for a nasal tube, in the case of a 13-year-old boy affected by an advanced stage of cherubism. Oral intubation using a laryngeal mask technique has already been reported, but problems appear during the exchange procedure and even more when direct laryngoscopy is impossible. Fiberscopic control of the exchange, and the introduction of a Cook Exchange Catheter into the trachea through the oral tube before withdrawal, permits oxygenation of the patient and acts as a guide for oral tube reintroduction if required.

Snake scope camera assisted endotracheal intubation: a procedural skills training in cadaver to prepare preclinical students for their clerkships.

PubMed

Tansatit, Tanvaa; Apinuntrum, Prawit; Phetudom, Thavorn

2012-02-01

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.

Middle finger length-based tracheal intubation depth improves the rate of appropriate tube placement in children.

PubMed

Zhou, Qing-he; Xiao, Wang-pin; Zhou, Hong-mei

2015-11-01

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.

BMI as a Predictor for Potential Difficult Tracheal Intubation in Males.

PubMed

Uribe, Alberto A; Zvara, David A; Puente, Erika G; Otey, Andrew J; Zhang, Jianying; Bergese, Sergio D

2015-01-01

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.

Comparing GlideScope Video Laryngoscope and Macintosh Laryngoscope Regarding Hemodynamic Responses During Orotracheal Intubation: A Randomized Controlled Trial

PubMed Central

Pournajafian, Ali Reza; Ghodraty, Mohammad Reza; Faiz, Seyed Hamid Reza; Rahimzadeh, Poupak; Goodarzynejad, Hamidreza; Dogmehchi, Enseyeh

2014-01-01

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

Comparison of glottic visualisation and ease of intubation with different laryngoscope blades.

PubMed

Kulkarni, Atul P; Tirmanwar, Amar S

2013-03-01

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.

Randomised controlled trial of thiopental for intubation in neonates

PubMed Central

Bhutada, A; Sahni, R; Rastogi, S; Wung, J

2000-01-01

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 acute drop in the heart rate and increase in blood pressure typically seen during intubation of unmedicated infants is associated with long term advantages to the infants remains to be determined.

 PMID:10634839

Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged.

PubMed

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

2016-04-01

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. All rights reserved.

A mannequin study of intubation with the AP advance and GlideScope Ranger videolaryngoscopes and the Macintosh laryngoscope.

PubMed

Hodd, Jack A R; Doyle, D John; Gupta, Shipra; Dalton, Jarrod E; Cata, Juan P; Brewer, Edward J; James, Monyulona; Sessler, Daniel I

2011-10-01

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 mannequins with normal airways. However, intubation with the APA was significantly faster than with the GlideScope in the difficult mannequin simulation.

A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients.

PubMed

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

2015-08-01

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. Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.

Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil and rocuronium: a randomised, prospective, clinical trial

PubMed Central

2014-01-01

Background Tracheal intubation without muscle relaxants is usually performed with remifentanil and propofol or sevoflurane. Remifentanil 1.0 to 4.0 μg·kg-1 and propofol 2.0-3.0 mg·kg-1 or sevoflurane up to 8.0 Vol% provide acceptable, i.e. excellent or good intubating conditions. We hypothesized that sevoflurane 1.0 MAC would provide acceptable intubating conditions when combined with propofol and remifentanil. Methods Eighty-three patients to be intubated were randomised to two groups. The SEVO group received propofol 1.5 mg kg-1, remifentanil 0.30 μg kg min-1 and sevoflurane 1.0 MAC; the MR group received the same doses of propofol and remifentanil plus rocuronium 0.45 mg kg-1. We evaluated intubation and extubation conditions, mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS). The vocal cords were examined for injury by videolaryngoscopy before and 24 hours after surgery. Results Acceptable intubating conditions were seen more frequently with rocuronium than with sevoflurane: 97% versus 82%; p = 0.03; the subscore for vocal cords was comparable: 100% versus 98%. MAP before intubation decreased significantly compared with the MAP at baseline to the same extent in both groups; ephedrine IV was given in 15 (SEVO) versus 16 (MR) patients; p = 0.93. BIS at tracheal intubation was 27 (13-65) in the SEVO group, 29 (14-62) in the MR group; p = 0.07. Vocal cord injuries (oedema, haematoma) were similar: 4 patients in each group. Conclusions Overall intubating conditions were better when rocuronium was used; the subscore for vocal cords was comparable. The incidence of side effects was the same in the two groups. Trial registration ClinicalTrials.Gov: NCT 01591031. PMID:24860256

Endotracheal Intubation with the King Laryngeal Tube™ In Situ Using Video Laryngoscopy and a Bougie: A Retrospective Case Series and Cadaveric Crossover Study.

PubMed

Dodd, Kenneth W; Kornas, Rebecca L; Prekker, Matthew E; Klein, Lauren R; Reardon, Robert F; Driver, Brian E

2017-04-01

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.

Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials.

PubMed

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

2018-01-20

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 evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.

Comparison of Effect of Ephedrine and Priming on the Onset Time of Vecuronium

PubMed Central

Anandan, Krishnadas; Suseela, Indu; Purayil, Harish Valiya

2017-01-01

Background: Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO4 pretreatment is good options. Aims: To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium. Settings and Design: A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital. Materials and Methods: After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18–60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40–70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted. Statistical Analysis Used: Chi-square test and independent t-test were done with PASW statistics 18 to analyze data. Results: The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s (P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups (P = 0.791). Hemodynamic parameters were comparable between groups at all time frames (P > 0.05). Conclusion: Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation. PMID:28663634

Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

PubMed

Gonzalez-Rivas, Diego; Bonome, Cesar; Fieira, Eva; Aymerich, Humberto; Fernandez, Ricardo; Delgado, Maria; Mendez, Lucia; de la Torre, Mercedes

2016-03-01

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 patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol

PubMed Central

Kriege, Marc; Alflen, Christian; Tzanova, Irene; Schmidtmann, Irene; Piepho, Tim; Noppens, Ruediger R

2017-01-01

Introduction The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. Methods and analysis The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. Ethics and dissemination The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. Trial registration number ClinicalTrials.gov NCT 02611986; pre-results. PMID:28827261

Role of the Truview EVO2 laryngoscope in the airway management of elective surgical patients: A comparison with the Macintosh laryngoscope

PubMed Central

Saxena, Arpita; Madan, Manish; Shrivastava, Uma; Mittal, Apurva; Dwivedi, Yogita; Agrawal, Archna; Puri, Rajeev

2013-01-01

Background: The Truview EVO2(C) laryngoscope (TL) is a recently introduced optical device designed to provide an unmagnified anterior image of the glottic opening and allow indirect laryngoscopy. Aim: This study is designed to determine whether the TL is a better alternative to the Macintosh laryngoscope (ML) for routine endotracheal intubations in patients with usual airway characteristics. Methods: We compared the Truview EVO2(C) and MLs in 140 elective surgical patients requiring general anaesthesia and intubation in a prospective crossover fashion. The two blades were compared in terms of Cormack and Lehane grades, time required for intubation, anaesthetists’ assessment of ease of intubation, intubation difficulty score, attempts at intubation, success rate, soft tissue damage and arterial oxygen saturation during laryngoscopy. The Student t test and Chi-square test were used to determine the statistical significance of parametric data and categorical data, respectively. Results: The Truview EVO2(C) blade provided a better laryngoscopic view than the Macintosh blade as suggested by improved Cormack and Lehane grades (in 48 patients), but required a longer time for intubation than the Macintosh blade (34.1 vs. 22.4 s), i.e., an improved view at the cost of longer mean intubation time. In spite of lower intubation difficulty scores, Truview EVO2(C) was considered as difficult to use on subjective assessment by the anaesthesiologist when compared with Macintosh. There was no difference observed between the two groups in attempts at intubation, success rate, soft tissue damage and arterial oxygen saturation during laryngoscopy. Conclusion: We opine that although Truview provides a better laryngoscopic view than Macintosh in difficult cases, it does not have an extra benefit over Macintosh otherwise, further indicating the need for more experience with the use of a Truview laryngoscope. PMID:23983287

Changing patterns in endotracheal intubation for anaesthesia trainees: a retrospective analysis of 80,000 cases over 10 years.

PubMed

Smith, N A; Tandel, A; Morris, R W

2011-07-01

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.

Ease of intubation: A randomized, double-blind study to compare two doses of rocuronium bromide for endotracheal intubation.

PubMed

Shukla, Aparna; Misra, Shilpi

2016-01-01

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.

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators.

PubMed

Kim, Jong Won; Park, Sang O; Lee, Kyeong Ryong; Hong, Dae Young; Baek, Kwang Je; Lee, Young Hwan; Lee, Jeong Hun; Choi, Pil Cho

2016-08-01

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.

[Predictive value of preoperative tests in estimating difficult intubation in patients who underwent direct laryngoscopy in ear, nose, and throat surgery].

PubMed

Karakus, Osman; Kaya, Cengiz; Ustun, Faik Emre; Koksal, Ersin; Ustun, Yasemin Burcu

2015-01-01

Predictive value of preoperative tests in estimating difficult intubation may differ in the laryngeal pathologies. Patients who had undergone direct laryngoscopy (DL) were reviewed, and predictive value of preoperative tests in estimating difficult intubation was investigated. Preoperative, and intraoperative anesthesia record forms, and computerized system of the hospital were screened. A total of 2611 patients were assessed. In 7.4% of the patients, difficult intubations were detected. Difficult intubations were encountered in some of the patients with Mallampati scoring (MS) system Class 4 (50%), Cormack-Lehane classification (CLS) Grade 4 (95.7%), previous knowledge of difficult airway (86.2%), restricted neck movements (cervical ROM) (75.8%), short thyromental distance (TMD) (81.6%), vocal cord mass (49.5%) as indicated in parentheses (p<0.0001). MS had a low sensitivity, while restricted cervical ROM, presence of a vocal cord mass, short thyromental distance, and MS each had a relatively higher positive predictive value. Incidence of difficult intubations increased 6.159 and 1.736-fold with each level of increase in CLS grade and MS class, respectively. When all tests were considered in combination difficult intubation could be classified accurately in 96.3% of the cases. Test results predicting difficult intubations in cases with DL had observedly overlapped with the results provided in the literature for the patient populations in general. Differences in some test results when compared with those of the general population might stem from the concomitant underlying laryngeal pathological conditions in patient populations with difficult intubation. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

A simple method for accurate endotracheal placement of an intubation tube in Guinea pigs to assess lung injury following chemical exposure.

PubMed

Nambiar, M P; Gordon, R K; Moran, T S; Richards, S M; Sciuto, A M

2007-01-01

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.

Effect of prophylactic bronchodilator treatment with intravenous colforsin daropate, a water-soluble forskolin derivative, on airway resistance after tracheal intubation.

PubMed

Wajima, Zen'ichiro; Shiga, Toshiya; Yoshikawa, Tatsusuke; Ogura, Akira; Imanaga, Kazuyuki; Inoue, Tetsuo; Ogawa, Ryo

2003-07-01

After induction of anesthesia, lung resistance increases. The authors hypothesized that prophylactic bronchodilator treatment with intravenous colforsin daropate, a water-soluble forskolin derivative, before tracheal intubation would result in decreased lung resistance and increased lung compliance after tracheal intubation when compared with placebo medication. Forty-six adult patients were randomized to placebo or colforsin daropate treatment. Patients in the control group received normal saline; patients in the colforsin group received 0.75 microg. kg-1 x min-1 colforsin daropate intravenously until the study ended. Thirty minutes after the study began, the authors administered 5 mg/kg thiamylal and 5 microg/kg fentanyl for induction of general anesthesia and 0.3 mg/kg vecuronium for muscle relaxation. A 15-mg. kg-1. h-1 continuous infusion of thiamylal followed anesthetic induction. Four, 8, 12, and 16 min after tracheal intubation, mean airway resistance (R(awm)), expiratory airway resistance (R(awe)), and dynamic lung compliance (C(dyn)) were measured. Patients in the colforsin group had significantly lower R(awm) and R(awe) and higher C(dyn) after intubation than those in the control group. Differences in R(awm), R(awe), and C(dyn) between the two groups persisted through the final measurement at 16 min. At 4 min after intubation, smokers had a higher R(awm) and a lower C(dyn) than nonsmokers in the control group. After treatment by intravenous colforsin daropate, R(awm), R(awe), and C(dyn) values were similar for smokers and nonsmokers after tracheal intubation. Prophylactic treatment with colforsin daropate produced lower R(awm) and R(awe) and higher C(dyn) after tracheal intubation when compared with placebo medication. Pretreatment before intubation may be beneficial and advantageous for middle-aged smokers.

Intubation biomechanics: laryngoscope force and cervical spine motion during intubation with Macintosh and Airtraq laryngoscopes.

PubMed

Hindman, Bradley J; Santoni, Brandon G; Puttlitz, Christian M; From, Robert P; Todd, Michael M

2014-08-01

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.

The effects of water lubrication of tracheal tubes on post-intubation airway complications: study protocol for a randomized controlled trial.

PubMed

Kim, Eugene; Yang, Seong Mi; Yoon, So Jeong; Bahk, Jae-Hyon; Seo, Jeong-Hwa

2016-11-25

Water is known to have lubricating properties, thus it is used for lubrication of tracheal tubes to reduce airway injuries caused by intubation. However, there is no definite evidence to substantiate the beneficial effects of lubricating tracheal tubes using water for attenuating airway injuries. Moreover, the lubrication pretreatment may cause contamination of the tube, leading to respiratory infections. Therefore, this trial aims to assess whether no pretreatment of tracheal tubes does not increase post-intubation airway complications as compared with water lubrication of tubes. This is a prospective, double-blind, single-center, parallel-arm, noninferiority, randomized controlled trial to be conducted in participants aged 20-80 years who are undergoing elective surgery under general anesthesia with orotracheal intubation. Participants are randomly assigned into one of two groups depending on whether intubation is performed using a tracheal tube lubricated with water (n = 150) or without any pretreatment (n = 150). The primary outcome is the incidence of sore throat at 0, 2, 4, and 24 h after surgery, which is analyzed with a noninferiority test. The secondary outcomes are the incidence and severity of postoperative hoarseness, oropharyngeal injuries, and respiratory infections. Because we hypothesized that lubricating tracheal tubes using water has no advantage in reducing airway injuries associated with intubation, we will compare the incidence of sore throat, which is the most common complaint after intubation, in a noninferiority manner. This is the first randomized controlled trial to investigate the possibly beneficial or harmful effects of lubricating tracheal tubes using water before intubation. We expect that this trial will provide useful evidence to formulate a protocol for preparing tracheal tubes before intubation. This trial is registered at ClinicalTrials.gov on 1 July 2015 ( NCT02492646 ).

[Comparison between VAMA(®) and Berman(®) cannulas for fibroscopic orotracheal intubation in anaesthetised patients].

PubMed

Castañeda Pascual, M; Batllori Gastón, M; Unzué Rico, P; Murillo Jaso, E; Dorronsoro Auzmendi, M; Martín Vizcaíno, M P

2013-03-01

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.

Cost of Chronic Obstructive Pulmonary Disease in the Emergency Department and Hospital: An Analysis of Administrative Data from 218 US Hospitals.

PubMed

Stanford, Richard H; Shen, Yingjia; McLaughlin, Trent

2006-01-01

Treatment of chronic obstructive pulmonary disease (COPD) in the emergency department (ED) or hospital accounts for a significant portion of COPD costs. This study estimates the cost of a COPD ED or hospitalization visit in the US. This observational study utilized administrative data from 218 acute care hospitals. ED/hospital discharges for COPD (International Classification of Diseases - Ninth Revision - Clinical Modification codes 491.xx. 492.xx, 496.xx) during 2001 were identified. Costs were determined for three groups: (i) ED only; (ii) standard admission; and (iii) severe admissions (intensive care unit [ICU] or intubation). Severe admissions were stratified into: (i) ICU/no intubation; (ii) intubation/no ICU; and (iii) ICU + intubation. Mean total costs and length of stay (LOS) were calculated for each group. A total of 59 735 ED/hospital encounters were identified: 20 431 ED only, 33 210 standard admissions, and 6094 severe admissions (4456 ICU/no intubation, 496 intubation/no ICU, and 1142 ICU/intubation). ED visits had a mean cost of $US571 +/- 507 (year 2001 value). Inpatient costs ranged from $US5997 (+/- 5752) for a standard admission to $US36 743 (+/- 62 886) for ICU plus intubation admissions, while LOS ranged from 5.1 days (+/- 4.5) to 14.8 days (+/- 16.7), respectively. In addition, only 10% of encounters required an intubation/ICU admission, but these accounted for 34% of the cost. Cost of a COPD hospitalization is substantial in the US, with one-third of those costs being associated with severe admissions, which make up only 10% of all COPD admissions. Treatments aimed at reducing hospitalizations and length of stay could result in substantial cost savings.

Evaluation of Optimum Dietary Threonine Requirement by Plasma Free Threonine and Ammonia Concentrations in Surgically Modified Rainbow Trout, Oncorhynchus mykiss

PubMed Central

Yun, Hyeonho; Park, Gunjun; Ok, Imho; Katya, Kumar; Heung, Silas; Bai, Sungchul C.

2015-01-01

This study was carried out to evaluate the dietary threonine requirement by measuring the plasma free threonine and ammonia concentrations in rainbow trout, Oncorhynchus mykiss after dorsal aorta cannulation. A total of 70 fish (average initial weight 506±8.2 g) were randomly distributed into each of the 14 net cages (5 fish/cage). After 48 hours (h) of feed deprivation, each group was intubated at 1% body weight with one of the seven L-amino acid based diets containing graded levels of threonine (0.42%, 0.72%, 0.92%, 1.12%, 1.32%, 1.52%, or 1.82% of diet, dry matter basis). Blood samples were taken at 0, 5, and 24 h after intubation. Post-prandial plasma free threonine concentrations (PPthr) of fish 5 h after intubation with diets containing 1.32% or more threonine were significantly higher than those of fish intubated with diets containing 1.12% or less threonine (p<0.05). Post-absorptive free threonine concentrations (PAthr) after 24 h of intubation of the fish with diets containing 0.92% or more threonine were significantly higher than those of fish intubated with diets containing 0.72% or less threonine. Post-prandial plasma ammonia concentrations (PPA, 5 h after intubation) were not significantly different among fish intubated with diets containing 1.12% or less threonine, except the PPA of fish intubated with diet containing 0.42% threonine. Broken-line model analyses of PPthr, PAthr, and PPA indicated that the dietary threonine requirement of rainbow trout should be between 0.95% (2.71) and 1.07% (3.06) of diet (% of dietary protein on a dry matter basis). PMID:25656187

C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: A manikin trial.

PubMed

Smereka, Jacek; Ladny, Jerzy R; Naylor, Amanda; Ruetzler, Kurt; Szarpak, Lukasz

2017-08-01

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.

The Pentax airway scope versus the Macintosh laryngoscope: Comparison of hemodynamic responses and concentrations of plasma norepinephrine to tracheal intubation

PubMed Central

2013-01-01

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

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates).

PubMed

Abdelgadir, Ibtihal S; Phillips, Robert S; Singh, Davinder; Moncreiff, Michael P; Lumsden, Joanne L

2017-05-24

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 are awaiting classification and two ongoing studies.Trial results show that a longer intubation time was required when indirect laryngoscopy, or videolaryngoscopy, was used instead of direct laryngoscopy (12 trials; n = 798; mean difference (MD) 5.49 seconds, 95% confidence interval (CI) 1.37 to 9.60; I 2 = 90%; very low-quality evidence). Researchers found no significant differences between direct and indirect laryngoscopy on assessment of success of the first attempt at intubation (11 trials; n = 749; risk ratio (RR) 0.96, 95% CI 0.91 to 1.02; I 2 = 67%; low-quality evidence) and observed that unsuccessful intubation (five trials; n = 263) was significantly increased in the indirect laryngoscopy, or videolaryngoscopy, group (RR 4.93, 95% CI 1.33 to 18.31; I 2 = 0%; low-quality evidence). Five studies reported the effect of intubation on oxygen saturation (n = 272; very low-quality evidence). Five children had desaturation during intubation: one from the direct laryngoscopy group and four from the indirect laryngoscopy, or videolaryngoscopy, group.Two studies (n = 100) reported other haemodynamic responses to intubation (very low-quality evidence). One study reported a significant increase in heart rate five minutes after intubation in the indirect laryngoscopy group (P = 0.007); the other study found that the heart rate change in the direct laryngoscopy group was significantly less than the heart rate change in the indirect laryngoscopy, or videolaryngoscopy, group (P < 0.001). A total of five studies (n = 244; very low-quality evidence) looked at evidence of trauma resulting from intubation. Investigators reported that only two children from the direct laryngoscopy group had trauma compared with no children in the indirect laryngoscopy, or videolaryngoscopy, group.Use of indirect laryngoscopy, or videolaryngoscopy, improved the percentage of glottic opening (five trials; n = 256). Studies noted no significant difference in Cormack and Lehane score (C&L) grade 1 (three trials; n = 190; RR 1.06, 95% CI 0.93 to 1.21; I 2 = 59%). Evidence suggests that indirect laryngoscopy, or videolaryngoscopy, leads to prolonged intubation time with an increased rate of intubation failure when compared with direct laryngoscopy (very low-quality evidence due to imprecision, inconsistency, and study limitations). Review authors had difficulty reaching conclusions on adverse haemodynamic responses and other adverse effects of intubation, as only a few children were reported to have these outcomes. Use of indirect laryngoscopy, or videolaryngoscopy, might lead to improved vocal cord view, but marked heterogeneity between studies made it difficult for review authors to reach conclusions on this outcome.

[Difficult Ventilation Requiring Emergency Endotracheal Intubation during Awake Craniotomy Managed by Laryngeal Mask Airway].

PubMed

Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko

2016-04-01

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.

Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation.

PubMed

Blaivas, Michael; Tsung, James W

2008-05-01

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.

A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets.

PubMed

MacNab, A J; MacPhail, I; MacNab, M K; Noble, R; O'Flaherty, D

1998-01-01

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.

Mayo registry for telemetry efficacy in arrest study: An evaluation of the feasibility of the do not intubate code status.

PubMed

Snipelisky, David; Dumitrascu, Adrian; Ray, Jordan; Roy, Archana; Matcha, Gautam; Harris, Dana; Vadeboncoeur, Tyler; Kusumoto, Fred; Burton, M Caroline

2017-12-06

Guidelines recommend discussing code status with patients on hospital admission. No study has evaluated the feasibility of a full code with do not intubate (DNI) status. A retrospective analysis of patients who experienced a cardiopulmonary arrest was performed between May 1, 2008 and June 20, 2014. A descriptive analysis was created based on whether patients required mechanical ventilatory support during the hospitalization and comparisons were made between both patient subsets. A total of 239 patients were included. Almost all (n = 218, 91.2%) required intubation during the hospitalization. Over half (n = 117, 53.7%) were intubated on the same day as the cardiopulmonary arrest and 91 patients (41.7%) were intubated at the time of arrest. Comparisons between intubated and non-intubated patients showed little differences in clinical characteristics, except for a higher proportion of medical cardiac etiology for admission in patients who did not require intubation (n = 10, 47.6% versus n = 55, 25.2%; p = 0.18) and initial arrest rhythm of ventricular tachycardia/fibrillation (n = 8, 38.1% versus n = 50, 22.9%; p = 0.37). No differences in 24-hour and posthospital survivals were present. Mechanical ventilatory support is commonly utilized in patients who experience a cardiopulmonary arrest. The DNI status may not be a feasible code status option for most patients.

Neurological deterioration during intubation in cervical spine disorders

PubMed Central

Durga, Padmaja; Sahu, Barada Prasad

2014-01-01

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

Does Video Laryngoscopy Offer Advantages over Direct Laryngoscopy during Cardiopulmonary Resuscitation?

PubMed

Saraçoğlu, Ayten; Bezen, Olgaç; Şengül, Türker; Uğur, Egin Hüsnü; Şener, Sibel; Yüzer, Fisun

2015-08-01

Interruption of chest compressions should be minimized because of its negative effects on survival. This randomized, controlled, cross-over study aimed to analyze the effectiveness of Macintosh, Miller, McCoy and McGrath laryngoscopes during with or without chest compressions in the scope of a simulated cardiopulmonary resuscitation scenario. The time required for successful tracheal intubation, number of attempts, dental trauma severity and the need for optimization manoeuvres were recorded during cardiopulmonary resuscitation with and without chest compressions. The experience with computer games during the last 10 years were asked to the participants and recorded. McCoy laryngoscope yielded the shortest time for successful tracheal intubation both in the presence of and without chest compressions. During the use of McCoy laryngoscopes, fewer tracheal intubation attempts, lower incidence of dental trauma and lower visual analogue scale scores on the ease of intubation were recorded. Participants who are experienced computer game players using Macintosh, McCoy and McGrath achieved successful tracheal intubation in a significantly shorter time during resuscitation without chest compressions. Dental trauma incidence and number of tracheal intubation attempts did not show any significant difference between the four laryngoscopes being related to the rate of playing computer games. McGrath video laryngoscopes do not appear to have advantages over direct laryngoscopes for securing a smooth and successful tracheal intubation during rhythmic chest compressions. We believe that as McCoy laryngoscope provided tracheal intubation in a shorter time and with fewer attempts, this laryngoscope may increase the success rate of resuscitation.

Comparisons of the Pentax-AWS, Glidescope, and Macintosh Laryngoscopes for Intubation Performance during Mechanical Chest Compressions in Left Lateral Tilt: A Randomized Simulation Study of Maternal Cardiopulmonary Resuscitation

PubMed Central

Lee, Sanghyun; Kim, Wonhee; Kang, Hyunggoo; Oh, Jaehoon; Lim, Tae Ho; Lee, Yoonjae; Kim, Changsun; Cho, Jun Hwi

2015-01-01

Purpose. Rapid advanced airway management is important in maternal cardiopulmonary resuscitation (CPR). This study aimed to compare intubation performances among Pentax-AWS (AWS), Glidescope (GVL), and Macintosh laryngoscope (MCL) during mechanical chest compression in 15° and 30° left lateral tilt. Methods. In 19 emergency physicians, a prospective randomized crossover study was conducted to examine the three laryngoscopes. Primary outcomes were the intubation time and the success rate for intubation. Results. The median intubation time using AWS was shorter than that of GVL and MCL in both tilt degrees. The time to visualize the glottic view in GVL and AWS was significantly lower than that of MCL (all P < 0.05), whereas there was no significant difference between the two video laryngoscopes (in 15° tilt, P = 1; in 30° tilt, P = 0.71). The progression of tracheal tube using AWS was faster than that of MCL and GVL in both degrees (all P < 0.001). Intubations using AWS and GVL showed higher success rate than that of Macintosh laryngoscopes. Conclusions. The AWS could be an appropriate laryngoscope for airway management of pregnant women in tilt CPR considering intubation time and success rate. PMID:26161426

Endoscopic dacryocystorhinostomy with and without silicone intubation: 4 years retrospective study.

PubMed

Longari, F; Dehgani Mobaraki, P; Ricci, A L; Lapenna, R; Cagini, C; Ricci, G

2016-08-01

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.

Assessment of the storz video Macintosh laryngoscope for use in difficult airways: A human simulator study.

PubMed

Bair, Aaron E; Olmsted, Kalani; Brown, Calvin A; Barker, Tobias; Pallin, Daniel; Walls, Ron M

2010-10-01

Video laryngoscopy has been shown to improve glottic exposure when compared to direct laryngoscopy in operating room studies. However, its utility in the hands of emergency physicians (EPs) remains undefined. A simulated difficult airway was used to determine if intubation by EPs using a video Macintosh system resulted in an improved glottic view, was easier, was faster, or was more successful than conventional direct laryngoscopy. Emergency medicine (EM) residents and attending physicians at two academic institutions performed endotracheal intubation in one normal and two identical difficult airway scenarios. With the difficult scenarios, the participants used video laryngoscopy during the second case. Intubations were performed on a medium-fidelity human simulator. The difficult scenario was created by limiting cervical spine mobility and inducing trismus. The primary outcome was the proportion of direct versus video intubations with a grade I or II Cormack-Lehane glottic view. Ease of intubation (self-reported via 10-cm visual analog scale [VAS]), time to intubation, and success rate were also recorded. Descriptive statistics as well as medians with interquartile ranges (IQRs) are reported where appropriate. The Wilcoxon matched pairs signed-rank test was used for comparison testing of nonparametric data. Participants (n = 39) were residents (59%) and faculty. All had human intubation experience; 51% reported more than 100 prior intubations. On difficult laryngoscopy, a Cormack-Lehane grade I or II view was obtained in 20 (51%) direct laryngoscopies versus 38 (97%) of the video-assisted laryngoscopies (p < 0.01). The median VAS score for difficult airways was 50 mm (IQR = 28–73 mm) for direct versus 18 mm (IQR = 9–50 mm) for video (p < 0.01). The median time to intubation in difficult airways was 25 seconds (IQR = 16–44 seconds) for direct versus 20 seconds (IQR = 12–35 seconds) for video laryngoscopy (p < 0.01). All intubations were successful without need for an invasive airway. In this simulation, video laryngoscopy was associated with improved glottic exposure, was perceived as easier, and was slightly faster than conventional direct laryngoscopy in a simulated difficult airway. Absence of secretions and blood limits the generalizability of our findings; human studies are needed.

Disposable stainless steel vs plastic laryngoscope blades among paramedics.

PubMed

Dos Santos, Frank D; Schnakofsky, Roberto; Cascio, Anthony; Liu, Junfeng; Merlin, Mark A

2011-07-01

Several studies have been published in the literature about intubation methods, but little is available on intubation equipment used in this setting. This is the first prehospital comparison of disposable plastic vs disposable stainless steel laryngoscope blades used by paramedics. The objective of this study was to compare prehospital intubation success rates on first attempt and overall number of attempts to obtain intubations using disposable plastic laryngoscopes blades vs disposable stainless steel laryngoscope blades. A retrospective prehospital cohort study was conducted during two 3-year periods. Two-way contingency table and χ(2) test were conducted to determine if there was a difference between the 2 types of blades. A proportional odds model with calculated 95% confidence interval (CI) and odd ratios were then calculated. A total of 2472 paramedic intubations were recorded over the 6-year period. The stainless steel single-use blades had a first attempt success rate of 88.9% vs 78.5% with plastic blades (P = .01; odds ratio, 1.94; 95% CI, 1.17-3.41). The stainless steel single-use laryngoscope blade had a lower number of attempts to successful intubation than the plastic blade (88.8% vs 74.3%, respectively) (P < .01; odds ratio, 1.64; 95% CI, 1.34-2.00). In the prehospital setting, stainless steel disposable blades were superior to plastic disposable blades in first attempt and overall number of attempts to intubation. Until further research is done, we recommend use of stainless steel blades for intubations in the prehospital setting by paramedics. Copyright © 2011 Elsevier Inc. All rights reserved.

Prophylaxis against the systemic hypotension induced by propofol during rapid-sequence intubation.

PubMed

el-Beheiry, H; Kim, J; Milne, B; Seegobin, R

1995-10-01

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.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

PubMed

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS ( P =0.001), respiratory rate ( P =0.001), and higher frequency of head ( P =0.02) and chest injuries ( P =0.04). The rate of VAP in PHI group was comparable to the TRI group ( P =0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Use of a Flexible Intubating Scope in Combination with a Channeled Video Laryngoscope for Managing a Difficult Airway in the Emergency Department.

PubMed

Sowers, Nicholas; Kovacs, George

2016-02-01

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.

Efficacy of video-guided laryngoscope in airway management skills of medical students.

PubMed

Peirovifar, Ali; Mahmoodpoor, Ata; Golzari, Samad Ej; Soleimanpour, Hassan; Eslampour, Yashar; Fattahi, Vahid

2014-10-01

Video-guided laryngoscopy, though unproven in achieving better success rates of laryngoscopy outcome and intubation, seems to provide better glottic visualization compared with direct laryngoscopy. The objective of this study was to compare the efficacy of video-guided laryngoscope (VGL) in the airway management skills of medical students. Medical students throughout their anesthesiology rotations were enrolled in this study. All students received standard training in the airway management during their course and were randomly allocated into two 20 person groups. In Group D, airway management was performed by direct laryngoscopy via Macintosh blade and in Group G intubation was performed via VGL. Time to intubation, number of laryngoscopy attempts and success rate were noted. Successful intubation was considered as the primary outcome. All data were analyzed using SPSS 16 software. Chi-square and Fisher's exact test were used for analysis of categorical variables. For analyzing continuous variables independent t-test was used. P < 0.05 was considered as statistically significant. Number of laryngoscopy attempts was less in Group G in comparison to Group D; this, however, was statistically insignificant (P: 0.18). Time to intubation was significantly less in Group G as compared to Group D (P: 0.02). Successful intubation in Group G was less frequently when compared to Group D (P: 0.66). Need for attending intervention, esophageal intubation and hypoxemic events during laryngoscopy were less in Group G; this, however, was statistically insignificant. The use of video-guided laryngoscopy improved the first attempt success rate, time to intubation, laryngoscopy attempts and airway management ability of medical students compared to direct laryngoscopy.

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults.

PubMed

Myatra, Sheila Nainan; Shah, Amit; Kundra, Pankaj; Patwa, Apeksh; Ramkumar, Venkateswaran; Divatia, Jigeeshu Vasishtha; Raveendra, Ubaradka S; Shetty, Sumalatha Radhakrishna; Ahmed, Syed Moied; Doctor, Jeson Rajan; Pawar, Dilip K; Ramesh, Singaravelu; Das, Sabyasachi; Garg, Rakesh

2016-12-01

The All India Difficult Airway Association (AIDAA) guidelines for management of the unanticipated difficult airway in adults provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in adults. They have been developed based on the available evidence; wherever robust evidence was lacking, or to suit the needs and situation in India, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. We recommend optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful. Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available. We recommend no more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95%. Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended. If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation. Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes 'complete ventilation failure', and emergency cricothyroidotomy should be performed. Patient counselling, documentation and standard reporting of the airway difficulty using a 'difficult airway alert form' must be done. In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.

Rocuronium versus succinylcholine for rapid sequence induction intubation.

PubMed

Tran, Diem T T; Newton, Ethan K; Mount, Victoria A H; Lee, Jacques S; Wells, George A; Perry, Jeffrey J

2015-10-29

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. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action. Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.

Comparison of Macintosh and Airtraq™ laryngoscopes in obese patients placed in the ramped position.

PubMed

Ranieri, D; Filho, S M; Batista, S; do Nascimento, P

2012-09-01

This study compared intubation conditions produced by the Macintosh and Airtraq™ laryngoscopes when used in obese patients in the ramped position. One hundred and thirty-two patients having bariatric surgery were placed in the ramped position and randomly assigned to have their tracheas intubated using either the Macintosh (n=64) or an Airtraq (n=68) laryngoscope. Mean (SD) intubation times were 37 (23) s and 14 (3) s for Macintosh and Airtraq, respectively (p<0.0001). Compared with the Macintosh laryngoscope, the Airtraq laryngoscope provided an improved vocal cord view as assessed by the Cormack and Lehane score (number of patients with Cormack-Lehane scores of 1/2/3/4/37/20/4/3 for the Macintosh, and 65/3/0/0 for the Airtraq laryngoscopes, p<0.0001). One patient in the Macintosh group had a failed intubation and intubation was achieved with the Airtraq. For obese patients in ramped position, Airtraq affords faster tracheal intubation than the Macintosh laryngoscope. Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.

[Comparison of airway scope and videolaryngoscope portable VLP-100 in the presence of a neck collar--a manikin study].

PubMed

Saito, Tomoyuki; Asai, Takashi; Arai, Takerou; Tsuchida, Misa; Ogawa, Katsumi; Okuda, Yasuhisa

2010-12-01

Tracheal intubation should be performed with great care in the multiple injury patient, particularly when damage to the cervical spine is suspected. The patient with unstable cervical spine requires a neck collar in prehospital area, and medical personnel may be required to perform tracheal intubation. We compared Macintosh laryngoscope with the Airway Scope (AWS), and Coopdeck videolaryngoscope portable VLP-100 (VLP-100) in a manikin model with the presence of a neck collar. We conducted a prospective study in 20 medical residents with little prior airway management experience. They inserted the AWS, VLP-100 and Macintosh laryngoscope, in turn, and the view of the glottis at laryngoscopy was graded, using a classification reported by Cormack and Lehane. Tracheal intubation time and the success rate of tracheal intubation (within 120 sec) were also recorded. The AWS provided a best view of the glottis, a shorter tracheal intubation time and a higher success rate of tracheal intubation, compared with VLP- 100 and Macintosh laryngoscope. The AWS may possess advantages over conventional direct laryngoscopes in patients with restricted neck movement.

Comparison of blind intubation through the I-gel and ILMA Fastrach by nurses during cardiopulmonary resuscitation: a manikin study.

PubMed

Melissopoulou, Theodora; Stroumpoulis, Konstantinos; Sampanis, Michail A; Vrachnis, Nikolaos; Papadopoulos, Georgios; Chalkias, Athanasios; Xanthos, Theodoros

2014-01-01

To investigate whether nursing staff can successfully use the I-gel and the intubating laryngeal mask Fastrach (ILMA) during cardiopulmonary resuscitation. Although tracheal intubation is considered to be the optimal method for securing the airway during cardiopulmonary resuscitation, laryngoscopy requires a high level of skill. Forty five nurses inserted the I-gel and the ILMA in a manikin, with continuous and without chest compressions. Mean intubation times for the ILMA and I-gel without chest compressions were 20.60 ± 3.27 and 18.40 ± 3.26 s, respectively (p < 0.0005). ILMA proved more successful than the I-gel regardless of compressions. Continuation of compressions caused a prolongation in intubation times for both the I-gel (p < 0.0005) and the ILMA (p < 0.0005). In this mannequin study, nursing staff can successfully intubate using the I-gel and the ILMA as conduits with comparable success rates, regardless of whether chest compressions are interrupted or not. Copyright © 2014 Elsevier Inc. All rights reserved.

Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer

PubMed Central

Gupta, Babita; Kohli, Santvana; Farooque, Kamran; Jalwal, Gopal; Gupta, Deepak; Sinha, Sumit; Chandralekha

2014-01-01

Overview: Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks. Materials and Methods: A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted. Results: The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L. Conclusion: Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate. PMID:25538514

Airway Management of Near-Complete Tracheal Transection by Through-the-Wound Intubation: A Case Report.

PubMed

Jean, Yuel-Kai; Potnuru, Paul; Diez, Christian

2018-06-11

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.

Usefulness and diagnostic value of the NEMA parameter combined with other selected bedside tests for prediction of difficult intubation.

PubMed

Torres, Kamil; Błoński, Marcin; Pietrzyk, Łukasz; Piasecka-Twaróg, Małgorzata; Maciejewski, Ryszard; Torres, Anna

2017-02-01

To assess the usefulness of the new NEMA (Neck Circumference Minus Acromion-Acromion Distance) parameter, in preoperative identification of patients' difficult intubation and compare it with other commonly used scales and tests. Prospective study. District Specialist Hospital of Lublin, Poland. Six hundreds twenty-nine patients underwent nonemergency surgical interventions. The NEMA parameter was confronted with: Modified Mallampati classification, TMD, RHTMD, NC, MPND, SMD, I-I D, A-AD, and medical history of difficult intubation and diagnosed obstructive sleep apnea syndrome or snoring. Higher medians of NEMA and Mallampati parameters were reported in patients with difficult intubation. AUC for Mallampati parameter was 0.733 while the NEMA parameter's AUC was 0.625. Sensitivity and specificity for Mallampati and NEMA parameter were respectively 0.79; 0.55 and 0.42; 0.75. Significantly higher MPN, RHTMD, Mallampati, and NEMA parameter were observed in patients in whom the BURP was used. Easy intubation occurs more frequently in patients with a history of OSAS or snoring than in those with difficult intubation. It seems that none of the known bedside tests for predicting difficult intubation have a discriminating power sufficient for clinicians. Our study draws attention to a novel parameter, called NEMA, which appears to be a strong predictor of DEI, especially in combination with the Mallampati scale. Copyright © 2016 Elsevier Inc. All rights reserved.

Submental Orotracheal Intubation in Maxillofacial Fracture Surgery: Report of Two Cases

PubMed Central

Tekelioğlu, Ümit Yaşar; Karabekmez, Furkan Erol; Demirhan, Abdullah; Akkaya, Akcan; Bayır, Hakan; Koçoğlu, Hasan

2013-01-01

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

Difficult intubation: are you prepared for it?

PubMed

Balcom, C

1994-01-01

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.

Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns.

PubMed

Freno, Daniel; Sahawneh, James; Harrison, Sarah; Sahawneh, Tim; Patterson, Scott; Kahn, Steven A

2018-05-01

Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy. Copyright © 2017. Published by Elsevier Ltd.

[Comparison of two shaping methods for double-lumen endotracheal tube intubation by Shikani optical stylet laryngoscope].

PubMed

Xu, T; Li, M; Xu, M; Guo, X Y

2016-12-18

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 with the concave aspect of the distal curvature saves SOS manipulation time, decreases the severity and incidence of postoperative hoarseness and sore throat. However, this modified shaping method increases the incidence of malposition of bronchial intubation and time for FOB identification of bronchial placement.

A survey of Canadian anesthesiologists' preferences in difficult intubation and "cannot intubate, cannot ventilate" situations.

PubMed

Wong, David T; Mehta, Arpan; Tam, Amanda D; Yau, Brian; Wong, Jean

2014-08-01

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.

Endotracheal tube placement by EMT-Basics in a rural EMS system.

PubMed

Pratt, Jeffrey C; Hirshberg, Alan J

2005-01-01

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.

Does systemic lidocaine reduce ketamine requirements for endotracheal intubation in calves?

PubMed

Lauper, Josiane; Marolf, Vincent; Levionnois, Olivier; Schelling, Esther; Meylan, Mireille; Spadavecchia, Claudia

2017-03-01

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.

Timing of intubation and ventilator-associated pneumonia following injury.

PubMed

Evans, Heather L; Zonies, David H; Warner, Keir J; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph

2010-11-01

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.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

PubMed Central

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role. PMID:29796145

Determination of the diagnostic value of the Modified Mallampati Score, Upper Lip Bite Test and Facial Angle in predicting difficult intubation: A prospective descriptive study.

PubMed

Mahmoodpoor, Ata; Soleimanpour, Hassan; Golzari, Samad Ej; Nejabatian, Arezoo; Pourlak, Tannaz; Amani, Masoumeh; Hajmohammadi, Saeed; Hosseinzadeh, Hamzeh; Esfanjani, Robab Mehdizadeh

2017-02-01

Difficult intubation is a significant cause of mortality and morbidity related to anesthesia. We decided to evaluate the value of Modified Mallampati Score, Upper Lip Bite Test and Facial Angle in the prediction of difficult intubation. In a prospective descriptive study, data from 132 patients who were candidates for elective maxillofacial surgeries under general anesthesia were gathered. Facial Angles were measured by a maxillofacial surgeon according to cephalometry. The Modified Mallampati Score and Upper Lip Bite Test were first measured by an anesthesiologist and then another anesthesiologist was assigned to record the Cormack and Lehane score during the intubation. Grades 3 and 4 were considered as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were calculated for all tests. Difficult intubation was reported in 12% of the patients. Facial Angle≤82.5° can predict difficult intubation with 87.5% sensitivity and 88.8% specificity. Among the three tests, a high Modified Mallampati Score had the highest specificity (94.5%) and a high Modified Mallampati Score and Facial Angle (FA≤82.5°) had the highest sensitivity (87.5%). The highest NPV, sensitivity and Youden index were observed when using Facial Angle with the Modified Mallampati Score or with Upper Lip Bite Test. Facial Angle has a high sensitivity, NPV and Youden index for the prediction of difficult intubation, but the best result is achieved when Facial Angle is used in combination with either the Modified Mallampati Score or Upper Lip Bit Test. Copyright © 2017 Elsevier Inc. All rights reserved.

Just-in-Time Video Laryngoscopy Versus Direct Laryngoscopy for Neonatal Intubation.

PubMed

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.

Tracheal intubation in patients with cervical spine immobilization: A comparison of McGrath(®) video laryngoscope and Truview EVO2(®) laryngoscope.

PubMed

Bhola, Ruchi; Bhalla, Swaran; Gupta, Radha; Singh, Ishwar; Kumar, Sunil

2014-05-01

Literature suggests that glottic view is better when using McGrath(®) Video laryngoscope and Truview(®) in comparison with McIntosh blade. The purpose of this study was to evaluate the effectiveness of McGrath Video laryngoscope in comparison with Truview laryngoscope for tracheal intubation in patients with simulated cervical spine injury using manual in-line stabilisation. This prospective randomised study was undertaken in operation theatre of a tertiary referral centre after approval from the Institutional Review Board. A total of 100 consenting patients presenting for elective surgery requiring tracheal intubation were randomly assigned to undergo intubation using McGrath(®) Video laryngoscope (n = 50) or Truview(®) (n = 50) laryngoscope. In all patients, we applied manual-in-line stabilisation of the cervical spine throughout the airway management. Statistical testing was conducted with the statistical package for the social science system version SPSS 17.0. Demographic data, airway assessment and haemodynamics were compared using the Chi-square test. A P < 0.05 was considered significant. The time to successful intubation was less with McGrath video laryngoscope when compared to Truview (30.02 s vs. 38.72 s). However, there was no significant difference between laryngoscopic views obtained in both groups. The number of second intubation attempts required and incidence of complications were negligible with both devices. Success rate of intubation with both devices was 100%. Intubation with McGrath Video laryngoscope caused lesser alterations in haemodynamics. Both laryngoscopes are reliable in case of simulated cervical spine injury using manual-in-line stabilisation with 100% success rate and good glottic view.

Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study.

PubMed

Knudsen, Kati; Nilsson, Ulrica; Högman, Marieann; Pöder, Ulrika

2016-08-30

Awake fiberoptic intubation is an alternative procedure for securing the airway and is a recommended option when a difficult airway is expected. The aim of the present study was to describe patient experiences with this procedure. A qualitative, descriptive design was used and patients were recruited from three county hospitals and one university hospital in Sweden. Data was collected by semi-structured interviews with 13 patients who underwent awake fiberoptic intubation. A qualitative content analysis extracted theme, categories, and subcategories. From the patient statements, one main theme emerged, feelings of being in a vulnerable situation but cared for in safe hands, which were described in five categories with 15 subcategories. The categories were: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff's competence, professional caring and support, and no hesitation about new awake intubation. The patients felt they lacked information about what to expect and relied on the professionals' expertise. Some patients felt overwhelmed by the information they were given and wanted less specific information about the equipment used but more information about how they would be cared for in the operating room. Undergoing awake intubation was an acceptable experience for most patients, whereas others experienced it as being painful and terrifying because they felt they could not breathe or communicate during the procedure itself. Tailored information about what to expect, ensuring eye contact and breathing instruction during the procedure seems to reduce patient distress when undergoing awake fiberoptic intubation. Most of the patients would not hesitate to undergo awake intubation again in the future if needed.

Patients with difficult intubation may need referral to sleep clinics.

PubMed

Chung, Frances; Yegneswaran, Balaji; Herrera, Francisco; Shenderey, Alex; Shapiro, Colin M

2008-09-01

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.

Endotracheal intubation: application of virtual reality to emergency medical services education.

PubMed

Mayrose, James; Myers, Jeffrey W

2007-01-01

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.

Monitoring the onset of neuromuscular blockade with double burst stimulation (DBS).

PubMed

Gorgias, N; Maidatsi, P; Zaralidou, A; Ourailoglou, V; Fakidou, A; Giala, M

1998-11-01

The present study was undertaken to evaluate the suitability of the DBS mode in the determination of the proper time to perform tracheal intubation following cisatracurium muscle relaxation. The DBS3.3 pattern was administered to the ulnar nerve at the wrist in 45 patients paralyzed with cisatracurium 0.15 mg.kg-1 and tracheal intubation was attempted immediately after the disappearance of both palpable contractions of the adductor pollicis. Intubation conditions were assessed with a standard four-graded scoring system and the onset time of the relaxant was determined. Forty-two patients (93%) exhibited acceptable intubation conditions as soon as both responses to DBS were absent and the estimated apparent onset time, according to the stimulation mode applied, was 114.68 +/- 13.2 sec. Our data suggest that disappearance of both palpable responses to DBS3.3 may be used as an accurate predictor of acceptable intubation conditions, following nondepolarizing relaxants such as cisatracurium.

Effects of fenoterol and ipratropium on respiratory resistance of asthmatics after tracheal intubation.

PubMed

Wu, R S; Wu, K C; Wong, T K; Tsai, Y H; Cheng, R K; Bishop, M J; Tan, P P

2000-03-01

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.

Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing.

PubMed

Repka, Michael X; Chandler, Danielle L; Holmes, Jonathan M; Hoover, Darren L; Morse, Christine L; Schloff, Susan; Silbert, David I; Tien, D Robbins

2009-05-01

To compare the outcomes of balloon catheter dilation and nasolacrimal intubation as treatment for congenital nasolacrimal duct obstruction after failed probing in children younger than 4 years. We conducted a prospective, nonrandomized, multicenter study that enrolled 159 children aged 6 months to younger than 48 months who had a history of a single failed nasolacrimal duct probing and at least 1 of the following clinical signs of nasolacrimal duct obstruction: epiphora, mucous discharge, or increased tear lake. One hundred ninety-nine eyes underwent either balloon catheter nasolacrimal duct dilation or nasolacrimal duct intubation. Treatment success was defined as absence of epiphora, mucous discharge, or increased tear lake at the outcome visit 6 months after surgery. Treatment success was reported in 65 of 84 eyes (77%; 95% confidence interval, 65%-85%) in the balloon catheter dilation group compared with 72 of 88 eyes (84% after adjustment for intereye correlation; 74%-91%) in the nasolacrimal intubation group (risk ratio for success for intubation vs balloon dilation, 1.08; 0.95-1.22). Both balloon catheter dilation and nasolacrimal duct intubation alleviate the clinical signs of persistent nasolacrimal duct obstruction in a similar percentage of patients.

A Prospective Observational Study of Technical Difficulty With GlideScope-Guided Tracheal Intubation in Children.

PubMed

Zhang, Bin; Gurnaney, Harshad G; Stricker, Paul A; Galvez, Jorge A; Isserman, Rebecca S; Fiadjoe, John E

2018-05-09

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 with technical difficulty had more attempts (median [interquartile range], 2 [1-3] than those without technical difficulty median (interquartile range, 1 [1-1; P value <.01]). A variety of clinicians experience technical difficulties with the GlideScope Cobalt videolaryngoscope in children. These difficulties result in more tracheal intubation attempts, an important risk factor for intubation-associated complications. Targeted education of clinicians may reduce the incidence of technical difficulties.

Basic needs and their predictors for intubated patients in surgical intensive care units.

PubMed

Liu, Jin-Jen; Chou, Fan-Hao; Yeh, Shu-Hui

2009-01-01

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.

Management of the difficult airway.

PubMed

Schwartz, D E; Wiener-Kronish, J P

1991-09-01

For clinicians involved in airway management, a plan of action for dealing with the difficult airway or a failed intubation should be developed well in advance of encountering a patient in whom intubation is not routine. When difficulty is anticipated, the equipment necessary for performing a difficult intubation should be immediately available. It also is prudent to have a surgeon skilled in performing a tracheotomy and a criothyroidotomy stand by. The intubation should be attempted in the awake state, preferably using the fiberoptic bronchoscope. The more challenging situation is when the difficult airway is confronted unexpectedly. After the first failed attempt at laryngoscopy, head position should be checked and the patient ventilated with oxygen by mask. A smaller styletted tube and possibly a different laryngoscope blade should be selected for a second attempt at intubation. The fiberoptic bronchoscope and other equipment for difficult intubation should be obtained. A second attempt should then be made. If this is unsuccessful, the patient should be reoxygenated, and assistance including a skilled anesthesiologist and surgeon should be summoned. On a third attempt, traction to the tongue can be applied by an assistant, a tube changer could be used to enter the larynx, or one of the other special techniques previously described can be used. If this third attempt fails, it may be helpful to have a physician more experienced in airway management attempt intubation after oxygen has been administered to the patient. If all attempts are unsuccessful, then invasive techniques to secure the airway will have to be performed.

Comparison of the Airtraq® and Truview® laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation in manikins

PubMed Central

Nasim, Sajid; Maharaj, Chrisen H; Butt, Ihsan; Malik, Muhammad A; O' Donnell, John; Higgins, Brendan D; Harte, Brian H; Laffey, John G

2009-01-01

Background Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq® and Truview® laryngoscopes may reduce this risk. Methods We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq® and Truview® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan® manikin. Results The Airtraq® reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview® increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq® devices. Conclusion The Airtraq® laryngoscope performed more favourably than the Macintosh and Truview® devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting. PMID:19216776

Comparison of the Glidescope® and Pentax AWS® laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation

PubMed Central

Nasim, Sajid; Maharaj, Chrisen H; Malik, Muhammad A; O' Donnell, John; Higgins, Brendan D; Laffey, John G

2009-01-01

Background Intubation of the trachea in the pre-hospital setting may be lifesaving in severely ill and injured patients. However, tracheal intubation is frequently difficult to perform in this challenging environment, is associated with a lower success rate, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Glidescope® and the AWS® laryngoscopes may reduce this risk. Methods We compared the efficacy of these devices to the Macintosh laryngoscope when used by 25 Advanced Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Glidescope® and the AWS® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan® manikin. Results Both the Glidescope® and the AWS® performed better than the Macintosh, and demonstrate considerable promise in this context. The AWS® had the least number of dental compressions in all three scenarios, and in the cervical spine immobilization scenario it required fewer maneuvers to optimize the view of the glottis. Conclusion The Glidescope® and AWS® devices possess advantages over the conventional Macintosh laryngoscope when used by Advanced Paramedics in normal and simulated difficult intubation scenarios in this manikin study. Further studies are required to extend these findings to the clinical setting. PMID:19445719

Contemporary ventilator management in patients with and at risk of ALI/ARDS.

PubMed

Chang, Steven Y; Dabbagh, Ousama; Gajic, Ognen; Patrawalla, Amee; Elie, Marie-Carmelle; Talmor, Daniel S; Malhotra, Atul; Adesanya, Adebola; Anderson, Harry L; Blum, James M; Park, Pauline K; Gong, Michelle Ng

2013-04-01

Ventilator practices in patients at risk for acute lung injury (ALI) and ARDS are unclear. We examined factors associated with choice of set tidal volumes (VT), and whether VT < 8 mL/kg predicted body weight (PBW) relates to the development of ALI/ARDS. We performed a secondary analysis of a multicenter cohort of adult subjects at risk of lung injury with and without ALI/ARDS at onset of invasive ventilation. Descriptive statistics were used to describe ventilator practices in specific settings and ALI/ARDS risk groups. Logistic regression analysis was used to determine the factors associated with the use of VT < 8 mL/kg PBW and the relationship of VT to ALI/ARDS development and outcome. Of 829 mechanically ventilated patients, 107 met the criteria for ALI/ARDS at time of intubation, and 161 developed ALI/ARDS after intubation (post-intubation ALI/ARDS). There was significant intercenter variability in initial ventilator settings, and in the incidence of ALI/ARDS and post-intubation ALI/ARDS. The median VT was 7.96 (IQR 7.14-8.94) mL/kg PBW in ALI/ARDS subjects, and 8.45 (IQR 7.50-9.55) mL/kg PBW in subjects without ALI/ARDS (P = .004). VT decreased from 8.40 (IQR 7.38-9.37) mL/kg PBW to 7.97 (IQR 6.90-9.23) mL/kg PBW (P < .001) in those developing post-intubation ALI/ARDS. Among subjects without ALI/ARDS, VT ≥ 8 mL/kg PBW was associated with shorter height and higher body mass index, while subjects with pneumonia were less likely to get ≥ 8 mL/kg PBW. Initial VT ≥ 8 mL/kg PBW was not associated with the post-intubation ALI/ARDS (adjusted odds ratio 1.30, 95% CI 0.74-2.29) or worse outcomes. Post-intubation ALI/ARDS subjects had mortality similar to subjects intubated with ALI/ARDS. Clinicians seem to respond to ALI/ARDS with lower initial VT. Initial VT, however, was not associated with the development of post-intubation ALI/ARDS or other outcomes.

Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial

PubMed Central

2011-01-01

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 patients undergoing emergent RSI, incidence and severity of oxygen desaturations, the quality of intubation conditions, and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium. Trial Registration ClinicalTrials.gov, number NCT00355368. PMID:21846380

Comparison of five video-assisted intubation devices by novice and expert laryngoscopists for use in the aeromedical evacuation environment.

PubMed

Wallace, Matthew C; Britton, SSgt Tyler; Meek, Robbie; Walsh-Hart, Sharon; Carter, Col Todd E; Lisco, Steven J

2017-01-01

The critically ill or injured patient undergoing military medical evacuation may require emergent intubation. Intubation may be life-saving, but it carries risks. The novice or infrequent laryngoscopist has a distinct disadvantage because experience is critical for the rapid and safe establishment of a secured airway. This challenge is compounded by the austere environment of the back of an aircraft under blackout conditions. This study determined which of five different video-assisted intubation devices (VAIDs) was best suited for in-flight use by U.S. Air Force Critical Care Air Transport Teams by comparing time to successful intubation between novice and expert laryngoscopists under three conditions, Normal Airway Lights on (NAL), Difficult Airway Lights on (DAL) and Difficult Airway Blackout (DAB), using manikins on a standard military transport stanchion and the floor with a minimal amount of setup time and extraneous light emission. A convenience sample size of 40 participants (24 novices and 16 experts) attempted intubation with each of the 5 different video laryngoscopic devices on high-fidelity airway manikins. Time to tracheal intubation and number of optimization maneuvers used were recorded. Kruskal-Wallis testing determined significant differences between the VAIDs in time to intubation for each particular scenario. Devices with significant differences underwent pair-wise comparison testing using rank-sum analysis to further clarify the difference. Device assembly times, startup times and the amount of light emitted were recorded. Perceived ease of use was surveyed. Novices were fastest with the Pentax AWS in all difficult airway scenarios. Experts recorded the shortest median times consistently using 3 of the 5 devices. The AWS was superior overall in 4 of the 6 scenarios tested. Experts and novices subjectively judged the GlideScope Ranger as easiest to use. The light emitted by all the devices was less than the USAF-issued headlamp. Novices intubated fastest with the Pentax AWS in all difficult airway scenarios. The GlideScope required the shortest setup time, and participants judged this device as the easiest to use. The GlideScope and AWS exhibited the two fastest total setup times. Both devices are suitable for in-flight use by infrequent and seasoned laryngoscopists.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

PubMed

Birnbach, David J; Rosen, Lisa F; Fitzpatrick, Maureen; Carling, Philip; Arheart, Kristopher L; Munoz-Price, L Silvia

2015-04-01

Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates.

PubMed

Hubble, Michael W; Brown, Lawrence; Wilfong, Denise A; Hertelendy, Attila; Benner, Randall W; Richards, Michael E

2010-01-01

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 interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure.

Use of video-assisted intubation devices in the management of patients with trauma.

PubMed

Aziz, Michael

2013-03-01

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.

[Case of awake intubation in semi-sitting position for a patient with myasthenia gravis combined with cervical disc hernia utilizing Pentax-AWS Airwayscope].

PubMed

Komasawa, Nobuyasu; Ueki, Ryusuke; Tomita, Yukihiko; Kaminoh, Yoshiroh; Tashiro, Chikara

2011-01-01

We report a case of awake intubation utilizing Pentax-AWS Airwayscope in semi-sitting position. A 74-year-old man with myasthenia gravis and cervical disc hernia was scheduled for distal gastrectomy under general anesthesia. He could not move his head due to severe cervical disc hernia and also could not sufficiently breathe due to the fatigue of respiratory muscles by myasthenia gravis in supine position. With fentanyl bolus administration and lidocaine spray for laryngotracheal anesthesia, we performed awake intubation in semi-sitting position with AWS from cranial side. The patient did not buck during intubation and no hemodynamic change was observed.

Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation.

PubMed

Jaeger, K; Ruschulte, H; Osthaus, A; Scheinichen, D; Heine, J

2000-01-01

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.

Utilization of virtual reality for endotracheal intubation training.

PubMed

Mayrose, James; Kesavadas, T; Chugh, Kevin; Joshi, Dhananjay; Ellis, David G

2003-10-01

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.

Rescue ventilation: resolving a "cannot mask ventilate, cannot intubate" situation during exchange of a Combitube for a definitive airway.

PubMed

Rich, James M; Mason, Andrew M; Tillmann, H A; Foreman, Michael

2009-10-01

Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.

[Selective left mainstem bronchial intubation in the neonatal intensive care unit].

PubMed

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.

Laryngeal complications by orotracheal intubation: Literature review.

PubMed

Mota, Luiz Alberto Alves; de Cavalho, Glauber Barbosa; Brito, Valeska Almeida

2012-04-01

 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.

A canine model of tracheal stenosis induced by cuffed endotracheal intubation

PubMed Central

Su, Zhuquan; Li, Shiyue; Zhou, Ziqing; Chen, Xiaobo; Gu, Yingying; Chen, Yu; Zhong, Changhao; Zhong, Minglu; Zhong, Nanshan

2017-01-01

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

[Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome].

PubMed

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.

Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?

PubMed

Paolini, Jean-Baptiste; Donati, François; Drolet, Pierre

2013-02-01

An adequate airway management plan is essential for patient safety. Recently, new tools have been developed as alternatives to direct laryngoscopy and intubation. Among these, video-laryngoscopy has enjoyed a rapid increase in popularity and is now considered by many as the first-line technique in airway management. This paradigm shift may have an impact on patient safety. Studies show that video-laryngoscopes are associated with better glottic visualization, a higher success rate for difficult airways, and a faster learning curve, resulting in a higher success rate for intubations by novice physicians. Thus, unanticipated difficult intubations may be less frequent if video-laryngoscopy is used as the first-line approach. In addition, on-screen viewing by the operator creates a new dynamic interaction during airway management. The entire operating room team can assess progress in real time, which enhances communication and improves teaching. However, if video-laryngoscopes become standard tools for tracheal intubation, these more costly devices will need to be widely available in all locations where airway management is conducted. Furthermore, algorithms for difficult intubation will require modification, and the question of selecting alternate devices will arise. If the incidence of difficult intubation decreases, the lack of motivation to teach and learn the use of alternative devices might adversely impact patient safety. The greater effectiveness of video-laryngoscopes associated with multi-person visualization could enhance overall patient safety during airway management. However, the routine use of video-laryngoscopy also introduces some issues that need to be addressed to avoid potentially dangerous pitfalls.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults†

PubMed Central

Frerk, C.; Mitchell, V. S.; McNarry, A. F.; Mendonca, C.; Bhagrath, R.; Patel, A.; O'Sullivan, E. P.; Woodall, N. M.; Ahmad, I.

2015-01-01

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

Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade.

PubMed

Alter, Scott M; Haim, Eithan D; Sullivan, Alex H; Clayton, Lisa M

2018-02-17

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.

Quality control in QuantiFERON-TB gold in-tube for screening latent tuberculosis infection in health care workers.

PubMed

Igari, Hidetoshi; Watanabe, Akira; Ichimura, Yasunori; Sakurai, Takayuki; Taniguchi, Toshibumi; Ishiwada, Naruhiko

2017-04-01

QuantiFERON-TB gold in-tube has been used for screening latent tuberculosis infection in newly employed health care workers in Japan. There have been a few studies concerning quality control. We retrospectively analysed QuantiFERON-TB gold in-tube results in a hospital in Japan. Interferon-γ values in three blood collection tubes for QuantiFERON-TB gold in-tube were analysed in association with the positivity rate. The data set consisted of health care workers aged 20-29 years during the 7 years between 2010 and 2016. The yearly QuantiFERON-TB gold in-tube positivity rate was 0.9%, 16.4%, 3.0%, 39.3%, 2.8%, 0.9% and 1.5%, and was extremely high in 2011 and 2013. The interferon-γ values in the tuberculosis antigen tube were elevated in these two years, as indicated by higher median and wider interquartile range. The interferon-γ value in the negative control tube was also higher in 2011. The higher interferon-γ values in collection tubes (tuberculosis antigen tube and/or negative control tube) resulted in higher QuantiFERON-TB gold in-tube positivity rate. The distribution of interferon-γ in tuberculosis antigen tube and negative control tube, as evaluated by median and interquartile range, proved to be an effective index for the quality control of QuantiFERON-TB gold in-tube. Copyright © 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Effects of premedication with oral gabapentin on intraocular pressure changes following tracheal intubation in clinically normal dogs.

PubMed

Trbolova, Alexandra; Ghaffari, Masoud Selk; Capik, Igor

2017-09-19

Gabapentin is an antiepileptic drug widely approved as an add-on therapy for epilepsy treatment in human and dogs. There is a clinical impression that gabapentin is a suitable drug which attenuates the IOP elevation associated with tracheal intubation in humans. The present study performed to determine the effects of oral gabapentin on intraocular pressure (IOP) changes following tracheal intubation in dogs. Twenty adult healthy dogs were randomly assigned to treatment (n = 10) and control (n = 10) groups. Dogs in the treatment group received oral gabapentin (50 mg/kg) 2 h before induction of anesthesia and dogs in the control group received oral gelatin capsule placebo at the same time. The dogs were anesthetized with propofol 6 mg/kg, and anesthesia was maintained with a constant infusion of 0.2 mg/kg/min of propofol for 20 min. IOP were measured immediately before induction and then repeated immediately after induction, as well as 5 min, 10 min and 15 min following tracheal intubation in both groups. IOP was significantly higher immediately after induction, and 5 min after tracheal intubation when compared with IOP reading before induction in the control group. There was no statistically significant change in IOPs immediately after induction, and 5 min after tracheal intubation in comparison to the values before induction in the treatment group. Based on the findings of this study, preanesthetic oral administration of gabapentin significantly prevents an increase in the IOP associated with tracheal intubation in dogs anesthetized with propofol.

Comparison of Coopdech®, CoPilot®, Intubrite®, and Macintosh laryngoscopes for tracheal intubation during pediatric cardiopulmonary resuscitation: a randomized, controlled crossover simulation trial.

PubMed

Szarpak, Łukasz; Czyżewski, Łukasz; Truszewski, Zenon; Kurowski, Andrzej; Gaszyński, Tomasz

2015-11-01

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.

Predictors of Silicone Tube Intubation Success in Patients with Lacrimal Drainage System Stenosis.

PubMed

Baek, Ji Sun; Lee, Saem; Lee, Jung Hye; Choi, Hye Sun; Jang, Jae Woo; Kim, Sung Joo

2016-06-01

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.

Comparison of the McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope by paramedics

PubMed Central

2011-01-01

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

Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes.

PubMed

Truszewski, Zenon; Czyzewski, Lukasz; Smereka, Jacek; Krajewski, Paweł; Fudalej, Marcin; Madziala, Marcin; Szarpak, Lukasz

2016-09-01

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.

[A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation].

PubMed

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 assisted intubation compared to other devices. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation.

PubMed

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 assisted intubation compared to other devices. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.

PubMed

Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

2015-11-01

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 awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics*

PubMed Central

Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

2015-01-01

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 awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. PMID:26449292

Technical realization of a sensorized neonatal intubation skill trainer for operators' retraining and a pilot study for its validation.

PubMed

Panizza, Davide; Scaramuzzo, Rosa T; Moscuzza, Francesca; Vannozzi, Ilaria; Ciantelli, Massimiliano; Gentile, Marzia; Baldoli, Ilaria; Tognarelli, Selene; Boldrini, Antonio; Cuttano, Armando

2018-01-04

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 personnel retraining.

Comparison of Preloaded Bougie versus Standard Bougie Technique for Endotracheal Intubation in a Cadaveric Model.

PubMed

Baker, Jay B; Maskell, Kevin F; Matlock, Aaron G; Walsh, Ryan M; Skinner, Carl G

2015-07-01

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.

Effect of just-in-time simulation training on tracheal intubation procedure safety in the pediatric intensive care unit.

PubMed

Nishisaki, Akira; Donoghue, Aaron J; Colborn, Shawn; Watson, Christine; Meyer, Andrew; Brown, Calvin A; Helfaer, Mark A; Walls, Ron M; Nadkarni, Vinay M

2010-07-01

Tracheal intubation-associated events (TIAEs) are common (20%) and life threatening (4%) in pediatric intensive care units. Physician trainees are required to learn tracheal intubation during intensive care unit rotations. The authors hypothesized that "just-in-time" simulation-based intubation refresher training would improve resident participation, success, and decrease TIAEs. For 14 months, one of two on-call residents, nurses, and respiratory therapists received 20-min multidisciplinary simulation-based tracheal intubation training and 10-min resident skill refresher training at the beginning of their on-call period in addition to routine residency education. The rate of first attempt and overall success between refresher-trained and concurrent non-refresher-trained residents (controls) during the intervention phase was compared. The incidence of TIAEs between preintervention and intervention phase was also compared. Four hundred one consecutive primary orotracheal intubations were evaluated: 220 preintervention and 181 intervention. During intervention phase, neither first-attempt success nor overall success rate differed between refresher-trained residents versus concurrent non-refresher-trained residents: 20 of 40 (50%) versus 15 of 24 (62.5%), P = 0.44 and 23 of 40 (57.5%) versus 18 of 24 (75.0%), P = 0.19, respectively. The resident's first attempt and overall success rate did not differ between preintervention and intervention phases. The incidence of TIAE during preintervention and intervention phases was similar: 22.0% preintervention versus 19.9% intervention, P = 0.62, whereas resident participation increased from 20.9% preintervention to 35.4% intervention, P = 0.002. Resident participation continued to be associated with TIAE even after adjusting for the phase and difficult airway condition: odds ratio 2.22 (95% CI 1.28-3.87, P = 0.005). Brief just-in-time multidisciplinary simulation-based intubation refresher training did not improve the resident's first attempt or overall tracheal intubation success.

Modified single-port non-intubated video-assisted thoracoscopic decortication in high-risk parapneumonic empyema patients.

PubMed

Hsiao, Chen-Hao; Chen, Ke-Cheng; Chen, Jin-Shing

2017-04-01

Parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction are risky to receive surgical decortication under general anesthesia. Non-intubated video-assisted thoracoscopy surgery is successfully performed to avoid complications of general anesthesia. We performed single-port non-intubated video-assisted flexible thoracoscopy surgery in an endoscopic center. In this study, the possible role of our modified surgery to treat fibrinopurulent stage of parapneumonic empyema with high operative risks is investigated. We retrospectively reviewed fibrinopurulent stage of parapneumonic empyema patients between July 2011 and June 2014. Thirty-three patients with coronary artery disease and reduced left ventricular ejection fraction were included in this study. One group received tube thoracostomy, and the other group received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Patient demographics, characteristics, laboratory findings, etiology, and treatment outcomes were compared. Mean age of 33 patients (24 males, 9 females) was 76.2 ± 9.7 years. Twelve patients received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication, and 21 patients received tube thoracostomy. Visual analog scale scores on postoperative first hour and first day were not significantly different in two groups (p value = 0.5505 and 0.2750, respectively). Chest tube drainage days, postoperative fever subsided days, postoperative hospital days, and total length of stay were significantly short in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication (p value = 0.0027, 0.0001, 0.0009, and 0.0065, respectively). Morbidities were low, and mortality was significantly low (p value = 0.0319) in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Single-port non-intubated video-assisted flexible thoracoscopy surgery decortication may be suggested to be a method other than tube thoracostomy to deal with fibrinopurulent stage of parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction.

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

PubMed Central

Jafra, Anudeep; Gombar, Satinder; Kapoor, Dheeraj; Sandhu, Harpreet Singh; Kumari, Kamlesh

2018-01-01

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

Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicentre, observational study of 2,327 patients.

PubMed

Sunde, Geir Arne; Heltne, Jon-Kenneth; Lockey, David; Burns, Brian; Sandberg, Mårten; Fredriksen, Knut; Hufthammer, Karl Ove; Soti, Akos; Lyon, Richard; Jäntti, Helena; Kämäräinen, Antti; Reid, Bjørn Ole; Silfvast, Tom; Harm, Falko; Sollid, Stephen J M

2015-08-07

Despite numerous studies on prehospital airway management, results are difficult to compare due to inconsistent or heterogeneous data. The objective of this study was to assess advanced airway management from international physician-staffed helicopter emergency medical services. We collected airway data from 21 helicopter emergency medical services in Australia, England, Finland, Hungary, Norway and Switzerland over a 12-month period. A uniform Utstein-style airway template was used for collecting data. The participating services attended 14,703 patients on primary missions during the study period, and 2,327 (16 %) required advanced prehospital airway interventions. Of these, tracheal intubation was attempted in 92 % of the cases. The rest were managed with supraglottic airway devices (5 %), bag-valve-mask ventilation (2 %) or continuous positive airway pressure (0.2 %). Intubation failure rates were 14.5 % (first-attempt) and 1.2 % (overall). Cardiac arrest patients showed significantly higher first-attempt intubation failure rates (odds ratio: 2.0; 95 % CI: 1.5-2.6; p < 0.001) compared to non-cardiac arrest patients. Complications were recorded in 13 %, with recognised oesophageal intubation being the most frequent (25 % of all patients with complications). For non-cardiac arrest patients, important risk predictors for first-attempt failure were patient age (a non-linear association) and administration of sedatives (reduced failure risk). The patient's sex, provider's intubation experience, trauma type (patient category), indication for airway intervention and use of neuromuscular blocking agents were not risk factors for first-attempt intubation failure. Advanced airway management in physician-staffed prehospital services was performed frequently, with high intubation success rates and low complication rates overall. However, cardiac arrest patients showed significantly higher first-attempt failure rates compared to non-cardiac arrest patients. All failed intubations were handled successfully with a rescue device or surgical airway. www.clinicaltrials.gov NCT01502111 . Registered 22 December 2011.

Preoperative airway assessment - experience gained from a multicentre cluster randomised trial and the Danish Anaesthesia Database.

PubMed

Nørskov, Anders Kehlet

2016-05-01

Difficulties with airway management in relation to general anaesthesia have been a challenge for the anaesthesiologist since the birth of anaesthesia. Massive landmark improvements have been made and general anaesthesia is now regarded as a safe procedure. However, rare, difficult airway management still occurs and it prompts increased risk of morbidity and mortality - especially when not anticipated. Several preoperative risk factors for airway difficulties have been identified, yet none have convincing diagnostic accuracy as stand alone tests. Combining several risk factors increase the predictive value of the test and multivariable risk models have been developed. The Simplified Airway Risk Index (SARI) is a predictive model developed for anticipation of a difficult direct laryngoscopy. However, neither the diagnostic accuracy of the SARI nor of any other model has been tested prospectively and compared with existing practice for airway assessment in a randomised trial setting. The first objective of this thesis was to quantify the proportion of unanticipated difficult intubation and difficult mask ventilation in Denmark. The second objective was to design a cluster randomised trial, using state of the art methodology, in order to test the clinical impact of using the SARI for preoperative airway assessment compared with a clinical judgement based on usual practice for airway assessment. Finally, to test if implementation of the SARI would reduce the proportion of unanticipated difficult intubation compared with usual care for airway assessment. This thesis is based on data from the Danish Anaesthesia Database (DAD). Paper 1 presents an observational cohort study on 188,064 patients who underwent tracheal intubation from 2008 to 2011. Data on the anaesthesiologists' preoperative anticipations of airway difficulties was compared with actual airway management conditions, thus enabling an estimation of the proportion of unanticipated difficulties with intubation and mask ventilation. Papers 2 and 3 outline the methodology and the pre-trial calculations and considerations leading to the DIFFICAIR trial described in Paper 4. The trial was designed to randomise anaesthesia department to either thorough education in, and subsequent use of the SARI for preoperative airway assessment or to continue usual care. Registration of the SARI in DAD was made mandatory in SARI departments and impossible in usual care departments. Conditions regarding anticipation of difficulties and actual airway managements were recorded as for Paper 1. DAD data made it possible to estimate an appropriate sample size, considering the between cluster variation, and to construct a stratification variable based on 2011 baseline values of the primary outcome used in the DIFFICAIR trial. Paper 1 revealed that 1.86% of all patients who were intubated, but not planned for advanced intubation techniques (e.g. video laryngoscopy), were unanticipated difficult to intubate. However, 75 to 93% of all difficult intubations were unanticipated. Furthermore, 94% of all difficult mask ventilations were unanticipated. In Paper 4, 59,514 patients were included in the primary analyses. The proportion of unanticipated difficult intubations was 2.38% (696/29,209) in SARI departments and 2.39% (723/30,305) in usual care departments. The adjusted odds ratio was 1.03 (95% CI: 0.77-1.38), p = 0.84. No significant differences were detected in other adjusted outcome measures and neither a 58% increase in patients anticipated to have intubation difficulties nor an 84% increase in patients scheduled for advanced intubation techniques in SARI departments reached statistical significance, p = 0.29 and p = 0.06 respectively. The papers constituting this thesis demonstrate that at high proportion of airway management difficulties are unanticipated. In a cluster randomised trial it was not possible to reduce the proportion of unanticipated difficult intubation in daily clinical practice by implementing a systematic approach for airway assessment compared with usual care. However, implementation of the SARI may increase the anticipation of intubation difficulties and it may change practice towards advanced intubation techniques. This thesis underlines the continued challenge anaesthesiologists face in predicting airway management related difficulties.

The combined use of Skype and the STORZ CMAC video laryngoscope in field intubation training with the Nebraska National Air Guard.

PubMed

Boedeker, Ben H; Bernhagen, Mary; Miller, David J; Miljkovic, Nikola; Kuper, Gail M; Murray, W Bosseau

2011-01-01

This study examined the feasibility of using Skype technology in basic manikin intubation instruction of Nebraska National Air Guard personnel at a Casualty Training Exercise. Results show that the Skype monitor provided clear sound and visualization of the airway view to the trainees and the combination of VoIP technology and videolaryngoscopy for intubation training was highly valued by study participants.

Asymptomatic vallecular cyst: case report.

PubMed

Yuce, Yucel; Uzun, Sennur; Aypar, Ulku

2013-01-01

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.

Video laryngoscopy in pre-hospital critical care - a quality improvement study.

PubMed

Rhode, Marianne Grønnebæk; Vandborg, Mads Partridge; Bladt, Vibeke; Rognås, Leif

2016-06-13

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 introducing McGrath MAC video laryngoscope. The implementation of the Standard Operating Procedure and check list for pre-hospital anaesthesia during the study period may have influenced the first-pass success rate and constitutes a potential confounder. The potential limitations of the McGrath MAC video laryngoscope when there are gastric content, blood and secretions in the airways need to be further investigated before the McGrath MAC video laryngoscope can be recommended as the primary device in all pre-hospital endotracheal intubations.

Protection afforded by respirators when performing endotracheal intubation using a direct laryngoscope, GlideScope®, and i-gel® device: A randomized trial

PubMed Central

Lim, Tae Ho; Oh, Jaehoon; Lee, Juncheol; Shin, Hyungoo

2018-01-01

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

Proper size of endotracheal tube for cleft lip and palate patients and intubation outcomes.

PubMed

Abdollahifakhim, Shahin; Sheikhzadeh, Dariush; Shahidi, Nikzad; Nojavan, Gholamreza; Bayazian, Gholamreza; Aleshi, Hamideh

2013-05-01

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.

The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration

PubMed Central

Cha, Dong Guk; Jeong, Ji Seon; Kwon, Hye Mee

2014-01-01

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

A new composite measure of colonoscopy: the Performance Indicator of Colonic Intubation (PICI).

PubMed

Valori, Roland M; Damery, Sarah; Gavin, Daniel R; Anderson, John T; Donnelly, Mark T; Williams, J Graham; Swarbrick, Edwin T

2018-01-01

 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.

Association of cumulative dose of haloperidol with next-day delirium in older medical ICU patients.

PubMed

Pisani, Margaret A; Araujo, Katy L B; Murphy, Terrence E

2015-05-01

To evaluate the association between cumulative dose of haloperidol and next-day diagnosis of delirium in a cohort of older medical ICU patients, with adjustment for its time-dependent confounding with fentanyl and intubation. Prospective, observational study. Medical ICU at an urban, academic medical center. Age 60 years and older admitted to the medical ICU who received at least one dose of haloperidol (n = 93). Of these, 72 patients were intubated at some point in their medical ICU stay, whereas 21 were never intubated. None. Detailed data were collected concerning time, dosage, route of administration of all medications, as well as for important clinical covariates, and daily status of intubation and delirium using the confusion assessment method for the ICU and a chart-based algorithm. Among nonintubated patients, and after adjustment for time-dependent confounding and important covariates, each additional cumulative milligram of haloperidol was associated with 5% higher odds of next-day delirium with odds ratio of 1.05 (credible interval [CI], 1.02-1.09). After adjustment for time-dependent confounding and covariates, intubation was associated with a five-fold increase in odds of next-day delirium with odds ratio of 5.66 (CI, 2.70-12.02). Cumulative dose of haloperidol among intubated patients did not change their already high likelihood of next-day delirium. After adjustment for time-dependent confounding, the positive associations between indicators of intubation and of cognitive impairment and next-day delirium became stronger. These results emphasize the need for more studies regarding the efficacy of haloperidol for treatment of delirium among older medical ICU patients and demonstrate the value of assessing nonintubated patients.

A comparison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal intubation during resuscitation by paramedics. A randomized, crossover, manikin study.

PubMed

Szarpak, Lukasz; Truszewski, Zenon; Czyzewski, Lukasz; Gaszynski, Tomasz; Rodríguez-Núñez, Antonio

2016-08-01

Prehospital tracheal intubation by paramedics during cardiopulmonary resuscitation (CPR) in children is challenging. The potential role of new intubation devices during CPR is unclear. Our objective was to assess the impact of CPR (with and without chest compressions [CCs]) on the success and time to intubation (TTI) with the Macintosh laryngoscope vs the McGrath video laryngoscope on a pediatric manikin. This was an open, prospective, randomized, crossover, manikin trial involving 95 paramedics who performed intubations in a PediaSIM pediatric high-fidelity manikin with Macintosh and McGrath laryngoscopes, with and without concomitant mechanical CCs. Primary outcome was the TTI, and secondary outcome was success of the attempt. Participants rated their best glottic view, the severity of the potential dental trauma, and subjective opinion about the difficulty of the procedure. The median TTI with the Macintosh in the scenario with uninterrupted CC was 33 (interquartile range [IQR], 24-36) seconds, which is significantly longer than TTI in the scenario with interrupted CC (23 [IQR, 20-29] seconds, P < .001). Time to intubation using the McGrath was similar in both scenarios: 20 (IQR, 17-23) seconds vs 19.5 (IQR, 17-22) seconds (P = .083). A statistically significant difference between McGrath and Macintosh was noticed in TTI both in scenario with (P < .001) and without CC (P = .017). McGrath video laryngoscope helps paramedics to intubate a pediatric manikin in a CPR scenario in less time and with fewer attempts than with the classical Macintosh, both in case of ongoing or stopped CC. McGrath use in actual patients could improve CPR quality by paramedics. Copyright © 2015 Elsevier Inc. All rights reserved.

Crisis management during anaesthesia: difficult intubation.

PubMed

Paix, A D; Williamson, J A; Runciman, W B

2005-06-01

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.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

PubMed

von Elm, E; Schoettker, P; Henzi, I; Osterwalder, J; Walder, B

2009-09-01

We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Nasal high-flow oxygen therapy improves arterial oxygenation during one-lung ventilation in non-intubated thoracoscopic surgery.

PubMed

Wang, Man-Ling; Hung, Ming-Hui; Chen, Jin-Shing; Hsu, Hsao-Hsun; Cheng, Ya-Jung

2018-05-01

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.

Advances in Laryngoscopy.

PubMed

Aziz, Michael

2015-01-01

Recent technological advances have made airway management safer. Because difficult intubation remains challenging to predict, having tools readily available that can be used to manage a difficult airway in any setting is critical. Fortunately, video technology has resulted in improvements for intubation performance while using laryngoscopy by various means. These technologies have been applied to rigid optical stylets, flexible intubation scopes, and, most notably, rigid laryngoscopes. These tools have proven effective for the anticipated difficult airway as well as the unanticipated difficult airway.

An evaluation of the retromolar space for oral tracheal tube placement for maxillofacial surgery in children.

PubMed

Arora, Suman; Rattan, Vidya; Bhardwaj, Neerja

2006-11-01

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.

Awake Fibreoptic Intubation for Forearm Injury in a Patient with Occipito-Cervical Fixator

PubMed Central

Akkaya, Akcan; Yıldız, İsa; Demirhan, Abdullah; Tekelioğlu, Ümit Yaşar; Koçoğlu, Hasan

2013-01-01

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

Betel quid, chewing habits and difficult intubation: A case report and critical appraisal of evidence for practice.

PubMed

Narendra, P L; Hegde, Harihar V; Vijaykumar, T K; Nallamilli, Samson

2015-01-01

Betel quid is used by 10-20% of world of population. Oral submucus fibrosis (OSF) is a chronic premalignant disease common in South Asian countries where betel quid is chewed. It is characterized by juxtaepithelial fibrosis of oral cavity and limited mouth opening, which can cause difficult intubation. A recent study in Taiwan has revealed long-term betel nut chewing is not predictor of difficult intubation. We describe two cases of OSF and critically analyze this study and its implications for clinical practice. OSF is now seen in Saudi Arabia and western countries with use of commercial betel quid substitutes. Although betel quid without tobacco is used in Taiwan, available evidence suggests rapid and early development of OSF where commercial chewing products like Pan Masala are used in India. Effects of betel quid may vary depending on the composition of quid and chewing habits. Studies where personal habits are involved must be analyzed carefully for external validity. Even though, Taiwan study is controlled, its validity outside Taiwan is highly questionable. Since OSF can cause unanticipated difficult intubation, thus during preanesthetic assessment, history of betel quid chewing, more importantly use of commercial chewing products is more likely to give clues to severity of OSF and possible difficult intubation. Further controlled trails in populations where commercial chewing products are used is necessary to detect association of chewing habits and difficult intubation.

Preventing pressure sores of the nasal ala after nasotracheal tube intubation: from animal model to clinical application.

PubMed

Huang, Tze-Ta; Tseng, Chih-En; Lee, Tsan-Mu; Yeh, Jen-Ying; Lai, Yu-Yung

2009-03-01

Nasal-ala pressure sores induced by nasotracheal intubation are common complications of oral and maxillofacial surgery, but are easily ignored. To determine whether such sores could be prevented, we studied the effects of a combination of cushioning material in an animal model, and then analyzed the efficacy of this combination clinically. Four pigs received nasotracheal intubation. Each pig received intubation for 4, 8, 12, or 16 hours. Outcomes from pigs undergoing 500-gram-weight compression on each nostril were compared: one nostril received an application of cushioning materials, and the contralateral nostril did not. After the required study period, clinical assessment and further evaluation were performed by measuring pressure-sore dimensions and performing incisional biopsies. Clinical applications of this protective technique were then undertaken. Eight patients who underwent intubation without Soft Liner (GC Co, Tokyo, Japan) and DuoDERM CGF (ConvaTec, Inc, Princeton, NJ) protection, and 10 patients with Soft Liner and DuoDERM protection, were evaluated. The protective efficacy of the cushioning materials was significant in the animal model as well as in clinical practice. Pressure sores were avoided on the protected side, with severe tissue necrosis documented on the control side. We found that the combined use of Soft Liner and DuoDERM reduced the size and severity of nasal-ala pressure sores attributable to nasotracheal intubation during oral and maxillofacial surgery.

Laryngoscope plastic blades in scheduled general anesthesia patients: a comparative randomized study.

PubMed

Galinski, Michel; Catineau, Jean; Rayeh, Fatima; Muret, Jane; Ciebiera, Jean-Pierre; Plantevin, Frédéric; Foucrier, Arnaud; Tual, Loic; Combes, Xavier; Adnet, Frédéric

2011-03-01

To compare two brands of disposable plastic laryngoscope blades, Vital View plastic blades and Heine XP plastic blades, with the reusable Heine Classic+ Macintosh metal blades. Prospective randomized, controlled, single-blinded study. Operating room of a university-affiliated hospital. 519 patients without criteria for predicted difficult intubation, undergoing scheduled surgery during general anesthesia. Patients were randomized to three groups according to laryngoscope blade brand. Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS) (IDS > 5 = procedure involving moderate to major difficulty). The percentage of intubations with an IDS > 5 was 3.1% in Group M (metal blade group), 5.1% in Group V (Vital View plastic blade group), and 10.0% in Group H (Heine plastic blade group). A significant difference was noted between Groups M and H (P = 0.02) but not between Groups M and V. Intubation may be more challenging when using Heine XP plastic blades but no significant difference exists between Vital-View plastic blades and Heine Classic+ metal blades. Copyright © 2011 Elsevier Inc. All rights reserved.

Comparison of 4 supraglotttic devices used by paramedics during simulated CPR : a randomized controlled crossover trial.

PubMed

Szarpak, Łukasz; Kurowski, Andrzej; Truszewski, Zenon; Robak, Oliver; Frass, Michael

2015-08-01

Ensuring an open airway during cardiopulmonary resuscitation is fundamental. The aim of this study was to determine the success rate of blind intubation during simulated cardiopulmonary resuscitation by untrained personnel. Four devices were compared in a simulated resuscitation scenario: ILMA (Intavent Direct Ltd, Buckinghamshire, United Kingdom), Cobra PLA (Engineered Medical Systems Inc, Indianapolis, IN), Supraglottic Airway Laryngopharyngeal Tube (SALT) (ECOLAB, St. Paul, MN), and Air-Q (Mercury Medical, Clearwater, FL). A group of 210 paramedics intubated a manikin with continuous chest compressions. The mean times to intubation were 40.46 ± 4.64, 33.96 ± 6.23, 17.2 ± 4.63, and 49.23 ± 13.19 seconds (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05). The success ratios of blind intubation for the devices were 86.7%, 85.7%, 100%, and 71.4% (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05). The study showed that the most efficient device with the shortest blind intubation time was the SALT device. Copyright © 2015 Elsevier Inc. All rights reserved.

Comparison of the Pentax, Truview, GlideScope, and the Miller laryngoscope for child intubation during resuscitation.

PubMed

Szarpak, Łukasz; Czyżewski, Łukasz; Kurowski, Andrzej

2015-03-01

The study was designed to compare the effectiveness of 3 video laryngoscopes with the Miller laryngoscope during pediatric resuscitation. This was a randomized crossover study involving 87 paramedics and 54 nurses. The primary end point of the study was the success rate of blind tracheal intubation, whereas the secondary end point was defined as the time from insertion of a device to the first manual ventilation of the manikin's lungs. The median time to intubation using the Pentax, Truview, GlideScope, and Miller varied with the times being 20.6 (interquartile range [IQR], 18-27) vs 20.1 (IQR, 18-23.3) vs 30.2 (IQR, 29.6-35) vs 41.3 (IQR, 33-45.2) seconds, respectively. The overall success ratios of intubation for the devices were 100% vs 100% vs 100% vs 79.4%. We concluded that, in a pediatric manikin scenario, the video laryngoscopes are safe devices and can be used for pediatric intubation during uninterrupted chest compressions. Further clinical studies are necessary to confirm these initial positive findings. Copyright © 2015 Elsevier Inc. All rights reserved.

Tracheal intubation using Macintosh and 2 video laryngoscopes with and without chest compressions.

PubMed

Kim, Young-Min; Kim, Ji-Hoon; Kang, Hyung-Goo; Chung, Hyun Soo; Yim, Hyeon-Woo; Jeong, Seung-Hee

2011-07-01

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.

Routine antibiotic cover for newborns intubated for aspirating meconium: is it necessary?

PubMed

Krishnan, L; Nasruddin; Prabhakar, P; Bhaskaranand, N

1995-05-01

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.

A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age.

PubMed

Szmuk, Peter; Ezri, Tiberiu; Evron, Shmuel; Roth, Yehudah; Katz, Jeffrey

2008-02-01

To present a concise history of tracheostomy and tracheal intubation for the approximately forty centuries from their earliest description around 2000 BC until the middle of the twentieth century, at which time a proliferation of advances marked the beginning of the modern era of anesthesiology. Review of the literature. The colorful and checkered past of tracheostomy and tracheal intubation informs contemporary understanding of these procedures. Often, the decision whether to perform a life-saving tracheostomy or tracheal intubation has been as important as the technical ability to perform it. The dawn of modern airway management owes its existence to the historical development of increasingly effective airway devices and to regular contributions of research into the pathophysiology of the upper airway.

A retrospective study of the performance of video laryngoscopy in an obstetric unit.

PubMed

Aziz, Michael F; Kim, Diana; Mako, Jeffrey; Hand, Karen; Brambrink, Ansgar M

2012-10-01

We evaluated the performance of tracheal intubation using video laryngoscopy in an obstetric unit. We analyzed airway management details during a 3-year period, and observed 180 intubations. All cases were managed with direct or video laryngoscopy. Direct laryngoscopy resulted in 157 out of 163 (95% confidence interval [CI], 92%-99%) first attempt successful intubations and failed once. Video laryngoscopy resulted in 18 of 18 (95% CI, 81%-100%) successful intubations on first attempt. The failed direct laryngoscopy was rescued with video laryngoscopy. The patients managed with video laryngoscopy frequently required urgent or emergency surgery and had predictors of difficult direct laryngoscopy in 16 of 18 cases. Video laryngoscopy may be a useful adjunct for obstetric airway management, and its role in this difficult airway scenario should be further studied.

Anaesthetic management in Gorlin-Goltz syndrome.

PubMed

Gosavi, Kundan S; Mundada, Surbhi D

2012-07-01

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.

Critical Analyses and Development of Training Mechanisms: Cholinergic Crisis and Pediatric/Neonatal Intubation

DTIC Science & Technology

2013-12-01

194-195. 9. Akierman A, Daya K , McPhail K , Singhal N, Steinke C, Thomson B . A comparison of three neonatal intubation training programs in calgary...1995;10(4):251-258. 226. Ruetzler K , Roessler B , Potura L, et al. Performance and skill retention of intubation by paramedics using seven different...LIMITATION OF ABSTRACT 18. NUMBER OF PAGES 19a. NAME OF RESPONSIBLE PERSON USAMRMC a. REPORT U b . ABSTRACT U c. THIS PAGE U UU

Intubation simulation with a cross-sectional visual guidance.

PubMed

Rhee, Chi-Hyoung; Kang, Chul Won; Lee, Chang Ha

2013-01-01

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.

Comparison of Airway Management Methods in Entrapped Patients: A Manikin Study.

PubMed

Martin, Andrew B; Lingg, Jim; Lubin, Jeffrey S

2016-01-01

Endotracheal intubation remains one of the most challenging skills in prehospital care. There is a minimal amount of data on the optimal technique to use when managing the airway of an entrapped patient. We hypothesized that use of a blindly placed device would result in both the shortest time to airway management and highest success rate. A difficult airway manikin was placed in a cervical collar and secured upside down in an overturned vehicle. Experienced paramedics and prehospital registered nurses used four different methods to secure the airway: direct laryngoscopy, digital intubation, King LT-D, and CMAC video laryngoscopy. Each participant was given three opportunities to secure the airway using each technique in random order. A study investigator timed each attempt and confirmed successful placement, which was determined upon inflation of the manikin's lungs. Intubation success rates were analyzed using a general estimating equations model to account for repeated measures and a linear mixed effects model for average time. Twenty-two prehospital providers participated in the study. The one-pass success rate for the King LT-D was significantly higher than direct laryngoscopy (OR 0.048, CI 0.006-0.351, p < 0.01) and digital intubation (OR 0.040, CI 0.005-0.297, p < 0.01). However, there was no statistical difference between the one-pass success rate of the King LT-D and CMAC video laryngoscopy (OR 0.302, 95% CI 0.026-3.44, p = 0.33). The one-pass median placement time of the King LT-D (22 seconds, IQR 17-26) was significantly lower (p < 0.001) than direct laryngoscopy (60 seconds, IQR 42-75), digital intubation (38 seconds, IQR 26-74), and the CMAC (51 seconds, IQR 43-76). In this study, while the King LT-D offered the quickest airway placement, success rates were not significantly greater than intubation using the CMAC video laryngoscope. Intubation using direct laryngoscopy and digital intubation were less successful and took more time. Use of a blindly placed device or a video laryngoscope may provide the best avenues for airway management of entrapped patients.

Tracheal intubation in the ice-pick position with video laryngoscopes: a randomised controlled trial in a manikin.

PubMed

Wetsch, Wolfgang A; Hellmich, Martin; Spelten, Oliver; Schier, Robert; Böttiger, Bernd W; Hinkelbein, Jochen

2013-09-01

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.

Pre-Hospital Intubation Factors and Pneumonia in Trauma Patients

PubMed Central

Warner, Keir; Bulger, Eileen M.; Sharar, Sam R.; Maier, Ronald V.; Cuschieri, Joseph

2011-01-01

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 the risk of VAP after aspiration. PMID:21933010

Pre-hospital intubation factors and pneumonia in trauma patients.

PubMed

Evans, Heather L; Warner, Keir; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph

2011-10-01

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.

Pre-hospital aspiration is associated with increased pulmonary complications.

PubMed

Fawcett, Vanessa J; Warner, Keir J; Cuschieri, Joseph; Copass, Michael; Grabinsky, Andreas; Kwok, Heemun; Rea, Thomas; Evans, Heather L

2015-04-01

Rates of ventilator-associated pneumonia (VAP) are highest among patients intubated on an emergency basis following trauma. We reported previously a retrospective analysis demonstrating an association between subjective aspiration and VAP after pre-hospital intubation. We hypothesize that by directing paramedics to note features of aspiration at intubation, we will confirm prospectively the association between pre-hospital aspiration and subsequent pneumonia in trauma patients. Paramedics collected data regarding aspiration at the time of intubation. All intubated patients admitted to a level 1 trauma center intensive care unit (ICU) were included. Data comprised a clinical impression of pre-hospital aspiration, as well as the presence and timing of blood and emesis in the airway. Injury severity, co-morbidities, and outcomes were collected from the trauma registry. Healthcare-associated pneumonia (HAP) was identified by medical record review of both bronchoalveolar lavage culture results and discharge diagnosis. Descriptive statistics and univariate analysis of outcomes by aspiration status, as well as covariable adjustment using propensity scores, were performed. Of the 228 patients, 89 (39%) were determined by paramedics to have aspirated. The majority of those who aspirated (84 [94%]) did so prior to intubation. Patients who aspirated had higher Injury Severity Scores than those who did not aspirate (25.0 ± 1.7 vs. 21.9 ± 1.5 points; p=0.04) and lower preintubation Glasgow Coma Scale scores (8.2 ± 0.50 vs. 9.6 ± 0.40; p=0.02). Of the 89 patients who aspirated around the time of intubation, 14 (16%) developed HAP vs. five (3.6%) of those who did not aspirate (p<0.01). We observed non-significant increases in mortality rate, ICU length of stay (LOS) and duration of mechanical ventilation after aspiration (deaths: 21 [23.6%] vs. 23 [16.6%]; p=0.19; ICU LOS: 5.3 ± 0.9 vs. 4.1 ± 0.5 days; p=0.13; duration of mechanical ventilation: 5.3 ± 1.2 vs. 3.2 ± 0.5 days; p=0.10). Aspiration prior to intubation was reported commonly by paramedics and was associated with a higher risk of HAP.

[The effect of esmolol on corrected-QT interval, corrected-QT interval dispersion changes seen during anesthesia induction in hypertensive patients taking an angiotensin-converting enzyme inhibitor].

PubMed

Ceker, Zahit; Takmaz, Suna Akın; Baltaci, Bülent; Başar, Hülya

2015-01-01

The importance of minimizing the exaggerated sympatho-adrenergic responses and QT interval and QT interval dispersion changes that may develop due to laryngoscopy and tracheal intubation during anesthesia induction in the hypertensive patients is clear. Esmolol decreases the hemodynamic response to laryngoscopy and intubation. However, the effect of esmolol in decreasing the prolonged QT interval and QT interval dispersion as induced by laryngoscopy and intubation is controversial. We investigated the effect of esmolol on the hemodynamic, and corrected-QT interval and corrected-QT interval dispersion changes seen during anesthesia induction in hypertensive patients using angiotensin converting enzyme inhibitors. 60 ASA I-II patients, with essential hypertension using angiotensin converting enzyme inhibitors were included in the study. The esmolol group received esmolol at a bolus dose of 500mcg/kg followed by a 100mcg/kg/min infusion which continued until the 4th min after intubation. The control group received 0.9% saline similar to the esmolol group. The mean blood pressure, heart rate values and the electrocardiogram records were obtained as baseline values before the anesthesia, 5min after esmolol and saline administration, 3min after the induction and 30s, 2min and 4min after intubation. The corrected-QT interval was shorter in the esmolol group (p=0.012), the corrected-QT interval dispersion interval was longer in the control group (p=0.034) and the mean heart rate was higher in the control group (p=0.022) 30s after intubation. The risk of arrhythmia frequency was higher in the control group in the 4-min period following intubation (p=0.038). Endotracheal intubation was found to prolong corrected-QT interval and corrected-QT interval dispersion, and increase the heart rate during anesthesia induction with propofol in hypertensive patients using angiotensin converting enzyme inhibitors. These effects were prevented with esmolol (500mcg/kg bolus, followed by 100mcg/kg/min infusion). During induction, the blood pressure tends to decrease with esmolol where care is needed. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Low Indeterminate Rates Associated With Use of the QuantiFERON-TB Gold In-Tube Test in Children With Inflammatory Bowel Disease on Long-term Infliximab.

PubMed

Vortia, Eugene; Uko, Victor E; Yen-Lieberman, Belinda; Frawley, Jill; Worley, Sarah E; Danziger-Isakov, Lara; Kaplan, Barbara; Mahajan, Lori

2018-03-19

Tumor necrosis factor alpha (TNF-α) inhibitors are linked with increased risk of reactivation of active tuberculosis. The QuantiFERON-TB Gold In-Tube test is approved for screening latent tuberculosis infection in children and adults. There are limited data on the test performance in children on long-term treatment with TNF-α inhibitors. The objective of this study was to assess the proportion of indeterminate results for the QuantiFERON-TB Gold In-Tube in children with inflammatory bowel disease (IBD) on long-term infliximab treatment and to evaluate the range of interferon-γ responses to mitogen. A single-center prospective study of children 5 to 19 years of age with IBD on long-term infliximab treatment (>3 months). Each child was assessed for tuberculosis exposure risk and had blood drawn for the QuantiFERON-TB Gold In-Tube. Data on the range of interferon-γ responses and final QuantiFERON-TB Gold In-Tube test results were collected. Ninety-three children were included, with a median age of 16 years. The median total duration of infliximab therapy was 34 months (range, 3-119 months). The QuantiFERON-TB Gold In-Tube was indeterminate in 1 patient (1.1%), positive in 2 patients, and negative in 90 patients. The maximum interferon-γ response to mitogen (10 IU/mL) was observed in 82 patients (88%), with only 1 patient having an inadequate response. The proportion of indeterminate results was significantly lower than the prospectively hypothesized rate of 8%, based on prior studies in nonimmunosuppressed patients (P = 0.004). Pediatric patients with IBD on long-term treatment with infliximab had an adequate interferon-γ response to mitogen and a low indeterminate rate when assessed with the QuantiFERON-TB Gold In-Tube test. This study demonstrates a robust interferon gamma response to phytohemagglutinin stimulation in a pediatric population on long-term therapy with infliximab. The QuantiFERON-TB Gold In-Tube test may therefore be useful as a periodic screening tactic for latent TB in children on long-term infliximab therapy.

Influence of the method of fluoride administration on toxicity and fluoride concentrations in Japanese quail

USGS Publications Warehouse

Fleming, W.J.; Schuler, C.A.

1988-01-01

Young Japanese quail (Coturnix japonica) were administered NaF for 16 d either in their diet or by esophageal intubation. Based on the total fluoride ion (Emg F-) intake over the l6-d experimental period, fluoride administered by intubation was at least six times more toxic than that fed in the diet. Dietary concentrations of 1,000 ppm F- (Emg F- for 16 d = approx. 144) produced no mortality, whereas intubated doses produced 73% or greater mortality in all groups administered 54 mg F- /kg/d or more (Emg F- for 16 d _ approx. 23 mg). GraphIc companson of the regression of log F- ppm in femurs/mg F- intake showed that fluoride levels in the femurs of quail administered fluoride by intubation were higher than in those administered fluoride in the diet.

Retrograde intubation: an alternative way for the management of difficult airway.

PubMed

Lama, P; Shrestha, B R

2008-01-01

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.

Endotracheal intubation - A life saving procedure, still potential hazardous to upper airway: A case report.

PubMed

Afreen, Mahrukh; Ansari, Murtaza Ahsan

2015-12-01

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.

Front teeth-to-carina distance in children undergoing cardiac catheterization.

PubMed

Hunyady, Agnes I; Pieters, Benjamin; Johnston, Troy A; Jonmarker, Christer

2008-06-01

Knowledge of normal front teeth-to-carina distance (FT-C) might prevent accidental bronchial intubation. The aim of the current study was to measure FT-C and to examine whether the Morgan formula for oral intubation depth, i.e., endotracheal tube (ETT) position at front teeth (cm) = 0.10 x height (cm) + 5, gives appropriate guidance when intubating children of different ages. FT-C was measured in 170 infants and children, aged 1 day to 19 yr, undergoing cardiac catheterization. FT-C was obtained as the sum of the ETT length at the upper front teeth/dental ridge and the distance from the ETT tip to the carina. The latter measure was taken from an anterior-posterior chest x-ray. There was close linear correlation between FT-C and height: FT-C (cm) = 0.12 x height (cm) + 5.2, R = 0.98. The linear correlation coefficients (R) for FT-C versus weight and age were 0.78 and 0.91, respectively. If the Morgan formula had been used for intubation, the ETT tip would have been at 90 +/- 4% of FT-C. No patient would have been bronchially intubated, but the ETT tip would have been less than 0.5 cm from the carina in 13 infants. FT-C can be well predicted from the height/length of the child. The Morgan formula provides good guidance for intubation in children but can result in a distal ETT tip position in small infants. Careful auscultation is necessary to ensure correct tube position.

Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate?

PubMed

Cemalovic, Nail; Scoccimarro, Anthony; Arslan, Albert; Fraser, Robert; Kanter, Marc; Caputo, Nicholas

2016-06-01

The main objective of the present study was to examine the perceived versus actual time to intubation (TTI) as an indication to help determine the situational awareness of Emergency Physicians during rapid sequence intubation and, additionally, to determine the physician's perception of desaturation events. A timed, observation prospective cohort study was conducted. A post-intubation survey was administered to the intubating physician. Each step of the procedure was timed by an observer in order to determine actual TTI. The number of desaturation events was also recorded. One hundred individual intubations were included. The provider perceived TTI was significantly different and underestimated when compared with the actual TTI (23 s, 95% confidence interval (CI) 20.4-25.49 vs 45.5 s, 95% CI 40.2-50.7, P < 0.001, respectively). Pearson correlation coefficient of perceived TTI to actual TTI was r(2)  = 0.39 (95% CI 0.21-0.54, P < 0.001). The provider perceived desaturation rate was also significantly different from actual desaturation rate (13, 95% CI 3-12 vs 23, 95% CI 13-29, P = 0.05, respectively). The overall time to desaturation was 65.1 s. Our findings have shown that provider's perception of TTI occurs sooner than actually observed. Also, the providers were less aware of desaturation during the procedure. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Endotracheal Intubation With and Without Night Vision Goggles in a Helicopter and Emergency Room Setting: A Manikin Study.

PubMed

Gellerfors, Mikael; Svensén, Christer; Linde, Joacim; Lossius, Hans Morten; Gryth, Dan

2015-09-01

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.

Optimization of Ultrasound Transducer Positioning for Endotracheal Tube Placement Confirmation in Cadaveric Model.

PubMed

Lonchena, Tiffany; So, Sokpoleak; Ibinson, James; Roolf, Peter; Orebaugh, Steven L

2017-02-01

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.

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation.

PubMed

Qureshi, Mosarrat J; Kumar, Manoj

2018-03-15

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 studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events. LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.

Bilateral vocal cord paralysis secondary to head and neck surgery.

PubMed

Tekin, Muhammet; Acar, Gul Ozbilen; Kaytaz, Asim; Savrun, Feray Karaali; Çelik, Melek; Cam, Osman Halit

2012-01-01

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.

Thirty years of submental intubation: a review.

PubMed

Lim, D; Ma, B C; Parumo, R; Shanmuhasuntharam, P

2018-05-03

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.

Anaesthetic management in Gorlin-Goltz syndrome

PubMed Central

Gosavi, Kundan S; Mundada, Surbhi D

2012-01-01

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

Securing a Difficult Airway: Tracheal Intubation Achieved after Deliberate Placement of an Endotracheal Tube in Esophagus: A New Approach

PubMed Central

Chopra, Vanilla; Mehta, Nandita; Dar, Mohd Reidwan

2017-01-01

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

Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial.

PubMed

Sitzwohl, Christian; Langheinrich, Angelika; Schober, Andreas; Krafft, Peter; Sessler, Daniel I; Herkner, Harald; Gonano, Christopher; Weinstabl, Christian; Kettner, Stephan C

2010-11-09

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 21 cm in women and 23 cm in men. By inserting the tube to these distances, however, the distal tip of the tube was less than 2.5 cm away from the carina (the recommended safety distance, to prevent inadvertent endobronchial intubation with changes in the position of the head in intubated patients) in 20% (24/118) of women and 18% (7/42) of men. Therefore optimal tube insertion depth was considered to be 20 cm in women and 22 cm in men. Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. NCT01232166.

Manikin Laryngoscopy Motion as a Predictor of Patient Intubation Outcomes: A Prospective Observational Study

PubMed Central

Kedarisetty, Suraj; Johnson, Jennifer Moitoza; Glaser, Dale; Delson, Nathan

2018-01-01

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.

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis.

PubMed

Caruana, Emmanuel; Chevret, Sylvie; Pirracchio, Romain

2017-03-01

The benefit of cricoid pressure during tracheal intubation is still debated and, due to its potential negative impact on laryngeal views, its routine use is questioned. The goal of this study was to estimate its impact on laryngeal view. All patients intubated in the prehospital setting were included. Three different propensity score (PS) models were used and compared in terms of the balance achieved between those patients who received cricoid pressure and those who did not. The PS model that optimised the balance was retained in order to estimate the relationship between cricoid pressure and the following outcomes: difficult laryngoscopy, intubation-related complications and difficult intubation. Among the 1195 patients included, 499 (41.7%) received cricoid pressure. The optimal PS included seven variables (cardiac arrest, altered neurological status, shock, respiratory distress, gender, obesity, patient's position). After PS matching, no significant risk difference (RD) in the rate of difficult laryngoscopy was found between the patients who received cricoid pressure and those who did not (RD=0.001, 95% CI -0.07 to 0.08, p=0.50). No significant difference was found in terms of difficult intubation (RD=0.06, 95% CI -0.13 to 0.25, p=0.28) and in terms of prevalence of complications, except for airway trauma that were more frequent in cricoid pressure group (RD=0.03, 95% CI 0.002 to 0.05, p=0.01). No significant relationship was found between the use of cricoid pressure for prehospital intubation and difficult laryngoscopy. Cricoid pressure was found to be associated with more airway trauma. This finding could question its routine use. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Incidence of Connected Consciousness after Tracheal Intubation: A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique.

PubMed

Sanders, Robert D; Gaskell, Amy; Raz, Aeyal; Winders, Joel; Stevanovic, Ana; Rossaint, Rolf; Boncyk, Christina; Defresne, Aline; Tran, Gabriel; Tasbihgou, Seth; Meier, Sascha; Vlisides, Phillip E; Fardous, Hussein; Hess, Aaron; Bauer, Rebecca M; Absalom, Anthony; Mashour, George A; Bonhomme, Vincent; Coburn, Mark; Sleigh, Jamie

2017-02-01

The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice. Two hundred sixty adult patients were recruited at six sites into a prospective cohort study of the isolated forearm technique after intubation. Demographic, anesthetic, and intubation data, plus postoperative questionnaires, were collected. Univariate statistics, followed by bivariate logistic regression models for age plus variable, were conducted. The incidence of isolated forearm technique responsiveness after intubation was 4.6% (12/260); 5 of 12 responders reported pain through a second hand squeeze. Responders were younger than nonresponders (39 ± 17 vs. 51 ± 16 yr old; P = 0.01) with more frequent signs of sympathetic activation (50% vs. 2.4%; P = 0.03). No participant had explicit recall of intraoperative events when questioned after surgery (n = 253). Across groups, depth of anesthesia monitoring values showed a wide range; however, values were higher for responders before (54 ± 20 vs. 42 ± 14; P = 0.02) and after (52 ± 16 vs. 43 ± 16; P = 0.02) intubation. In patients not receiving total intravenous anesthesia, exposure to volatile anesthetics before intubation reduced the odds of responding (odds ratio, 0.2 [0.1 to 0.8]; P = 0.02) after adjustment for age. Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.

Psychological traits influence autonomic nervous system recovery following esophageal intubation in health and functional chest pain.

PubMed

Farmer, A D; Coen, S J; Kano, M; Worthen, S F; Rossiter, H E; Navqi, H; Scott, S M; Furlong, P L; Aziz, Q

2013-12-01

Esophageal intubation is a widely utilized technique for a diverse array of physiological studies, activating a complex physiological response mediated, in part, by the autonomic nervous system (ANS). In order to determine the optimal time period after intubation when physiological observations should be recorded, it is important to know the duration of, and factors that influence, this ANS response, in both health and disease. Fifty healthy subjects (27 males, median age 31.9 years, range 20-53 years) and 20 patients with Rome III defined functional chest pain (nine male, median age of 38.7 years, range 28-59 years) had personality traits and anxiety measured. Subjects had heart rate (HR), blood pressure (BP), sympathetic (cardiac sympathetic index, CSI), and parasympathetic nervous system (cardiac vagal tone, CVT) parameters measured at baseline and in response to per nasum intubation with an esophageal catheter. CSI/CVT recovery was measured following esophageal intubation. In all subjects, esophageal intubation caused an elevation in HR, BP, CSI, and skin conductance response (SCR; all p < 0.0001) but concomitant CVT and cardiac sensitivity to the baroreflex (CSB) withdrawal (all p < 0.04). Multiple linear regression analysis demonstrated that longer CVT recovery times were independently associated with higher neuroticism (p < 0.001). Patients had prolonged CSI and CVT recovery times in comparison to healthy subjects (112.5 s vs 46.5 s, p = 0.0001 and 549 s vs 223.5 s, p = 0.0001, respectively). Esophageal intubation activates a flight/flight ANS response. Future studies should allow for at least 10 min of recovery time. Consideration should be given to psychological traits and disease status as these can influence recovery. © 2013 John Wiley & Sons Ltd.

Trauma airway management in emergency departments: a multicentre, prospective, observational study in Japan.

PubMed

Nakao, Shunichiro; Kimura, Akio; Hagiwara, Yusuke; Hasegawa, Kohei

2015-02-04

Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan. Analysis of data from a prospective, observational, multicentre registry-the Japanese Emergency Airway Network (JEAN) registry. 13 academic and community EDs from different geographic regions across Japan. 723 trauma patients who underwent emergency intubation from March 2010 through August 2012. ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events. A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0-50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs. In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals. 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.

Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial.

PubMed

Portas, M; Canal, M I; Barrio, M; Alonso, M; Cabrerizo, P; López-Gil, M; Zaballos, M

2018-03-01

Airway management is still a major cause of anesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q ® and the LMA Fastrach™ for fiberoptic guided tracheal intubation. Thirty-three anesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fiberoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q ® /LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anesthesia trainees were measured. There was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10±3s for the Air-Q ® and 11±3s for the LMA Fastrach™, P=.07. Time taken to intubate the trachea was shorter with the air-Q ® , 38±15 s, than with the LMA Fastrach™, 47±19s, P=.017. Overall procedure time was significantly shorter with the Air-Q ® as compared with the LMA Fastrach™, with a mean time of 74±21s and 87±28s respectively, P=.002. Air-Q ® removal was considered easier than LMA Fastrach™ removal, P=.005. There were no tube dislodgements during the removal of the dedicated airways. Inexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q ® and LMA Fastrach™ in a clinically acceptable time with high success. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Transfer of skills and comparison of performance between king vision® video laryngoscope and macintosh blade following an AHA airway management course.

PubMed

Wolf, Lukas E; Aguirre, José A; Vogt, Christian; Keller, Christian; Borgeat, Alain; Bruppacher, Heinz R

2017-01-10

To potentially optimize intubation skill teaching in an American Heart Association® Airway Management Course® for novices, we investigated the transfer of skills from video laryngoscopy to direct laryngoscopy and vice versa using King Vision® and Macintosh blade laryngoscopes respectively. Ninety volunteers (medical students, residents and staff physicians) without prior intubation experience were randomized into three groups to receive intubation training with either King Vision® or Macintosh blade or both. Afterwards they attempted intubation on two human cadavers with both tools. The primary outcome was skill transfer from video laryngoscopy to direct laryngoscopy assessed by first attempt success rates within 60 s. Secondary outcomes were skill transfer in the opposite direction, the efficacy of teaching both tools, and the success rates and esophageal intubation rates of Macintosh blade versus King Vision®. Performance with the Macintosh blade was identical following training with either Macintosh blade or King Vision® (unadjusted odds ratio [OR] 1.09, 95% confidence interval [95% CI] 0.5-2.6). Performance with the King Vision® was significantly better in the group that was trained on it (OR 2.7, 95% CI 1.2-5.9). Success rate within 60 s with Macintosh blade was 48% compared to 52% with King Vision® (OR 0.85, 95% CI 0.4-2.0). Rate of esophageal intubations with Macintosh blade was significantly higher (17% versus 4%, OR 5.0, 95% CI 1.1-23). We found better skill transfer from King Vision® to Macintosh blade than vice versa and fewer esophageal intubations with video laryngoscopy. For global skill improvement in an airway management course for novices, teaching only video laryngoscopy may be sufficient. However, success rates were low for both devices.

Endoscopic Cold Incision, Balloon Dilation, Mitomycin C Application, and Steroid Injection for Adult Laryngotracheal Stenosis

PubMed Central

Parker, Noah P.; Bandyopadhyay, Dipankar; Misono, Stephanie; Goding, George S.

2017-01-01

Objectives/Hypothesis To describe the presentation, stenosis characteristics, etiological differences, and outcomes of adult laryngotracheal stenosis treated with endoscopic cold incision, balloon dilation, topical mitomycin C application, and steroid injection. Study Design Retrospective chart review. Methods Demographic and clinical data were extracted for patients treated between March 2000 and December 2010. Prolonged intubation and idiopathic patient data were utilized for comparative analysis. Results Eighty patients (65 females; 15 males; 220 procedures; 2.9 years mean follow-up) presented with dyspnea (81%) and/or exercise intolerance (40%). Most commonly, etiologies were idiopathic (53 of 80; 66%) or prolonged intubation (14 of 80; 18%). Mean procedures per patient and interval between procedures were 2.8 procedures and 405 days, respectively. Mean stenosis length and distance from the caudal phonating edge of the true vocal folds were 9 mm and 19 mm. Complication, tracheotomy, and open-procedure rates were 1.8%, 1.4%, and 10.0%, respectively. Patients with more than two procedures demonstrated a mean 4-mm reduction in stenosis length and a 2-mm cephalad progression of stenosis over time. More caudal stenoses required more frequent procedures. Procedures were less frequent as more procedures were performed. Stenosis characteristics, interval between procedures, and total procedures were similar between idiopathic patients with or without intubation histories, but different between idiopathic and prolonged intubation patients. Conclusions This procedure was shown to be a viable option in adult laryngotracheal stenosis. Repeat dilation was likely, but was performed without adversely affecting stenosis characteristics. Stenoses farther from the vocal folds required procedures more frequently. Idiopathic patients with a history of brief, elective intubation had stenosis characteristics and responses to therapy similar to idiopathic patients without an intubation history. Both idiopathic groups together demonstrated stenosis characteristics and responses to therapy dissimilar to patients with a history of prolonged intubation. PMID:23086662

Transoral tracheal intubation of rodents using a fiberoptic laryngoscope.

PubMed

Costa, D L; Lehmann, J R; Harold, W M; Drew, R T

1986-06-01

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.

Effects of conventional vs high-dose rocuronium on the QTc interval during anesthesia induction and intubation in patients undergoing coronary artery surgery: a randomized, double-blind, parallel trial

PubMed Central

Öztürk, T.; Ağdanlı, D.; Bayturan, Ö.; Çıkrıkcı, C.; Keleş, G.T.

2015-01-01

Myocardial ischemia, as well as the induction agents used in anesthesia, may cause corrected QT interval (QTc) prolongation. The objective of this randomized, double-blind trial was to determine the effects of high- vs conventional-dose bolus rocuronium on QTc duration and the incidence of dysrhythmias following anesthesia induction and intubation. Fifty patients about to undergo coronary artery surgery were randomly allocated to receive conventional-dose (0.6 mg/kg, group C, n=25) or high-dose (1.2 mg/kg, group H, n=25) rocuronium after induction with etomidate and fentanyl. QTc, heart rate, and mean arterial pressure were recorded before induction (T0), after induction (T1), after rocuronium (just before laryngoscopy; T2), 2 min after intubation (T3), and 5 min after intubation (T4). The occurrence of dysrhythmias was recorded. In both groups, QTc was significantly longer at T3 than at baseline [475 vs 429 ms in group C (P=0.001), and 459 vs 434 ms in group H (P=0.005)]. The incidence of dysrhythmias in group C (28%) and in group H (24%) was similar. The QTc after high-dose rocuronium was not significantly longer than after conventional-dose rocuronium in patients about to undergo coronary artery surgery who were induced with etomidate and fentanyl. In both groups, compared with baseline, QTc was most prolonged at 2 min after intubation, suggesting that QTc prolongation may be due to the nociceptive stimulus of intubation. PMID:25714880

Comparison of the effect of rocuronium dosing based on corrected or lean body weight on rapid sequence induction and neuromuscular blockade duration in obese female patients

PubMed Central

Sakızcı-Uyar, Bahar; Çelik, Şeref; Postacı, Aysun; Bayraktar, Yeşim; Dikmen, Bayazit; Özkoçak-Turan, Işıl; Saçan, Özlem

2016-01-01

Objectives: To compare onset time, duration of action, and tracheal intubation conditions in obese patients when the intubation dose of rocuronium was based on corrected body weight (CBW) versus lean body weight (LBW) for rapid sequence induction. Methods: This prospective study was carried out at Numune Education and Research Hospital, Ankara, Turkey between August 2013 and May 2014. Forty female obese patients scheduled for laparoscopic surgery under general anesthesia were randomized into 2 groups. Group CBW (n=20) received 1.2 mg/kg rocuronium based on CBW, and group LBW (n=20) received 1.2 mg/kg rocuronium based on LBW. Endotracheal intubation was performed 60 seconds after injection of muscle relaxant, and intubating conditions were evaluated. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis. Onset time, defined as time to depression of the twitch tension to 95% of its control value, and duration of action, defined as time to achieve one response to train-of-four stimulation (T1) were recorded. Results: No significant differences were observed between the groups in intubation conditions or onset time (50-60 seconds median, 30-30 interquartile range [IQR]). Duration of action was significantly longer in the CBW group (60 minutes median, 12 IQR) than the LBW group (35 minutes median, 16 IQR; p<0.01). Conclusion: In obese patients, dosing of 1.2 mg/kg rocuronium based on LBW provides excellent or good tracheal intubating conditions within 60 seconds after administration and does not lead to prolonged duration of action. PMID:26739976

An active simulator for neonatal intubation: Design, development and assessment.

PubMed

Baldoli, Ilaria; Tognarelli, Selene; Vangi, Ferdinando; Panizza, Davide; Scaramuzzo, Rosa T; Cuttano, Armando; Laschi, Cecilia; Menciassi, Arianna

2017-01-01

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.

A new universal laryngoscope blade: a preliminary comparison with Macintosh laryngoscope blades.

PubMed

Gerlach, Klaus; Wenzel, Volker; von Knobelsdorff, Georg; Steinfath, Markus; Dörges, Volker

2003-04-01

The Dörges universal laryngoscope blade has several features designed to facilitate tracheal intubation. The number of laryngoscope blades may be reduced from four to two, or even one, which indicate less space requirement and costs. This new universal laryngoscope blade, has a lower profile (height 15 vs. 22 mm) than a Macintosh laryngoscope blade size 3 and 4, which may facilitate manoeuvring of the laryngoscope in the mouth. In random order, 40 non-anaesthesia senior house officers used a Macintosh laryngoscope blade size 3 or 4 in an adult airway management trainer, a Macintosh laryngoscope blade size 2 in a paediatric airway management trainer, and the Dörges universal laryngoscope blade for both airway management trainers to perform orotracheal intubation. The number of intubation attempts and failures was counted. Participants reported the laryngoscopic view according to Cormack and Lehane. The time from touching the laryngoscope to the first adequate lung insufflation was measured, and subjective assessment regarding handling of both blades was recorded. Number of intubation failures, the laryngoscopic view according to Cormack and Lehane, and subjective assessment was comparable between groups. Orotracheal intubation of the adult airway management trainer with the Dörges universal laryngoscope blade took significantly less time compared to the Macintosh laryngoscope blades (14 (7-57) vs. 20 (8-43) s; P<0.001); all other intubating times were comparable. In conclusion, in this model, the Dörges universal laryngoscope blade was comparable to the Macintosh laryngoscope blades size 2-4, and may save time, cost and space.

Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children?

PubMed

Varghese, Elsa; Kundu, Ratul

2014-08-01

Both Miller and Macintosh blades are widely used for laryngoscopy in small children, though the Miller blade is more commonly recommended in pediatric anesthetic literature. The aim of this study was to compare laryngoscopic views and ease and success of intubation with Macintosh and Miller blades in small children under general anesthesia. One hundred and twenty children aged 1-24 months were randomized for laryngoscopy to be performed in a crossover manner with either the Miller or the Macintosh blade first, following induction of anesthesia and neuromuscular blockade. The tips of both the blades were placed at the vallecula. Intubation was performed following the second laryngoscopy. The glottic views with and without external laryngeal maneuver (ELM) and ease of intubation were observed. Similar glottic views with both blades were observed in 52/120 (43%) children, a better view observed with the Miller blade in 35/120 (29%) children, and with the Macintosh blade in 33/120 (28%). Laryngoscopy was easy in 65/120 (54%) children with both the blades. Restricted laryngoscopy was noted in 55 children: in 27 children with both the blades, 15 with Miller, and 13 with Macintosh blade. Laryngoscopic view improved following ELM with both the blades. In children aged 1-24 months, the Miller and the Macintosh blades provide similar laryngoscopic views and intubating conditions. When a restricted view is obtained, a change of blade may provide a better view. Placing the tip of the Miller blade in the vallecula provides satisfactory intubating conditions in this age group. © 2014 John Wiley & Sons Ltd.

Using King Vision video laryngoscope with a channeled blade prolongs time for tracheal intubation in different training levels, compared to non-channeled blade.

PubMed

Kriege, Marc; Alflen, Christian; Noppens, Ruediger R

2017-01-01

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.

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients.

PubMed

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

2017-05-01

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.

Selective molecularly imprinted polymer combined with restricted access material for in-tube SPME/UHPLC-MS/MS of parabens in breast milk samples.

PubMed

Souza, Israel D; Melo, Lidervan P; Jardim, Isabel C S F; Monteiro, Juliana C S; Nakano, Ana Marcia S; Queiroz, Maria Eugênia C

2016-08-17

A new molecularly imprinted polymer modified with restricted access material (a hydrophilic external layer), (MIP-RAM) was synthesized via polymerization in situ in an open fused silica capillary. This stationary phase was used as sorbent for in-tube solid phase microextraction (in-tube SPME) to determine parabens in breast milk samples by ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Scanning electron micrographs (SEM) illustrate MIP surface modification after glycerol dimethacrylate (hydrophilic monomer) incorporation. The interaction between parabens and MIP-RAM was investigated by Fourier-transform infrared (FTIR) spectroscopy. The Scatchard plot for MIP-RAM presented two linear parts with different slopes, illustrating binding sites with high- and low-affinity. Endogenous compounds exclusion from the MIP-RAM capillary was demonstrated by in-tube SPME/LC-UV assays carried out with blank milk samples. The in-tube SPME/UHPLC-MS/MS method presented linear range from 10 ng mL(-1) (LLOQ) to 400 ng mL(-1) with coefficients of determination higher than 0.99, inter-assay precision with coefficient of variation (CV) values ranging from 2 to 15%, and inter-assay accuracy with relative standard deviation (RSD) values ranging from -1% to 19%. Analytical validation parameters attested that in-tube SPME/UHPLC-MS/MS is an appropriate method to determine parabens in human milk samples to assess human exposure to these compounds. Analysis of breast milk samples from lactating women demonstrated that the proposed method is effective. Copyright © 2016 Elsevier B.V. All rights reserved.

Telepresent intubation supervision is as effective as in-person supervision of procedurally naive operators.

PubMed

Prescher, Hannes; Grover, Emily; Mosier, Jarrod; Stolz, Uwe; Biffar, David E; Hamilton, Allan J; Sakles, John C

2015-03-01

Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.

Variable stiffness colonoscope versus regular adult colonoscope: meta-analysis of randomized controlled trials.

PubMed

Othman, M O; Bradley, A G; Choudhary, A; Hoffman, R M; Roy, P K

2009-01-01

The variable stiffness colonoscope (VSC) may have theoretical advantages over standard adult colonoscopes (SACs), though data are conflicting. We conducted a meta-analysis to compare the efficacies of the VSC and SAC. We searched Medline (1966 - 2008) and abstracts of gastroenterology scientific meetings in the 5 years to February 2008, only for randomized clinical trials (RCTs) of adult patients. Trial quality was assessed using the Delphi list. In a meta-analysis with a fixed effects model, cecal intubation rates, cecal intubation times, abdominal pain scores, sedation used, and use of ancillary maneuvers, were compared in separate analyses, using weighted mean differences (WMDs), standardized mean differences (SMDs), or odds ratios (ORs). Seven RCTs satisfied the inclusion criteria (1923 patients), four comparing VSC with SAC procedures in adults, and three evaluating the pediatric VSC. There was no significant heterogeneity among the studies. The overall trial quality was adequate. Cecal intubation rate was higher with the use of VSC (OR = 2.08, 95 % confidence interval [CI] 1.29 to 3.36). The VSC was associated with lower abdominal pain scores and a decreased need for sedation during colonoscopy. Cecal intubation time was similar for the two colonscope types (WMD = - 0.21 minutes, 95 % CI - 0.85 to 0.43). Because of the nature of the intervention no studies were blinded. There was no universal method for using the VSC. Compared with the SAC, VSC use was associated with a higher cecal intubation rate, less abdominal pain, and decreased need for sedation. However, cecal intubation times were similar for the two colonoscope types.

Desflurane or isoflurane for paediatric ENT anaesthesia. A comparison of intubating conditions and recovery profile.

PubMed

Wilhelm, W; Berner, K; Grundmann, U; Palz, M; Larsen, R

1998-12-01

The inhaled anaesthetic desflurane is characterized by a rapid wash-in and wash-out and may be useful for short paediatric ENT procedures. Therefore, this study was designed to compare the effects of desflurane or isoflurane on intubating conditions and recovery characteristics in paediatric ENT patients. In this prospective, randomised investigation, we studied 44 children scheduled for ENT surgery, aged 4-12 yr and classified ASA I-II. After thiopentone induction (5-8 mg/kg) the lungs were ventilated by face mask and the vaporizer was dialed to 1 MAC (age-adapted) of desflurane of isoflurane. A reduced dose of vecuronium (0.05 mg/kg) was administered, and intubating conditions were rated 3 min later. Following tracheal intubation, 50% nitrous oxide were added, and the concentration of desflurane or isoflurane was adjusted according to clinical needs. At the end of surgery all anaesthetics were discontinued simultaneously and recovery times were recorded. Intubating conditions were rated significantly better for desflurane (excellent or good 20 of 22) than for isoflurane (12 of 22). Recovery times were significantly shorter for desflurane than for isoflurane (mean +/- SE): spontaneous ventilation 4.0 +/- 0.5 min vs. 6.0 +/- 0.7 min, extubation 8.4 +/- 0.7 vs. 11.4 +/- 1.1 min and arrival at PACU 11.5 +/- 0.8 vs. 16.6 +/- 1.5 min. No airway complications (coughing, laryngospasm, or desaturation < 97%) were noted for either anaesthetic. Following an intravenous induction improved intubating conditions, shorter recovery times and the lack of airway complications make desflurane a suitable alternative to isoflurane for paediatric ENT anaesthesia.

Comparison of wiping and rinsing techniques after oral care procedures in critically ill patients during endotracheal intubation and after extubation: A prospective cross-over trial.

PubMed

Muramatsu, Keita; Matsuo, Koichiro; Kawai, Yusuke; Yamamoto, Tsukasa; Hara, Yoshitaka; Shimomura, Yasuyo; Yamashita, Chizuru; Nishida, Osamu

2018-06-26

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.

Critical Airway Team: A Retrospective Study of an Airway Response System in a Pediatric Hospital.

PubMed

Sterrett, Emily C; Myer, Charles M; Oehler, Jennifer; Das, Bobby; Kerrey, Benjamin T

2017-12-01

Objective Study the performance of a pediatric critical airway response team. Study Design Case series with chart review. Setting Freestanding academic children's hospital. Subjects and Methods A structured review of the electronic medical record was conducted for all activations of the critical airway team. Characteristics of the activations and patients are reported using descriptive statistics. Activation of the critical airway team occurred 196 times in 46 months (March 2012 to December 2015); complete data were available for 162 activations (83%). For 49 activations (30%), patients had diagnoses associated with difficult intubation; 45 (28%) had a history of difficult laryngoscopy. Results Activation occurred at least 4 times per month on average (vs 3 per month for hospital-wide codes). The most common reasons for team activation were anticipated difficult intubation (45%) or failed intubation attempt (20%). For 79% of activations, the team performed an airway procedure, most commonly direct laryngoscopy and tracheal intubation. Bronchoscopy was performed in 47% of activations. Surgical airway rescue was attempted 4 times. Cardiopulmonary resuscitation occurred in 41 activations (25%). Twenty-nine patients died during or following team activation (18%), including 10 deaths associated with the critical airway event. Conclusion Critical airway team activation occurred at least once per week on average. Direct laryngoscopy, tracheal intubation, and bronchoscopic procedures were performed frequently; surgical airway rescue was rare. Most patients had existing risk factors for difficult intubation. Given our rate of serious morbidity and mortality, primary prevention of critical airway events will be a focus of future efforts.

Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients.

PubMed

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

1987-02-01

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)

A comparison of a traditional endotracheal tube versus ETView SL in endotracheal intubation during different emergency conditions

PubMed Central

Truszewski, Zenon; Krajewski, Paweł; Fudalej, Marcin; Smereka, Jacek; Frass, Michael; Robak, Oliver; Nguyen, Bianka; Ruetzler, Kurt; Szarpak, Lukasz

2016-01-01

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 improved with the ETView. The time to glottis view, tube insertion, and cuff block were all found to be shorter with the ETView. Trial Registration: clinicaltrials.gov Identifier: NCT02733536. PMID:27858851

A comparison of a traditional endotracheal tube versus ETView SL in endotracheal intubation during different emergency conditions: A randomized, crossover cadaver trial.

PubMed

Truszewski, Zenon; Krajewski, Paweł; Fudalej, Marcin; Smereka, Jacek; Frass, Michael; Robak, Oliver; Nguyen, Bianka; Ruetzler, Kurt; Szarpak, Lukasz

2016-11-01

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, and cuff block were all found to be shorter with the ETView. clinicaltrials.gov Identifier: NCT02733536.

Effect of gabapentin pretreatment on the hemodynamic response to laryngoscopy and tracheal intubation in treated hypertensive patients.

PubMed

Bala, Indu; Bharti, Neerja; Ramesh, Nanjangud P

2015-09-01

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 received ephedrine boluses and in whom isoflurane had to be increased due to hypertension. No episode of bradycardia, tachycardia, dysrhythmia, or ST-T wave changes was reported. Gabapentin 800 mg in a single or double dose was equally effective in attenuating the hypertensive response to laryngoscopy and tracheal intubation in treated hypertensive patients. Copyright © 2015. Published by Elsevier B.V.

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit.

PubMed

Joshi, Raj; Hypes, Cameron D; Greenberg, Jeremy; Snyder, Linda; Malo, Josh; Bloom, John W; Chopra, Harsharon; Sakles, John C; Mosier, Jarrod M

2017-03-01

Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.

Tube introducer and modified Celestin tube for use in palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy.

PubMed Central

Atkinson, M; Ferguson, R; Parker, G C

1978-01-01

A new method for palliative intubation of inoperable neoplasms at or near the cardia is described. A guidewire is passed through the stricture, which is dilated using Eder Puestow metal olive dilators. The tube to be inserted is mounted on an introducer, which grips its distal end from inside, and is slid into position along the wire under radiological control. Twenty-five patients have been intubated with one death directly resulting from the procedure. The method provides a simple and relatively safe means of relieving dysphagia and improving nutrition. Images Fig. 2 PMID:79517

Long term intubation and successful weaning in two children with Guillain-Barre syndrome.

PubMed

Javed, H; Nair, M P; Koul, R L; Chacko, A; Fazalullah, M

2000-07-01

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.

Comparison of Metal and Plastic Disposable Laryngoscope Blade with Reusable Macintosh Blade in Difficult and Inhalation Injury Airway Scenario: A Manikin Study.

PubMed

Moritz, Andreas; Heinrich, Sebastian; Irouschek, Andrea; Birkholz, Torsten; Prottengeier, Johannes; Schmidt, Joachim

2017-01-01

Single-use plastic blades (SUPB) and single-use metal blades (SUMB) for direct laryngoscopy and tracheal intubation have not yet been compared with reusable metal blades (RUMB) in difficult airway scenarios. The purpose of our manikin study was to compare the effectiveness of these different laryngoscope blades in a difficult airway scenario, as well as in a difficult airway scenario with simulated severe inhalation injury. Thirty anesthetists performed tracheal intubation (TI) with each of the three laryngoscope blades in the two scenario manikins. In the inhalation injury scenario, SUPB were associated with prolonged intubation times when compared with the metal blades. In the inhalation injury scenario, both metal laryngoscope blades provided a quicker, easier, and safer TI. In the difficult airway scenario, intubation times were significantly prolonged in the SUPB group in comparison to the RUMB group, but there were no significant differences between the SUPB and the SUMB. In this scenario, the RUMB demonstrated the shortest intubation times and seems to be the most effective device. Generally, results are in line with previous studies showing significant disadvantages of SUPB in both manikin scenarios. Therefore, metal blades might be beneficial, especially in the airway management of patients with inhalation injury. Copyright © 2016 Elsevier Inc. All rights reserved.

The dose effect of ephedrine on the onset time of vecuronium.

PubMed

Kim, Kyo S; Cheong, Mi A; Jeon, Jeong W; Lee, Jeong H; Shim, Jae C

2003-04-01

A small dose of ephedrine decreases the onset time of rocuronium and cisatracurium; however, ephedrine might be associated with adverse hemodynamic effects. The appropriate dose of ephedrine has not been determined. We, therefore, studied 120 patients anesthetized with fentanyl 2 microg/kg and propofol 2-2.5 mg/kg who were randomly divided to receive either ephedrine (30, 70, or 110 microg/kg) or saline. During propofol anesthesia, the neuromuscular block was monitored by mechanomyography by using submaximal current of train-of-four stimulation every 10 s. To determine cardiac output, a transcutaneous Doppler probe was placed externally at the suprasternal notch. Tracheal intubation was performed by a blinded investigator at 2 min after vecuronium. Neuromuscular block, intubating conditions, and hemodynamic effects were measured during the induction of anesthesia. Both ephedrine 70 and 110 microg/kg improved intubating conditions at 2 min after vecuronium; however, 110 microg/kg was associated with adverse hemodynamic effects. We conclude that ephedrine 70 microg/kg given before the induction of anesthesia improved intubating conditions at 2 min after vecuronium, probably by increased cardiac output without significant adverse hemodynamic effects. Ephedrine 70 microg/kg given before the induction of anesthesia improved tracheal intubating conditions at 2 min after vecuronium by increased cardiac output without significant adverse hemodynamic effects.

Evaluation of a smartphone camera system to enable visualization and image transmission to aid tracheal intubation with the Airtraq(®) laryngoscope.

PubMed

Lee, Delice Weishan; Thampi, Swapna; Yap, Eric Peng Huat; Liu, Eugene Hern Choon

2016-06-01

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.

Is endotracheal intubation a non-beneficial treatment in patients with respiratory failure due to paraquat poisoning?

PubMed Central

Wu, Meng-Ruey; Hsiao, Chia-Ying; Cheng, Chun-Han; Liao, Feng-Ching; Chao, Chuan-Lei; Chen, Chun-Yen; Yeh, Hung-I

2018-01-01

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

Usefulness of warm water and oil assistance in colonoscopy by trainees.

PubMed

Park, Sung Chul; Keum, Bora; Kim, Eun Sun; Jung, Eun Suk; Lee, Sehe Dong; Park, Sanghoon; Seo, Yeon Seok; Kim, Yong Sik; Jeen, Yoon Tae; Chun, Hoon Jai; Um, Soon Ho; Kim, Chang Duck; Ryu, Ho Sang

2010-10-01

Success rate of cecal intubation, endoscopist's difficulty, and procedure-related patient pain are still problems for beginners performing colonoscopy. New methods to aid colonoscopic insertion such as warm water instillation and oil lubrication have been proposed. The aim of this study is to evaluate the feasibility of using warm water or oil in colonoscopy. Colonoscopy was performed in 117 unsedated patients by three endoscopists-in-training. Patients were randomly allocated to three groups, using a conventional method with administration of antispasmodics, warm water instillation, and oil lubrication, respectively. Success rate of total intubation within time limit (15 min), cecal intubation time, degree of endoscopist's difficulty, and level of patient discomfort were compared among the three groups. Cecal intubation time was shorter in the warm water group than in the conventional and oil groups. Degree of procedural difficulty was lower in the warm water group, and patient pain score was higher in the oil lubrication group, compared with the other groups. However, there was no significant difference in success rate of intubation within time limit among the three groups. The warm water method is a simple, safe, and feasible method for beginners. Oil lubrication may not be a useful method compared with conventional and warm water method.

Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability.

PubMed

Lennarson, P J; Smith, D W; Sawin, P D; Todd, M M; Sato, Y; Traynelis, V C

2001-04-01

The purpose of this study was to characterize and compare segmental cervical motion during orotracheal intubation in cadavers with and without a complete subaxial injury, as well as to examine the efficacy of commonly used stabilization techniques in limiting that motion. Intubation procedures were performed in 10 fresh human cadavers in which cervical spines were intact and following the creation of a complete C4-5 ligamentous injury. Movement of the cervical spine during direct laryngoscopy and intubation was recorded using video fluoroscopy and examined under the following conditions: 1) without stabilization; 2) with manual in-line cervical immobilization; and 3) with Gardner-Wells traction. Subsequently, segmental angular rotation, subluxation, and distraction at the injured C4-5 level were measured from digitized frames of the recorded video fluoroscopy. After complete C4-5 destabilization, the effects of attempted stabilization on distraction, angulation, and subluxation were analyzed. Immobilization effectively eliminated distraction, and diminished angulation, but increased subluxation. Traction significantly increased distraction, but decreased angular rotation and effectively eliminated subluxation. Orotracheal intubation without stabilization had intermediate results, causing less distraction than traction, less subluxation than immobilization, but increased angulation compared with either intervention. These results are discussed in terms of both statistical and clinical significance and recommendations are made.

Modeling water vapor and heat transfer in the normal and the intubated airways.

PubMed

Tawhai, Merryn H; Hunter, Peter J

2004-04-01

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.

Palmar skin conductance variability and the relation to stimulation, pain and the motor activity assessment scale in intensive care unit patients

PubMed Central

2013-01-01

Introduction Many intensive care unit (ICU) patients describe pain and other adverse feelings that may impact long-term psychological morbidity. Sympathetically mediated palmar skin conductance variability is related to emotionally induced perspiration and correlates with pain levels in the perioperative setting but has not been studied in ICU patients. Methods Twenty non-intubated and 20 intubated general ICU patients were included in this observational study. Patients were monitored with the MED-STORM Pain Monitoring System®. The number of skin conductance fluctuations per second (NSCF) was measured in parallel with bedside observation during one hour of intensive care, including rest, procedures and patient-staff interactions. Arousal-agitation level was monitored with the motor activity assessment scale (MAAS). Pain was monitored with the numeric rating scale (0 to 10) in patients able to communicate or by observation in patients unable to communicate. Results In non-intubated patients, NSCF increased with increasing stimulation/pain but also with higher MAAS (P = 0.002). An interaction effect was found, with increased NSCF response to stimulation/pain with increasing MAAS (P < 0.001). In intubated patients, NSCF increased significantly with increasing stimulation/pain (P < 0.001). In contrast to non-intubated patients, no difference in NSCF between MAAS levels was found for any given degree of stimulation in intubated patients. Conclusions In critically ill patients, NSCF may be more useful evaluating emotional distress rather than pain alone. It needs to be assessed whether NSCF monitoring is clinically useful and whether controlling emotional distress with the aid of such monitoring may impact on patient care and outcomes. PMID:23510014

Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis

PubMed Central

2012-01-01

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

Anesthetic and cardiorespiratory effects of a 1:1 mixture of propofol and thiopental sodium in dogs.

PubMed

Ko, J C; Golder, F J; Mandsager, R E; Heaton-Jones, T; Mattern, K L

1999-11-01

To compare anesthetic and cardiorespiratory effects of a 1:1 (vol:vol) mixture of propofol and thiopental sodium with either drug used alone in dogs. Randomized crossover study. 10 healthy Walker Hounds. Dogs received propofol (6 mg/kg [2.7 mg/lb] of body weight), thiopental (15 mg/kg [6.8 mg/lb]), or a mixture of propofol (6 mg/kg) and thiopental (15 mg/kg) at 1-week intervals. Drugs were slowly administered i.v. over 90 seconds or until dogs lost consciousness. Increments of 10% of the initial dose were administered until intubation was possible. Amount of drug required for intubation, quality of induction and recovery, times from induction to intubation and to walking with minimal ataxia, and duration of intubation and lateral recumbency were recorded. Heart and respiratory rates, mean, systolic, and diastolic blood pressure, hemoglobin saturation of oxygen (SpO2), and end-tidal CO2 concentration (ETCO2) were determined before and after intubation. Amounts of propofol and thiopental required to permit intubation were less, but not significantly so, when administered in combination than when administered alone. Duration of lateral recumbency and time from induction to walking were greater and recovery quality was worse in the thiopental group, compared with the other groups. Dogs in all groups remained normotensive. Respiratory rate, heart rate, ETCO2, and SpO2 did not differ among groups. A 1:1 mixture of propofol and thiopental induced anesthesia of similar quality to propofol or thiopental alone. Recovery quality and recovery times were similar to those of propofol and superior to those of thiopental.

Comparison of single-use and reusable metal laryngoscope blades for orotracheal intubation during rapid sequence induction of anesthesia: a multicenter cluster randomized study.

PubMed

Amour, Julien; Le Manach, Yannick Le; Borel, Marie; Lenfant, François; Nicolas-Robin, Armelle; Carillion, Aude; Ripart, Jacques; Riou, Bruno; Langeron, Olivier

2010-02-01

Single-use metal laryngoscope blades are cheaper and carry a lower risk of infection than reusable metal blades. The authors compared single-use and reusable metal blades during rapid sequence induction of anesthesia in a multicenter cluster randomized trial. One thousand seventy-two adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using the opposite type of blade. The primary endpoint was the rate of failed intubation, and the secondary endpoints were the incidence of complications (oxygen desaturation, lung aspiration, and/or oropharynx trauma) and the Cormack and Lehane score. Both groups were similar in their main characteristics, including the risk factors for difficult intubation. The rate of failed intubation was significantly decreased with single-use metal blades at the first attempt compared with reusable blades (2.8 vs. 5.4%, P < 0.05). In addition, the proportion of grades III and IV in Cormack and Lehane score were also significantly decreased with single-use metal blades (6 vs. 10%, P < 0.05). The global complication rate did not reach statistical significance, although the same trend was noted (6.8% vs. 11.5%, P = not significant). An investigator survey and a measure of illumination pointed that illumination might have been responsible for this result. The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia.

Ketamine use for rapid sequence intubation in Australian and New Zealand emergency departments from 2010 to 2015: A registry study.

PubMed

Ferguson, Ian; Alkhouri, Hatem; Fogg, Toby; Aneman, Anders

2018-06-11

This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53). Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Cadaveric study of movement in the unstable upper cervical spine during emergency management: tracheal intubation and cervical spine immobilisation—a study protocol for a prospective randomised crossover trial

PubMed Central

Popp, Erik; Hüttlin, Petra; Weilbacher, Frank; Münzberg, Matthias; Schneider, Niko; Kreinest, Michael

2017-01-01

Introduction Emergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and cervical spine immobilisation can potentially exacerbate cervical spinal cord injury. However, the evidence that previous studies have provided remains unclear, due to lack of a direct measurement technique for dural sac's space during dynamic processes. Our study will use myelography method and a wireless human motion tracker to characterise and compare the change of dural sac's space during tracheal intubations and cervical spine immobilisation in the presence of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. Methods and analysis Perform laryngoscopy and intubation, video laryngoscope intubation, laryngeal tube insertion, fiberoptic intubation and cervical collar application on cadaveric models of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. The change of dural sac's space and the motion of unstable cervical segment are recorded by video fluoroscopy with previously performing myelography, which enables us to directly measure dural sac's space. Simultaneously, the whole cervical spine motion is recorded at a wireless human motion tracker. The maximum dural sac compression and the maximum angulation and distraction of the injured segment are measured by reviewing fluoroscopic and myelography images. Ethics and dissemination This study protocol has been approved by the Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany. The results will be published in relevant emergency journals and presented at relevant conferences. Trial registration number DRKS00010499. PMID:28864483

Verification of endotracheal intubation in obese patients - temporal comparison of ultrasound vs. auscultation and capnography.

PubMed

Pfeiffer, P; Bache, S; Isbye, D L; Rudolph, S S; Rovsing, L; Børglum, J

2012-05-01

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.

Effect of laryngoscopy on middle ear pressure during anaesthesia induction.

PubMed

Degerli, Semih; Acar, Baran; Sahap, Mehmet; Horasanlı, Eyup

2013-01-01

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.

A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success.

PubMed

Olvera, David J; Stuhlmiller, David F E; Wolfe, Allen; Swearingen, Charles F; Pennington, Troy; Davis, Daniel P

2018-02-21

Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance. The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success. The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation. A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311). An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

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.

PubMed

Ni, Yue-Nan; Luo, Jian; Yu, He; Liu, Dan; Ni, Zhong; Cheng, Jiangli; Liang, Bin-Miao; Liang, Zong-An

2017-04-01

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.

Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries.

PubMed

Frank, B S; Lewis, R J

1997-06-01

Accidental extubation is a potentially serious event for pediatric or neonatal patients with respiratory failure, especially in clinical settings in which personnel capable of performing reintubation may not be readily available. Thus the rate of accidental extubation in small intensive care units that operate without 24-hour in-house physician availability may be an important quality assurance indicator. The objective of this study were to determine the accidental extubation rate at a single small pediatric intensive care unit (PICU) and compare it with published reports. This study was carried out in a six-bed PICU at Washoe Medical Center in Reno, Nevada, with a relatively low level of patient acuity, as measured by PRISM score and the frequency of intubation, and without 24-hour in-house physician availability. All intubated patients admitted during the 5-year period from January 1, 1989 to December 31, 1993 were included. The primary outcome measure was the occurrence of accidental extubation. We observed only two accidental extubations in 1,749 intubated-patient-days (IPD) (0.114 accidental extubations/100 IPD [95% confidence interval 0.014-0.413 accidental extubations/ 100 IPD]). This rate of accidental extubation was compared with data in published reports from neonatal intensive care units (NICUs) and PICUs, which ranged from 0.14 accidental extubations/100 IPD to 4.36 accidental extubations/100 IPD. The dependence of the observed accidental extubation rate on unit size and institutional experience with intubated patients, as measured by the average number of intubated patients, was examined. We found no evidence that the accidental extubation rate is higher in smaller units or units with less institutional experience. Low rates can be achieved in small units with low acuity.

Randomized controlled study comparing the hemodynamic response to laryngoscopy and endotracheal intubation with McCoy, Macintosh, and C-MAC laryngoscopes in adult patients

PubMed Central

Buhari, Faiza Sulaiman; Selvaraj, Venkatesh

2016-01-01

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

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events.

PubMed

Hayat, Umar; Lee, Peter J; Ullah, Hamid; Sarvepalli, Shashank; Lopez, Rocio; Vargo, John J

2017-09-01

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.

Risk factors of lower respiratory tract infection in patients after tracheal intubation under general anesthesia in the Chinese health care system: A meta-analysis.

PubMed

Xu, Xuan; Yang, Xianxian; Li, Shangyingying; Luo, Mei; Qing, Ying; Zhou, Xipeng; Xue, Jian; Qiu, Jingfu; Li, Yingli

2016-11-01

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.

May we practise endotracheal intubation on the newly dead?

PubMed Central

Ardagh, M

1997-01-01

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

[Laryngeal mask for intubation (Fastrach)].

PubMed

Añez Simón, C; Boada Pié, S; Solsona Dellá, B

2000-10-01

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.

Non-intubated uniportal left-lower lobe upper segmentectomy (S6)

PubMed Central

Navarro-Martinez, Jose; Bolufer, Sergio; Sesma, Julio; Lirio, Francisco; Galiana, Maria; Rivera, Maria Jesus

2017-01-01

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

Non-intubated uniportal left-lower lobe upper segmentectomy (S6).

PubMed

Galvez, Carlos; Navarro-Martinez, Jose; Bolufer, Sergio; Sesma, Julio; Lirio, Francisco; Galiana, Maria; Rivera, Maria Jesus

2017-01-01

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.

Video-laryngoscopy introduction in a Sub-Saharan national teaching hospital: luxury or necessity?

PubMed Central

Alain, Traoré Ibrahim; Drissa, Barro Sié; Flavien, Kaboré; Serge, Ilboudo; Idriss, Traoré

2015-01-01

Tracheal intubation using Macintosh blade is the technique of choice for the liberation of airways. It can turn out to be difficult, causing severe complications which can entail the prognosis for survival or the adjournment of the surgical operation. The video-laryngoscope allows a better display of the larynx and a good exposure of the glottis and then making tracheal intubation simpler compared with a conventional laryngoscope. It is little spread in sub-Saharan Africa and more particularly in Burkina Faso because of its high cost. We report our first experiences of use of the video-laryngoscope through two cases of difficult tracheal intubation which had required the adjournment of the interventions. It results that the video-laryngoscope makes tracheal intubation easier even in it's the first use because of the good glottal display which it gives and because its allows apprenticeship easy. Therefore, it is not a luxury to have it in our therapeutic arsenal. PMID:27047621

Effect of rocuronium on the bispectral index under anesthesia and tracheal intubation.

PubMed

Yue, Hui; Han, Jinyu; Liu, Ling; Wang, Kaiyuan; Li, Jincheng

2016-12-01

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 changes under both normal and deep sedation.

Case report of primary intestinal lymphangiectasia diagnosed in an octogenarian by ileal intubation and by push enteroscopy after missed diagnosis by standard colonoscopy and EGD.

PubMed

Cappell, Mitchell S; Edhi, Ahmed; Amin, Mitual

2018-01-01

Primary intestinal lymphangiectasia (PIL) is a rare, presumably congenital lesion that is usually diagnosed in patients < 3 years old, is rarely first diagnosed in adulthood, and when first diagnosed in adulthood typically presents with symptoms for many years. Although PIL is often identified by endoscopic abnormalities, it must be emphasized that the jejunoileum/distal duodenum must be intubated for diagnosis because the lesions are present in these regions. This work demonstrates that 1)-PIL can occur in an octogenarian; 2)-shows that the characteristic endoscopic findings are not found at colonoscopy without terminal ileal intubation; and 3)-may be missed at standard EGD without distal duodenal intubation. A patient initially presented at age 83 with symptoms of watery diarrhea, abdominal distention, 5-Kg-weight-gain, and weakness for one month, and had typical clinical findings of PIL including chylous ascites, pleural effusions, bilateral pitting leg edema, hypoalbuminemia, borderline lymphopenia, hypovitaminosis-D, and hypocalcemia. Protein-losing-enteropathy was demonstrated by positive stool tests for alpha-1-antitrypsin. Standard colonoscopy revealed no significant lesions, but terminal ileal intubation during colonoscopy demonstrated creamy-white, punctate, mucosal lesions in terminal ileum, characteristic of lymphangiectasia. EGD with intubation to mid-descending duodenum revealed no significant lesions, but subsequent enteroscopy demonstrated lesions in distal duodenum/proximal jejunum similar to those in terminal ileum characteristic of lymphangiectasia. Histopathologic analysis of lesions of terminal ileum/distal duodenum demonstrated dilated mucosal vessels, confirmed as lymphatic vessels by immunohistochemistry. PIL was diagnosed after excluding secondary causes of intestinal lymphangiectasia. Patient placed on standard PIL diet: oral supplements of medium-chain triglycerides, a high protein diet, supplements of fat-soluble vitamins, and avoiding long-chain fatty acids, with marked clinical improvement. This work shows that: 1)-standard EGD and colonoscopy may miss characteristic lesions of PIL, 2)-enteroscopy or terminal ileal intubation at colonoscopy may be required for the diagnosis because lesions are typically located in distal duodenum/jejunoileum; and 3)-PIL can first present in the very elderly even with symptoms of short duration. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Case report of primary intestinal lymphangiectasia diagnosed in an octogenarian by ileal intubation and by push enteroscopy after missed diagnosis by standard colonoscopy and EGD

PubMed Central

Cappell, Mitchell S.; Edhi, Ahmed; Amin, Mitual

2018-01-01

Abstract Rationale: Primary intestinal lymphangiectasia (PIL) is a rare, presumably congenital lesion that is usually diagnosed in patients < 3 years old, is rarely first diagnosed in adulthood, and when first diagnosed in adulthood typically presents with symptoms for many years. Although PIL is often identified by endoscopic abnormalities, it must be emphasized that the jejunoileum/distal duodenum must be intubated for diagnosis because the lesions are present in these regions. This work demonstrates that 1)-PIL can occur in an octogenarian; 2)-shows that the characteristic endoscopic findings are not found at colonoscopy without terminal ileal intubation; and 3)-may be missed at standard EGD without distal duodenal intubation. Diagnoses: A patient initially presented at age 83 with symptoms of watery diarrhea, abdominal distention, 5-Kg-weight-gain, and weakness for one month, and had typical clinical findings of PIL including chylous ascites, pleural effusions, bilateral pitting leg edema, hypoalbuminemia, borderline lymphopenia, hypovitaminosis-D, and hypocalcemia. Protein-losing-enteropathy was demonstrated by positive stool tests for alpha-1-antitrypsin. Standard colonoscopy revealed no significant lesions, but terminal ileal intubation during colonoscopy demonstrated creamy-white, punctate, mucosal lesions in terminal ileum, characteristic of lymphangiectasia. EGD with intubation to mid-descending duodenum revealed no significant lesions, but subsequent enteroscopy demonstrated lesions in distal duodenum/proximal jejunum similar to those in terminal ileum characteristic of lymphangiectasia. Histopathologic analysis of lesions of terminal ileum/distal duodenum demonstrated dilated mucosal vessels, confirmed as lymphatic vessels by immunohistochemistry. PIL was diagnosed after excluding secondary causes of intestinal lymphangiectasia. Interventions/Outcomes: Patient placed on standard PIL diet: oral supplements of medium-chain triglycerides, a high protein diet, supplements of fat-soluble vitamins, and avoiding long-chain fatty acids, with marked clinical improvement. Lessons: This work shows that: 1)-standard EGD and colonoscopy may miss characteristic lesions of PIL, 2)-enteroscopy or terminal ileal intubation at colonoscopy may be required for the diagnosis because lesions are typically located in distal duodenum/jejunoileum; and 3)-PIL can first present in the very elderly even with symptoms of short duration. PMID:29505002

Comparison of the Glidescope®, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study.

PubMed

Langley, Adrian; Mar Fan, Gabriel

2014-02-28

Smart phone technology is becoming increasingly integrated into medical care.Our study compared an iPhone modified flexible fibreoptic bronchoscope as an intubation aid and clinical teaching tool with an unmodified bronchoscope, Glidescope® and Macintosh laryngoscope in a simulated normal and difficult airway scenario. Sixty three anaesthesia providers, 21 consultant anaesthetists, 21 registrars and 21 anaesthetic nurses attempted to intubate a MegaCode Kelly™ manikin, comparing a normal and difficult airway scenario for each device. Primary endpoints were time to view the vocal cords (TVC), time to successful intubation (TSI) and number of failed intubations with each device. Secondary outcomes included participant rated device usability and preference for each scenario. Advantages and disadvantages of the iPhone modified bronchoscope were also discussed. There was no significant difference in TVC with the iPhone modified bronchoscope compared with the Macintosh blade (P = 1.0) or unmodified bronchoscope (P = 0.155). TVC was significantly shorter with the Glidescope compared with the Macintosh blade (P < 0.001), iPhone (P < 0.001) and unmodified bronchoscope (P = 0.011). The iPhone bronchoscope TSI was significantly longer than all other devices (P < 0.001). There was no difference between anaesthetic consultant or registrar TVC (P = 1.0) or TSI (P = 0.252), with both being less than the nurses (P < 0.001). Consultant anaesthetists and nurses had a higher intubation failure rate with the iPhone modified bronchoscope compared with the registrars. Although more difficult to use, similar proportions of consultants (14/21), registrars (15/21) and nurses (15/21) indicated that they would be prepared to use the iPhone modified bronchoscope in their clinical practice. The Glidescope was rated easiest to use (P < 0.001) and was the preferred device by all participants for the difficult airway scenario. The iPhone modified bronchoscope, in its current configuration, was found to be more difficult to use compared with the Glidescope® and unmodified bronchoscope; however it offered several advantages for teaching fibreoptic intubation technique when video-assisted bronchoscopy was unavailable.

A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation

PubMed Central

2013-01-01

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 were recorded. Conclusions Our study shows that ultrasonography can replace waveform capnography in confirming ETT placement in centres without capnography. This can reduce incidence of unrecognised oesophageal intubation and prevent morbidity and mortality. Trial registration National Medical Research Register NMRR11100810230. PMID:23826756

Supplementation of diets for lactating sows with zinc amino acid complex and gastric nutriment-intubation of suckling pigs with zinc methionine on mineral status, intestinal morphology and bacterial translocation in lipopolysaccharide-challenged weaned pigs.

PubMed

Metzler-Zebeli, B U; Caine, W R; McFall, M; Miller, B; Ward, T L; Kirkwood, R N; Mosenthin, R

2010-04-01

Sixty-four pigs from 16 sows were used to evaluate addition of zinc amino acid complex (ZnAA) to lactating sows and gastric nutriment-intubation of zinc methionine (ZnMet) to suckling pigs on mineral status, intestinal morphology and bacterial translocation after weaning. Sows were fed a barley-based diet supplying 120 ppm zinc (Zn; control) or the control diet supplemented with 240 ppm Zn from ZnAA. At birth, day-10 and day-21 (weaning) of age, pigs from each litter were nutriment-intubated with 5 ml of an electrolyte solution without or with 40 mg Zn from ZnMet. At weaning, 24 h prior to the collection of small and large intestinal lymph nodes and sections of the duodenum, jejunum and ileum, the pigs received an intramuscular injection of saline without or with 150 microg/kg body weight of Escherichia coli O26:B6 lipopolysaccharide (LPS). With the exception of a tendency (p = 0.09) for lower serum concentration of copper in pigs at weaning from ZnAA-supplemented sows, there were no differences (p > 0.1) than for pigs from control-fed sows for mineral status or intestinal morphology. Nutriment-intubation of ZnMet increased serum (p = 0.001) and liver (p = 0.003) Zn concentrations, number of goblet cells per 250 microm length of jejunal villous epithelium (p = 0.001) and tended (p = 0.06) to enhance jejunum mucosa thickness. Interactive effects (p < 0.05) for higher jejunal villi height and villi:crypt ratio and increased ileal goblet cell counts were apparent for pigs from ZnAA-supplemented sows that also received nutriment-intubation of ZnMet. Challenge with LPS increased (p = 0.05) ileal villous width. Nutriment-intubation of ZnMet decreased (p = 0.05) anaerobic bacteria colony forming unit counts in the large intestinal mesenteric lymph nodes. In conclusion, nutriment-intubation of ZnMet increased serum and liver tissue concentrations of Zn and resulted in limited improvement to intestinal morphology of weaned pigs.

Effects of lead shot ingestion on selected cells of the mallard immune system

USGS Publications Warehouse

Rocke, T.E.; Samuel, M.D.

1991-01-01

The immunologic effects of lead were measured in game-farm mallards (Anas platyrhynchos) that ingested lead shot while foraging naturally, mallards intubated with lead shot, and unexposed controls. Circulating white blood cells (WBC) declined significantly in male mallards exposed to lead by either natural ingestion or intubation, but not females. Spleen plaque-forming cell (SPFC) counts were significantly lower in mallards intubated with lead pellets compared to controls. Declines in WBC and SPFC means with increasing tissue lead concentrations provide further evidence that lead exposure reduced immunologic cell numbers. Hormonal activity and diet may have influenced the immunologic effects of lead exposure in this study.

Performance-based comparison of neonatal intubation training outcomes: simulator and live animal.

PubMed

Andreatta, Pamela B; Klotz, Jessica J; Dooley-Hash, Suzanne L; Hauptman, Joe G; Biddinger, Bea; House, Joseph B

2015-02-01

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) and 52 weeks (P = .001) and cognitive scores after 52 weeks (P = .001). The results of this study demonstrate the feasibility of using valid, reliable assessment instruments to assess clinician competency and self-efficacy in the performance of neonatal intubation. We demonstrated the relative equivalency of live animal and simulation-based models as tools to support acquisition of neonatal intubation skills. Retention of performance abilities was greater for subjects trained using the simulator, likely because it afforded greater opportunity for repeated practice. Outcomes in each assessment area were influenced by the previous intubation experience of participants. This suggests that neonatal intubation training programs could be tailored to the level of provider experience to make efficient use of time and educational resources. Future research focusing on the uses of assessment in the applied clinical environment, as well as identification of optimal training cycles for performance retention, is merited.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation.

PubMed

Birnbach, David J; Rosen, Lisa F; Fitzpatrick, Maureen; Carling, Philip; Arheart, Kristopher L; Munoz-Price, L Silvia

2015-11-01

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 fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

A prospective study of the severity of early respiratory distress in late preterms compared to term infants.

PubMed

Kitsommart, Ratchada; Phatihattakorn, Chayawat; Pornladnun, Pornpat; Paes, Bosco

2016-01-01

To compare the severity of early respiratory distress in late preterm (LPT) versus term infants. A prospective cohort study was conducted in a tertiary care neonatal unit in Thailand. Levels of respiratory support, duration of intubation, and short term morbidities were compared between LPT and term infants. Two-hundred nineteen LPT and 564 term infants were included over a period of 2 years (2009-2011). 106 (48.4%) LPTs versus 58 (10.3%) term infants received non-invasive ventilation or intubation [p < 0.001; OR (95% CI) 8.2 (5.6, 12.0)]. The intubation rate was 24.7% in LPTs versus 7.3% in term infants [p < 0.001; OR (95% CI) 4.18 (2.7, 6.5)]. The duration of intubation was longer in LPT infants (median 5.0 versus 2.0 days. p = 0.03). There was a non-significant trend towards a higher mortality rate in the LPT group [p = 0.14; OR (95% CI) 3.9 (0.7, 23.5)]. This is one of three published prospective studies on the topic. The study design lends more robust credence to the results previously identified only in retrospective and systematic reviews. LPT infants are more likely to require positive-pressure ventilation support and incur a longer duration of intubation. A trend towards greater mortality is prevalent compared to term infants.

Improved procedural performance following a simulation training session may not be transferable to the clinical environment.

PubMed

Finan, E; Bismilla, Z; Campbell, C; Leblanc, V; Jefferies, A; Whyte, H E

2012-07-01

Neonatal intubation is a life-saving procedural skill required by pediatricians. Trainees receive insufficient clinical exposure to develop this competency. Traditional training comprises a Neonatal Resuscitation Program (NRP) complemented by clinical experience. More recently, simulation is being used in procedural skills training. The objective of this study is to examine the impact of a simulation session, which teaches the skill of neonatal intubation by comparing pre- and post-intervention performance, and examining transferability of skill acquisition to the clinical setting. First-year pediatric residents with NRP training, but no previous neonatal experience, attended a 2-h intubation education session conducted by two experienced respiratory therapists. Individual components of the skill were taught, followed by practice on a high-fidelity infant mannequin with concurrent feedback. Skills were assessed using a validated neonatal intubation checklist (CL) and a five-point global rating scale (GRS), pre- and immediately post-intervention, using the mannequin. Clinical intubations performed in the subsequent 8-week neonatal intensive-care unit (NICU) rotation were evaluated by documenting success rates, time taken to intubate, and CL and GRS scores. Performance was also compared with similar data collected on intubations performed by a historical cohort of first-year residents who did not receive the training intervention. Data were analyzed using descriptive statistics, Student's t-test and χ (2)-test as appropriate, and analysis of variance. Thirteen residents participated in the educational session. Mean pre-intervention CL score was 65.4 ± 18% (s.d.) and GRS was 3 ± 0.7 (s.d.). Performance improved following the intervention with post-training CL score of 93 ± 5% (P<0.0001) and GRS of 3.92 ± 0.4 (P=0.0003). These trainees performed 40 intubations during their subsequent NICU rotation, with a success rate of 67.5% compared with 63.15% in the cohort group (NS). However, mean CL score for the study trainees during the NICU rotation was 64.6 ± 20%, significantly lower than their post-training CL score (P<0.001), and significantly lower than the historical cohort score of 82.5 ± 15.4% (P=0.001). In the intervention group, there were no significant differences between the pre-intervention and real-life CL scores of 65 ± 18% and 64.63 %, respectively, and the pre-intervention and real-life GRS of 3.0 ± 0.7 and 2.95 ± 0.86, respectively. Trainees showed significant improvement in intubation skills immediately post intervention, but this did not translate into improved-clinical performance, with performance returning to baseline. In fact, significantly higher CL scores were demonstrated by the cohort group. These data suggest that improved performance in the simulation environment may not be transferable to the clinical setting. They also support the evidence that although concurrent feedback may lead to improved performance immediately post training intervention, this does not result in improved skill retention overall.

Botulism from Drinking Pruno

PubMed Central

Mase, Sundari R.; Cole, Barbara; Stiles, John; Rosenberg, Jon; Velasquez, Linda; Radner, Allen; Inami, Greg

2009-01-01

Foodborne botulism occurred among inmates at 2 prisons in California in 2004 and 2005. In the first outbreak, 4 inmates were hospitalized, 2 of whom required intubation. In the second event, 1 inmate required intubation. Pruno, an alcoholic drink made illicitly in prisons, was the novel vehicle for these cases. PMID:19116055

Mechanical ventilation for severe asthma.

PubMed

Leatherman, James

2015-06-01

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.

Double silicone tube intubation for the management of partial lacrimal system obstruction.

PubMed

Demirci, Hakan; Elner, Victor M

2008-02-01

To evaluate the effectiveness of double silicone intubation for the management of partial lacrimal drainage system obstruction in adults. Observational retrospective case series. Twenty-four eyes of 18 consecutive adult patients with partial lacrimal system obstruction managed at the University of Michigan. Retrospective review of symptoms and signs, duration of silicone intubation, and complications. Resolution of tearing. Preoperative tearing, negative Jones I testing, positive Jones II testing, and resistance to positive-pressure irrigation were present in all eyes (100%). The first silicone tube was removed after a mean of 11+/-7 months, and the second tube after 16+/-6 months. Postoperatively, at a mean of 21+/-9 months after removal of both tubes, tearing remained resolved in 19 eyes (79%) and remained improved in 2 eyes (8%). In eyes with resolved tearing, Jones I testing became positive, and there was no resistance to positive-pressure irrigation. Persistent tearing in 3 eyes (13%) required treatment with external dacryocystorhinostomy. The only complication was peripunctal pyogenic granulomas in 2 eyes. Double silicone intubation is an effective minimally invasive technique for treatment of partial lacrimal system obstruction in adults.

The Role of Presepsin Obtained from Tracheal Aspirates in the Diagnosis of Early Onset Pneumonia in Intubated Newborns.

PubMed

Savić, Dragana; Simović, Aleksandra; Marković, Slavica; Kostić, Gordana; Vuletić, Biljana; Radivojević, Snezana; Lišanin, Marina; Igrutinović, Zoran; Pavlović, Radisa

2018-04-14

To investigate the role of presepsin obtained from tracheal aspirate of intubated newborns in the diagnosis of early neonatal pneumonia. A cross-sectional observational study was performed on 60 intubated newborns during the two-year period. Tracheal aspirate for examination was taken in aseptic conditions in usual toilets, by lavage with 2 ml of 0.9% NaCl in Mucus suction set. On the same day, presepsin (blood) was measured. There were 34 newborns in the examined group (with pneumonia) and 26 in the control group. Patient groups were similar regarding demographic characteristics related to gender and Apgar score. The coefficients of simple linear correlation revealed the statistically significant connection between presepsin (from tracheal aspirate) and birth body weight, presepsin (plasma), maternal infection and pneumonia. Significant differences in the values of presepsin (from tracheal aspirate) (p < 0.001) and birth body weight (p = 0.036) were found. In intubated newborns, measurements of presepsin obtained from tracheal aspirate suggested that it can be used as a complementary marker in diagnosing early onset neonatal pneumonia.

Dosage effect of rocuronium on intraoperative neuromonitoring in patients undergoing thyroid surgery.

PubMed

Han, Yang-dong; Liang, Feng; Chen, Peng

2015-01-01

The effect of different concentrations of rocuronium bromide used for anesthesia induction during thyroid surgery on the intraoperative recurrent laryngeal nerve monitoring was evaluated. One hundred patients undergoing thyroid operation were randomized into five groups (20 patients per group). Patients in group I were operated and monitored without the use of rocuronium bromide. Patients in groups II-V were respectively injected with 0.5x, 1x, 1.5x, and 2x ED95 rocuronium bromide intravenously. The time from injecting the rocuronium bromide to the beginning of tube insertion was recorded, the conditions of tracheal intubation were evaluated, and the changes in blood pressure and pulse during the intubation process were monitored. Vagus nerve/recurrent laryngeal nerve evoked muscle potential was monitored using the NIM-Response3.0 nerve electromyography monitor. The amplitude of electromyography signal was recorded every 5 min during 30 min after successful tracheal intubation. The tracheal intubation success rate was 100% in all groups. Compared with group I, intubating condition scores (Cooper scores) in the patients of groups II-V were higher (P < 0.05). The stability of intraoperative neuromonitoring signal amplitude in groups I-III met the monitoring standards. The findings suggest that the use of 0.5x or 1x ED95 rocuronium bromide during the anesthesia induction can improve the tracheal tube conditions without affecting the intraoperative recurrent laryngeal nerve monitoring. The use of 1x ED95 rocuronium bromide induction was associated with the best results.

Vision-related quality of life in patients undergoing silicone tube intubation for lacrimal passage obstructions.

PubMed

Kabata, Yoshiaki; Goto, Satoshi; Takahashi, Genichiro; Tsuneoka, Hiroshi

2011-07-01

To evaluate the changes in vision-related quality of life in patients with lacrimal passage obstructions undergoing silicone tube intubations. Prospective, consecutive, comparative, interventional case series. Forty-five patients with the chief complaint of epiphora diagnosed with complete and unilateral lacrimal passage obstructions were enrolled. Exclusion criteria included history of congenital nasolacrimal stenosis; lacrimal passage obstructions resulting from trauma, tumor, or chemotherapy; previous lacrimal passage surgery; and partial and functional nasolacrimal duct obstructions. Silicone tube intubation using a Nunchaku-style tube was performed under direct visualization with dacryoendoscope in all patients. Operations were considered as successful when the irrigating fluid could pass through the lacrimal passage and the disappearance of dye was observed in dye disappearance test and the patients' epiphora symptoms improved 3 months postoperatively. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was self-administered in all patients preoperatively and 3 months postoperatively. Patients' preoperative and 3-months-postoperative NEI VFQ-25 scores were compared. Operations were successful in 40 patients (89%). Fully completed questionnaires were received from 32 patients (80%). Silicone tube intubation using a Nunchaku-style tube was associated with a significant improvement of the NEI VFQ-25 composite score (P = .0001), ocular pain score (P < .0001), and mental health score (P = .0003). Relief of epiphora by silicone tube intubation using a Nunchaku-style tube treatment significantly improved the vision-related quality of life in patients with lacrimal passage obstructions. Copyright © 2011 Elsevier Inc. All rights reserved.

Assessing anesthesiology residents' out-of-the-operating-room (OOOR) emergent airway management.

PubMed

Rochlen, Lauryn R; Housey, Michelle; Gannon, Ian; Mitchell, Shannon; Rooney, Deborah M; Tait, Alan R; Engoren, Milo

2017-07-15

At many academic institutions, anesthesiology residents are responsible for managing emergent intubations outside of the operating room (OOOR), with complications estimated to be as high as 39%. In order to create an OOOR training curriculum, we evaluated residents' familiarity with the content and correct adherence to the American Society of Anesthesiologists' Difficult Airway Algorithm (ASA DAA). Residents completed a pre-simulation multiple-choice survey measuring their understanding and use of the DAA. Residents then managed an emergent, difficult OOOR intubation in the simulation center, where two trained reviewers assessed performance using checklists. Post-simulation, the residents completed a survey rating their behaviors during the simulation. The primary outcome was comprehension and adherence to the DAA as assessed by survey responses and behavior in the simulation. Sixty-three residents completed both surveys and the simulation. Post-survey responses indicated a shift toward decreased self-perceived familiarity with the DAA content compared to pre-survey responses. During the simulation, 22 (35%) residents were unsuccessful with intubation. Of these, 46% placed an LMA and 46% prepared for cricothyroidotomy. Nineteen residents did not attempt intubation. Of these, only 31% considered LMA placement, and 26% initiated cricothyroidotomy. Many anesthesiology residency training programs permit resident autonomy in managing emergent intubations OOOR. Residents self-reported familiarity with the content of and adherence to the DAA was higher than that observed during the simulation. Curriculum focused on comprehension of the DAA, as well as improving communication with higher-level physicians and specialists, may improve outcomes during OOORs.

Prior esophagogastroduodenoscopy does not affect the cecal intubation time at bidirectional endoscopies

PubMed Central

Öner, Osman Zekai; Demirci, Rojbin Karakoyun; Gündüz, Umut Rıza; Aslaner, Arif; Koç, Ümit; Bülbüller, Nurullah

2013-01-01

Bidirectional endoscopy (BE) is often used to assess patients for the reason of anemia or to screen asymptomatic population for malignancy. Limited clinical data favors to perform first the upper gastrointestinal system endoscopy, but its effect to the duration of colonoscopy is yet to be determined. The aim of this retrospective study is to evaluate the effect of upper gastrointestinal system endoscopy on the time to achieve cecal intubation during colonoscopy in patients undergoing BE. Patients of four endoscopists at similar experience levels were retrospectively identified and categorized into the upper gastrointestinal system endoscopy before colonoscopy group (group 1) or the colonoscopy only group (group 2). The demographics, clinical data and the time to achieve cecal intubation for each patient were analyzed. The mean time to achieve cecal intubation in the first group that included 319 cases was 8.4 ± 0.93 minutes and the mean time in the second group that included 1672 cases was 8.56 ± 1.16 minutes. There was no statistically significant difference between the groups. There was also no significant difference between the Group 1 and Group 2 when compared according to which of the four endoscopists performed the procedures. Performing the upper gastrointestinal system endoscopy prior to colonoscopy did not affect the time to achieve cecal intubation. Considering that performing the upper gastrointestinal system endoscopy prior to the colonoscopy is more advantageous in terms of patient comfort and analgesic requirement, beginning to BE with it seems more favorable. PMID:23936601

Quality of Vision in Eyes With Epiphora Undergoing Lacrimal Passage Intubation.

PubMed

Koh, Shizuka; Inoue, Yasushi; Ochi, Shintaro; Takai, Yoshihiro; Maeda, Naoyuki; Nishida, Kohji

2017-09-01

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.

A Non-invasive Real-time Localization System for Enhanced Efficacy in Nasogastric Intubation.

PubMed

Sun, Zhenglong; Foong, Shaohui; Maréchal, Luc; Tan, U-Xuan; Teo, Tee Hui; Shabbir, Asim

2015-12-01

Nasogastric (NG) intubation is one of the most commonly performed clinical procedures. Real-time localization and tracking of the NG tube passage at the larynx region into the esophagus is crucial for safety, but is lacking in current practice. In this paper, we present the design, analysis and evaluation of a non-invasive real-time localization system using passive magnetic tracking techniques to improve efficacy of the clinical NG intubation process. By embedding a small permanent magnet at the insertion tip of the NG tube, a wearable system containing embedded sensors around the neck can determine the absolute position of the NG tube inside the body in real-time to assist in insertion. In order to validate the feasibility of the proposed system in detecting erroneous tube placement, typical reference intubation trajectories are first analyzed using anatomically correct models and localization accuracy of the system are evaluated using a precise robotic platform. It is found that the root-mean-squared tracking accuracy is within 5.3 mm for both the esophagus and trachea intubation pathways. Experiments were also designed and performed to demonstrate that the system is capable of tracking the NG tube accurately in biological environments even in presence of stationary ferromagnetic objects (such as clinical instruments). With minimal physical modification to the NG tube and clinical process, this system allows accurate and efficient localization and confirmation of correct NG tube placement without supplemental radiographic methods which is considered the current clinical standard.

Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates.

PubMed

Audil, Hadiyah Y; Tse, Sara; Pezzano, Chad; Mitchell-van Steele, Amy; Pinheiro, Joaquim M B

2018-05-22

Background : We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives : To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil's safety and usability in a teaching hospital context. Methods : Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results : 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks' gestation). Extubation was successful in 88%, vs. 33% with morphine premedication ( p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions : Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.

Comparison of Oral and Axillary Temperatures in Intubated Pediatric Patients.

PubMed

Wood, Danielle; Heitschmidt, Mary; Fogg, Louis

2018-05-10

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.

[Causes of vocal cord dyscinesia and its original factors after endotracheal intubation].

PubMed

Sun, Anke; Zhang, Tiezheng; Liu, Wenyuan; Tang, Weiwei; Guo, Xiaohong

2012-03-01

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.

Straight video blades are advantageous than curved blades in simulated pediatric difficult intubation.

PubMed

Saracoglu, Kemal T; Eti, Zeynep; Kavas, Ayse D; Umuroglu, Tumay

2014-03-01

It is still controversial which laryngoscope may be a better option in unanticipated difficult airway in pediatric patients. The aim of the present study was to compare two direct and two video-assisted laryngoscope devices for the management of difficult pediatric airway. Forty-five anesthesiology residents and nurse anesthetists participated in the study. Macintosh, Miller, Storz Miller, and McGrath Mac curved laryngoscopes were used for tracheal intubation of 3-6-month Airsim Pierre Robin manikin. We compared the duration of successful intubation, number of attempts, glottic view grades, severity of dental trauma, the use of optimization maneuvers, and the difficulty of use of the devices with straight and curved laryngoscope blades. Successful intubation duration was significantly lower in Storz Miller device, and the number of intubation attempts was significantly higher in the Macintosh laryngoscope (P < 0.01). According to the Cormack and Lehane classification, Grades 1 and 2 glottic view was 20% for Macintosh and 40% for Miller laryngoscope, while it was 100% for Storz Miller and 80% for McGrath (P < 0.001). Difficulty VAS scores of Storz Miller device were significantly lower than the scores of Macintosh, Miller, and McGrath laryngoscopes (15.7 ± 14.89, 34.7 ± 26.44, 31.5 ± 26.74, 33.4 ± 26.67 mm, respectively; P < 0.01). The severity of dental trauma was significantly lower in Storz Miller compared with Macintosh, Miller, and McGrath laryngoscopes (0.96 ± 1.04, 1.67 ± 1.15, 1.38 ± 1.05, 1.42 ± 1.27, respectively; P < 0.01). Storz Miller laryngoscope was found to have advantages over the other laryngoscopes in regard to glottic view, duration of successful intubation, number of attempts, dental trauma severity, need for additional maneuvers, and ease of use. © 2013 John Wiley & Sons Ltd.

Efficiency of a pneumatic device in controlling cuff pressure of polyurethane-cuffed tracheal tubes: a randomized controlled study

PubMed Central

2013-01-01

Background The primary objective of this study was to determine the efficiency of a pneumatic device in controlling cuff pressure (Pcuff) in patients intubated with polyurethane-cuffed tracheal tubes. Secondary objectives were to determine the impact of continuous control of Pcuff, and cuff shape on microaspiration of gastric contents. Methods Prospective randomized controlled study. All patients requiring intubation and mechanical ventilation ≥48 h were eligible. The first 32 patients were intubated with tapered polyurethane-cuffed, and the 32 following patients were intubated with cylindrical polyurethane-cuffed tracheal tubes. Patients randomly received 24 h of continuous control of Pcuff using a pneumatic device (Nosten®), and 24 h of routine care of Pcuff using a manometer. Target Pcuff was 25 cmH2O. Pcuff was continuously recorded, and pepsin was quantitatively measured in all tracheal aspirates during these periods. Results The pneumatic device was efficient in controlling Pcuff (med [IQ] 26 [24, 28] vs 22 [20, 28] cmH2O, during continuous control of Pcuff and routine care, respectively; p = 0.017). In addition, percentage of patients with underinflation (31% vs 68%) or overinflation (53% vs 100%) of tracheal cuff, and percentage of time spent with underinflation (0.9 [0, 17] vs 14% [4, 30]) or overinflation (0 [0, 2] vs 32% [9, 54]) were significantly (p < 0.001) reduced during continuous control of Pcuff compared with routine care. No significant difference was found in microaspiration of gastric content between continuous control of Pcuff compared with routine care, or between patients intubated with tapered compared with cylindrical polyurethane-cuffed tracheal tubes. Conclusion The pneumatic device was efficient in controlling Pcuff in critically ill patients intubated with polyurethane-cuffed tracheal tubes. Trial registration The Australian New Zealand Clinical Trials Registry (NCT01351259) PMID:24369057

A prospective, randomised, clinical study to compare the use of McGrath(®), Truview(®) and Macintosh laryngoscopes for endotracheal intubation by novice and experienced Anaesthesiologists.

PubMed

Bakshi, Sumitra G; Vanjari, Vinayak S; Divatia, Jigeeshu V

2015-07-01

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.

A prospective, randomised, clinical study to compare the use of McGrath®, Truview® and Macintosh laryngoscopes for endotracheal intubation by novice and experienced Anaesthesiologists

PubMed Central

Bakshi, Sumitra G; Vanjari, Vinayak S; Divatia, Jigeeshu V

2015-01-01

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

A randomized multi-institutional crossover comparison of the GlideScope® Cobalt Video laryngoscope to the flexible fiberoptic bronchoscope in a Pierre Robin manikin.

PubMed

Fiadjoe, John E; Hirschfeld, Matthew; Wu, Stephan; Markley, James; Gurnaney, Harshad; Jawad, Abbas F; Stricker, Paul; Kilbaugh, Todd; Ross, Patrick; Kovatsis, Pete

2015-08-01

The GlideScope Cobalt Video laryngoscope is being used more often in children with challenging laryngoscopy. There are, however, no pediatric trials comparing it to flexible fiberoptic bronchoscopy, the current accepted gold standard. This preliminary manikin study compares the first-attempt intubation success of the GlideScope Cobalt video laryngoscope to the flexible fiberoptic bronchoscope when performed by attending pediatric anesthesiologists at two major pediatric centers. This prospective randomized, crossover study evaluated 120 attempts (60 with each study device) to intubate the AirSim Pierre Robin manikin (PRM) with fiberoptic bronchoscopy and video laryngoscopy (VL). Attending pediatric anesthesiologists from two quaternary pediatric centers were eligible to participate. Each attending anesthesiologist randomly performed a single tracheal intubation attempt with one of the study devices followed by the alternate method. The primary outcome was the first-attempt success rate of tracheal intubation. Blinding was not feasible. We hypothesized that first-attempt success would be higher with fiberoptic bronchoscopy. Thirty anesthesiologists from each center were randomized to use one of the study devices followed by the alternate method. We analyzed all participants' data. There was no overall difference in first-attempt success between VL and fiberoptic bronchoscopy (88.3% vs 85% respectively, P = 0.59). There were significant institutional differences in first-attempt success using VL (76.7% vs 100%). There was no difference in first-attempt success of tracheal intubation using VL vs fiberoptic bronchoscopy when performed by attending anesthesiologists at two large pediatric centers. However, institutional differences exist in success rates with VL across the two centers. Results from single-center device evaluations should be verified by multi-center evaluations. A significant proportion of attending anesthesiologists lack experience with advanced airway devices; targeted education may enhance intubation success and patient safety. © 2015 John Wiley & Sons Ltd.

Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure.

PubMed

El-Jawahri, Areej; Paasche-Orlow, Michael K; Matlock, Dan; Stevenson, Lynne Warner; Lewis, Eldrin F; Stewart, Garrick; Semigran, Marc; Chang, Yuchiao; Parks, Kimberly; Walker-Corkery, Elizabeth S; Temel, Jennifer S; Bohossian, Hacho; Ooi, Henry; Mann, Eileen; Volandes, Angelo E

2016-07-05

Conversations about goals of care and cardiopulmonary resuscitation (CPR)/intubation for patients with advanced heart failure can be difficult. This study examined the impact of a video decision support tool and patient checklist on advance care planning for patients with heart failure. This was a multisite, randomized, controlled trial of a video-assisted intervention and advance care planning checklist versus a verbal description in 246 patients ≥64 years of age with heart failure and an estimated likelihood of death of >50% within 2 years. Intervention participants received a verbal description for goals of care (life-prolonging care, limited care, and comfort care) and CPR/intubation plus a 6-minute video depicting the 3 levels of care, CPR/intubation, and an advance care planning checklist. Control subjects received only the verbal description. The primary analysis compared the proportion of patients preferring comfort care between study arms immediately after the intervention. Secondary outcomes were CPR/intubation preferences and knowledge (6-item test; range, 0-6) after intervention. In the intervention group, 27 (22%) chose life-prolonging care, 31 (25%) chose limited care, 63 (51%) selected comfort care, and 2 (2%) were uncertain. In the control group, 50 (41%) chose life-prolonging care, 27 (22%) selected limited care, 37 (30%) chose comfort care, and 8 (7%) were uncertain (P<0.001). Intervention participants (compared with control subjects) were more likely to forgo CPR (68% versus 35%; P<0.001) and intubation (77% versus 48%; P<0.001) and had higher mean knowledge scores (4.1 versus 3.0; P<0.001). Patients with heart failure who viewed a video were more informed, more likely to select a focus on comfort, and less likely to desire CPR/intubation compared with patients receiving verbal information only. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01589120. © 2016 American Heart Association, Inc.

C-MAC videolaryngoscope versus Macintosh laryngoscope for tracheal intubation: A systematic review and meta-analysis with trial sequential analysis.

PubMed

Hoshijima, Hiroshi; Mihara, Takahiro; Maruyama, Koichi; Denawa, Yohei; Mizuta, Kentaro; Shiga, Toshiya; Nagasaka, Hiroshi

2018-06-09

The C-MAC laryngoscope (C-MAC) is a videolaryngoscope that uses a modified Macintosh blade. Although several anecdotal reports exist, it remains unclear whether the C-MAC is superior to the Macintosh laryngoscope for tracheal intubation in the adult population. Systematic review, meta-analysis. Operating room, intensive care unit. For inclusion in our analysis, studies had to be prospective randomised trials which compared the C-MAC with the Macintosh laryngoscope for tracheal intubation in the adult population. Data on success rates, intubation time, glottic visualisation and incidence of external laryngeal manipulations (ELM) during tracheal intubation were extracted from the identified studies. In subgroup analysis, we separated those parameters to assess the influence of the airway condition (normal or difficult) and laryngoscopists (novice or experienced). We conducted a trial sequential analysis (TSA). Sixteen articles with 18 trials met the inclusion criteria. The C-MAC provided better glottic visualisation compared to the Macintosh (RR, 1.08; 95% CI, 1.03-1.14). TSA corrected the CI to 1.01-1.19; thus, total sample size reached the required information size (RIS). Success rates and intubation time did not differ significantly between the laryngoscopes. TSA showed that total sample size reached the RIS for success rates. The TSA Z curve surpassed the futility boundary. The C-MAC required less ELM compared to the Macintosh (RR, 0.83; 95% CI, 0.72-0.96). TSA corrected the CI to 0.67-1.03; 52.3% of the RIS was achieved. In difficult airways, the C-MAC showed superior success rates, glottic visualisation, and less ELM compared to the Macintosh. Among experienced laryngoscopists, the C-MAC offered better glottic visualisation with less ELM than the Macintosh. The C-MAC provided better glottic visualisation and less ELM (GRADE: Very Low or Moderate), with improved success rates, glottic visualisation, and less ELM in difficult airways. Copyright © 2018 Elsevier Inc. All rights reserved.

Comparison of the glidescope®, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study

PubMed Central

2014-01-01

Background Smart phone technology is becoming increasingly integrated into medical care. Our study compared an iPhone modified flexible fibreoptic bronchoscope as an intubation aid and clinical teaching tool with an unmodified bronchoscope, Glidescope® and Macintosh laryngoscope in a simulated normal and difficult airway scenario. Methods Sixty three anaesthesia providers, 21 consultant anaesthetists, 21 registrars and 21 anaesthetic nurses attempted to intubate a MegaCode Kelly™ manikin, comparing a normal and difficult airway scenario for each device. Primary endpoints were time to view the vocal cords (TVC), time to successful intubation (TSI) and number of failed intubations with each device. Secondary outcomes included participant rated device usability and preference for each scenario. Advantages and disadvantages of the iPhone modified bronchoscope were also discussed. Results There was no significant difference in TVC with the iPhone modified bronchoscope compared with the Macintosh blade (P = 1.0) or unmodified bronchoscope (P = 0.155). TVC was significantly shorter with the Glidescope compared with the Macintosh blade (P < 0.001), iPhone (P < 0.001) and unmodified bronchoscope (P = 0.011). The iPhone bronchoscope TSI was significantly longer than all other devices (P < 0.001). There was no difference between anaesthetic consultant or registrar TVC (P = 1.0) or TSI (P = 0.252), with both being less than the nurses (P < 0.001). Consultant anaesthetists and nurses had a higher intubation failure rate with the iPhone modified bronchoscope compared with the registrars. Although more difficult to use, similar proportions of consultants (14/21), registrars (15/21) and nurses (15/21) indicated that they would be prepared to use the iPhone modified bronchoscope in their clinical practice. The Glidescope was rated easiest to use (P < 0.001) and was the preferred device by all participants for the difficult airway scenario. Conclusions The iPhone modified bronchoscope, in its current configuration, was found to be more difficult to use compared with the Glidescope® and unmodified bronchoscope; however it offered several advantages for teaching fibreoptic intubation technique when video-assisted bronchoscopy was unavailable. PMID:24575885

Characteristics and outcomes of men who fail to leak on intubated urodynamics prior to artificial urinary sphincter placement.

PubMed

Weissbart, Steven J; Coutinho, Karl; Chughtai, Bilal; Sandhu, Jaspreet S

2014-12-01

To report the characteristics and anti-incontinence outcomes of men who fail to demonstrate incontinence on intubated urodynamics (UDS). From 2005 to 2013, the records of men who underwent UDS prior to artificial urinary sphincter (AUS) were reviewed. The histories, UDS, endoscopies, and anti-incontinence outcomes of men who failed to demonstrate incontinence on intubated UDS were recorded. In our UDS protocol, the urodynamic urethral catheter was removed and the UDS was repeated to elicit incontinence without the urethral catheter. The valsalva leak point pressure (VLPP) was obtained via the rectal catheter in these men. All men were status post radical prostatectomy for prostate cancer. Nineteen percent (32) of the study population (169) had non-demonstrable incontinence on intubated UDS. Mean age at the time of UDS was 62 (range 48-81). All patients demonstrated incontinence on UDS upon removal of the urethral catheter. Their mean VLPP was 79.3 (SD 36.7). Fifty-six percent (18) of these men had an anastomotic stricture (AS) and 37.5% (12) had a history of radiotherapy treatment, of which six also had an AS. Mean pads per day at the time of UDS was 4.6 (SD 2.9). At a mean follow up of 40.7 months (SD 24.7) from AUS placement, mean pads per day was 0.87 (SD 1.2). Men who fail to demonstrate incontinence on intubated UDS have a high rate of AS and history of radiotherapy treatment, which is a known cause for urethra fibrosis and scarring. Regardless, these men can achieve excellent anti-incontinence outcomes.

Impact of Rocuronium and Succinylcholine on Sedation Initiation After Rapid Sequence Intubation.

PubMed

Johnson, Eric G; Meier, Alex; Shirakbari, Alicia; Weant, Kyle; Baker Justice, Stephanie

2015-07-01

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.

Pediatric Tracheotomy: A 5-Year Experience in Düzce University Medical Faculty

PubMed Central

Ünlü, İlhan; İlhan, Ethem; Ünlü, Elif Nisa; Ateş, Hakan; Gün, Emrah; Yaman, Hüseyin; Güçlü, Ender

2015-01-01

Objective Tracheotomy is one of the oldest surgical procedures. Pediatric tracheotomy indications have changed in recent decades. Currently, tracheotomy is performed because of prolonged intubation, upper airway obstruction, neuromuscular, and craniofacial anomalies instead of acute airway infections. This study aims to present our experience regarding indications and complications of tracheotomy in pediatric patients. Methods We retrospectively evaluated 17 pediatric patients who underwent tracheotomy because of prolonged intubation, increased pulmonary secretions, and upper respiratory tract obstruction from June 2010 to June 2015. The patients’ age, gender, tracheotomy indications, duration of intubation, complications, and actual clinical condition were recorded. Results Tracheotomy was performed on 17 pediatric patients in our clinic. Discharged patients were followed with a 3-month routine check. Six patients (35.29%) had died because of a primary disease during follow-up, and one (5.88%) of them was a one-day-old newborn who had anomalies that were incompatible with life. In one patient, emergency tracheotomy was performed because of a tracheal trauma. None of the patients has been decannulated except one (5.88%). One (5.88%) patient had an accidental decannulation, while another had bleeding in the operation field. The total minor complication rate was 11.76%, and no major complication was observed. Two (11.76%) of the discharged patients underwent re-operation for widening of the tracheotomy stoma during their routine visit. Conclusion Currently, tracheotomy in pediatric patients is mostly performed for prolonged intubation and upper respiratory tract obstruction for which intubation is not possible. Tracheotomy enables the discharge of these patients after training their families. PMID:29391991

Cost comparison of re-usable and single-use fibrescopes in a large English teaching hospital.

PubMed

McCahon, R A; Whynes, D K

2015-06-01

A number of studies in the U.S.A. and mainland Europe have described the costs of fibreoptic tracheal intubation. However, no such data from the UK appear available. We performed a cost assessment of fibreoptic intubation, using re-usable (various devices from Olympus, Acutronic and Karl Storz) and single-use (Ambu aScope) fibrescopes, at the Queens Medical Centre, Nottingham, U.K., between 1 January 2009 and 31 March 2014. The total annual cost of fibreoptic intubation with re-usable fibrescopes was £46,385. Based on 141 fibreoptic intubations per year, this equated to £329 per use, an average dominated by repair/maintenance costs (43%) and capital depreciation costs (42%). In comparison, the total annual cost of using single-use fibrescopes for the same work would have been around £200 per use. The analysis enabled us to develop a generic model, wherein we were able to describe the relationship between total cost of use vs number of uses for a fibrescope. An 'isopleth' was identified for this relationship: a line that joined all the points where the cost of re-usable vs single-use fibrescopes was equal. It appears cheaper to use single-use fibrescopes at up to 200 fibreoptic intubations per year (a range commensurate with normal practice) even when the repair rate for re-usable fibrescopes is low. Any centre, knowing its fibrescope use and repair rate, can plot its data similarly to help ascertain which of the re-usable or single-use fibrescope represents better value. © 2015 The Association of Anaesthetists of Great Britain and Ireland.

Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics.

PubMed

Kheterpal, Sachin; Martin, Lizabeth; Shanks, Amy M; Tremper, Kevin K

2009-04-01

There are no existing data regarding risk factors for impossible mask ventilation and limited data regarding its incidence. The authors sought to determine the incidence, predictors, and outcomes associated with impossible mask ventilation. The authors performed an observational study over a 4-yr period. For each adult patient undergoing a general anesthetic, preoperative patient characteristics, detailed airway physical exam, and airway outcome data were collected. The primary outcome was impossible mask ventilation defined as the inability to exchange air during bag-mask ventilation attempts, despite multiple providers, airway adjuvants, or neuromuscular blockade. Secondary outcomes included the final, definitive airway management technique and direct laryngoscopy view. The incidence of impossible mask ventilation was calculated. Independent (P < 0.05) predictors of impossible mask ventilation were identified by performing a logistic regression full model fit. Over a 4-yr period from 2004 to 2008, 53,041 attempts at mask ventilation were recorded. A total of 77 cases of impossible mask ventilation (0.15%) were observed. Neck radiation changes, male sex, sleep apnea, Mallampati III or IV, and presence of beard were identified as independent predictors. The receiver-operating-characteristic area under the curve for this model was 0.80 +/- 0.03. Nineteen impossible mask ventilation patients (25%) also demonstrated difficult intubation, with 15 being intubated successfully. Twelve patients required an alternative intubation technique, including two surgical airways and two patients who were awakened and underwent successful fiberoptic intubation. Impossible mask ventilation is an infrequent airway event that is associated with difficult intubation. Neck radiation changes represent the most significant clinical predictor of impossible mask ventilation in the patient dataset.

A comparison of three induction regimens using succinylcholine, vecuronium, or no muscle relaxant: impact on the intraoperative monitoring of the lateral spread response in hemifacial spasm surgery: study protocol for a randomised controlled trial

PubMed Central

2012-01-01

Background Surgical microvascular decompression (MVD) is the curative treatment for hemifacial spasm (HFS). Monitoring MVD by recording the lateral spread response (LSR) intraoperatively can predict a successful clinical outcome. However, the rate of the LSR varies between trials, and the reason for this variation is unclear. The aim of our trial is to evaluate the rate of the LSR after intubation following treatment with succinylcholine, vecuronium, or no muscle relaxant. Methods and design This trial is a prospective randomised controlled trial of 96 patients with HFS (ASA status I or II) undergoing MVD under general anaesthesia. Patients are randomised to receive succinylcholine, vecuronium, or no muscle relaxant before intubation. Intraoperative LSR will be recorded until dural opening. The primary outcome of this study is the rate of the LSR, and the secondary outcomes are post-intubation pharyngolaryngeal symptoms, the rate of difficult intubations, the rate of adverse haemodynamic events and the relationship between the measurement of LSR or not, and clinical success rates at 30 days after surgery. Discussion This study aims to evaluate the impact of muscle relaxants on the rate of the LSR, and the study may provide evidence supporting the use of muscle relaxants before intubation in patients with HFS undergoing MVD surgery. Trials registration http://www.chictr.org/ ChiCTR-TRC-11001504 Date of registration: 24 June, 2011. The date the first patient was randomised: 30 September, 2011. PMID:22958580

Transareolar Single-Port Needlescopic Thoracic Sympathectomy Under Intravenous Anesthesia Without Intubation: A Randomized Controlled Trial.

PubMed

Chen, Jianfeng; Du, Quan; Lin, Min; Lin, Jianbo; Li, Xu; Lai, Fancai; Tu, Yuanrong

2016-12-01

Transareolar single-port needlescopic thoracic sympathectomy under intravenous anesthesia without intubation has rarely been attempted in managing primary palmar hyperhidrosis (PPH). The objective of this study is to evaluate the feasibility and safety of this minimally invasive technique. From May 2012 to May 2015, 168 male patients with severe PPH underwent single-port endoscopic thoracic sympathectomy (ETS) and were randomly allocated to groups A or B. Patients in group A underwent nonintubated transareolar ETS with a 2-mm needle endoscope, while those in group B underwent intubated transaxillary ETS with a 5-mm thoracoscope. All procedures were performed successfully. The palms of all patients became dry and warm immediately after surgery. The mean resuscitation time was significantly shorter in nonintubated patients than in intubated patients. Postoperative sore throat occurred in 4 patients in group A and in 32 patients in group B (P < .01). The mean incision length was significantly shorter in group A than in group B. The mean postoperative pain scores were markedly higher in group B than in group A. The mean cost of anesthesia was considerably lower in nonintubated patients than in intubated patients. The mean cosmetic scores were higher in group A than in group B (P < .01). Nonintubated transareolar single-port ETS with a needle endoscope is a safe, effective, and minimally invasive therapeutic procedure, which allows a smaller incision with less pain and excellent cosmetic results. This novel procedure can be performed in a routine clinical practice for male patients with severe PPH.

Mallampati test as a predictor of laryngoscopic view.

PubMed

Adamus, Milan; Fritscherova, Sarka; Hrabalek, Lumir; Gabrhelik, Tomas; Zapletalova, Jana; Janout, Vladimir

2010-12-01

To determine the accuracy of the modified Mallampati test for predicting difficult tracheal intubation. A cross-sectional, clinical, observational, non-blinded study. A quality analysis of anesthetic care. Operating theatres and department of anesthesiology in a university hospital. Following the local ethics committee approval and patients' informed consent to anesthesia, all adult patients (> 18 yrs) presenting for any type of non-emergency surgical procedures under general anesthesia requiring endotracheal intubation were enrolled. Prior to anesthesia, Samsoon and Young's modification of the Mallampati test (modified Mallampati test) was performed. Following induction, the anesthesiologist described the laryngoscopic view using the Cormack-Lehane scale. Classes 3 or 4 of the modified Mallampati test were considered a predictor of difficult intubation. Grades 3 or 4 of the Cormack-Lehane classification of the laryngoscopic view were defined as impaired glottic exposure. The sensitivity, specificity, positive and negative predictive value, relative risk, likelihood ratio and accuracy of the modified Mallampati test were calculated on 2x2 contingency tables. Of the total 1,518 patients enrolled, 48 had difficult intubation (3.2%). We failed to detect as many as 35.4% patients in whom glottis exposure during direct laryngoscopy was inadequate (sensitivity 0.646). Compared to the original article by Mallampati, we found lower specificity (0.824 vs. 0.995), lower positive predictive value (0.107 vs. 0.933), higher negative predictive value (0.986 vs. 0.928), lower likelihood ratio (3.68 vs. 91.0) and accuracy (0.819 vs. 0.929). When used as a single examination, the modified Mallampati test is of limited value in predicting difficult intubation.

Nurse and Patient Characteristics Associated with Duration of Nurse Talk During Patient Encounters in ICU

PubMed Central

Nilsen, Marci Lee; Sereika, Susan; Happ, Mary Beth

2012-01-01

Background Communication interactions between nurses and mechanically ventilated patients in the intensive care unit (ICU) are typically brief. Factors associated with length of nurses’ communication have not been explored. Objective To examine the association between nurse and patient characteristics and duration of nurse talk. Methods In this secondary analysis, we calculated duration of nurse talk in the first 3-minutes of video-recorded communication observation sessions for each nurse-patient dyad (n=89) in the SPEACS study (4 observation sessions/dyad, n=356). In addition, we explored the association between nurses’ characteristics (age, gender, credentials, nursing experience, and critical care experience) and patients’ characteristics (age, gender, race, education, delirium, agitation-sedation, severity of illness, level of consciousness, prior intubation history, days intubated prior to study enrollment, and type of intubation) on duration of nurse talk during the 3-minute interaction observation. Results Duration of nurse talk ranged from 0–123 seconds and varied significantly over the 4 observation sessions (p=.007). Averaging the duration of nurse talk over the observation sessions, differences in talk time between the units varied significantly by study group (p<.001). Talk duration was negatively associated with a Glasgow Coma Scale ≤ 14 (p=.008). Length of intubation prior to study enrollment had a curvilinear relationship with talking duration (linear p=.002, quadratic p=.013); the point of inflection was at 23 days. Nurse characteristics were not significantly related to duration of nurse talk. Conclusion Length of time the patient is intubated, and the patient’s level of consciousness may influence duration of nurse communication in ICU. PMID:23305914

Anesthetic Management by Laryngeal Mask Airway in a Patient With a History of Difficult Intubation Resulting in Dental Injuries

PubMed Central

Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro

2015-01-01

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

Effects of combination oral care on oral health, dry mouth and salivary pH of intubated patients: A randomized controlled trial.

PubMed

Jang, Chun Sun; Shin, Yong Soon

2016-10-01

Intubated patients are at risk of oral health problems. Although a variety of oral care regimens for intubated patients have been studied, there is a lack of research on the effects of combination oral care that includes tooth brushing, chlorhexidine and cold water. This open-labelled, randomized, controlled trial aimed to evaluate the effects of combination oral care on oral health status. Participants aged 20 years and older were recruited on the first day after intubation through convenience sampling in a medical intensive care unit. Random assignment was performed using an internet randomization service. The primary outcome was oral health status. Data were collected during May and June 2013. Participants were randomized to one of two groups (23 intervention and 21 control). The final analysis included 18 patients with combination oral care and 17 in the control group. The intervention group had better oral health (effect size = 1.56), less dry mouth and higher salivary pH than the control group. Any additional burden of providing combination oral care to patients who are mechanically ventilated is worthwhile in terms of clinical outcomes. © 2016 John Wiley & Sons Australia, Ltd.

Resource utilization patterns using non-invasive ventilation in neonates with respiratory distress syndrome.

PubMed

Chavez, Thomas A; Lakshmanan, Ashwini; Figueroa, Lizzette; Iyer, Narayan; Stavroudis, Theodora A; Garingo, Arlene; Friedlich, Philippe S; Ramanathan, Rangasamy

2018-05-24

To describe the frequency of non-invasive ventilation (NIV) and endotracheal intubation use in neonates diagnosed with respiratory distress syndrome (RDS); to describe resources utilization (length of stay (LOS), charges, costs) among NIV and intubated RDS groups. Retrospective study from the national Kid's Inpatient Database of the Healthcare Cost and Utilization Project, for the years 1997-2012. Propensity scoring and multivariate regression analysis used to describe differences. A total of 595,254 out of 42,912,090 cases were identified with RDS. There was an increase in NIV use from 6% in 1997 to 17% in 2012. After matching, patients receiving NIV only were associated with shorter LOS: (95%CI) 25 (25.3,25.7) vs. 35 (34.2,34.9) days, decreased costs: ($/1k) 46.1 (45.5,46.8) vs. 65.0 (64.1,66.0), decreased charges: 130.3 (128.6,132.1) vs. 192.1 (189.5,194.6) compared to intubated neonates. There was a three-fold increase in NIV use within the 15-year study period. NIV use was associated with decreased LOS, charges and costs compared to intubated patients.

Simple and fast orotracheal intubation procedure in rats.

PubMed

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

2016-05-06

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.

Nasal CPAP in the delivery room for newborns with extremely low birth weight in a hospital in a developing country.

PubMed

Gonçalves-Ferri, W A; Martinez, F E

2013-10-01

The objective of this study was to determine the feasibility of the use of continuous positive airway pressure installed prophylactically in the delivery room (DR-CPAP), for infants with a birth weight between 500 and 1000 g in settings with limited resources. During 23 months, infants with a birth weight between 500 and 1000 g consecutively received DR-CPAP. A total of 33 infants with low birth weight were enrolled, 16 (48.5%) were females. Only 14 (42.4%) received antenatal corticosteroids and only 2 of those 14 (14.3%) infants weighing 500-750 g were not intubated in the delivery room, and apnea was given as the reason for intubation of these patients. Of the 19 infants in the 751-1000 g weight range, 9 (47.4%) were intubated in the delivery room, 6 due to apnea and 3 due to respiratory discomfort. For DR-CPAP to be successful, it is probably necessary for preterm babies to be more prepared at birth to withstand the respiratory effort without the need for intubation. Antenatal corticosteroids and better prenatal monitoring are fundamental for success of DR-CPAP.

Comparison of cough reflex testing with videoendoscopy in recently extubated intensive care unit patients.

PubMed

Kallesen, Molly; Psirides, Alex; Huckabee, Maggie-Lee

2016-06-01

Orotracheal intubation is known to impair cough reflex, but the validity of cough reflex testing (CRT) as a screening tool for silent aspiration in this population is unknown. One hundred and six participants in a tertiary-level intensive care unit (ICU) underwent CRT and videoendoscopic evaluation of swallowing (VES) within 24 hours of extubation. Cough reflex threshold was established for each participant using nebulized citric acid. Thirty-nine (37%) participants had an absent cough to CRT. Thirteen (12%) participants aspirated on VES, 9 (69%) without a cough response. Sensitivity of CRT to identify silent aspiration was excellent, but specificity was poor. There was a significant correlation between intubation duration and presence of aspiration on VES (P= .0107). There was no significant correlation between silent aspiration on VES and length of intubation, age, sex, diagnosis at intensive care unit admission, indication for intubation, Acute Physiology and Chronic Health Evaluation III score, morphine equivalent dose, or time of testing postextubation. Intensive care unit patients are at increased risk of aspiration in the 24 hours following extubation, and an impaired cough reflex is common. However, CRT overidentifies risk of silent aspiration in this population. Copyright © 2016 Elsevier Inc. All rights reserved.

Tracheal intubation prevented with administration of Fab antivenom after severe crotaline envenomation.

PubMed

Bebarta, Vikhyat S; Ferre, Robinson M; Peck, Michael

2010-07-01

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.

Comparison of the reusable standard GlideScope® video laryngoscope and the disposable cobalt GlideScope® video laryngoscope for tracheal intubation in an academic emergency department: a retrospective review.

PubMed

Sakles, John C; Patanwala, Asad E; Mosier, Jarrod; Dicken, John; Holman, Nathan

2014-04-01

The objective was to compare the first-pass success and clinical performance characteristics of the reusable standard GlideScope® video laryngoscope (sGVL) and the disposable Cobalt GlideScope® video laryngoscope (cGVL). This was a retrospective analysis of prospectively collected data recorded into a continuous quality improvement database at an urban academic emergency department (ED). The intent of the database is to evaluate operator performance and to track practice patterns used for intubation in the ED. Between July 1, 2007, and June 30, 2013, operators recorded all consecutive intubations performed in the ED. The database included patient demographics and detailed information about each intubation, such as device(s) used, reason for device selection, method of intubation, difficult airway characteristics, number of intubation attempts, and outcome of each attempt. The operator also evaluated the presence of lens fogging and extent of lens contamination. The primary outcome measure was first-pass success. Secondary outcome measures were ultimate success, Cormack-Lehane (CL) view of the airway, presence of lens fogging, and extent of lens contamination. Only adult patients age 18 years or older intubated with the sGVL or cGVL using a stylet, and who had data forms completed at the time of intubation, were included in this study. A total of 583 intubations were included in the study, 504 with the sGVL and 79 with cGVL. First pass success was achieved in 81.0% (95% confidence interval [CI]=77.3% to 84.3%) of patients in the sGVL group and in 58.2% (95% CI=46.6% to 69.2%) of patients in the cGVL group. In a multivariate logistic regression analysis, the sGVL was associated with a higher first pass success than the cGVL (odds ratio [OR]=3.3, 95% CI=1.9 to 5.8). The ultimate success of the sGVL was 92.1% (95% CI=89.4% to 94.3%) and the cGVL was 72.2% (95% CI=60.9% to 81.7%). A CL grade I or II view was obtained in 93.2% (95% CI=90.7% to 95.3%) in the sGVL group and 86.1% (95% CI=76.5% to 92.8%) in the cGVL group. Lens fogging occurred in 33.3% (95% CI=29.2% to 37.6%) of the cases in the sGVL group and 59.5% (95% CI=47.9% to 70.4%) of the cases in the cGVL group. Significant lens contamination occurred in 5.0% (95% CI=3.2% to 7.2%) of the sGVL group and 21.5% (95% CI=13.1% to 32.2%) of the cGVL group. In this observational study, the sGVL had higher first pass and overall success than the disposable cGVL. The cGVL had significantly higher incidence of lens fogging and contamination, which may partially account for its lower success. A prospective randomized trial is needed to confirm these findings. © 2014 by the Society for Academic Emergency Medicine.

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

PubMed

Stourac, Petr; Adamus, Milan; Seidlova, Dagmar; Pavlik, Tomas; Janku, Petr; Krikava, Ivo; Mrozek, Zdenek; Prochazka, Martin; Klucka, Jozef; Stoudek, Roman; Bartikova, Ivana; Kosinova, Martina; Harazim, Hana; Robotkova, Hana; Hejduk, Karel; Hodicka, Zuzana; Kirchnerova, Martina; Francakova, Jana; Obare Pyszkova, Lenka; Hlozkova, Jarmila; Sevcik, Pavel

2016-05-01

Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007). We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

Within-Subject Interlaboratory Variability of QuantiFERON-TB Gold In-Tube Tests

DTIC Science & Technology

2012-09-06

QuantiFERONH-TB Gold In-Tube test (QFT-GIT) is a viable alternative to the tuberculin skin test (TST) for detecting Mycobacterium tuberculosis infection...viable alternative to the tuberculin skin test (TST) for detecting Mycobacterium tuberculosis infection. However, within-subject variability may limit test...release assays (IGRAs) are designed to detect both latent Mycobacterium tuberculosis infection (LTBI) and infections manifesting as active

Comparing Patient Satisfaction and Intubating Conditions Using Succinylcholine or Low-Dose Rocuronium for Rigid Bronchoscopy: A Randomized Study.

PubMed

Ghezel-Ahmadi, Verena; Ghezel-Ahmadi, David; Mangen, Jacques; Bolukbas, Servet; Welker, Andreas; Kuerschner, Veit Christian; Fischer, Andreas; Schirren, Joachim; Beck, Grietje

2015-09-01

Despite its serious side effects, succinylcholine is commonly used for neuromuscular relaxation in short procedures, such as rigid bronchoscopy and tracheobronchial interventions. The application of low-dose rocuronium reversed by low-dose sugammadex might be a modern alternative. The aim of this study was to compare patient satisfaction, incidence of postoperative myalgia (POM) as well as intubating conditions of these two muscle relaxants for rigid bronchoscopy. A single-center, prospective-randomized, blinded study of 95 patients, scheduled for rigid bronchoscopy and tracheobronchial intervention was conducted. The patients were anesthetized with propofol, remifentanil and either low-dose succinylcholine (S) (0.5 mg/kg) or low-dose rocuronium (0.25 mg/kg) with sugammadex (RS) (0.5 mg/kg). All patients were evaluated on the first and second postinterventional day for their satisfaction with the treatment (rigid bronchoscopy) using a Numeric Analog Rating Scale (NAS 0-10) and the presence and severity of POM (NAS 1-4). Intubating conditions were assessed as excellent, good, or poor on the basis of position of vocal cords and reaction to insertion of the rigid bronchoscope. Patients in the S group were less satisfied with the treatment than patients in RS group (72.7 vs. 93.7%, p = 0.007). The incidence of POM on the first day after intervention was significantly higher in the S group then in the RS group (56.9% vs. 4.3%, p < 0.001). Although the intubation was faster (p < 0.001) and the intubating conditions significantly superior (p < 0.003) with succinylcholine, acceptable conditions were also achieved with low-dose rocuronium in 75% of patients. The anesthetic drug costs were significantly higher in the RS group then in the S group (p < 0.001). The results suggest that low-dose rocuronium provided better patient satisfaction and less POM. But with the use of low-dose succinylcholine, the intubating conditions are more comfortable, and it is less expensive than rocuronium/sugammadex. Georg Thieme Verlag KG Stuttgart · New York.

Airway difficulty in Mallampati 'class zero' patients: a prospective double-blind observational study.

PubMed

Hegde, Harihar V; Prasad, Kothegala C; Bhat, Manjunath T; Hegde, Jyothirmay S; Santhosh Mysore, C b; Yaliwal, Vijay G; Raghavendra Rao, P

2012-07-01

Assessment of Mallampati class is an integral part of preoperative airway evaluation. Increasing Mallampati class is known to be associated with greater difficulty with intubation, but some cases of airway difficulty in Mallampati 'class zero' patients have been reported. We undertook this study to evaluate intubation difficulty and to correlate this with indirect laryngoscopy findings in Mallampati class zero patients. The incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation were also evaluated. Prospective double-blind observational study. A tertiary care medical college hospital in Karnataka, India. September 2010 to April 2011. Patients of either sex, 18 years and older, presenting for preanaesthetic examination for elective surgery were evaluated. All patients with Mallampati class zero airway undergoing general anaesthesia with tracheal intubation were included. Exclusion criteria were upper airway disorder, unstable cervical spine, increased risk for aspiration, ischaemic heart disease, increased intracranial pressure, respiratory distress, those unable to sit upright, or infected with hepatitis B, hepatitis C, HIV or pulmonary tuberculosis, or requiring emergency surgery. All underwent indirect laryngoscopy performed by the otorhinolaryngologist and subsequently, direct laryngoscopy performed by the anaesthesiologist. Intubation difficulty was assessed by the Cormack & Lehane grades. Evaluation of intubation difficulty and correlation with indirect laryngoscopy findings in Mallampati class zero patients. Estimation of the incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation. Twenty women and thirteen men, aged 18-65 years, of Mallampati class zero were identified out of 1937 (incidence, 1.7%). The data of 27 patients were analysed. Two patients had 'difficult' mask ventilation. All had a 'predicted easy' airway on indirect laryngoscopy and 'easy' (Cormack & Lehane grade 1 or 2) tracheal intubation. Upon direct laryngoscopy, the epiglottis was described as 'large' in 10 (37%) patients. A Mallampati class zero per se is not associated with difficult airway unless other airway characteristics contribute to the difficulty. Even though the epiglottis may be large and overhanging, it rarely causes airway difficulty in Mallampati class zero airway.

Lack of respiratory depression in paracetamol-codeine combination overdoses.

PubMed

Heppell, Simon P E; Isbister, Geoffrey K

2017-06-01

Codeine containing analgesics are commonly taken in overdose, but the frequency of respiratory depression is unknown. We investigated whether paracetamol-codeine combination overdoses caused respiratory depression more than paracetamol alone. We reviewed deliberate self-poisoning admissions with paracetamol (>2 g) and paracetamol-codeine combinations presenting to a tertiary toxicology unit (1987-2013). Demographic information, clinical effects, treatment (naloxone, length of stay [LOS], mechanical ventilation) were extracted from a prospective database. Primary outcome was naloxone requirement or ventilation for respiratory depression. From 4488 presentations, 1376 admissions were included with paracetamol alone (929), paracetamol-codeine combinations (346) or paracetamol-codeine-doxylamine combinations (101) without co-ingestants. Median age was 23 years (12-89 years); 1002 (73%) were female. Median dose was 12 g (interquartile range [IQR]: 7.5-20 g). Median LOS was 16 h (IQR: 6.5-27 h) and 564 (41%) were given acetylcysteine. Significantly larger paracetamol doses were ingested and more acetylcysteine given in paracetamol alone versus paracetamol combination overdoses. Seven out of 1376 patients were intubated or received naloxone (0.5%; 95% CI: 0.2-1.1%), three intubated, three given naloxone and one both. Three out of 929 patients ingesting paracetamol alone (0.3%; 95% CI: 0.1-1%) required intubation or naloxone, compared to two out of 346 ingesting paracetamol-codeine combinations (0.6%; 95% CI: 0.1-2.3%; absolute difference, 0.26%; 95% CI: -0.7-1.2%; P = 0.62). Two out of 101 patients ingesting paracetamol-codeine-doxylamine combinations (2%; 95% CI: 0.3-8%) required intubation or naloxone. Four patients were intubated for reasons other than respiratory depression: hepatotoxicity (2), retrieval (1), no data (1). Two out of 929 (0.2%) paracetamol alone overdoses had a Glasgow coma score < 9 compared to three out of 346 (0.9%) in the paracetamol-codeine group. Paracetamol-codeine combination overdoses are rarely associated with severe respiratory depression, with only two given naloxone and none intubated for respiratory depression. © 2016 The British Pharmacological Society.

Anaesthetic induction with alfaxalone in the ball python (Python regius): dose response and effect of injection site.

PubMed

James, Lauren E; Williams, Catherine Ja; Bertelsen, Mads F; Wang, Tobias

2018-05-01

To characterise the minimum dose of intramuscular alfaxalone required to facilitate intubation for mechanical ventilation, and to investigate the impact of cranial versus caudal injection on anaesthetic depth. Randomised crossover study. Six healthy juvenile ball pythons (Python regius). Three dosages (10, 20 and 30 mg kg -1 ) of alfaxalone were administered to each python in a caudal location with a minimum 2 weeks washout. Induction and recovery were monitored by assessing muscle tone, righting reflex, response to a noxious stimulus and the ability to intubate. A subsequent experiment assessed the influence of injection site by comparing administration of 20 mg kg -1 alfaxalone in a cranial location (1 cm cranial to the heart) with the caudal site. Respiration rate was monitored throughout, and when intubation was possible, snakes were mechanically ventilated. Regardless of dose and injection site, maximum effect was reached within 10.0 ± 2.7 minutes. When administered at the caudal injection site, intubation was only successful after a dosage of 30 mg kg- 1 , which is higher than in previous reports for other reptiles. However, intubation was possible in all cases after 7.2 ± 1.6 minutes upon cranial administration of 20 mg kg -1 , and anaesthetic duration was significantly lengthened (p < 0.001). Both 30 mg kg -1 at the caudal site and 20 mg kg -1 at the cranial site led to apnoea approximately 10 minutes post-injection, at which time the snakes were intubated and mechanically ventilated. Alfaxalone provided rapid, smooth induction when administered intramuscularly to pythons, and may serve as a useful induction agent prior to provision of volatile anaesthetics. The same dosage injected in the cranial site led to deeper anaesthesia than when injected caudally, suggesting that shunting to the liver and first-pass metabolism of alfaxalone occur when injected caudally, via the renal portal system. Copyright © 2018 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

Comparison of the force applied on oral structures during intubation attempts by novice physicians between the Macintosh direct laryngoscope, Airway Scope and C-MAC PM: a high-fidelity simulator-based study.

PubMed

Nakanishi, Taizo; Shiga, Takashi; Homma, Yosuke; Koyama, Yasuaki; Goto, Tadahiro

2016-05-23

We examined whether the use of Airway Scope (AWS) and C-MAC PM (C-MAC) decreased the force applied on oral structures during intubation attempts as compared with the force applied with the use of Macintosh direct laryngoscope (DL). Prospective cross-over study. A total of 35 novice physicians participated. We used 6 simulation scenarios based on the difficulty of intubation and intubation devices. Our primary outcome measures were the maximum force applied on the maxillary incisors and tongue during intubation attempts, measured by a high-fidelity simulator. The maximum force applied on maxillary incisors was higher with the use of the C-MAC than with the DL and AWS in the normal airway scenario (DL, 26 Newton (N); AWS, 18 N; C-MAC, 52 N; p<0.01) and the difficult airway scenario (DL, 42 N; AWS, 24 N; C-MAC, 68 N; p<0.01). In contrast, the maximum force applied on the tongue was higher with the use of the DL than with the AWS and C-MAC in both airway scenarios (DL, 16 N; AWS, 1 N; C-MAC, 7 N; p<0.01 in the normal airway scenario; DL, 12 N; AWS, 4 N; C-MAC, 7 N; p<0.01 in the difficult airway scenario). The use of C-MAC, compared with the DL and AWS, was associated with the higher maximum force applied on maxillary incisors during intubation attempts. In contrast, the use of video laryngoscopes was associated with the lower force applied on the tongue in both airway scenarios, compared with the DL. Our study was a simulation-based study, and further research on living patients would be warranted. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Which score should be used in intubated patients’ Glasgow coma scale or full outline of unresponsiveness?

PubMed Central

Gorji, Mohammad Ali Heidari; Gorji, Ali Morad Heidari; Hosseini, Seyed Hossein

2015-01-01

Background and Aims: Today Glasgow coma scale (GCS) is the most well-known and common score for evaluation of the level of consciousness and outcome predict after traumatic brain injuries in the world. Regarding to some advantages of the full outline of unresponsiveness (FOUR) score over GCS in intubated patients, we’re going to compare the precision of these two scores in predicting the outcome predict in intubated patients. Methods: This research was a diagnostic-based study, which was conducted prospectively on 80 patients with Traumatic brain injury who were intubated and admitted to Intensive Care Unit (ICU) of Educational Hospitals of Mazandaran University of Medical Science during February 2013 to August 2013. The scores of FOUR and GCS were measured by the researcher in the first 24 h of admission in ICU. The information's recorded in the check list including the mortality rate of early and late inside of the hospital interred to excel. The findings were analyzed using SPSS software, through descriptive statistics and regression logistic. Results: The results showed of 80 patients 21 patients (20%) were female and 59 patients (80%) were male. The age average of the samples was 33.80 ± 12.60 ranging from 16 to 60 years old. 21 patients (26.2%) died during treatment. Of 21 patients, 15 patients died during first 14 days (18.7%) and 6 patients died after 14 years (7.5%). The area under curve (AUC) of FOUR score in early mortality was 0.90 (C1 = 0.95, 0.88–0.90). The amount AUC for GCS was 0.80 (C1 = 0.95, 0.78–0.84), which in delayed mortality it was ordered as 0.86 (C1 = 0.95, 0.84–0.90) and 0.89 (C1 = 0.95, 0.78–0.88). Conclusion: The research results indicated that FOUR score is more exact and more practical in intubated patients regarding lack of verbal response factor in early mortality prediction in GCS. Hence, it is recommended for health professionals to use the FOUR score to predict the early outcome of intubated patients with traumatic brain injuries. PMID:26097814

A simple blind placement of the left-sided double-lumen tubes.

PubMed

Zong, Zhi Jun; Shen, Qi Ying; Lu, Yao; Li, Yuan Hai

2016-11-01

One-lung ventilation (OLV) has been commonly provided by using a double-lumen tube (DLT). Previous reports have indicated the high incidence of inappropriate DLT positioning in conventional maneuvers.After obtaining approval from the medical ethics committee of First Affiliated Hospital of Anhui Medical University and written consent from patients, 88 adult patients belonging to American society of anesthesiologists (ASA) physical status grade I or II, and undergoing elective thoracic surgery requiring a left-side DLT for OLV were enrolled in this prospective, single-blind, randomized controlled study. Patients were randomly allocated to 1 of 2 groups: simple maneuver group or conventional maneuver group. The simple maneuver is a method that relies on partially inflating the bronchial balloon and recreating the effect of a carinal hook on the DLTs to give an idea of orientation and depth. After the induction of anesthesia the patients were intubated with a left-sided Robertshaw DLT using one of the 2 intubation techniques. After intubation of each DLT, an anesthesiologist used flexible bronchoscopy to evaluate the patient while the patient lay in a supine position. The number of optimal position and the time required to place DLT in correct position were recorded.Time for the intubation of DLT took 100 ± 16.2 seconds (mean ± SD) in simple maneuver group and 95.1 ± 20.8 seconds in conventional maneuver group. The difference was not statistically significant (P = 0.221). Time for fiberoptic bronchoscope (FOB) took 22 ± 4.8 seconds in simple maneuver group and was statistically faster than that in conventional maneuver group (43.6 ± 23.7 seconds, P < 0.001). Nearly 98% of the 44 intubations in simple maneuver group were considered as in optimal position while only 52% of the 44 intubations in conventional maneuver group were in optimal position, and the difference was statistically significant (P < 0.001).This simple maneuver is more rapid and more accurate to position left-sided DLTs, it may be substituted for FOB during positioning of a left-sided DLT in condition that FOB is unavailable or inapplicable.

Impact of cap-assisted colonoscopy on the learning curve and quality in colonoscopy: a randomized controlled trial.

PubMed

Tang, Zhouwen; Zhang, Daniel S; Thrift, Aaron P; Patel, Kalpesh K

2018-03-01

Colonoscopy competency assessment in trainees traditionally has been informal. Comprehensive metrics such as the Assessment of Competency in Endoscopy (ACE) tool suggest that competency thresholds are higher than assumed. Cap-assisted colonoscopy (CAC) may improve competency, but data regarding novice trainees are lacking. We compared CAC versus standard colonoscopy (SC) performed by novice trainees in a randomized controlled trial. All colonoscopies performed by 3 gastroenterology fellows without prior experience were eligible for the study. Exclusion criteria included patient age <18 or >90 years, pregnancy, prior colon resection, diverticulitis, colon obstruction, severe hematochezia, referral for EMR, or a procedure done without patient sedation. Patients were randomized to either CAC or SC in a 1:1 fashion. The primary outcome was the independent cecal intubation rate (ICIR). Secondary outcomes were cecal intubation time, polyp detection rate, polyp miss rate, adenoma detection rate, ACE tool scores, and cumulative summation learning curves. A total of 203 colonoscopies were analyzed, 101 in CAC and 102 in SC. CAC resulted in a significantly higher cecal intubation rate, at 79.2% in CAC compared with 66.7% in SC (P = .04). Overall cecal intubation time was significantly shorter at 13.7 minutes for CAC versus 16.5 minutes for SC (P =.02). Cecal intubation time in the case of successful independent fellow intubation was not significantly different between CAC and SC (11.6 minutes vs 12.7 minutes; P = .29). Overall ACE tool motor and cognitive scores were higher with CAC. Learning curves for ICIR approached the competency threshold earlier with cap use but reached competency for only 1 fellow. The polyp detection rate, polyp miss rate, and adenoma detection rate were not significantly different between groups. CAC resulted in significant improvement in ICIR, overall ACE tool scores, and trend toward competency on learning curves when compared with SC in colonoscopy trainees without prior colonoscopy experience. (Clinical trial registration number: NCT02472730.). Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques.

PubMed

Simma, Leopold; Cincotta, Domenic; Sabato, Stefan; Long, Elliot

2017-09-01

Airway emergencies presenting to the emergency department (ED) are usually managed with conventional equipment and techniques. The patient group managed urgently in the operating room (OR) has not been described. This study aims to describe a case series of children presenting to the ED with airway emergencies managed urgently in the OR, particularly the anaesthetic equipment and techniques used and airway findings. A retrospective cohort study undertaken at The Royal Children's Hospital, Melbourne, Australia. All patients presenting to the ED between 1 January 2012 and 30 July 2015 (42 months) with an airway emergency who were subsequently managed in the OR were included. Patient characteristics, anaesthetic equipment and technique and airway findings were recorded. Twenty-two airway emergencies in 21 patients were included over the study period, on average one every 2 months. Median age was 18 months and 43% were male. Inhalational induction was used in 77.3%, combined inhalational and intravenous induction in 9.1%, and intravenous induction alone in 13.6%. The most commonly used inhalational induction agent was sevoflurane, and the most commonly used intravenous induction agents were ketamine and propofol. Ten airway emergencies did not require intubation, seven for removal of inhaled foreign body, two with progressive tracheal stenosis requiring emergent dilatation and one examination under anaesthesia to rule out inhaled foreign body. Of the 12 airway emergencies that required immediate intubation, direct laryngoscopy was used in 9 and fibre-optic intubating bronchoscopy in 3. For intubations performed by direct laryngoscopy, one was difficult (Cormack and Lehane grade 3). First pass success was 83.3%. Adverse events occurred in 3/22 (13.6%) cases. Advanced airway techniques, including inhalational induction and intubation via fibre-optic intubating bronchoscope, are rarely but predictably required in the management of patients presenting to the ED. Institutions caring for children should prepare in advance where such patients should be managed, by whom, and provide equipment and training for their care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Comparative Analysis of the Usefulness of the GlideScope®, Macintosh, and McCoy Laryngoscopes for Endotracheal Intubation in Patients with Obesity: A Randomized, Clinical Trial

PubMed Central

Akbarzadeh, Seyed Reza; Taghavi Gillani, Maryar; Tabari, Masoumeh; Morovatdar, Negar

2017-01-01

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 3 groups. These results suggested using GlideScope® in patients with high BMI to reduce laryngoscopy time. PMID:29696123

Optimal dose of rocuronium bromide undergoing adenotonsillectomy under 5% sevoflurane with fentanyl.

PubMed

Huh, Hyub; Park, Jeong Jun; Kim, Ji Yeong; Kim, Tae Hoon; Yoon, Seung Zhoo; Shin, Hye Won; Lee, Hye-Won; Lim, Hye-Ja; Cho, Jang Eun

2017-10-01

Adenotonsillectomy is a short surgical procedure under general anaesthesia in children. An ideal muscle relaxant for adenotonsillectomy would create an intense neuromuscular block while having a quick recovery time without postoperative morbidity. We compared the effect of different doses of rocuronium for the tracheal intubation in children under 5% sevoflurane and fentanyl. 75 children (aged 3-10 years, ASA I) scheduled for adenotonsillectomy were enrolled. Anaesthesia was induced with propofol 2.5 mg/kg, followed by fentanyl 2 μg/kg. After mask ventilation with 5 vol% sevoflurane in 100% oxygen for 2 min, 2 ml of study drug was administered intravenously, i.e., either normal saline (S Group) or one of two doses (0.15 or 0.3 mg/kg) of rocuronium. We assessed conditions during tracheal intubation and also recorded the surgical condition, the time from discontinuation of sevoflurane to extubation and PAED scale, pain scores in PACU. Rocuronium groups (96% and 100%, respectively; P < 0.01) showed statistically superior clinically acceptable intubating conditions than the saline group (72%). The 0.3 mg/kg rocuronium (80%) treatment clearly resulted in excellent intubating conditions compared with the 0.15 mg/kg group (44%; p = 0.028). There was no significant difference in the time to extubation and surgical condition, and in the postoperative measures of emergence delirium, pain, and recovery time among the three groups. A dose of 0.3 mg/kg rocuronium may provide optimal intubating conditions without delayed recovery in 5% sevoflurane anaesthesia with fentanyl in children undergoing adenotonsillectomy. NCT02467595. Copyright © 2017 Elsevier B.V. All rights reserved.

Management of critical illness with non-invasive ventilation by an Australian HEMS

PubMed Central

Coggins, Andrew R; Cummins, Erin N; Burns, Brian

2016-01-01

Background Non-invasive ventilation (NIV) therapy is widely used for the management of acute respiratory failure. The objective of this study was to investigate the current use of NIV during interhospital retrievals in an Australian physician-led aeromedical service. Methods We reviewed patients receiving NIV during interhospital retrieval at the Greater Sydney Area Helicopter Medical Services (GSA-HEMS) over a 14-month period. The main objectives were to describe the number of retrievals using NIV, the need for intubation in NIV patients and the effect of the therapy on mission duration. Results Over the study period, 3018 missions were reported; 106 cases (3.51%) involved administration of NIV therapy during the retrieval. The most common indication for NIV was pneumonia (34.0%). 86/106 patients received a successful trial of NIV therapy prior to interhospital transfer. 58 patients were transferred on NIV, while 28 patients had NIV removed during transport. None of these 86 patients required intubation or died, although 17/86 ultimately required intubation within 24 hours at the receiving centre. 20/106 patients required intubation at the referring hospital after a failed trial of NIV therapy. NIV was successfully used in all available transport platforms including rotary wing. Patients receiving NIV were found to have prolonged mission durations compared with other GSA-HEMS patients (222.5 vs 193 min). This increase in mission duration was largely attributable to NIV failure, resulting in a need for Rapid Sequence Intubation at the referring hospital. Conclusions With careful patient selection, the use of interhospital NIV is feasible and appears to be safe in a retrieval system with care provided by a critical care physician. PMID:27371641

Midline submental intubation might be the preferred alternative to oral and nasal intubation in elective oral and craniomaxillofacial surgery when indicated.

PubMed

Jin, Huijun; Patil, Pavan Manohar

2015-01-01

No consensus exists to date regarding the best method of controlling the airway for oral or craniomaxillofacial surgery when orotracheal and nasotracheal intubations are unsuccessful or contraindicated. The most commonly used method of tracheostomy has been associated with a high degree of morbidity. Therefore, the present study was conducted to determine the indications, safety, efficacy, time required, drawbacks, complications, and costs of the midline submental intubation (SMI) approach in elective oral and craniomaxillofacial surgical procedures. A retrospective case series study was used to evaluate the surgical, financial, and photographic records of all patients who had undergone oral or craniomaxillofacial operations at Sharda University School of Dental Sciences, Greater Noida, from April 2006 to March 2014. The indications, drawbacks, time required for the procedure, ability to provide a secure airway, intra- and postoperative complications, and additional costs associated with SMI were analyzed. Of the 2,823 patients treated, the present study included 120 patients (97 men and 23 women, aged 19 to 60 years). The average time required for SMI was 10 ± 2 minutes. No episode of intraoperative oxygen desaturation was noted. One intraoperative complication, an injury to the ventral surface of the tongue, was encountered. Two patients developed infection at the skin incision site. No significant additional cost was incurred with the use of SMI. SMI has been successfully used in elective oral and craniomaxillofacial surgical procedures for which oral and nasal intubations were either not indicated or not possible. The advantages include a quick procedure, insignificant complications, the ability to provide a stable airway, and no added costs, making SMI a quick, safe, efficient, and cost-effective alternative in such cases. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

The total face mask is more comfortable than the oronasal mask in noninvasive ventilation but is not associated with improved outcome.

PubMed

Chacur, Fernando Hauaji; Vilella Felipe, Luis Marcelo; Fernandes, Cintia Gonçalves; Lazzarini, Luiz Claudio Oliveira

2011-01-01

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.

A randomized trial of nasal prong or face mask for respiratory support for preterm newborns.

PubMed

McCarthy, Lisa K; Twomey, Anne R; Molloy, Eleanor J; Murphy, John F A; O'Donnell, Colm P F

2013-08-01

Resuscitation guidelines recommend that respiratory support should be given to newborns via a face mask (FM) in the delivery room (DR). Respiratory support given to preterm newborns via a single nasal prong (SNP; ie, short nasal tube, nasopharyngeal tube) may be more effective. We wished to determine whether giving respiratory support to preterm newborns with a SNP rather than a FM reduces the rate of intubation in the DR. Infants <31 weeks' gestation were randomized just before delivery to SNP (endotracheal tube shortened to 5 cm) or FM. Randomization was stratified by gestation (<28 weeks, 28-30(+6)). Infants with apnea, respiratory distress, and/or heart rate <100 received positive pressure ventilation with a T-piece. The primary outcome was intubation and mechanical ventilation in the DR. Infants in both groups were intubated for heart rate <100 and/or apnea despite PPV and not solely for surfactant administration. All other aspects of treatment in the DR and NICU were the same. Relevant secondary outcomes were recorded and data were analyzed by using the intention-to-treat principle. One hundred forty-four infants were enrolled. The rate of intubation in the DR was the same in both groups (11/72 [15%] vs 11/72 [15%], P = 1.000]. Infants assigned to SNP had lower SpO2 at 5 minutes and received a higher maximum concentration of oxygen in the DR. There were no significant differences in other secondary outcomes. Giving respiratory support to newborn infants <31 weeks' gestation via a SNP, compared with a FM, did not result in less intubation and ventilation in the DR.

Prehospital anaesthesia performed by physician/critical care paramedic teams in a major trauma network in the UK: a 12 month review of practice.

PubMed

McQueen, Carl; Crombie, Nicholas; Hulme, Jonathan; Cormack, Stef; Hussain, Nageena; Ludwig, Frank; Wheaton, Steve

2015-01-01

In the West Midlands region of the UK, delivery of pre-hospital care has been remodelled through introduction of a 24 h Medical Emergency Response Incident Team (MERIT). Teams including physicians and critical care paramedics (CCP) are deployed to incidents on land-based and helicopter-based platforms. Clinical practice, including delivery of rapid sequence induction of anaesthesia (RSI), is underpinned by standard operating procedures (SOP). This study describes the first 12 months experience of prehospital RSI in the MERIT scheme in the West Midlands. Retrospective review of the MERIT clinical database for the 12 months following the launch of the scheme. Data was collected relating to the number of RSIs performed; indication for RSI; number of intubation attempts; grade of view on laryngoscopy and the base speciality/grade of the operator performing intubation. MERIT teams were activated 1619 times, attending scene in 1029 cases. RSI was performed 142 times (13.80% of scene attendances). There was one recorded case of failure to intubate requiring insertion of a supraglottic airway device (0.70%). In over a third of RSI cases, CCPs performed laryngoscopy and intubation (n=53, 37.32%). Proficiency of obtaining Grade I view at laryngoscopy was similar for physicians (74.70%) and CCPs (77.36%). Intubation was successful at the first attempt in over 90% of cases. This study demonstrates that operation within a system that provides high levels of exposure, underpinned by comprehensive and robust training and governance frameworks, promotes levels of performance in successful prehospital RSI regardless of base speciality or profession. 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.

Dexmedetomidine for an awake fiber-optic intubation of a parturient with Klippel-Feil syndrome, Type I Arnold Chiari malformation and status post released tethered spinal cord presenting for repeat cesarean section

PubMed Central

Shah, Tanmay H.; Badve, Manasi S.; Olajide, Kowe O.; Skorupan, Havyn M.; Waters, Jonathan H.; Vallejo, Manuel C.

2011-01-01

Patients with Klippel-Feil Syndrome (KFS) have congenital fusion of their cervical vertebrae due to a failure in the normal segmentation of the cervical vertebrae during the early weeks of gestation and also have myriad of other associated anomalies. Because of limited neck mobility, airway management in these patients can be a challenge for the anesthesiologist. We describe a unique case in which a dexmedetomidine infusion was used as sedation for an awake fiber-optic intubation in a parturient with Klippel-Feil Syndrome, who presented for elective cesarean delivery. A 36-year-old female, G2P1A0 with KFS (fusion of cervical vertebrae) who had prior cesarean section for breech presentation with difficult airway management was scheduled for repeat cesarean delivery. After obtaining an informed consent, patient was taken in the operating room and non-invasive monitors were applied. Dexmedetomidine infusion was started and after adequate sedation, an awake fiber-optic intubation was performed. General anesthetic was administered after intubation and dexmedetomidine infusion was continued on maintenance dose until extubation. Klippel-Feil Syndrome (KFS) is a rare congenital disorder for which the true incidence is unknown, which makes it even rare to see a parturient with this disease. Patients with KFS usually have other congenital abnormalities as well, sometimes including the whole thoraco-lumbar spine (Type III) precluding the use of neuraxial anesthesia for these patients. Obstetric patients with KFS can present unique challenges in administering anesthesia and analgesia, primarily as it relates to the airway and dexmedetomidine infusion has shown promising result to manage the airway through awake fiberoptic intubation without any adverse effects on mother and fetus. PMID:24765318

Effect of Increased Body Mass Index on Complication Rates during Laryngotracheal Surgery Utilizing Jet Ventilation.

PubMed

Barry, Rachel A; Fink, Daniel S; Pourciau, Dusty Cole; Hayley, Kasey; Lanius, Rachael; Hayley, Schuylor; Sims, Eddy; McWhorter, Andrew J

2017-09-01

Objective Jet ventilation has been used for >30 years as an anesthetic modality for laryngotracheal surgery. Concerns exist over increased risk with elevated body mass index (BMI). We reviewed our experience using jet ventilation for laryngotracheal stenosis to assess for complication rates with substratification by BMI. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods A total of 126 procedures with jet ventilation were identified from October 2006 to December 2014. Complications were recorded, including intubation, unplanned admission, readmission, dysphonia, oral trauma, pneumothorax, pneumomediastinum, and tracheostomy. Lowest intraoperative oxygen saturation and maximum end-tidal CO 2 (ETCO 2 ) levels were recorded. Results Among 126 patients, 43, 77, and 6 had BMIs of <25, 25-35, and 36-45, respectively. In the BMI <25 group, there was 1 unplanned intubation. Mean maximum ETCO 2 was 36.51 with no hypoxemia observed. In the BMI 25-35 group, 2 patients required intubation, and 1 sustained minor oral trauma. The mean maximum ETCO 2 was 38.85, with 4 patients having oxygen saturation <90%. In the BMI 36-45 group, 2 patients required intubation. The mean maximum ETCO 2 was 41 with no hypoxemia observed. BMI and length of stenosis were statistically significant variables associated with incidence of intraoperative intubation. Conclusion Increased BMI was associated with an increase in highest ETCO 2 intraoperatively. However, this was not associated with an increase in major complications. Jet ventilation was performed without significant adverse events in this sample, and it is a viable option if used with an experienced team in the management of laryngotracheal stenosis.

Intubation is not a marker for coma after in-hospital cardiac arrest: A retrospective study.

PubMed

Berg, Katherine M; Grossestreuer, Anne V; Uber, Amy; Patel, Parth V; Donnino, Michael W

2017-10-01

In-hospital cardiac arrest (IHCA) strikes over 200,000 people in the United States annually. Targeted temperature management (TTM) is considered beneficial in other settings, but there is no prospective data for IHCA. Recent work on TTM and IHCA found an association between TTM and worse outcome. However, the authors used intubation as a marker for coma to determine eligibility for TTM. The validity of this approach is unexplored. Retrospective, single center study of adult patients with IHCA occurring in an intensive care unit, intubated prior to or during the event, or immediately after ROSC. We evaluated the percentage of patients documented as comatose after arrest, defined as Glasgow Comas Score (GCS) <8 for the primary analysis. We also evaluated the difference in hospital survival in patients with GCS <8 versus ≥8. Two sensitivity analyses using different methods for defining coma using post-ROSC GCS were conducted. 29/102 (28%) intubated patients had a post-ROSC GCS≥8, and 22 (22%) were documented as following commands. Survival in patients with GCS≥8 vs.<8 was 62% (18/29) vs. 37% (27/73) in unadjusted analysis (p=0.02). The adjusted odds ratio for survival to hospital discharge was 3.81 (95%CI: 1.37-10.61, p=0.01). Results were similar in both sensitivity analyses. Intubation prior to or during IHCA was not a valid marker of coma after ROSC. Post-ROSC mental status was associated with hospital survival, and thus could be an important confounder when conducting observational studies on the association of TTM with outcomes in this patient population. Copyright © 2017 Elsevier B.V. All rights reserved.

Efficacy of cuff inflation media to prevent postintubation-related emergence phenomenon: air, saline and alkalinized lignocaine.

PubMed

Shroff, Prerana P; Patil, Vijay

2009-06-01

We wished to examine the efficacy of different media used for inflation of tracheal tube cuffs. In our prospective randomized, controlled study over 3 months, there were 150 patients of either sex undergoing surgery under general anaesthesia with controlled ventilation with nitrous oxide and oxygen. The patients were divided into three equal groups (air, isotonic saline and alkalinized lignocaine as inflation media) using sealed envelope technique. The volume of the inflation medium, intracuff pressure, duration of intubation, volume of the inflation medium withdrawn from the cuff and complications like tube intolerance, coughing on tube, restlessness, hoarseness, sore throat, breathlessness and laryngospasm were analysed. Continuous data are presented as mean +/- SD, whereas categorical data are presented as frequencies and percentages. A [chi]2, analysis of variance and student's t-test were used to analyse the data. A P value less than 0.05 was considered as statistically significant. Age, sex, duration of intubation, intracuff pressure at the time of intubation were comparable. After intubation at all intervals, the intracuff pressure was higher in the air group with statistical significance at 5 min, 30 min, 1 h and just before extubation when air and saline groups were comparable and at all intervals after intubation up to just before extubation when air and lignocaine groups were comparable. The volume of air increased just before extubation in the air group, as compared with a fall in volume in the other groups. Tube intolerance, hoarseness and sore throat were least in the lignocaine group. We found that alkalinized 2% lignocaine and saline are better cuff inflation media, than air.

Tracheal intubation during pediatric cardiopulmonary resuscitation: A videography-based assessment in an emergency department resuscitation room.

PubMed

Donoghue, Aaron; Hsieh, Ting-Chang; Nishisaki, Akira; Myers, Sage

2016-02-01

To describe procedural characteristics of tracheal intubation (TI) during cardiopulmonary resuscitation (CPR) in a pediatric emergency department, and to characterize interruptions in CPR associated with TI performance. Retrospective single center case series. Resuscitations in a pediatric ED are videorecorded for quality improvement. Children who underwent TI while receiving chest compressions were eligible for inclusion. Intubations done by methods other than direct laryngoscopy were excluded. Background data included patient age and training background of intubator. Data on intubation attempts (success, laryngoscopy time) and chest compressions (interruptions, duration of pauses) were collected. Between December 2012 and February 2014, 32 patients had 59 TI attempts performed during CPR. Overall first attempt success at TI was 15/32 (47%); a median of 2 attempts were made per patient (range 1 to 4). Median laryngoscopy time was 47s (range 8-115s). 32/59 (54%) TI attempts had an associated interruption in CPR; the median interruption duration was 25s (range 3-64s). TI attempts without interruption in CPR were successful in 20/32 (63%) compared to 11/27 (41%) when CPR was paused (p=0.09). Laryngoscopy time was not significantly different between TI attempts with (47±21s) and without (47±26s; p=0.2) interruptions in compressions. 25/32 (78%) of pauses exceeded 10s in duration. TI during pediatric CPR results in significant interruptions in chest compressions. Procedural outcomes were not significantly different between attempts with and without compressions paused. In children receiving CPR, TI should be performed without pausing chest compressions. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation.

PubMed

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

2013-12-01

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.

Association of Post-extubation Dysphagia With Tongue Weakness and Somatosensory Disturbance in Non-neurologic Critically Ill Patients

PubMed Central

2017-01-01

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

Endoscopic palliation of esophageal and cardial cancer: Nd:YAG laser and prosthesis

NASA Astrophysics Data System (ADS)

Norberto, Lorenzo; Ranzato, Riccardo; Marino, Saverio; Angriman, Imerio; Vella, Vincenzo; Donadi, Michele; D'Amico, D. F.

1997-12-01

From November 1, 1992 to January 31, 1997, 227 patients with inoperable esophageal and cardial carcinomas were treated with Nd:YAG laser therapy and prosthesis intubation. The retrograde technique was used in most cases. The tumor involved in 75 pts the Cardia, in 65 the middle thoracic esophagus, in 47 pts the lower thoracic esophagus, in 23 in the upper thoracic esophagus and in 17 in the cervical esophagus. The indications for palliative Nd:YAG laser and prosthesis intubation were a locally advanced or metastatic tumor in 146 pts (64.4%) and poor surgical risk in 81 pts (35.6%). The quality of palliation was evaluated according to the ability to swallow. The mean survival rate of the patients during the follow up was 22 weeks for the laser therapy and 16 weeks for the prosthesis intubation.

Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy.

PubMed

Johnston, Lindsay C; Auerbach, Marc; Kappus, Liana; Emerson, Beth; Zigmont, Jason; Sudikoff, Stephanie N

2014-01-01

GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

Airway management in a bleeding adult following tonsillectomy: a case report.

PubMed

Brar, Manjit Singh

2009-12-01

A 37-year-old morbidly obese man with a history of obstructive sleep apnea underwent elective tonsillectomy. The patient was successfully intubated with an 8.0-mm regular cuffed endotracheal tube. A large video laryngoscope (GlideScope, Verathon Inc, Bothell, Washington) was used for intubation, as airway assessment indicated a potentially difficult airway. The surgery was uneventful, but active bleeding was noticed in the oropharynx after extubation. The patient was reintubated, again with the use of a GlideScope. The bleeding site was cauterized, and the patient was extubated after meeting the criteria for an awake extubation. He was discharged home the following day. Eight days postoperatively, the patient returned to the emergency center with spontaneous bleeding from the oropharynx. He was taken to the operating room and, based on the previous GlideScope use, an attempt was made to intubate the patient with a GlideScope. The attempt failed, as the GlideScope screen was blurred by the presence of blood in the oropharynx, even though the oropharynx was suctioned. Resuctioning and reinsertion of the GlideScope probe did not provide an adequate visual field. After 2 failed attempts, the use of the GlideScope was abandoned. Subsequently, the patient's trachea was successfully intubated with a size 4 Macintosh blade.

Respiratory care practitioners as primary providers of neonatal intubation in a community hospital: an analysis.

PubMed

Noblett, K E; Meibalane, R

1995-10-01

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.

The effect of music listening on older adults undergoing cardiovascular surgery.

PubMed

Twiss, Elizabeth; Seaver, Jean; McCaffrey, Ruth

2006-01-01

The purpose of this study was to determine the effect of music listening on postoperative anxiety and intubation time in patients undergoing cardiovascular surgery. Coronary artery disease and valvular heart disease affect approximately 15 million Americans and 5 million persons in the U.K. annually, with the majority of these patients being older adults. The anxiety experienced before, during and after surgery increases cardiovascular workload, thereby prolonging recovery time. Music listening as a nursing intervention has shown an ability to reduce anxiety. The study used a randomized control trial design. Sixty adults older than 65 years were randomly assigned to the control and the experimental groups. The experimental group listened to music during and after surgery, while the control group received standard postoperative care. The Spielberger State Trait Anxiety Inventory was administered to both groups before surgery and 3 days postoperatively. The mean of the differences between scores was compared using analysis of variance. Differences in mean intubation time were measured in both groups. Older adults who listened to music had lower scores on the state anxiety test (F = 5.57, p = .022) and had significantly fewer minutes of postoperative intubation (F = 5.45, p = .031) after cardiovascular surgery. Older adults undergoing cardiovascular surgery who listen to music had less anxiety and reduced intubation time than those who did not.

Difficult airway management practice patterns among anesthesiologists practicing in the United States: have we made any progress?

PubMed

Ezri, Tiberiu; Szmuk, Peter; Warters, R David; Katz, Jeffrey; Hagberg, Carin A

2003-09-01

To determine the extent instruction and practice in the use of airway devices and techniques varies among anesthesiologists practicing in the United States. Survey questionnaire. University medical center. Questionnaires were completed by American-trained anesthesiologists who attended the 1999 American Society of Anesthesiologists (ASA) Annual Meeting. Data collected included demographics, education, skills with airway devices/techniques, management of clinical difficult airway scenarios, and the use of the ASA Difficult Airway Algorithm. 1) DEMOGRAPHICS: 452 questionnaires were correctly completed; 62% attending anesthesiologists, 70% <50 years, 81% males, 44% from academic institutions, 63% >10 years of practice, 81% night duty, 77% board certified. 2) Education: 71% had at least one educational modality: difficult airway rotation, workshops, conferences, books, and simulators. 3) Skills: Miller blade 61%, Bullard laryngoscope 32%, LMA 86%, Combitube 43%, bougie 43%, exchangers 47%, cuffed oropharyngeal airway (COPA) 34%, retrograde 41%, transtracheal needle jet ventilation 34%, cricothyrotomy 21%, fiberoptics 59%, and blind nasal intubation 78%. The average reported use of special airway devices/techniques was 47.5%. 4) Management choices: failed intubation/ventilation: LMA (81%) and for all other situations: fiberoptic intubation. Use of ASA Difficult Airway Algorithm in clinical practice (86%). Fiberoptic intubation and the LMA are most popular in management of the difficult airway.

Choice of Intravenous Agents and Intubation Neuromuscular Blockers by Anesthesia Providers

DTIC Science & Technology

1996-09-01

of this study to determine if experience of the provider made a difference in the agent chosen. Both quantitative and qualitative methods were...comparison of quantitative and qualitative data of induction and intubation agents collected from CRNAs and MDAs according to experience of both types of...providers was analyzed to provide meaningful data. The difference in choice of agents by experience was found not to be significant. IV CHOICE OF

Difficult airway management in a patient with a parapharyngeal tumor.

PubMed

Ji, Sung-Mi

2015-09-01

A 47-year-old man was referred to the operating room to treat a dentigenous cyst of the mandibular bone. Initial assessment of the airway was considered normal. However, after the induction of anesthesia, we could not intubate the patient due to severe distortion of the glottis. Fiberoptic bronchoscopy and video laryngoscopy were not effective. Intubation using a retrograde wire technique was successful. After the conclusion of surgery, the patient recovered without any complications. Subsequent magnetic resonance imaging of the patient's neck showed a 6 × 4 × 8.6 cm heterogeneous T2 hyperintense, T1 isointense well-enhancing mass in the prestyloid parapharyngeal space. The patient was scheduled for excision of the mass. We planned awake intubation with fiberoptic bronchoscopy. The procedure was successful and the patient recovered without complications. Anesthetic induction can decrease the muscle tone of the airway and increase airway distortion. Therefore, careful airway assessment is necessary.

Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis.

PubMed

Ahn, Eun Jin; Choi, Geun Joo; Kang, Hyun; Baek, Chong Wha; Jung, Yong Hun; Woo, Young Cheol; Bang, Si Ra

2016-01-01

Air-Q® (air-Q) is a supraglottic airway device which can be used as a guidance of intubation in pediatric as well as in adult patients. We evaluated the efficacy and safety of air-Q compared to other airway devices during general anesthesia in pediatric patients by conducting a systematic review and meta-analysis. A total of 10 studies including 789 patients were included in the final analysis. Compared with other supraglottic airway devices, air-Q showed no evidence for a difference in leakage pressure and insertion time. The ease of insertion was significantly lower than other supraglottic airway devices. The success rate of intubation was significantly lower than other airway devices. However, fiberoptic view was better through the air-Q than other supraglottic airway devices. Therefore, air-Q could be a safe substitute for other airway devices and may provide better fiberoptic bronchoscopic view.

Management of subtotal tracheal section with esophageal perforation: a catastrophic complication of tracheostomy.

PubMed

Caronia, Francesco Paolo; Fiorelli, Alfonso; Arrigo, Ettore; Santini, Mario; Castorina, Sergio

2016-05-01

Herein, we reported a catastrophic condition as the almost complete rupture of trachea associated with esophageal lesion following an urgent surgical tracheostomy performed for unexpected difficult intubation. The extent of lesions required a surgical management. We decided against a resection and an end to end anastomosis but preferred to perform a direct suture of the lesion due to the presence of local and systemic infection. Then, the diagnosis of a tracheal fistula led us to perform a direct suture of the defect that was covered with muscle flaps. Actually the patient is alive without problems. Emergency situations as unexpected airway difficult intubation increase morbidity and mortality rate of tracheostomy also in expert hands. Sometimes these events are unpredictable. Mastery with a number of advanced airway technique should be sought when faced dealing with unexpected difficult intubations and written consent of such a concern should be given to the patient.

Non-Invasive Mechanical Ventilation in Critically Ill Trauma Patients: A Systematic Review

PubMed Central

Yıldırım, Fatma; Ferrari, Giovanni; Antonelli, Andrea; Delis, Pablo Bayoumy; Gündüz, Murat; Karcz, Marcin; Papadakos, Peter; Cosentini, Roberto; Dikmen, Yalım; Esquinas, Antonio M.

2018-01-01

There is limited literature on non-invasive mechanical ventilation (NIMV) in patients with polytrauma-related acute respiratory failure (ARF). Despite an increasing worldwide application, there is still scarce evidence of significant NIMV benefits in this specific setting, and no clear recommendations are provided. We performed a systematic review, and a search of clinical databases including MEDLINE and EMBASE was conducted from the beginning of 1990 until today. Although the benefits in reducing the intubation rate, morbidity and mortality are unclear, NIMV may be useful and does not appear to be associated with harm when applied in properly selected patients with moderate ARF at an earlier stage of injury by experienced teams and in appropriate settings under strict monitoring. In the presence of these criteria, NIMV is worth attempting, but only if endotracheal intubation is promptly available because non-responders to NIMV are burdened by an increased mortality when intubation is delayed. PMID:29744242

Airway Management during Thyroidectomy for a Giant Goitre due to McCune-Albright Syndrome

PubMed Central

2018-01-01

There have been no case reports to date describing the technical aspects of tracheal intubation in a patient with a goitre associated with McCune-Albright syndrome (MAS), even though goitre is frequently observed in this condition. I describe a case of resection of a giant goitre in a patient with MAS, with difficult airway management. Preoperative investigation showed that the trachea was shifted to the right by the goitre, with the narrowest part of the tracheal lumen 4 mm in diameter. There was dome-shaped protuberance of the posterior pharyngeal wall into the airway. The patient had an S-shaped total spine, a short neck, and a relatively large jaw, which interfered with airway visualisation during intubation. Anaesthesia was induced with light sedation and supplemental oxygen. Endotracheal intubation was successfully performed using a fiberoptic laryngoscope and a flexible, spiral-wound, obtuse-tipped tracheal tube. PMID:29854469

Determining the effectiveness of illustrated communication material for communication with intubated patients at an intensive care unit.

PubMed

Otuzoğlu, Münevver; Karahan, Azize

2014-10-01

Communication with non-speaking patients in intensive care unit is stress for both nurse and patients. Semi-experimental study that took place at a University Hospital was to develop illustrated material for patient communication and determine its effectiveness. The study sample consisted of 90 intubated patients at the Adult Cardiovascular Intensive Care Unit who had undergone open heart surgery. The patients were divided into the intervention and control groups. Data analysis was with descriptive statistics and the χ(2) test. The illustrated communication material was stated to be helpful by 77.8% and partially helpful by 22.2% of the intervention group patients regarding the communication between the health-care staff and the patients. Control group patients had more difficulties communicating with the health-care staff. Illustrated communication material was an effective method in communicating with intubated patients. © 2013 Wiley Publishing Asia Pty Ltd.

Life-Saving Esophageal Intubation in Neonate With Undiagnosed Tracheal Agenesis: A Case Report.

PubMed

Sattler, Christopher; Chiao, Franklin; Stein, David; Murphy, Denise

2017-07-01

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.

Management of esophageal stenting-associated esophagotracheal fistula, tracheal stenosis and tracheal rupture: a case report and review of the literature.

PubMed

Ji, Fanceng; Nie, Peihe; Yi, Fuxia; Zhang, Limin

2015-01-01

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.

Effectiveness of mouthpiece nebulization and nasal swab stick packing for topical anesthesia in awake fiberoptic nasotracheal intubation.

PubMed

Techanivate, Anchalee; Leelanukrom, Ruenreong; Prapongsena, Prut; Terachinda, Danuchit

2007-10-01

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 (10%) were dissatisfied because of numbness of the tongue and difficulty in swallowing; two patients (6.7%) had no comment; and one patient (3.3%) was unable to evaluate due to unplanned tracheostomy. In the present study technique of topical anesthesia using 2% lidocaine 5 mL mouthpiece nebulization and 10% cocaine 1 mL soaked nasal swab stick packing is useful and safe for awake fiberoptic nasotracheal intubation in patients with suspected difficult intubation. 76.7% of the patient did not require more local anesthesia and 80% were satisfied with this technique.

Voice related quality of life in pediatric patients with a history of prematurity.

PubMed

Walz, Patrick C; Hubbell, Michael P; Elmaraghy, Charles A

2014-07-01

To determine incidence of dysphonia in patients with history of prematurity and evaluate the correlation between dysphonia and risk factors unique to premature infants. The aim of this study is to determine parent-perceived vocal quality in patients with history of prematurity and whether duration of intubation, number of intubations, and incidence of patent ductus arteriosus repair were correlated with these perceptions. Cohort study of premature patients presenting to outpatient clinics from January 2010 to January 2013 in tertiary care center. Patients gestational age ≤37 weeks at birth without history of tracheostomy or known vocal fold pathology were eligible. A volunteer sample was obtained from patients presenting in Otolaryngology clinics from January 2010 to January 2013 whose parents agreed to complete surveys. Outcomes were assessed via parental completion of pediatric voice outcomes score (pVOS) and pediatric voice-related quality of life (pVRQOL) instruments. The primary outcome assessed was the incidence of dysphonia in infants with a history of prematurity without known vocal pathology. Additionally, patient factors associated with dysphonia were evaluated. The hypothesis tested was formulated prior to data collection. Sixty-nine participants were included. Mean age at follow-up was 28 (3-197) months. Mean gestational age was 29 (23-37) weeks. Mean intubation duration was 3 (0-22) weeks and median number of intubations was 1 (range 0-5). Voice outcome scores varied widely with pVRQOL scores demonstrating a mean of 89.2±18.1 (25-100) and pVOS with a mean of 11.4±2.2 (0-13). Univariate analysis utilized Spearman correlation coefficients for continuous variables and Wilcoxon Two-sample test for categorical groups. Significance was set at p<0.05. All significant univariate associations were placed in a multivariate model. Duration of intubation ≥4 weeks was the only factor which correlated with dysphonia on multivariate analysis (p=0.0028, OR=6.4, 95% CI=1.9-21.6). The data suggest that prolonged intubation is associated with poorer long term parent-perceived voice quality in premature patients. Further study is required to correlate parent perceptions with objective vocal quality data and physical findings of vocal pathology. These data may increase the clinician's suspicion for and evaluation of dysphonia in this population. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Prehospital oral chlorhexidine does not reduce the rate of ventilator-associated pneumonia among critically ill trauma patients: A prospective concurrent-control study.

PubMed

Mohr, Nicholas M; Pelaez Gil, Carlos A; Harland, Karisa K; Faine, Brett; Stoltze, Andrew; Pearson, Kent; Ahmed, Azeemuddin

2015-08-01

The purpose of the study was to test the hypothesis that prehospital oral chlorhexidine administered to intubated trauma patients will decrease the Clinical Pulmonary Infection Score (CPIS) during the first 2 days of hospitalization. Prospective interventional concurrent-control study of all intubated adult trauma patients transported by air ambulance to a 711-bed Midwestern academic trauma center over a 1-year period. Patients transported by 2 university-based helicopters were treated with oral chlorhexidine after intubation, and the control group was patients transported by other air transport services. Sixty-seven patients were enrolled, of which 23 received chlorhexidine (9 patients allocated to the intervention were not treated). The change in CPIS score was no different between the intervention and control groups by intention to treat (1.06- vs 1.40-point reduction, P = .520), and no difference was observed in tracheal colonization (29.0% vs 36.7%, P = .586). No differences were observed in the rate of clinical pneumonia (8.7% vs 8.6%, P = .987) or mortality (P = .196) in the per-protocol chlorhexidine group. The prehospital administration of oral chlorhexidine does not reduce the CPIS score over the first 48 hours of admission for intubated trauma patients. Further study should explore other prehospital strategies of reducing complications of critical illness. Copyright © 2015 Elsevier Inc. All rights reserved.

Temporal variation of the leak pressure of uncuffed endotracheal tubes following pediatric intubation: an observational study.

PubMed

Patel, Shreya; Lalwani, Kirk; Koh, Jeffrey; Wu, Lei; Fu, Rongwei

2014-06-01

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.

Treatment of post-intubation laryngeal granulomas: systematic review and proportional meta-analysis.

PubMed

Rimoli, Caroline Fernandes; Martins, Regina Helena Garcia; Catâneo, Daniele Cristina; Imamura, Rui; Catâneo, Antonio José Maria

2018-04-14

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.

Fatal and near-fatal asthma in children: the critical care perspective.

PubMed

Newth, Christopher J L; Meert, Kathleen L; Clark, Amy E; Moler, Frank W; Zuppa, Athena F; Berg, Robert A; Pollack, Murray M; Sward, Katherine A; Berger, John T; Wessel, David L; Harrison, Rick E; Reardon, Jean; Carcillo, Joseph A; Shanley, Thomas P; Holubkov, Richard; Dean, J Michael; Doctor, Allan; Nicholson, Carol E

2012-08-01

To characterize the clinical course, therapies, and outcomes of children with fatal and near-fatal asthma admitted to pediatric intensive care units (PICUs). This was a retrospective chart abstraction across the 8 tertiary care PICUs of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Inclusion criteria were children (aged 1-18 years) admitted between 2005 and 2009 (inclusive) for asthma who received ventilation (near-fatal) or died (fatal). Data collected included medications, ventilator strategies, concomitant therapies, demographic information, and risk variables. Of the 261 eligible children, 33 (13%) had no previous history of asthma, 218 (84%) survived with no known complications, and 32 (12%) had complications. Eleven (4%) died, 10 of whom had experienced cardiac arrest before admission. Patients intubated outside the PICU had a shorter duration of ventilation (median, 25 hours vs 84 hours; P < .001). African-Americans were disproportionately represented among the intubated children and had a shorter duration of intubation. Barotrauma occurred in 15 children (6%) before admission. Pharmacologic therapy was highly variable, with similar outcomes. Of the children ventilated in the CPCCRN PICUs, 96% survived to hospital discharge. Most of the children who died experienced cardiac arrest before admission. Intubation outside the PICU was correlated with shorter duration of ventilation. Complications of barotrauma and neuromyopathy were uncommon. Practice patterns varied widely among the CPCCRN sites. Copyright © 2012 Mosby, Inc. All rights reserved.

Increased incidence of clinical hypotension with etomidate compared to ketamine for intubation in septic patients: A propensity matched analysis.

PubMed

Van Berkel, Megan A; Exline, Matthew C; Cape, Kari M; Ryder, Lindsay P; Phillips, Gary; Ali, Naeem A; Doepker, Bruce A

2017-04-01

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.

Rocuronium versus vecuronium during fentanyl induction in patients undergoing coronary artery surgery.

PubMed

Smith, C E; Botero, C; Holbrook, C; Pinchak, A C; Hagen, J F

1999-10-01

To evaluate the neuromuscular, ventilatory, and cardiovascular effects of rocuronium and vecuronium. Randomized, prospective, blinded study. Tertiary care teaching center, single institution. Patients undergoing elective coronary artery bypass graft procedure. Patients received rocuronium, 1.0 mg/kg (n = 17), or vecuronium, 0.15 mg/kg (n = 15), during fentanyl induction of anesthesia. Measures consisted of time to visual loss of orbicularis oculi twitches in response to facial nerve stimulation, ease of mask ventilation, hemodynamics, need for vasoactive drugs, and tracheal intubating conditions. Median time to twitch loss was faster (p < 0.05) after rocuronium (60 s) than after vecuronium (>84 s). Within 45 seconds, only 3 of 17 patients in the rocuronium group had moderate-to-severe difficulty with mask ventilation versus 12 of 15 patients in the vecuronium group (p < 0.05). Tracheal intubating conditions were excellent in all patients after rocuronium. In the vecuronium group, intubating conditions were excellent in 46%, good in 27%, and poor in 27% (p < 0.05 vrocuronium). Patients receiving vecuronium were more likely to require ephedrine and phenylephrine for hypotension (10/15 patients v 5/17 patients for rocuronium, p < 0.05). There were no clinically important differences in hemodynamic variables, oxygen metabolism, or myocardial ischemia between groups. During narcotic induction of anesthesia, rocuronium was associated with lower requirement for vasopressors, faster onset of neuromuscular blockade, and better conditions for mask ventilation and tracheal intubation compared with vecuronium.

The effect of carbonated beverages on colorimetric end-tidal CO(2) determination

PubMed

Qureshi; Park; Sturmann; Hsu

2000-10-01

Esophageal intubation is a significant complication of attempted airway control. Colorimetric end-tidal CO(2) monitors are highly sensitive and specific for detecting the presence of CO(2). There are reports of false-positive end-tidal CO(2) readings from esophageal intubations in patients who had ingested carbonated beverages. OBJECTIVE: To determine whether carbonated gastric contents can affect colorimetric end-tidal CO(2) readings. METHODS: End-tidal CO(2) was measured in sacrificed piglets at measured time intervals after instillation of 5-, 10-, 15-, and 20-mL aliquots of Diet Coke were placed into the stomach via a 28-French orogastric tube followed by esophageal intubation. The stomach was completely evacuated prior to each instillation and rechecked for baseline CO(2). RESULTS: Compiled data from three piglets (20-30 kg). Piglets were not ventilated or moved and determinations were measured at 20 degrees while supine. All data collected within 2 hours postmortem (table 24-1). CONCLUSIONS: The colorimetric end-tidal CO(2) turned "yellow" and did not change to blue with extended insufflations. The CO(2) of a small quantity of carbonated beverage in the stomach could be "blown off" by multiple insufflations. We conclude that esophageal intubation in the setting of recent ingestion of a carbonated beverage may result in a false-positive end-tidal CO(2) determination.

Outcomes of revision external dacryocystorhinostomy and nasal intubation by bicanalicular silicone tubing under endonasal endoscopic guidance.

PubMed

Ari, Seyhmus; Kürşat Cingü, Abdullah; Sahin, Alparslan; Gün, Ramazan; Kiniş, Vefa; Caça, Ihsan

2012-01-01

To evaluate the long-term treatment outcomes in patients who underwent revision of external dacryocystorhinostomy (DCR) and nasal intubation by bicanalicular silicone tubing (BSTI) under endonasal endoscopic guidance. Data from 28 patients with recurrent dacryocystitis were retrospectively reviewed. Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance was performed in 28 eyes of 28 patients. The patients were evaluated with respect to the reason of recurrence, time to recurrence, time to revision, duration of follow-up and surgical success. Endoscopic endonasal examination detected an osteotomy-side obstruction by the excessive granulation tissue in 24 patients (86%), nasal septal deviation in three patients (10%) and nasal polyp in one patient (4%). Recurrence occurred after a mean duration of 5.3±3.7 months following the first operation. The mean time between the first DCR operation and the revision DCR was 11.5 ± 9.3 months. After a mean follow-up of 14.9±7.8 months, the rate of anatomic success alone was 85% (24/28); the rate of subjective success was 78% (22/28). Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance can be recommended in patients with recurrent dacryocystitis as a surgical approach that achieves satisfactory objective and subjective success rates.

Outcomes of revision external dacryocystorhinostomy and nasal intubation by bicanalicular silicone tubing under endonasal endoscopic guidance

PubMed Central

Ari, Şeyhmus; Kürşat Cingü, Abdullah; Şahin, Alparslan; Gün, Ramazan; Kiniş, Vefa; Çaça, İhsan

2012-01-01

AIM To evaluate the long-term treatment outcomes in patients who underwent revision of external dacryocystorhinostomy (DCR) and nasal intubation by bicanalicular silicone tubing (BSTI) under endonasal endoscopic guidance. METHODS Data from 28 patients with recurrent dacryocystitis were retrospectively reviewed. Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance was performed in 28 eyes of 28 patients. The patients were evaluated with respect to the reason of recurrence, time to recurrence, time to revision, duration of follow-up and surgical success. RESULTS Endoscopic endonasal examination detected an osteotomy-side obstruction by the excessive granulation tissue in 24 patients (86%), nasal septal deviation in three patients (10%) and nasal polyp in one patient (4%). Recurrence occurred after a mean duration of 5.3±3.7 months following the first operation. The mean time between the first DCR operation and the revision DCR was 11.5 ± 9.3 months. After a mean follow-up of 14.9±7.8 months, the rate of anatomic success alone was 85% (24/28); the rate of subjective success was 78% (22/28). CONCLUSION Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance can be recommended in patients with recurrent dacryocystitis as a surgical approach that achieves satisfactory objective and subjective success rates. PMID:22762058

Electrophoretic deposition of graphene oxide onto carbon fibers for in-tube solid-phase microextraction.

PubMed

Feng, Juanjuan; Wang, Xiuqin; Tian, Yu; Bu, Yanan; Luo, Chuannan; Sun, Min

2017-09-29

Carbon fibers (CFs) were functionalized with graphene oxide (GO) by an electrophoretic deposition (EPD) method for in-tube solid-phase microextraction (SPME). GO-CFs were filled into a poly(ether ether ketone) (PEEK) tube to obtain a fibers-in-tube SPME device, which was connected with high performance liquid chromatography (HPLC) equipment to build online SPME-HPLC system. Compared with CFs, GO-CFs presented obviously better extraction performance, due to excellent adsorption property and large surface area of GO. Using ten polycyclic aromatic hydrocarbons (PAHs) as model analytes, the important extraction conditions were optimized, such as sample flow rate, extraction time, organic solvent content and desorption time. An online analysis method was established with wide linear range (0.01-50μgL -1 ) and low detection limits (0.001-0.004μgL -1 ). Good sensitivity resulted from high enrichment factors (1133-3840) of GO-CFs in-tube device towards PAHs. The analysis method was used to online determination of PAHs in wastewater samples. Some target analytes were detected and relative recoveries were in the range of 90.2-112%. It is obvious that the proposed GO-CFs in-tube device was an efficient extraction device, and EPD could be used to develop nanomaterials functionalized sorbents for sample preparation. Copyright © 2017 Elsevier B.V. All rights reserved.

Comparison of the effects of Truview PCD™ video laryngoscopy and Macintosh blade direct laryngoscopy in geriatric patients.

PubMed

Kurnaz, Muhammed M; Sarıtaş, Aykut

2016-12-01

To compare the effects of Truview PCD™ video laryngoscopy (TVL) and Macintosh blade direct laryngoscopy (MDL) on hemodynamic responses observed during laryngoscopy and orotracheal intubation conditions in geriatric patients. Randomized prospective study. Operating room. One hundred patients in the risk group American Society of Anesthesiologists I to III aged 65 years and older underwent elective surgery under general anesthesia. This prospective study was performed between January 2014 and February 2015 after institutional ethics committee approval. Patients were randomly allocated to 2 groups, namely, TVL and MDL. Hemodynamic parameters, modified Cormack-Lehane grade, intubation period, and preoperative examination (age, sex, American Society of Anesthesiologists, modified Mallampati test score, and thyromental and sternomental distances) of patients were evaluated. There were no statistically significant differences in hemodynamic responses (heart rates and mean arterial pressure) between the 2 groups (P>.05). The median intubation period in the TVL group was significantly higher than observed in the MDL group (t=4.594; P<.05). The laryngoscopy views in TVL group were better than the views in MDL group. The Cormack-Lehane grade in the TVL group was lower when compared to the MDL group. The TVL system does not provide significant hemodynamic response sparing or shorten orotracheal intubation times when compared to MDL in geriatric patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Effect of Etomidate Versus Combination of Propofol-Ketamine and Thiopental-Ketamine on Hemodynamic Response to Laryngoscopy and Intubation: A Randomized Double Blind Clinical Trial.

PubMed

Gholipour Baradari, Afshin; Firouzian, Abolfazl; Zamani Kiasari, Alieh; Aarabi, Mohsen; Emadi, Seyed Abdollah; Davanlou, Ali; Motamed, Nima; Yousefi Abdolmaleki, Ensieh

2016-02-01

Laryngoscopy and intubation frequently used for airway management during general anesthesia, is frequently associated with undesirable hemodynamic disturbances. The aim of this study was to compare the effects of etomidate, combination of propofol-ketamine and thiopental-ketamine as induction agents on hemodynamic response to laryngoscopy and intubation. In a double blind, randomized clinical trial a total of 120 adult patients of both sexes, aged 18 - 45 years, scheduled for elective surgery under general anesthesia were randomly assigned into three equally sized groups. Patients in group A received etomidate (0.3 mg/kg) plus normal saline as placebo. Patients in group B and C received propofol (1.5 mg/kg) plus ketamine (0.5 mg/kg) and thiopental sodium (3 mg/kg) plus ketamine (0.5 mg/kg), respectively for anesthesia induction. Before laryngoscopy and tracheal intubation, immediately after, and also one and three minutes after the procedures, hemodynamic values (SBP, DBP, MAP and HR) were measured. A repeated measurement ANOVA showed significant changes in mean SBP and DBP between the time points (P < 0.05). In addition, the main effect of MAP and HR were statistically significant during the course of study (P < 0.05). Furthermore, after induction of anesthesia, the three study groups had significantly different SBP, DBP and MAP changes overtime (P < 0.05). However, HR changes over time were not statistically significant (P > 0.05). Combination of propofol-ketamine had superior hemodynamic stability compared to other induction agents. Combination of propofol-ketamine may be recommended as an effective and safe induction agent for attenuating hemodynamic responses to laryngoscopy and intubation with better hemodynamic stability. Although, further well-designed randomized clinical trials to confirm the safety and efficacy of this combination, especially in critically ill patients or patients with cardiovascular disease, are warranted.

Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis.

PubMed

Fouche, Pieter F; Stein, Christopher; Simpson, Paul; Carlson, Jestin N; Zverinova, Kristina M; Doi, Suhail A

2018-01-29

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.

A novel method for right one-lung ventilation modeling in rabbits.

PubMed

Xu, Ze-Ping; Gu, Lian-Bing; Bian, Qing-Ming; Li, Peng-Yi; Wang, Li-Jun; Chen, Xiao-Xiang; Zhang, Jing-Yuan

2016-08-01

There is no standard method by which to establish a right one-lung ventilation (OLV) model in rabbits. In the present study, a novel method is proposed to compare with two other methods. After 0.5 h of baseline two-lung ventilation (TLV), 40 rabbits were randomly divided into sham group (TLV for 3 h as a contrast) and three right-OLV groups (right OLV for 3 h with different methods): Deep intubation group, clamp group and blocker group (deeply intubate the self-made bronchial blocker into the left main bronchus, the novel method). These three methods were compared using a number of variables: Circulation by heart rate (HR), mean arterial pressure (MAP); oxygenation by arterial blood gas analysis; airway pressure; lung injury by histopathology; and time, blood loss, success rate of modeling. Following OLV, compared with the sham group, arterial partial pressure of oxygen and arterial hemoglobin oxygen saturation decreased, peak pressure increased and lung injury scores were higher in three OLV groups at 3 h of OLV. All these indexes showed no differences between the three OLV groups. During right-OLV modeling, less time was spent in the blocker group (6±2 min), compared with the other two OLV groups (13±4 min in deep intubation group, P<0.05; 33±9 min in clamp group, P<0.001); more blood loss was observed in clamp group (11.7±2.8 ml), compared with the other two OLV groups (2.3±0.5 ml in deep intubation group, P<0.001; 2.1±0.6 ml in blocker group, P<0.001). The first-time and final success rate of modeling showed no differences among the three OLV groups. Deep intubation of the self-made bronchial blocker into the left main bronchus is an easy, effective and reliable method to establish a right-OLV model in rabbits.

Decrease in delivery room intubation rates after use of nasal intermittent positive pressure ventilation in the delivery room for resuscitation of very low birth weight infants.

PubMed

Biniwale, Manoj; Wertheimer, Fiona

2017-07-01

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.

Post-intubation sore throat and menstruation cycles.

PubMed

Orandi, Amirali; Orandi, Amirhossein; Najafi, Atabak; Hajimohammadi, Fatemeh; Soleimani, Sara; Zahabi, Somayeh

2013-09-01

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 cycles, there was no significant association between menstrual cycle and sore throat incidence.

An update on out-of-hospital airway management practices in the United States.

PubMed

Diggs, Leigh Ann; Yusuf, Juita-Elena Wie; De Leo, Gianluca

2014-07-01

We characterized out-of-hospital airway management interventions, outcomes, and complications using the 2012 NEMSIS Public-Release Research Data Set containing almost 20 million Emergency Medical Services activations from 40 states and two territories. We compared the outcomes with a previous study that used 2008 NEMSIS data containing 16 states with 4 million EMS activations. Patients who received airway management interventions including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and surgical) were identified. Using descriptive statistics, airway management success and complications were examined in the full cohort and key subsets including cardiac arrest, non-arrest medical, non-arrest injury, children<10 years, children 10-19 years, rapid sequence intubation (RSI), population setting, U.S. census region, and U.S. census division. Among 19,831,189 EMS activations, there were 74,993 ETIs, 21,990 alternate airways, and 1332 cricothyroidotomies. ETI success rates were: overall 63,956/74,993 (85.3%; 95% CI: 85.0-85.5), cardiac arrest 33,558/39,270 (85.5%), non-arrest medical 12,215/13,611 (89.7%), non-arrest injury (90.1%), children <10 years 2069/2468 (83.8%), children 10-19 years 1647/1900 (86.7%), adults >19 years 58,965/69,144 (85.3%), and rapid sequence intubation 5265/5658 (93.1%). Major complications included bleeding 677 (4.4 per 1000 interventions), vomiting 1221 (8 per 1000 interventions), esophageal intubation immediately detected 874 (5.7 per 1000 interventions), and esophageal intubations other 219 (1.4 per 1000 interventions). Low out-of-hospital ETI and alternate airway success rates were observed. These data may guide national efforts to improve out-of-hospital airway management quality leading efforts to better educate providers on ETI. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

A novel method for right one-lung ventilation modeling in rabbits

PubMed Central

Xu, Ze-Ping; Gu, Lian-Bing; Bian, Qing-Ming; Li, Peng-Yi; Wang, Li-Jun; Chen, Xiao-Xiang; Zhang, Jing-Yuan

2016-01-01

There is no standard method by which to establish a right one-lung ventilation (OLV) model in rabbits. In the present study, a novel method is proposed to compare with two other methods. After 0.5 h of baseline two-lung ventilation (TLV), 40 rabbits were randomly divided into sham group (TLV for 3 h as a contrast) and three right-OLV groups (right OLV for 3 h with different methods): Deep intubation group, clamp group and blocker group (deeply intubate the self-made bronchial blocker into the left main bronchus, the novel method). These three methods were compared using a number of variables: Circulation by heart rate (HR), mean arterial pressure (MAP); oxygenation by arterial blood gas analysis; airway pressure; lung injury by histopathology; and time, blood loss, success rate of modeling. Following OLV, compared with the sham group, arterial partial pressure of oxygen and arterial hemoglobin oxygen saturation decreased, peak pressure increased and lung injury scores were higher in three OLV groups at 3 h of OLV. All these indexes showed no differences between the three OLV groups. During right-OLV modeling, less time was spent in the blocker group (6±2 min), compared with the other two OLV groups (13±4 min in deep intubation group, P<0.05; 33±9 min in clamp group, P<0.001); more blood loss was observed in clamp group (11.7±2.8 ml), compared with the other two OLV groups (2.3±0.5 ml in deep intubation group, P<0.001; 2.1±0.6 ml in blocker group, P<0.001). The first-time and final success rate of modeling showed no differences among the three OLV groups. Deep intubation of the self-made bronchial blocker into the left main bronchus is an easy, effective and reliable method to establish a right-OLV model in rabbits. PMID:27446346

Determination of aflatoxins in food samples by automated on-line in-tube solid-phase microextraction coupled with liquid chromatography-mass spectrometry.

PubMed

Nonaka, Y; Saito, K; Hanioka, N; Narimatsu, S; Kataoka, H

2009-05-15

A simple and sensitive automated method for determination of aflatoxins (B1, B2, G1, and G2) in nuts, cereals, dried fruits, and spices was developed consisting of in-tube solid-phase microextraction (SPME) coupled with liquid chromatography-mass spectrometry (LC-MS). Aflatoxins were separated within 8 min by high-performance liquid chromatography using a Zorbax Eclipse XDB-C8 column with methanol/acetonitrile (60/40, v/v): 5mM ammonium formate (45:55) as the mobile phase. Electrospray ionization conditions in the positive ion mode were optimized for MS detection of aflatoxins. The pseudo-molecular ions [M+H](+) were used to detect aflatoxins in selected ion monitoring (SIM) mode. The optimum in-tube SPME conditions were 25draw/eject cycles of 40 microL of sample using a Supel-Q PLOT capillary column as an extraction device. The extracted aflatoxins were readily desorbed from the capillary by passage of the mobile phase, and no carryover was observed. Using the in-tube SPME LC-MS with SIM method, good linearity of the calibration curve (r>0.9994) was obtained in the concentration range of 0.05-2.0 ng/mL using aflatoxin M1 as an internal standard, and the detection limits (S/N=3) of aflatoxins were 2.1-2.8 pg/mL. The in-tube SPME method showed >23-fold higher sensitivity than the direct injection method (10 microL injection volume). The within-day and between-day precision (relative standard deviations) at the concentration of 1 ng/mL aflatoxin mixture were below 3.3% and 7.7% (n=5), respectively. This method was applied successfully to analysis of food samples without interference peaks. The recoveries of aflatoxins spiked into nuts and cereals were >80%, and the relative standard deviations were <11.2%. Aflatoxins were detected at <10 ng/g in several commercial food samples.

Transcanalicular Laser-Assisted Dacryocystorhinostomy With Endonasal Augmentation in Primary Nasolacrimal Duct Obstruction: Our Experience.

PubMed

Goel, Ruchi; Nagpal, Smriti; Kumar, Sushil; Meher, Ravi; Kamal, Saurabh; Garg, Sonam

To evaluate and compare the success rate of transcanalicular laser-assisted dacryocystorhinostomy with endonasal augmentation, with and without intubation, in patients suffering from primary acquired nasolacrimal duct obstruction, at 1 year of follow up. A prospective, randomized interventional pilot study was conducted at a tertiary care center, in accordance with the guidelines of Declaration of Helsinki. Sixty eyes of 60 adult patients with primary acquired nasolacrimal duct obstruction were included. The participants were divided randomly into 2 equal groups (A and B-without and with bicanalicular intubation, respectively). An osteotomy was first created using 980 nm diode laser (set at 8W continuous mode) transcanalicularly and then enlarged intranasally using Blakesley's nasal forceps, followed by bicanalicular silicon intubation in group B patients. The tubes were removed at the end of 8 weeks. The ostium size was assessed endoscopically at 8 weeks and again at the end of follow up, at 1 year. A successful outcome was defined in terms of ostium patency at the end of 1 year. The results were analyzed at the end of a follow up of 1 year, using various statistical tests (p < 0.05). The mean age of the patients was 35.3 ± 15.89 years, with 23 male and 37 female patients, the 2 groups having a similar male:female ratio. An overall success rate of 90% was achieved at the end of 1 year with no statistically significant difference between the groups. Postoperative complications like tube displacement and punctal, canalicular injury were more in the intubated group. The average osteotomy size was 8.06 ± 5.4 mm at the end of 1 year. Transcanalicular laser-assisted dacryocysto rhinostomy, with endonasal augmentation, is a scarless, effective, daycare procedure, for treatment of primary acquired nasolacrimal duct obstruction with no additional advantage offered by silicone intubation.

Effect of Cricoid Pressure on Laryngeal View During Macintosh, McGrath MAC X-Blade and GlideScope Video Laryngoscopies

PubMed Central

Arslan, Zehra İpek; Solak, Mine

2017-01-01

Objective Cricoid pressure is useful in fasted patients requiring emergency intubation. We compared the effect of cricoid pressure on laryngeal view during Macintosh, McGrath MAC X-Blade and GlideScope video laryngoscopy. Methods After obtaining approval from the Human Research Ethics Committee and written informed consent from patients, we enrolled 120 patients (American Society of Anesthesiologists I–II, age 18–65 years) undergoing elective surgery that required endotracheal intubation in this prospective randomised study. Patients were divided into three groups (Macintosh, McGrath MAC X-Blade and GlideScope). Results Demographic and airway variables were similar in the groups. Cormack-Lehane grades were improved or unchanged on using cricoid pressure in Macintosh and McGrath MAC X-Blade groups. However, laryngeal views worsened in 12 patients (30%), remained unchanged in 26 patients (65%) and improved in 2 patients (5%) in the GlideScope group (p<0.001). Insertion and intubation times for Macintosh and McGrath MAC X-Blade video laryngoscopes were similar. Insertion times for GlideScope and Macintosh video laryngoscopes were similar, but were longer than those for the McGrath MAC X-Blade video laryngoscope (p=0.02). Tracheal intubation took longer with the GlideScope video laryngoscope than with the other devices (p<0.001 and p=0.003). Mean arterial pressures after insertion increased significantly in Macintosh and GlideScope groups (p=0.004 and p=0.001, respectively) compared with post-induction values. Heart rates increased after insertion in all three groups compared with post-induction values (p<0.001). Need for optimisation manoeuvres and postoperative minor complications were comparable in all three groups. Conclusion Although all three devices are useful for normal or difficult intubation, cricoid pressure improved Cormack-Lehane grades of Macintosh and McGrath MAC X-Blade video laryngoscopes but statistically significantly worsened that of the GlideScope video laryngoscope. PMID:29359076

Pathogenic Link Between Postextubation Pneumonia and Ventilator-Associated Pneumonia: An Experimental Study.

PubMed

Rezoagli, Emanuele; Zanella, Alberto; Cressoni, Massimo; De Marchi, Lorenzo; Kolobow, Theodor; Berra, Lorenzo

2017-04-01

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 ventilation should be considered to avert the onset of PEP.

[Difficult reintubation during a Fantoni's tracheostomy resolved using a laryngeal mask].

PubMed

Ould-Ahmed, M; Mas, B; Paris, A; Caroff, P; Segalen, F

2001-04-01

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.

Studies of the Effects of Perfluorocarbon Emulsions on Platelet Number and Function in Models of Critical Battlefield Injury

DTIC Science & Technology

2016-01-01

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

Temporomandibular Joint Ankylosis: "A Pediatric Difficult Airway Management".

PubMed

Sharma, Anoop; Dwivedi, Deepak; Sharma, Ram Murti

2018-01-01

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.

Management of in-tube projectiles using acoustic channel

NASA Astrophysics Data System (ADS)

Kostina, M. A.; Bortalevich, S. I.; Loginov, E. L.; Shinyakov, Y. A.; Sukhorukov, M. P.

2018-03-01

The article describes the method of measuring the distance from the operator's console installed outside the pipe to the in-tube projectile. A method for measuring distance in the absence of an echo signal is proposed. To do this, two identical ultrasonic locators operating at different frequencies were installed inside and outside the pipeline. The change in the duration of an acoustic pulse propagating in a circular waveguide with rigid walls is shown, which leads to a decrease in the data transfer rate.

Successful silicon stent for life-threatening tracheal wall laceration.

PubMed

Yamamoto, Shinichi; Endo, Shunsuke; Endo, Tetsuya; Mitsuda, Sayaka

2013-01-01

We report an 86-year-old woman with a large tracheal laceration caused by tracheal intubation at cardiopulmonary arrest who underwent a successful stent procedure. Tracheal laceration developed in the membranous portion longitudinally 6 cm in length to 2 cm above the carina. Following 9 days' tracheal intubation, a Y-shaped silicon stent was inserted over the lacerated trachea. Four months after the stenting procedure, we removed the Y-shaped silicon stent from the healed membranous wall. The patient returned to daily life without requiring thoracotomy.

Truview EVO2 and standard Macintosh laryngoscope for tracheal intubation during cardiopulmonary resuscitation: a comparative randomized crossover study.

PubMed

Gaszynska, Ewelina; Gaszynski, Tomasz

2014-09-01

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 was better for MCL compared with Truview EVO2 laryngoscope in both scenarios (P = 0.0029 and P = 0.0004 in no-CPR and CPR scenarios). The number of EI with MCL was 30% versus 13.3% (P = 0.0113), and for Truview EVO2 it was 20.45% versus 15.56% in CPR and no-CPR scenarios, respectively. The application of Truview EVO2 during uninterrupted chest compressions increased TTI but increased the success ratio of ETI and decreased number of EIs.

Dangerous blind tracheal intubation attempt due to fiberscope non-availability in a pediatric patient with retropharyngeal abscess caused by a large fish bone.

PubMed

Li, Bi-Lian; Xu, Ying-Yi; Jiang, Yan-Fang; Liu, Wen-Xing; Kuang, Xiao-Hua; Ni, Jin

2015-01-01

In China, foods containing bones are sometimes fed to young infants. Occasionally, this practice results in bone aspiration and retropharyngeal abscess, a potentially life-threatening infection in the deep space of the neck that can compromise the airway. The main concern in managing patients with retropharyngeal abscess is airway management. In China, not all hospitals and operating rooms are equipped with fiberscopes, particularly pediatric-size fiberscopes. Emergency airway management can be dangerous when a fiberscope is unavailable. We present the case of a 21-month-old baby girl with a retropharyngeal abscess secondary to fish bone ingestion. During an attempted blind tracheal intubation due to fiberscope non-availability, the abscess ruptured, and the pus released from it obstructed the airway. The patient was successfully treated despite the inadequate resources and dangerous complication. We recommend a detailed preoperative airway assessment and preparation for fiberscopic tracheal intubation in such patients to prevent this dangerous complication.

Subglottic granuloma after aortic replacement: resection via flexible bronchoscopy after an emergency tracheostomy

PubMed Central

Nose, Naohiro; So, Tetsuya; Sekimura, Atsushi; Miyata, Takeaki; Yoshimatsu, Takashi

2014-01-01

A subglottic granuloma is one of the late-phase complications that can occur after intubation. It can cause a life-threatening airway obstruction; therefore, a rapid diagnosis and appropriate treatment plan is necessary. A 62-year-old male had undergone an emergency total arch replacement for acute aortic dissection. Postoperative ventilation support had been performed until the 15th postoperative day (POD). He was discharged from the hospital on POD 30. On POD 50, he was brought to our hospital by an ambulance with severe dyspnea. A large subglottic granuloma occupying the trachea was identified by flexible bronchoscopy. After an emergency tracheostomy, resection of the granuloma with argon plasma coagulation via flexible bronchoscopy was performed safely. Physicians should suspect a post-intubation subglottic granuloma when patients who have undergone intubation report feeling throat discomfort. Resection via flexible bronchoscopy after tracheostomy is a safe and feasible procedure that may shorten the duration of therapy and hospital stay. PMID:25180216

Capillary liquid chromatographic analysis of fat-soluble vitamins and beta-carotene in combination with in-tube solid-phase microextraction.

PubMed

Xu, Hui; Jia, Li

2009-01-01

A capillary liquid chromatography (CLC) system with UV/vis detection was coupled with an in-tube solid-phase microextraction (SPME) device for the analysis of fat-soluble vitamins and beta-carotene. A monolithic silica-ODS column was used as the extraction medium. An optical-fiber flow cell with a long light path in the UV/vis detector was utilized to further enhance the detection sensitivity. In the in-tube SPME/CLC system, the pre-condition of the extraction column and the effect of the injection volume were investigated. The detection limits (LOD) for the fat-soluble vitamins and beta-carotene were in the range from 1.9 to 173 ng/mL based on the signal-to-noise ratio of 3 (S/N=3). The relative standard deviations of migration time and peak area for each analyte were less than 5.0%. The method was applied to the analysis of fat-soluble vitamins and beta-carotene contents in corns.

Anatomy-driven design of a prototype video laryngoscope for extremely low birth weight infants

NASA Astrophysics Data System (ADS)

Baker, Katherine; Tremblay, Eric; Karp, Jason; Ford, Joseph; Finer, Neil; Rich, Wade

2010-11-01

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.

[Perioperative Management of a Child with Vocal Adhesion Leading to Unexpected Difficult Airway].

PubMed

Hitosugi, Takashi; Tsukamoto, Masanori; Fujiwara, Shigeki; Yokoyama, Takeshi

2016-06-01

We report a child with vocal cord adhesion encountered during induction of anesthesia. A 4-month-old girl was scheduled for bilateral lip plasty. She was intubated for one week due to pneumonia at the age of 3 days. Hoarseness and stridor appeared just after extubation. Although laryngo-fiberoptic examination had been tried several times, otorhinologists could not find any abnormality. We once decided to postpone the operation because of severe stridor. However, laryngofiberoptic examination could not reveal any abnormality, and we rescheduled the operation. Tracheal intubation using laryngoscope was not possible due to vocal cord adhesion. Finally, 2.5 mm ID tracheal tube was intubated by using a fiberscope, and lip plasty was performed. The patient stayed in the ICU for 7 days after surgery. Tracheotomy was performed 3 weeks after the operation. We should pay attention to stridor in an infant before general anesthesia, since it suggests severe airway narrowing although laryngo-fiberoptic examination could not find any abnormalities.

Remifentanil Prevents Withdrawal Movements Caused by Intravenous Injection of Rocuronium

PubMed Central

Choi, Byung In; Choi, Seung Ho; Shin, Yang-Sik; Lee, Sung Jin; Yoon, Kyung Bong; Shin, Seo Kyung

2008-01-01

Purpose The incidence of pain induced withdrawal movement following intravenous injection of rocuronium is high. This randomized, double-blind, placebo-controlled study was designed to evaluate the effect of pretreatment of remifentanil on the withdrawal movements due to intravenous injection of rocuronium during anesthetic induction. Materials and Methods Ninety adult female patients undergoing thyroidectomy were randomly allocated to three groups. Each patient intravenously received one of three solutions of equal volume (4 mL): normal saline (Group I, n = 30), 0.5 µg/kg remifentanil (Group II, n = 30) or 1 µg/kg remifentanil (Group III, n = 30). Thirty seconds after remifentanil administration, anesthesia was induced with 5 mg/kg IV thiopental. Twenty seconds after thiopental injection, 0.6 mg/kg IV rocuronium was administered (injection rate of 0.5 mL/sec) and patients' withdrawal movements were assessed. Mean arterial pressure (MAP) and heart rate were assessed on arrival in the operation room, before the tracheal intubation and immediately, 1 and 2 min after the tracheal intubation. Results The incidence of withdrawal movements was significantly lower in both of the remifentanil groups (3 and 0% in Group II and III, respectively) than in the saline group (70%). Remifentanil attenuated the increase of heart rate and MAP immediately and 1 min after the tracheal intubation. Conclusion The pretreatment with 0.5 and 1.0 µg/kg remifentanil of bolus doses prevented the withdrawal movements caused by rocuronium injection, and effectively blunted cardiovascular activation following tracheal intubation. PMID:18452256

Respiratory mechanics during sevoflurane anesthesia in children with and without asthma.

PubMed

Habre, W; Scalfaro, P; Sims, C; Tiller, K; Sly, P D

1999-11-01

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.

A comparison of different types of hazardous material respirators available to anesthesiologists.

PubMed

Candiotti, Keith A; Rodriguez, Yiliam; Shekhter, Ilya; Castillo-Pedraza, Catalina; Rosen, Lisa Forman; Arheart, Kristopher L; Birnbach, David J

2012-01-01

Despite anesthesiology personnel involvement in initial treatment of patients exposed to potentially lethal agents, less than 40 percent of US anesthesiology training programs conduct training to manage these patients.(1) No previous studies have evaluated performance of anesthesiologists wearing protective gear. The authors compared the performance of anesthesiologists intubating a high-fidelity mannequin while wearing either a powered air-purifying respirator (PAPR) or a negative pressure respirator (NPR). Twenty participants practiced intubations on a high-fidelity simulator until comfortable. Each subject performed 10 repetitions, initially without any gear, then while wearing a protective suit, gloves, and respirator. The order of gear use was randomized and all subjects used both devices. Time for task completion were recorded, and at the end of the trial, subjects were asked to rate their comfort with the equipment. After controlling for other variables, overall statistically slower total performance times were observed with use of the PAPR when compared to the control arm and use of the NPR (p 5 0.01 and p < 0.007, respectively). Of the total 90 intubations, only one proved to be esophageal and initially undetected. The use of an NPR or PAPR does not preclude an anesthesiologist from successfully intubating, but practice is necessary. The slightly better performance with the NPR is weighed against the improved comfort of the PAPR and the fact that PAPR users could wear eyeglasses. Neither type of gear allowed the users to auscultate the lung fields to confirm correct endotracheal tube placement.

The effect of laryngoscope handle size on possible endotracheal intubation success in university football, ice hockey, and soccer players.

PubMed

Delaney, J Scott; Al-Kashmiri, Ammar; Baylis, Penny-Jane; Aljufaili, Mahmood; Correa, José A

2012-07-01

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.

Comparison of hemodynamic effects of intravenous etomidate versus propofol during induction and intubation using entropy guided hypnosis levels.

PubMed

Shah, Shagun Bhatia; Chowdhury, Itee; Bhargava, Ajay Kumar; Sabbharwal, Bhawnish

2015-01-01

This study aimed to compare the hemodynamic responses during induction and intubation between propofol and etomidate using entropy guided hypnosis. Sixty ASA I & II patients in the age group 20-60 yrs, scheduled for modified radical mastectomy were randomly allocated in two groups based on induction agent Etomidate or Propofol. Both groups received intravenous midazolam 0.03 mg kg(-1) and fentanyl 2 μg kg(-1) as premedication. After induction with the desired agent titrated to entropy 40, vecuronium 0.1 mg kg(-1) was administered for neuromuscular blockade. Heart rate, systolic, diastolic and mean arterial pressures, response entropy [RE] and state entropy [SE] were recorded at baseline, induction and upto three minutes post intubation. Data was subject to statistical analysis SPSS (version 12.0) the paired and the unpaired Student's T-tests for equality of means. Etomidate provided hemodynamic stability without the requirement of any rescue drug in 96.6% patients whereas rescue drug ephedrine was required in 36.6% patients in propofol group. Reduced induction doses 0.15mg kg(-1) for etomidate and 0.98 mg kg(-1) for propofol, sufficed to give an adequate anaesthetic depth based on entropy. Etomidate provides more hemodynamic stability than propofol during induction and intubation. Reduced induction doses of etomidate and propofol titrated to entropy translated into increased hemodynamic stability for both drugs and sufficed to give an adequate anaesthetic depth.

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

PubMed Central

Gulabani, Michell; Gurha, Pavan; Dass, Prashant; Kulshreshtha, Nishi

2015-01-01

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

Comparison of hemodynamic effects of intravenous etomidate versus propofol during induction and intubation using entropy guided hypnosis levels

PubMed Central

Shah, Shagun Bhatia; Chowdhury, Itee; Bhargava, Ajay Kumar; Sabbharwal, Bhawnish

2015-01-01

Background and Aims: This study aimed to compare the hemodynamic responses during induction and intubation between propofol and etomidate using entropy guided hypnosis. Material and Methods: Sixty ASA I & II patients in the age group 20-60 yrs, scheduled for modified radical mastectomy were randomly allocated in two groups based on induction agent Etomidate or Propofol. Both groups received intravenous midazolam 0.03 mg kg-1 and fentanyl 2 μg kg-1 as premedication. After induction with the desired agent titrated to entropy 40, vecuronium 0.1 mg kg-1 was administered for neuromuscular blockade. Heart rate, systolic, diastolic and mean arterial pressures, response entropy [RE] and state entropy [SE] were recorded at baseline, induction and upto three minutes post intubation. Data was subject to statistical analysis SPSS (version 12.0) the paired and the unpaired Student's T-tests for equality of means. Results: Etomidate provided hemodynamic stability without the requirement of any rescue drug in 96.6% patients whereas rescue drug ephedrine was required in 36.6% patients in propofol group. Reduced induction doses 0.15mg kg-1 for etomidate and 0.98 mg kg-1 for propofol, sufficed to give an adequate anaesthetic depth based on entropy. Conclusion: Etomidate provides more hemodynamic stability than propofol during induction and intubation. Reduced induction doses of etomidate and propofol titrated to entropy translated into increased hemodynamic stability for both drugs and sufficed to give an adequate anaesthetic depth. PMID:25948897

Airway accidents in critical care unit: A 3-year retrospective study in a Public Teaching Hospital of Eastern India

PubMed Central

Dasgupta, Sugata; Singh, Shipti Shradha; Chaudhuri, Arunima; Bhattacharya, Dipasri; Choudhury, Sourav Das

2016-01-01

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

Prehospital Endotracheal Intubation in Warm Climates: Caution is Required.

PubMed

Daniel, Yann; Habas, Sébastien; Cruc, Maximilien

2016-09-01

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.

Automatic detection of oesophageal intubation based on ventilation pressure waveforms shows high sensitivity and specificity in patients with pulmonary disease.

PubMed

Kalmar, Alain F; Absalom, Anthony; Rombouts, Pieter; Roets, Jelle; Dewaele, Frank; Verdonck, Pascal; Stemerdink, Arjanne; Zijlstra, Jan G; Monsieurs, Koenraad G

2016-08-01

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.

Online in-tube microextractor coupled with UV-Vis spectrophotometer for bisphenol A detection.

PubMed

Poorahong, Sujittra; Thammakhet, Chongdee; Thavarungkul, Panote; Kanatharana, Proespichaya

2013-01-01

A simple and high extraction efficiency online in-tube microextractor (ITME) was developed for bisphenol A (BPA) detection in water samples. The ITME was fabricated by a stepwise electrodeposition of polyaniline, polyethylene glycol and polydimethylsiloxane composite (CPANI) inside a silico-steel tube. The obtained ITME coupled with UV-Vis detection at 278 nm was investigated. By this method, the extraction and pre-concentration of BPA in water were carried out in a single step. Under optimum conditions, the system provided a linear dynamic range of 0.1 to 100 μM with a limit of detection of 20 nM (S/N ≥3). A single in-tube microextractor had a good stability of more than 60 consecutive injections for 10.0 μM BPA with a relative standard deviation of less than 4%. Moreover, a good tube-to-tube reproducibility and precision were obtained. The system was applied to detect BPA in water samples from six brands of baby bottles and the results showed good agreement with those obtained from the conventional GC-MS method. Acceptable percentage recoveries from the spiked water samples were obtained, ranging from 83-102% for this new method compared with 73-107% for the GC-MS standard method. This new in-tube CPANI microextractor provided an excellent extraction efficiency and a good reproducibility. In addition, it can also be easily applied for the analysis of other polar organic compounds contaminated in water sample.

Does high-flow nasal cannula oxygen improve outcome in acute hypoxemic respiratory failure? A systematic review and meta-analysis.

PubMed

Lin, Si-Ming; Liu, Kai-Xiong; Lin, Zhi-Hong; Lin, Pei-Hong

2017-10-01

To evaluate the efficacy of high-flow nasal cannula (HFNC) in the rate of intubation and mortality for patients with acute hypoxemic respiratory failure. We searched Pubmed, EMBASE, and the Cochrane Library for relevant studies. Two reviewers extracted data and reviewed the quality of the studies independently. The primary outcome was the rate of intubation; secondary outcome was mortality in the hospital. Study-level data were pooled using a random-effects model when I2 was >50% or a fixed-effects model when I2 was <50%. Eight randomized controlled studies with a total of 1,818patients were considered. Pooled analysis showed that no statistically significant difference was found between groups regarding the rate of intubation (odds ratio [OR] = 0.79; 95% confidence interval [CI]: 0.60-1.04; P = 0.09; I2 = 36%) and no statistically significant difference was found between groups regarding hospital mortality (OR = 0.89; 95% CI: 0.62-127; P = 0.51; I2 = 47%). The use of HFNC showed a trend toward reduction in the intubation rate, which did not meet statistical significance, in patients with acute respiratory failure compared with conventional oxygen therapy (COT) and noninvasive ventilation (NIV). Moreover no difference in mortality. So, Large, well-designed, randomized, multi-center trials are needed to confirm the effects of HFNC in acute hypoxemic respiratory failure patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study.

PubMed

Parsch, Cathrin S; Boonstra, Adrianne; Teubner, David; Emmerton, Wade; McKenny, Brian; Ellis, Daniel Y

2017-06-01

The aim of this study was to review mental health patients transported by a dedicated statewide critical care retrieval team before and after the implementation of a ketamine sedation guideline. This is a a retrospective cohort study of mental health patients with acute behavioural disturbance, transported between January 2010 and December 2015. A total of 78 patients were transported in the study period, 50 before and 28 after implementation of the ketamine guideline in June 2013. The introduction of the ketamine guideline was associated with a significant reduction in intubation for transport (36.00 vs 7.14%) (odds ratio 0.14, 95% confidence interval 0.02-0.71, P < 0.01). The likelihood of utilising ketamine for non-intubated patients (n = 58) was higher in the period after implementation (37.50 vs 84.62%, odds ratio 9.17, 95% confidence interval 2.54-33.08, P < 0.005). The incidence of complications in our series was low. The implementation of a ketamine clinical practice guideline for agitated mental health patients was associated with an increase in the number of patients receiving ketamine as part of their sedation regime and a reduction in the number of patients requiring intubation for transport. Appropriately trained critical care retrieval teams should consider ketamine as part of the sedation regime for agitated mental health patients. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

In situ pediatric trauma simulation: assessing the impact and feasibility of an interdisciplinary pediatric in situ trauma care quality improvement simulation program.

PubMed

Auerbach, Marc; Roney, Linda; Aysseh, April; Gawel, Marcie; Koziel, Jeannette; Barre, Kimberly; Caty, Michael G; Santucci, Karen

2014-12-01

This study aimed to evaluate the feasibility and measure the impact of an in situ interdisciplinary pediatric trauma quality improvement simulation program. Twenty-two monthly simulations were conducted in a tertiary care pediatric emergency department with the aim of improving the quality of pediatric trauma (February 2010 to November 2012). Each session included 20 minutes of simulated patient care, followed by 30 minutes of debriefing that focused on teamwork, communication, and the identification of gaps in care. A single rater scored the performance of the team in real time using a validated assessment instrument for 6 subcomponents of care (teamwork, airway, intubation, breathing, circulation, and disability). Participants completed a survey and written feedback forms. A trend analysis of the 22 simulations found statistically significant positive trends for overall performance, teamwork, and intubation subcomponents; the strength of the upward trend was the strongest for the teamwork (τ = 0.512), followed by overall performance (τ = 0.488) and intubation (τ = 0.433). Two hundred fifty-one of 398 participants completed the participant feedback form (response rate, 63%), reporting that debriefing was the most valuable aspect of the simulation. An in situ interdisciplinary pediatric trauma simulation quality improvement program resulted in improved validated trauma simulation assessment scores for overall performance, teamwork, and intubation. Participants reported high levels of satisfaction with the program, and debriefing was reported as the most valuable component of the program.

Obstructive sleep apnea and postoperative complications in patients undergoing coronary artery bypass graft surgery: a need for preventive strategies.

PubMed

Amra, Babak; Niknam, Nasim; Sadeghi, Mohsen Mir Mohammad; Rabbani, Majid; Fietze, Ingo; Penzel, Thomas

2014-11-01

Obstructive sleep apnea (OSA) is very frequent and often unrecognized in surgical patients. OSA is associated with perioperative complications. We evaluated the effects of OSA on postoperative complications and hospital outcomes in patients undergoing coronary artery bypass graft (CABG) surgery. Candidates of elective CABG were evaluated by the Berlin questionnaire for OSA. After surgery, patients were assessed for postoperative complications, re-admission to the Intensive Care Unit (ICU), duration of intubation, re-intubation, days spent in the ICU and the hospital. We studied 61 patients who underwent CABG from which 25 (40.9%) patients had OSA. Patients with OSA had higher body mass index (29.5 ± 3.9 vs. 26.0 ± 3.7 kg/m(2), P = 0.003) and higher frequency of hypertension (68.0% vs. 30.5%, P = 0.003), dyslipidemia (36.0% vs. 5.5%, P = 0.004), and pulmonary disease (16.0 vs. 2.7%, P = 0.08). Regarding the surgical outcomes, OSA patients had longer intubation duration (0.75 ± 0.60 vs. 0.41 ± 0.56 days, P = 0.03). Obstructive sleep apnea is frequent, but unrecognized among patients undergoing CABG. In these patients, OSA is associated with prolonged intubation duration. Preventing these problems may be possible by early diagnosis and management of OSA in cardiac surgery patients. Further studies with larger sample of patients and longer follow-ups are required in this regard.

Postoperative laryngeal symptoms in a general surgery setting. Clinical study.

PubMed

Geraci, Girolamo; Cupido, Francesco; Lo Nigro, Chiara; Sciuto, Antonio; Sciumè, Carmelo; Modica, Giuseppe

2013-01-01

Vocal cord injuries (VI), postoperative hoarseness (PH), dysphonia (DN), dysphagia (DG) and sore throat (ST) are common complications after general anesthesia; there is actually a lack of consensus to support the proper timing for post-operative laryngoscopy that is reliable to support the diagnosis of laryngeal or vocal fold lesions after surgery and there are no valid studies about the entity of laryngeal trauma in oro-tracheal intubation. Aim of our study is to evaluate the statistical relation between anatomic, anesthesiological and surgical variables in the case of PH, DG or impaired voice register. 50 patients (30 thyroidectomies, 8 videolaparoscopic cholecistectomies, 2 right emicolectomies, 2 left emicolectomies, 1 gastrectomy, 1 hemorrhoidectomy, 1 nefrectomy, 1 diagnostic videothoracoscopy, 1 superior right lung lobectomy, 1 appendicectomy, 1 incisional hernia repair, 1 low anterior rectal resection, 1 radical hysterectomy) underwent clinical evaluation and direct laryngoscopy before surgery, within 6 hours, after 72 hours and after 30 days, to evaluate motility and breathing space, phonatory motility, true and false vocal folds and arytenoids oedema. We evaluated also mean age (56.6 ± 3.6 years), male:female ratio (1:1.5), cigarette smoke (20%), atopic comorbidity (17/50 = 34%), Mallampati class (32% 1, 38% 2, 26% 3, 2% 4), mean duration of intubation (159 minutes, range 50 - 405 minutes), Cormack-Lehane score (34% 1, 22% 2, 22% 3, 2% 4), difficult intubation in 9 cases (18%). No complication during the laryngoscopy were registered. We investigated the statistic relationship between pre and intraoperative variables and laryngeal symptoms and lesions. In our experience, statistically significant relations were found in prevalence of vocal folds oedema in smokers (p < 0.005), self limiting DG and DN in younger patients (p < 0.005) and in thyroidectomy (p < 0.01), DG after thyroidectomy (p < 0.01). The short preoperative use of steroids and antihistaminic to prevent allergic reactions appears not related to reduction or prevention of DN, DG, PH and ST. No statistical relation in incidence of postoperative complications was found for the prolonged intubation, gastro-esophageal reflux, BURP manoeuvre (backward upward right sided pressure) and Mallampati and Cormack-Lehane class more than 2, maintenance with sevoflurane 2% and use of stilet. Direct laryngoscopy is essential for the detection of arytenoid lesions after orotracheal intubation for general anesthesia. In our opinion, a part of temporary post-operative DN or PH is due to monolateral or bilateral arytenoids oedema, secondary to prolonged or difficult orotracheal intubation, valuable with laryngoscopy 72 hours after surgery. Is necessary to adjunct these complications in the surgical informed consensus scheme.

Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

PubMed

Patel, Bhakti K; Wolfe, Krysta S; Pohlman, Anne S; Hall, Jesse B; Kress, John P

2016-06-14

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 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers). Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings. clinicaltrials.gov Identifier: NCT01680783.

Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy

PubMed Central

Tee, Hoi-Poh; Corte, Crispin; Al-Ghamdi, Hamdan; Prakoso, Emilia; Darke, John; Chettiar, Raman; Rahman, Wassim; Davison, Scott; Griffin, Sean P; Selby, Warwick S; Kaffes, Arthur J

2010-01-01

AIM: To study the significance of cap-fitted colonoscopy in improving cecal intubation time and polyp detection rate. METHODS: This study was a prospective randomized controlled trial conducted from March 2008 to February 2009 in a tertiary referral hospital at Sydney. The primary end point was cecal intubation time and the secondary endpoint was polyp detection rate. Consecutive cases of total colonoscopy over a 1-year period were recruited. Randomization into either standard colonoscopy (SC) or cap-assisted colonoscopy (CAC) was performed after consent was obtained. For cases randomized to CAC, one of the three sizes of cap was used: D-201-15004 (with a diameter of 15.3 mm), D-201-14304 (14.6 mm) and D-201-12704 (13.0 mm). All of these caps were produced by Olympus Medical Systems, Japan. Independent predictors for faster cecal time and better polyp detection rate were also determined from this study. RESULTS: There were 200 cases in each group. There was no significant difference in terms of demographic characteristics between the two groups. CAC, when compared to the SC group, had no significant difference in terms of cecal intubation rate (96.0% vs 97.0%, P = 0.40) and time (9.94 ± 7.05 min vs 10.34 ± 6.82 min, P = 0.21), or polyp detection rate (32.8% vs 31.3%, P = 0.75). On the subgroup analysis, there was no significant difference in terms of cecal intubation time by trainees (88.1% vs 84.8%, P = 0.40), ileal intubation rate (82.5% vs 79.0%, P = 0.38) or total colonoscopy time (23.24 ± 13.95 min vs 22.56 ± 9.94 min, P = 0.88). On multivariate analysis, the independent determinants of faster cecal time were consultant-performed procedures (P < 0.001), male patients (P < 0.001), non-usage of hyoscine (P < 0.001) and better bowel preparation (P = 0.01). The determinants of better polyp detection rate were older age (P < 0.001), no history of previous abdominal surgery (P = 0.04), patients not having esophagogastroduodenoscopy in the same setting (P = 0.003), trainee-performed procedures (P = 0.01), usage of hyoscine (P = 0.01) and procedures performed for polyp follow-up (P = 0.01). The limitations of the study were that it was a single-center experience, no blinding was possible, and there were a large number of endoscopists. CONCLUSION: CAC did not significantly different from SC in term of cecal intubation time and polyp detection rate. PMID:20712051

Creating protective appliances for preventing dental injury during endotracheal intubation using intraoral scanning and 3D printing: a technical note

PubMed Central

Cho, Jin-Hyung; Park, Wonse; Park, Kyeong-Mee; Kim, Seo-Yul

2017-01-01

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

Creating protective appliances for preventing dental injury during endotracheal intubation using intraoral scanning and 3D printing: a technical note.

PubMed

Cho, Jin-Hyung; Park, Wonse; Park, Kyeong-Mee; Kim, Seo-Yul; Kim, Kee-Deog

2017-03-01

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.

Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory arrest.

PubMed

Schlossmacher, Pascal; Martinet, Olivier; Testud, Richard; Agesilas, Fabrice; Benhamou, Léon; Gauzëre, Bernard Alex

2006-02-01

We report the life-saving use of Griggs percutaneous tracheostomy in an arrested patient with complex upper airway obstruction, as a result of burns, smoke injuries and iterative tracheal intubation attempts. The technique was performed blindly at bedside to treat an acute episode of failed ventilation and intubation and cardiac arrest in a patient with altered neck anatomy. The intervention salvaged the situation, leaving a definitive airway. The feasibility of using an emergency Griggs percutaneous tracheostomy versus cricothyroidotomy is suggested in selected cases.

Airway Management in a Patient with Wolf-Hirschhorn Syndrome.

PubMed

Gamble, John F; Kurian, Dinesh J; Udani, Andrea G; Greene, Nathaniel H

2016-01-01

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.

Airway Management in a Patient with Wolf-Hirschhorn Syndrome

PubMed Central

Udani, Andrea G.

2016-01-01

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

[A case of extensive pulmonary atelectasis after intubation in a patient undergoing elective tympanoplasty].

PubMed

Sugimoto, Kenzaburo; Satoh, Masaaki; Kai, Makiko; Sata, Naho; Takeuchi, Mamoru

2013-10-01

A 33-year-old male, without significant medical history, underwent elective tympanoplasty. It was difficult to manage his airway because of overbites, small jaw, and short neck. After intubation, his left chest revealed obvious abnormality in sound and movement, and showed free air in the mediastinum on X ray. CT revealed extensive atelectasis. Although he is a current smoker, the length of preoperative smoking cessation necessary to decrease postoperative pulmonary complications is not clear. This case demonstrates the importance of preoperative preparation including education in smoking damage.

Anaesthetic management in a case of huge plunging ranula.

PubMed

Sheet, Jagabandhu; Mandal, Anamitra; Sengupta, Swapnadeep; Jana, Debaleena; Mukherji, Sudakshina; Swaika, Sarbari

2014-01-01

Plunging ranula is a rare form of mucous retention cyst arising from submandibular and sublingual salivary glands, which may occasionally become huge occupying the whole of the floor of the mouth and extending into the neck, thus, restricting the neck movement as well as disfiguring the normal airway anatomy. Without fiberoptic assistance, blind or retrograde nasal intubation remains valuable choices in this type of situation. Here, we present a case of successful management of airway by blind nasal intubation in a patient posted for excision of a huge plunging ranula.

Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport.

PubMed

Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald

2016-11-01

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 use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures.

The neuromuscular effects of rocuronium under sevoflurane-remifentanil or propofol-remifentanil anesthesia: a randomized clinical comparative study in an Asian population.

PubMed

Lee, Sangseok; Ro, Young Jin; Koh, Won Uk; Nishiyama, Tomoki; Yang, Hong-Seuk

2016-08-22

We conducted a prospective, randomized, multicenter study to evaluate the differences in the blocking effect of different doses of rocuronium between sevoflurane- or propofol-remifentanil anesthesia in an Asian population. A total of 368 ASA I-II patients was enrolled. Anesthesia was induced with 2.0 mg/kg propofol and 0.1 μg/kg/min remifentanil (TIVA) or 5.0 vol.% sevoflurane with 0.1 μg/kg/min remifentanil (SEVO). Tracheal intubation was facilitated at 180 s after the administration of rocuronium at 0.3, 0.6, or 0.9 mg/kg and then intubation condition was evaluated. The time to maximum block and recovery profile were monitored by TOF stimulation of the ulnar nerve and by recording the adductor pollicis response using acceleromyography. The numbers of patients with clinically acceptable intubation conditions were 41, 82, and 97 % (TIVA) and 34, 85, and 90 % (SEVO) at each dose of rocuronium, respectively. There were no significant differences in the time to maximum block between groups at each rocuronium dose. There were significant differences in the recovery to a train-of-four ratio of 90 % between the groups: 42.7 (19.5), 74.8 (29.9), and 118.4 (35.1) min (TIVA) and 66.5 (39.3), 110.2 (43.5), and 144.4 (57.5) min (SEVO) at 0.3, 0.6, and 0.9 mg/kg, respectively (P < 0.001). There are no significant differences in intubation conditions between propofol-remifentanil and sevoflurane-remifentanil anesthesia at the same dose of rocuronium. The type of anesthetic does not significantly influence the time to maximum block by rocuronium. Rocuronium at a dose of 0.9 mg/kg should be used for better intubation conditions with both anesthesia regimens in an Asian population. UMIN-CTR Clinical Trial ( http://www.umin.ac.jp/ctr/index.htm ; UMIN#000007289 ; date of registration 14(th) February 2012).

Automated in-tube solid-phase microextraction coupled with liquid chromatography/electrospray ionization mass spectrometry for the determination of beta-blockers and metabolites in urine and serum samples.

PubMed

Kataoka, H; Narimatsu, S; Lord, H L; Pawliszyn, J

1999-10-01

The technique of automated in-tube solid-phase microextraction (SPME) coupled with liquid chromatography/electrospray ionization mass spectrometry (LC/ESI-MS) was evaluated for the determination of beta-blockers in urine and serum samples. In-tube SPME is an extraction technique for organic compounds in aqueous samples, in which analytes are extracted from the sample directly into an open tubular capillary by repeated draw/eject cycles of sample solution. LC/MS analyses of beta-blockers were initially performed by liquid injection onto a LC column. Nine beta-blockers tested in this study gave very simple ESI mass spectra, and strong signals corresponding to [M + H]+ were observed for all beta-blockers. The beta-blockers were separated with a Hypersil BDS C18 column using acetonitrile/methanol/water/acetic acid (15:15:70:1) as a mobile phase. To optimize the extraction of beta-blockers, several in-tube SPME parameters were examined. The optimum extraction conditions were 15 draw/eject cycles of 30 microL of sample in 100 mM Tris-HCl (pH 8.5) at a flow rate of 100 microL/min using an Omegawax 250 capillary (Supelco, Bellefonte, PA). The beta-blockers extracted by the capillary were easily desorbed by mobile-phase flow, and carryover of beta-blockers was not observed. Using in-tube SPME/LC/ESI-MS with selected ion monitoring, the calibration curves of beta-blockers were linear in the range from 2 to 100 ng/mL with correlation coefficients above 0.9982 (n = 18) and detection limits (S/N = 3) of 0.1-1.2 ng/mL. This method was successfully applied to the analysis of biological samples without interference peaks. The recoveries of beta-blockers spiked into human urine and serum samples were above 84 and 71%, respectively. A serum sample from a patient administrated propranolol was analyzed using this method and both propranolol and its metabolites were detected.

Evaluation of guppy (Poecilia reticulata Peters) immunization against Tetrahymena sp. by enzyme-linked immunosorbent assay (ELISA).

PubMed

Sharon, Galit; Nath, Pulak R; Isakov, Noah; Zilberg, Dina

2014-09-15

Analysis of the effectiveness of guppy (Poecilia reticulata Peters) immunization based on measurements of antibody (Ab) titers suffers from a shortage of reagents that can detect guppy antibodies (Abs). To overcome this problem, we immunized mice with different preparations of guppy immunoglobulins (Igs) and used the mouse antisera to develop a quantitative enzyme-linked immunosorbent assay (ELISA). The most efficient immunogen for mouse immunization was guppy Igs adsorbed on protein A/G beads. Antisera from mice boosted with this immunoglobulin (Ig) preparation were highly specific and contained high Ab titers. They immunoreacted in a Western blot with Ig heavy and light chains from guppy serum, and Ig heavy chain from guppy whole-body homogenate. The mouse anti-guppy Ig was applied in an ELISA aimed at comparing the efficiency of different routes of guppy immunization against Tetrahymena: (i) anal intubation with sonicated Tetrahymena (40,000 Tetrahymena/fish in a total volume of 10 μL) mixed with domperidon, deoxycholic acid and free amino acids (valine, leucine, isoleucine, phenylalanine and tryptophan), or (ii) intraperitoneal (i.p.) injection of sonicated Tetrahymena in complete Freund's adjuvant (15,000 Tetrahymena/fish in total a volume of 20 μL). Negative control fish were anally intubated with the intubation mixture without Tetrahymena, or untreated. ELISA measurement of anti-Tetrahymena Ab titer revealed a significantly higher level of Abs in i.p.-immunized guppies, compared to the anally intubated and control fish. In addition, the efficiency of immunization was tested by monitoring guppy mortality following (i) i.p. challenge with Tetrahymena (900 Tetrahymena/fish) or (ii) cold stress followed by immersion in water containing 10,000 Tetrahymena/mL. Fish mortality on day 14 post-Tetrahymena infection by i.p. injection exceeded 50% in the control and anally intubated fish, compared to 31% in i.p.-immunized fish. Immunization did not protect from pathogen challenge by immersion. The results suggest a direct correlation between the anti-Tetrahymena Ab response and fish resistance to i.p.-injected Tetrahymena, but not to infection by immersion preceded by cold stress. Copyright © 2014 Elsevier B.V. All rights reserved.

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.

PubMed

Yassin, Hany Mahmoud; Abdel Moneim, Ahmed Tohamy; Mostafa Bayoumy, Ahmed Sherin; Bayoumy, Hasan Metwally; Taher, Sameh Galal

2017-01-01

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.

Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport

PubMed Central

Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald

2016-01-01

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. Hospital and EMS providers should use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures. PMID:27833679

Endoscopic endonasal dacryocystorhinostomy with ostial stent intubation following nasolacrimal duct stent incarceration.

PubMed

Wang, Xiaopeng; Bian, Yang; Yan, Wentao; Daniel, Pelaez; Tu, Yunhai; Wu, Wencan

2015-01-01

To study the feasibility of endoscopic endonasal dacryocystorhinostomy (EE-DCR) with novel lacrimal ostial stent (LOS) intubation for patients with chronic dacryocystitis with incarceration of a previously implanted nasolacrimal duct stent (NDS). According to surgical procedure, 166 patients (167 eyes) were divided into two groups: EE-DCR with LOS intubation was performed on 126 patients (127 eyes) in the EE-DCR group; while external dacryocystorhinostomy (E-DCR) with silicone tube intubation was performed on 40 patients (40 eyes) in the E-DCR group. The LOS or silicone tube was retained for 3-6 months. All patients were followed up for 12-36 months. Success rate of tear drainage reconstruction (TDR) and complications were retrospectively compared. Excluding patients with early detachment of the LOS or the silicone tube, or with incomplete follow-up period, 117 patients (117 eyes) in the EE-DCR group and 36 patients (36 eyes) in the E-DCR group were included. The mean surgical time was 45.8 ± 11.5 min in the EE-DCR group and 68.1 ± 23.8 min in the E-DCR group (p < 0.001). Intraoperatively, the lacrimal sac was observed to become very small and its walls were thin, hyperemic and fragile, firmly attaching to the NDS by fibrous bands in all eyes. Upon final review, success rate of TDR was 83.8% (98/117) in the EE-DCR group, while 58.3% (21/36) in the E-DCR group (p < 0.01). Failure of TDR due to ostial closure by excessive fibrosis occurred in 14 out of 19 patients in the EE-DCR group, significantly less than the 11 out of 15 patients with failed TDR in the E-DCR group (χ(2 )= 6.959, p < 0.01). No significant difference existed in failures due to granuloma occluding the ostium or common canaliculus obstruction. EE-DCR with LOS intubation may be an effective procedure to manage the special subgroup of patients with chronic dacryocystitis with incarcerations of a previously implanted NDS.

Rocuronium Versus Suxamethonium: A Survey of First-line Muscle Relaxant Use in UK Prehospital Rapid Sequence Induction.

PubMed

Hartley, Emma L; Alcock, Roger

2015-04-01

Prehospital anaesthesia in the United Kingdom (UK) is provided by Helicopter Emergency Medical Service (HEMS) and British Association for Immediate Care (BASICS), a road-based service. Muscle relaxation in rapid sequence induction (RSI) has been traditionally undertaken with the use of suxamethonium; however, rocuronium at higher doses has comparable intubating conditions with fewer side effects. The aim of this survey was to establish how many prehospital services in the UK are now using rocuronium as first line in RSI. An online survey was constructed identifying choice of first-line muscle relaxant for RSI and emailed to lead clinicians for BASICS and HEMS services across the UK. If rocuronium was used, further questions regarding optimal dose, sugammadex, contraindications, and difference in intubating conditions were asked. A total of 29 full responses (93.5%) were obtained from 31 services contacted. Suxamethonium was used first line by 17 prehospital services (58.6%) and rocuronium by 12 (41.4%). In 11 services (91.7%), a dose of 1 mg/kg of rocuronium was used, and in one service, 1.2 mg/kg (8.3%) was used. No services using rocuronium carried sugammadex. In five services, slower relaxation time was found using rocuronium (41.7%), and in seven services, no difference in intubation conditions were noted (58.3%). Contraindications to rocuronium use included high probability of difficult airway and anaphylaxis. Use of rocuronium as first-line muscle relaxant in prehospital RSI is increasing. Continued auditing of practice will ascertain which services have adopted change and identify if complications of failed intubation increase as a result.

Intubations and airway management: An overview of Hassles through third millennium.

PubMed

Alanazi, Abdullah

2015-01-01

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.

Simple and rapid analysis of endocrine disruptors in liquid medicines and intravenous injection solutions by automated in-tube solid-phase microextraction/high performance liquid chromatography.

PubMed

Mitani, Kurie; Narimatsu, Shizuo; Izushi, Fumio; Kataoka, Hiroyuki

2003-07-14

A simple and rapid method was developed for analyzing contamination of endocrine disruptors in liquid medicines and intravenous injection solutions. Endocrine disrupting compounds such as bisphenol A (BPA), alkylphenols and phthalates were quantitated by on-line in-tube solid-phase microextraction coupled with high performance liquid chromatography (in-tube SPME/HPLC) with UV detection. The liquid medicines and intravenous injection solutions could be used directly without any pretreatment, and the BPA, alkylphenols and phthalates in these solutions were automatically analyzed. The limits of quantification for these compounds were 1-10 ng/ml. Recoveries of these compounds spiked to the intravenous injection solutions was over 80%, except for some phthalates. Di-n-butyl phthalate (DBP) was detected at a concentration of 7-60 ng/ml in most intravenous injection solutions in plastic containers, but it was not detected in solutions in glass bottles. Diethyl phthalate, di-n-propyl phthalate, DBP and di-2-ethylhexyl phthalate (DEHP) were also detected in syrup, lotion and eye drops in plastic containers. On the other hand, BPA and alkylphenols were not detected at all in these solutions. DEHP contamination from an administration set increased when total vitamin formulation was added to the infusion solution. DEHP was easily leached from polyvinyl chloride tubing by polysorbate 80. The in-tube SPME/HPLC method is simple, rapid and automatic, and it provides a useful tool for the screening and determination of endocrine disruptor contamination in liquid medicines and intravenous injection solutions.

[Blocking the spray of contaminants from patients' exhalent using a tracheal detecting bulb during endotracheal intubation].

PubMed

Tong, You-liang; Sun, Ming; Wang, Zhen; Li, Bin; Xie, Jue; Ye, Hui

2011-11-01

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.

Comparing the Effect of Echinacea and Chlorhexidine Mouthwash on the Microbial Flora of Intubated Patients Admitted to the Intensive Care Unit.

PubMed

Safarabadi, Mehdi; Ghaznavi-Rad, Ehsanollah; Pakniyat, Abdolghader; Rezaie, Korosh; Jadidi, Ali

2017-01-01

Providing intubated patients admitted to the intensive care units with oral healthcare is one of the main tasks of nurses in order to prevent Ventilator-Associated Pneumonia (VAP). This study aimed at comparing the effects of two mouthwash solutions (echinacea and chlorhexidine) on the oral microbial flora of patients hospitalized in the intensive care units. In this clinical trial, 70 patients aged between18 and 65 years undergoing tracheal intubation through the mouth in three hospitals in Arak, were selected using simple random sampling and were randomly divided into two groups: the intervention group and the control group. The oral health checklist was used to collect the data (before and after the intervention). The samples were obtained from the orally intubated patients and were then cultured in selective media. Afterwards, the aerobic microbial growth was investigated in all culture media. The data were analyzed using SPSS software. The microbial flora in the echinacea group significantly decreased after the intervention ( p < 0.0001) and it was also the case withmicrobial flora of the patients in the chlorhexidine group ( p < 0.001). After 4 days, the oral microbial flora of the patients in the intervention group was lower than that of the patients in the control group ( p < 0.001). The results showed that the echinacea solution was more effective in decreasing the oral microbial flora of patients in the intensive care unit. Given the benefits of the components of the herb Echinacea, it can be suggested as a viable alternative to chlorhexidine.

[Anesthesia for surgery of degenerative and abnormal cervical spine].

PubMed

Béal, J L; Lopin, M C; Binnert, M

1993-01-01

A feature common to all congenital or inflammatory abnormalities of the cervical spine is an actual or potential reduction in the lumen of the spinal canal. The spinal cord and nerve roots are at risk. During intubation, and positioning the patient on the table, all untoward movements of the cervical spine may lead to spinal cord compression. Abnormalities of the cervical spine carry the risk of a difficult intubation. If there is much debate as to what constitutes optimum management of the airway, there is no evidence that any one method is the best. Recognizing the possible instability and intubating with care, are probably much more important in preserving neurological function than any particular mode of intubation. During maintenance of anaesthesia, the main goal is to preserve adequate spinal cord perfusion in order to prevent further damage. Spinal cord blood flow seems to be regulated by the same factors as cerebral blood flow. Hypercapnia increases cord blood flow while hypocapnia decreases it. Therefore, normocapnia or mild hypocapnia is recommended. Induced hypotension is frequently used to decrease blood loss. However, in patients with a marginally perfused spinal cord, the reduction in blood flow may cause ischaemia of the spinal cord and may therefore be relatively contraindicated. In addition to standard intraoperative monitoring, spinal cord monitoring is almost mandatory. Monitoring somatosensory evoked potentials is used routinely. However, the major limitation is that this technique only monitors dorsal column function; theoretically, motor paralysis can occur despite a lack of change in recorded signals. Neurogenic motor evoked potentials may now be used to monitor anterior spinal cord integrity.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventilator-associated pneumonia risk decreased by use of oral moisture gel in oral health care.

PubMed

Takeyasu, Yoshihiro; Yamane, Gen-Yuki; Tonogi, Morio; Watanabe, Yutaka; Nishikubo, Shuichi; Serita, Ryohei; Imura, Kumiko

2014-01-01

Although oral health care has a preventive effect against ventilator-associated pneumonia (VAP), the most effective method of oral health care in this respect remains to be established. The objective of this single-center, randomized, controlled trial was to investigate the relationship between VAP and various methods of oral health care. All patients included in the study (n=142) were on mechanical ventilation with oral intubation at the intensive care unit of the Tokyo Dental College Ichikawa General Hospital. They were divided into two groups, one receiving standard oral health care (Standard group), and the other receiving oral health care using an oral moisture gel instead of water (Gel group). After removal of the intubation tube, biofilm on cuff of the tube was stained with a disclosing agent to determine the contamination level. Factors investigated included sex, age, number of remaining teeth, intubation time, fever ≥38.5°C, VAP, cuff contamination level, and time required for one oral health care session. No VAP occurred in either group during the study period. The level of cuff contamination was significantly lower in the Gel group than the Standard group, and the time required for one session of oral health care was shorter (p<0.001). Multivariate analysis revealed use of the oral moisture gel as a factor affecting cuff contamination level. Use of an oral moisture gel decreased invasion of the pharynx by bacteria and contaminants together with biofilm formation on the intubation tube cuff. These results suggest that oral health care using an oral moisture gel is effective in preventing cuff contamination.

Features of lateral cephalograms associated with difficult laryngoscopy in Japanese children undergoing oral and maxillofacial surgery.

PubMed

Kohjitani, Atsushi; Miyawaki, Takuya; Miyawaki, Shouichi; Nakamura, Norifumi; Iwase, Yoko; Nishihara, Kazuhide; Ohno, Sachi; Shimada, Masahiko; Sugiyama, Kazuna

2013-11-01

Difficult laryngoscopy and tracheal intubation are occasionally encountered in children with congenital anomalies or micrognathia. However, no study has elucidated anatomical etiology in relation to craniofacial development. Two hundred ten patients aged 8 months-18 years were analyzed. We analyzed the lateral cephalograms of: (i) eight patients in whom laryngoscopy was anticipated as difficult before anesthesia and who were unable to be intubated by direct laryngoscopy and needed fiberoptic bronchoscopy (group A); (ii) 11 patients in whom laryngoscopy was anticipated as difficult before anesthesia but who were able to be intubated by direct laryngoscopy (group B); and (iii) 191 patients in whom laryngoscopy was anticipated as easy before anesthesia and was actually found to be easy (group C). Eight cephalometric parameters were measured and age-parameter relationships were plotted. Logistic regression analysis was performed to characterize group A children for each of the cephalometric variables. Apparently insufficient growth of the mandible was observed in the group A children. Furthermore, the group A children of aged <4 years had undeveloped maxilla, longer mandibular plane-hyoid distances (≥1.3 cm), and deeper depth of the oropharynx; those of aged ≥4 years showed increased inclination of the mandible (sella-nasion plane to mandibular plane angle of ≥46.5°). Difficult laryngoscopy and tracheal intubation are expected in children aged <4 years with lower-positioned hyoid bone caused by caudal larynx as well as undeveloped maxilla and mandible, and in those aged ≥4 years with increased inclination of the mandible as well as undeveloped mandible. © 2013 John Wiley & Sons Ltd.

Nasal bi-level positive airway pressure (BiPAP) versus nasal continuous positive airway pressure (CPAP) in preterm infants ≤32 weeks: A retrospective cohort study.

PubMed

Rong, Zhi-Hui; Li, Wen-Bin; Liu, Wei; Cai, Bao-Huan; Wang, Jing; Yang, Min; Li, Wei; Chang, Li-Wen

2016-05-01

To investigate whether Bi-level positive airway pressure (BiPAP), compared with nasal continuous positive airway pressure (CPAP), is a more effective therapeutic strategy in preterm infants ≤32 weeks. All inborn infants between 26(+1) and 32(+6) weeks' gestation, admitted to the neonatal intensive care unit (NICU ) of Tongji Medical Hospital between 1 January, 2010 and 31 December, 2011 (the 2010-2011 cohort or CPAP cohort) and between 1 January, 2012 and 31 December, 2013 (the 2012-2013 cohort or BiPAP cohort), were retrospectively identified. The primary outcome was intubation in infants < 72 h of age; secondary outcomes were mortality and the incidence of bronchopulmonary dysplasia (BPD). There were 213 in the 2010-2011 cohort and 243 infants in the 2012-2013 cohort. There were fewer infants intubated within the first 72 h of age in the 2012-2013 cohort than in the 2010-2011 cohort (15% vs. 23%, P < 0.05). Of the infants who received some form of positive airway pressure, 12/94 (13%) of infants on BiPAP versus 23/74 (31%) on CPAP were subsequently intubated (P < 0.01). There was no difference in the incidence of moderate and severe BPD between the two groups (7% vs. 8%, P=0.52). In this retrospective cohort study, we found BiPAP, compared with CPAP, reduced the need for intubation within the first 72 h of age. © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Effect-site concentration of remifentanil required to blunt haemodynamic responses during tracheal intubation: A randomized comparison between single- and double-lumen tubes.

PubMed

Kim, Tae Kyong; Hong, Deok Man; Lee, Seo Hee; Paik, Hyesun; Min, Se Hee; Seo, Jeong-Hwa; Jung, Chul-Woo; Bahk, Jae-Hyon

2018-01-01

Objective To investigate the effect-site concentration of remifentanil required to blunt haemodynamic responses during tracheal intubation with a single-lumen tube (SLT) or a double-lumen tube (DLT). Methods Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly allocated to either the SLT or DLT group. All patients received a target-controlled infusion of propofol and a predetermined concentration of remifentanil. Haemodynamic parameters during intubation were recorded. The effect-site concentration of remifentanil was determined using a delayed up-and-down sequential allocation method. Results A total of 92 patients were enrolled in the study. The effective effect-site concentrations of remifentanil required to blunt haemodynamic responses in 50% of patients (EC 50 ) estimated by isotonic regression with bootstrapping was higher in the DLT than the SLT group (8.5 ng/ml [95% confidence interval (CI) 8.0-9.5 ng/ml] versus 6.5 ng/ml [95% CI 5.6-6.7 ng/ml], respectively). Similarly, the effective effect-site concentrations of remifentanil in 95% of patients in the DLT group was higher than the SLT group (9.9 ng/ml [95% CI 9.8-10.0 ng/ml] versus 7.0 ng/ml [95% CI 6.9-7.0 ng/ml], respectively). Conclusions This study demonstrated that a DLT requires a 30% higher EC 50 of remifentanil than does an SLT to blunt haemodynamic responses during tracheal intubation when combined with a target-controlled infusion of propofol. Trial registration Clinicaltrials.gov identifier: NCT01542099.

Corrosion casting of the subglottis following endotracheal tube intubation injury: a pilot study in Yorkshire piglets

PubMed Central

2013-01-01

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

[Neuromuscular blocking effects of Org 9426 (rocuronium bromide); a comparative study with vecuronium bromide in Japanese patients].

PubMed

Shingu, Koh; Masuzawa, Munehiro; Omote, Keiichi; Namiki, Akiyoshi; Kikuchi, Hirosato; Kawamada, Miwako; Sato, Shigehito; Kimura, Tomomasa; Hatano, Norio; Nakatsuka, Hideki; Morita, Kiyoshi; Hara, Tetsuya; Kanmura, Yuichi; Takeda, Junzo

2006-09-01

Efficacy and safety of Org 9426 were compared with those of vecuronium bromide in Japanese patients. We studied 88 Japanese patients undergoing surgery requiring general anesthesia. Patients were allocated randomly to receive intubation dose of 0.6 mg x kg(-1), 0.9 mg x kg(-1) of Org 9426 or 0.1mg x kg(-1) of vecuronium. Following an intubation dose, patients received maintenance doses of 0.1, 0.15 or 0.2 mg x kg(-1) of Org 9426 or 0.025 mg x kg(-1) of vecuronium. The neuromuscular block was monitored with acceleromyography using TOF stimuli. Sevoflurane was administered to all treatment groups after intubation. The onset times of the 0.6 and 0.9 mg x kg(-1) of Org 9426 groups were 84.6 and 77.1 sec respectively, which showed statistical difference between the onset time of 0.1 mg x kg(-1) of vecuronium, 125.7 sec. The intubation condition was similar among three treatment groups. The clinical durations of 0.6 and 0.9 mg x kg(-1) of Org 9426 and 0.1 mg x kg(-1) of vecuronium were 53.4, 73.4 and 59.9 min, respectively. Clinical duration and spontaneous recovery time of maintenance dose of 0.15 mg x kg(-1) of Org 9426 were similar to those of 0.025 mg x kg(-1) of vecuronium. Org 9426 showed more rapid onset time than that of vecuronium and similar clinical duration and recovery times to those of vecuronium in Japanese patients.

Automated cuff pressure modulation: a novel device to reduce endotracheal tube injury.

PubMed

Chadha, Neil K; Gordin, Arie; Luginbuehl, Igor; Patterson, Greg; Campisi, Paolo; Taylor, Glenn; Forte, Vito

2011-01-01

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.

Outcome of Guillain–Barre syndrome patients with respiratory paralysis

PubMed Central

Kalita, J.; Ranjan, A.

2016-01-01

Background and Aims: To evaluate the outcome of patients with Guillain–Barre syndrome (GBS) having respiratory failure treated with modified intubation policy. Design and Methods: Consecutive patients with GBS having single breath count below 12 and respiratory rate >30/min were included and their clinical details noted. The patients were intubated and mechanically ventilated (MV) if their PaO2 was <60 mmHg on venturi mask, PaCo2 > 50 mmHg or pH < 7.3. Their electrophysiological subtypes and complications were noted. The hospital mortality and 3 months outcome were compared in MV and those could be managed without MV even with respiratory compromise. Results: Out of 369 patients, 102 (27.6%) patients had respiratory compromise who were included in this study. Of the patients with respiratory compromise, 44 (43.1%) were intubated and mechanically ventilated after a median of 4 days of hospitalization. The median duration of MV was 21 (range 1–88) days. The patients with autonomic dysfunction (56.8% vs. 19%), facial weakness (78% vs. 36.2%), bulbar weakness (81.8% vs. 31%), severe weakness (63.8% vs. 31%) and high transaminase level (47.7% vs. 25.9%) needed MV more frequently. In our study, 6.8% patients died and 26.6% had poor outcome which was similar between MV and non-MV patients. The MV patients had longer hospitalization and more complications compared with non-MV group. Conclusion: In GBS patients with respiratory compromise, conservative intubation does not increase mortality and disability. PMID:26475599

Clinical dysphagia risk predictors after prolonged orotracheal intubation

PubMed Central

de Medeiros, Gisele Chagas; Sassi, Fernanda Chiarion; Mangilli, Laura Davison; Zilberstein, Bruno; de Andrade, Claudia Regina Furquim

2014-01-01

OBJECTIVES: To elucidate independent risk factors for dysphagia after prolonged orotracheal intubation. METHODS: The participants were 148 consecutive patients who underwent clinical bedside swallowing assessments from September 2009 to September 2011. All patients had received prolonged orotracheal intubations and were admitted to one of several intensive care units of a large Brazilian school hospital. The correlations between the conducted water swallow test results and dysphagia risk levels were analyzed for statistical significance. RESULTS: Of the 148 patients included in the study, 91 were male and 57 were female (mean age, 53.64 years). The univariate analysis results indicated that specific variables, including extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking, and other signs, were possible significant high-risk indicators of dysphagia onset. The multivariate analysis results indicated that cervical auscultation and coughing were independent predictive variables for high dysphagia risk. CONCLUSIONS: Patients displaying extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking and other signs should benefit from early swallowing evaluations. Additionally, early post-extubation dysfunction recognition is paramount in reducing the morbidity rate in this high-risk population. PMID:24473554

Use of a Supraglottic Airway to Relieve Ventilation-Impeding Gastric Insufflation During Emergency Airway Management in an Infant.

PubMed

Dodd, Kenneth W; Strobel, Ashley M; Driver, Brian E; Reardon, Robert F

2016-10-01

Positive-pressure bag-valve-mask ventilation during emergency airway management often results in significant gastric insufflation, which may impede adequate ventilation and oxygenation. Current-generation supraglottic airways have beneficial features, such as channels for gastric decompression while ventilation is ongoing. A 5-week-old female infant required resuscitation for hypoxemic respiratory failure caused by rhinovirus with pneumonia. Bag-valve-mask ventilation led to gastric insufflation that compromised ventilation, thereby interfering with intubation because of precipitous oxygen desaturation during laryngoscopy. A current-generation supraglottic airway (LMA Supreme; Teleflex Inc, Morrisville, NC) was used to facilitate gastric decompression while ventilation and oxygenation was ongoing. After gastric decompression, ventilation was markedly improved and the pulse oxygen saturation improved to 100%. Intubation was successful on the next attempt, without oxygen desaturation. Current-generation supraglottic airways have 3 distinct advantages compared with first-generation supraglottic airways, which make them better devices for emergency airway management: gastric decompression ports, conduits for intubation, and higher oropharyngeal leak pressures. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Airway management through submental derivation: a safe and easily reproduced alternative for patients with complex facial trauma

PubMed Central

2018-01-01

Objectives Airway management in patients with panfacial trauma is complicated. In addition to involving facial lesions, such trauma compromises the airway, and the use of intermaxillary fixation makes it difficult to secure ventilation by usual approaches (nasotracheal or endotracheal intubation). Submental airway derivation is an alternative to tracheostomy and nasotracheal intubation, allowing a permeable airway with minimal complications in complex patients. Materials and Methods This is a descriptive, retrospective study based on a review of medical records of all patients with facial trauma from January 2003 to May 2015. In total, 31 patients with complex factures requiring submental airway derivation were included. No complications such as bleeding, infection, vascular, glandular, or nervous lesions were presented in any of the patients. Results The use of submental airway derivation is a simple, safe, and easy method to ensure airway management. Moreover, it allows an easier reconstruction. Conclusion Based on these results, we concluded that, if the relevant steps are followed, the use of submental intubation in the treatment of patients with complex facial trauma is a safe and effective option. PMID:29535964

Severed cuff inflation tubing of endotracheal tube: A novel way to prevent cuff deflation.

PubMed

Rao, Amrut K; Chaudhuri, Souvik; Joseph, Tim T; Kamble, Deependra; Gotur, Gopal; Venkatesh, Sandeep

2014-01-01

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.

Clinical dysphagia risk predictors after prolonged orotracheal intubation.

PubMed

Medeiros, Gisele Chagas de; Sassi, Fernanda Chiarion; Mangilli, Laura Davison; Zilberstein, Bruno; Andrade, Claudia Regina Furquim de

2014-01-01

To elucidate independent risk factors for dysphagia after prolonged orotracheal intubation. The participants were 148 consecutive patients who underwent clinical bedside swallowing assessments from September 2009 to September 2011. All patients had received prolonged orotracheal intubations and were admitted to one of several intensive care units of a large Brazilian school hospital. The correlations between the conducted water swallow test results and dysphagia risk levels were analyzed for statistical significance. Of the 148 patients included in the study, 91 were male and 57 were female (mean age, 53.64 years). The univariate analysis results indicated that specific variables, including extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking, and other signs, were possible significant high-risk indicators of dysphagia onset. The multivariate analysis results indicated that cervical auscultation and coughing were independent predictive variables for high dysphagia risk. Patients displaying extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking and other signs should benefit from early swallowing evaluations. Additionally, early post-extubation dysfunction recognition is paramount in reducing the morbidity rate in this high-risk population.

Neonatal Ethanol Exposure Causes Behavioral Deficits in Young Mice.

PubMed

Xu, Wenhua; Hawkey, Andrew B; Li, Hui; Dai, Lu; Brim, Howard H; Frank, Jacqueline A; Luo, Jia; Barron, Susan; Chen, Gang

2018-04-01

Fetal ethanol (EtOH) exposure can damage the developing central nervous system and lead to cognitive and behavioral deficits, known as fetal alcohol spectrum disorders (FASD). EtOH exposure to mouse pups during early neonatal development was used as a model of EtOH exposure that overlaps the human third-trimester "brain growth spurt"-a model that has been widely used to study FASD in rats. C57BL/6 male and female mice were exposed to EtOH (4 g/kg/d) on postnatal days (PD) 4 to 10 by oral intubation. Intubated and nontreated controls were also included. Behavioral testing of the offspring, including open field, elevated plus maze, and Morris water maze, was performed on PD 20 to 45. EtOH exposure during PD 4 to 10 resulted in hyperactivity and deficits in learning and memory in young mice with no apparent sex differences. Based on these data, this neonatal intubation mouse model may be useful for future mechanistic and genetic studies of FASD and for screening of novel therapeutic agents. Copyright © 2018 by the Research Society on Alcoholism.

Tunnel vision.

PubMed

Valenzuela, Terence; Mosier, Jarrod; Sakles, John

2013-01-01

Since 2000, many studies of advanced emergency airway management have appeared in the medical literature. Although most described patients in the operating room, intensive care unit or emergency department, studies of video laryngoscopy in the field are in progress and beginning to appear in the literature. Video laryngoscopy provides better views of the glottis, and it permits more successful intubations with fewer attempts. Price reductions as more devices, some specifically intended for EMS, enter the market will lower the entry costs for adoption. It is my prediction that in five years, video laryngoscopy will be the method of choice for endotracheal intubation in the field.

The perils of dental vacation: possible anaesthetic and medicolegal consequences.

PubMed

Feltracco, Paolo; Gaudio, Rosa Maria; Barbieri, Stefania; Tiano, Letizia; Iacobone, Maurizio; Viel, Giovanni; Tonetti, Tommaso; Galligioni, Helmut; Bortolato, Andrea; Ori, Carlo; Avato, Francesco Maria

2013-01-01

The aim of this paper is to emphasize anaesthesiologists' difficulty in detecting poor dentition in cases of poorly applied prostheses and/or advanced periodontal disease, and to establish whether it is possible, and in which conditions, to calculate compensation in cases of dental damage postlaryngoscopy and/or intubation. The main complex problem here lies in trying to reconstruct exactly what the dental situation was before the teeth were damaged. For this reason the important preoperative factors (dental prostheses, crown fractures, parodontal disease, etc.) must be clearly shown before surgery on a dental chart. Two cases of interest, both to anaesthesiologists practising intubation and medicolegal physicians who have to deal with potential claims, are briefly reported. The first patient was a 55-year-old diabetic patient, who underwent emergency surgery for acute abdominal pathology. He had gone outside Italy for dental treatment three years previously and now presented with very poor pre-existing dentition, carefully noted on an anaesthetic chart. He now demanded compensation for dental damage due to intubation in Italy; the resulting dental treatment was very expensive because substantial remedial work was required. The second patient had received treatment outside Italy, work which involved cosmetic coating of the teeth. After surgery in Italy, she demanded compensation because one tooth, which had been coated and appeared to be healthy, was broken after emergency intubation. In both cases, the patients demanded very high compensation. Dental tourism alone accounts for more than 250,000 patients each year who combine a holiday with dental treatment in Eastern Europe. However, if prosthetic devices or conservative treatments are not applied correctly, it should be noted that durability may be poorer than expected, but iatrogenic damage may also be caused.

The Influence of the Severity of Chronic Virus-Related Liver Disease on Propofol Requirements during Propofol-Remifentanil Anesthesia

PubMed Central

Wu, Jian; Huang, Su-Qin; Chen, Qing-Lian

2013-01-01

Purpose The purpose of this study was to investigate the influence of chronic virus-related liver disease severity on propofol requirements. Materials and Methods In this study, 48 male patients with chronic hepatitis B infection were divided into three groups according to Child-Turcotte-Pugh classification of liver function (groups A, B, and C with mild, moderate and severe liver disease, respectively). After intubation, propofol concentration was adjusted by ±0.3 µg/mL increments to maintain bispectral index in the range of 40-60. Target propofol concentrations at anesthesia initiation, pre-intubation and pre-incision were recorded. Results The initial concentration used in group C was significantly lower than that used in group A or B (p<0.05), whereas no difference was observed between groups A and B. At pre-intubation, the actual required concentration of propofol increased significantly (3.2 µg/mL) in group A (p<0.05), which lead to significant differences between the groups (p<0.05). At pre-incision, the requirements for propofol decreased significantly in both groups A and B (3.0 µg/mL and 2.7 µg/mL, respectively) compared with those at pre-intubation (p<0.05), and were significantly different for all three groups (p<0.05), with group C demonstrating the lowest requirement (2.2 µg/mL). The required concentrations of propofol at pre-incision were similar to those at induction. Conclusion In this study, propofol requirements administered by target-controlled infusion to maintain similar depths of hypnosis were shown to depend on the severity of chronic virus-related liver dysfunction. In other words, patients with the most severe liver dysfunction required the least amount of propofol. PMID:23225825

Evaluation of the use of midazolam as a co-induction agent with ketamine for anaesthesia in sedated ponies undergoing field castration.

PubMed

Allison, A; Robinson, R; Jolliffe, C; Taylor, P M

2018-05-01

There are limited investigations comparing ketamine to a ketamine-midazolam co-induction. To compare quality and safety of general anaesthesia induced using ketamine alone with anaesthesia co-induced using ketamine and midazolam. Randomised, double blinded, placebo controlled trial. After i.v. detomidine (20 μg/kg) thirty-eight ponies undergoing field castration received either 0.06 mg/kg (0.6 mL/50 kg) midazolam (group M) or 0.6 mL/50 kg placebo (group P) with 2.2 mg/kg ketamine i.v. for anaesthetic induction. Quality of anaesthetic induction, endotracheal intubation, surgical relaxation and recovery were scored using combinations of simple descriptive and visual analogue scales. Time of sedation, induction, start of endotracheal intubation, first movement, sternal recumbency and standing were recorded, as were time, number and total quantity of additional i.v. detomidine and ketamine injections. Cardiorespiratory variables were assessed every 5 min. Adverse effects were documented. Data were tested for normality and analysed with a mixed model ANOVA, Fisher's exact test, unpaired Students' t test and Wilcoxon Rank-sum as appropriate; P<0.05 was considered significant. Group M had better scores for induction (P = 0.005), intubation (P<0.001) and surgical relaxation (P<0.001) and required fewer additional injections of detomidine and ketamine (P = 0.04). Time (minutes) from induction to first movement (P<0.001), sternal recumbency (P =< 0.001) and standing was longer (P = 0.05) in group M. Recoveries were uneventful with no difference in quality between groups (P = 0.78). Clinical study with noninvasive monitoring undertaken in field conditions. Ketamine-midazolam co-induction compared to ketamine alone improved quality of induction, ease of intubation and muscle relaxation without impacting recovery quality. © 2017 EVJ Ltd.