Intubation of infants with Pierre Robin syndrome: the use of the paraglossal approach combined with a gum-elastic bougie in six consecutive cases

Infants with Pierre Robin syndrome are known to be difficult to intubate. We evaluated the paraglossal approach combined with a gum elastic bougie for intubation of these infants. Whilst under general anaesthesia, a conventional laryngoscopy was performed; if it failed to obtain a laryngoscopic grade I or II view, intubation was attempted using a paraglossal approach and a gum elastic bougie. Six consecutive infants were studied. Conventional laryngoscopy failed in all infants whilst the paraglossal approach combined with a gum elastic bougie was successful in five of the cases. The paraglossal approach combined with a gum elastic bougie made intubation easy in most children with severe Pierre Robin syndrome and difficult laryngoscopy. Therefore we recommend this as the first line for airway management in such children. However, a fibreoptic bronchoscope and an anaesthetist trained in fibreoptic intubation must still be present when dealing with severe Pierre Robin syndrome infants.     

The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet

PURPOSE: To compare the ease of tracheal intubation facilitated by the gum elastic bougie or the malleable stylet while applying cricoid pressure. METHODS: Sixty American Society of Anesthesiologists I-III adult patients undergoing elective surgeries participated in this study. After induction of anesthesia with 2.5 mg x kg(-1) propofol and vecuronium 0.1 mg x kg(-1), the laryngeal view was assessed without and with cricoid pressure. Patients were allocated randomly into two groups: a gum elastic bougie or stylet group. One of the two devices was used for tracheal intubation while applying cricoid pressure. The duration and ease of tracheal intubation was recorded. MAIN RESULTS: In 58 patients, the trachea was intubated at the first attempt. In the stylet group, tracheal intubation was difficult and needed more time, especially when the glottic opening was not visible. In the bougie group, the duration and ease of intubation was not influenced by laryngeal view. In the remaining two patients with Cook's modified 3b laryngeal view, it was impossible to intubate the trachea with these devices. CONCLUSIONS: Applying cricoid pressure worsened laryngeal view. The use of a gum elastic bougie was more effective than the use of a stylet to facilitate intubation.     

Comparison of the Airway Scope, gum elastic bougie and fibreoptic bronchoscope in simulated difficult tracheal intubation: a manikin study

We compared the Airway Scope with a gum elastic bougie and fibreoptic bronchoscope in a manikin with a simulated Cormack and Lehane Grade 3 laryngoscopic view. Twenty-seven anaesthetists intubated the trachea of the manikin with these devices and the time required for intubation was measured. They were then asked to rate the subjective difficulty of intubation (1 = very easy; 5 = very difficult). Mean (SD) intubation times were 16.6 (11.2) s with the Airway Scope, 29.4 (10.9) s with the gum elastic bougie (p < 0.0001), and 30.6 (20.0) s with the fibreoptic bronchoscope (p < 0.0001). The median (range) difficulty was 2 (1-4) with the Airway Scope, 3 (2-4) with the gum elastic bougie (p < 0.001), and 2 (1-5) with the fibreoptic bronchoscope (p = 0.014). In Cormack and Lehane grade 3 laryngoscopic views, the Airway Scope may enable faster and easier tracheal intubation than does a Macintosh laryngoscope with a gum elastic bougie or a fibreoptic bronchoscope.     

Evaluation of the new Viewmax laryngoscope in a simulated difficult airway

BACKGROUND: In this study, we evaluated the learning curve and performance of the Viewmax laryngoscope during simulated difficult laryngoscopy in an intubation manikin (Laerdal Airway Management Trainer). METHODS: To determine the learning curve, 25 anaesthesiologists without previous experience with the Viewmax laryngoscope performed 10 successive intubations in an intubation manikin with a normal airway. Time to intubation and failed intubation attempts were recorded. Another manikin was modified to enable comparison of the Viewmax laryngoscope with Macintosh and McCoy laryngoscopes. The time to intubation, number of failed intubation attempts, modified Cormack and Lehane (MCL) laryngeal view grading, percentage of glottic opening (POGO score), use of gum elastic bougie and subjective rating of degree of difficulty were recorded. RESULTS: The learning curve for the Viewmax laryngoscope showed a progressive decrease in time to successful intubation and reached a plateau at the sixth attempt. In simulated difficult laryngoscopy, the Viewmax laryngoscope demonstrated significantly better laryngeal view than the Macintosh and McCoy laryngoscopes in terms of MCL grading (Macintosh, P = 0.01; McCoy, P < 0.01) and POGO score (Macintosh, P < 0.01; McCoy, P < 0.01). The time required for intubation in simulated difficult laryngoscopy for the Viewmax laryngoscope was significantly longer than that for the Macintosh (P = 0.02) and McCoy (P < 0.01) laryngoscopes. There was no significant difference in the degree of difficulty, number of failed intubations and use of gum elastic bougie. CONCLUSION: When compared with the Macintosh and McCoy laryngoscopes in a manikin, the Viewmax laryngoscope appears to improve the view of the larynx but requires a longer time for tracheal intubation.     

Simulated difficult intubation

A randomised study was carried out to compare the efficacy of the gum elastic bougie and the stylet in a simulated difficult intubation. A laryngoscopy assessment, as described by Cormack and Lehane, was made in 100 patients. A Grade 3 view was then simulated. In the Bougie First Group (50 patients) two attempts were made to pass a gum elastic bougie and a tracheal tube into the trachea. If these first two attempts were not successful, two further attempts at intubation were allowed with a stylet placed in the tracheal tube. In the Stylet First Group (50 patients) the order was reversed. After two attempts the tube was correctly placed in the trachea in 96% of cases in the Bougie First Group compared to only 66% of cases in the Stylet First Group (p < 0.001). We recommend that a gum elastic bougie should be readily available and that anaesthetists should use it in preference to a stylet whenever a good view of the glottis is not immediately available.     

Tracheal intubation through the laryngeal mask airway using a gum elastic bougie: the effect of head position

STUDY OBJECTIVE: To determine the effect of head position on success of tracheal intubation through a Laryngeal Mask Airway (LMA) using a gum elastic bougie. DESIGN: Randomized, controlled study. SETTING: Anesthesia and operating rooms of the University Hospital, Nottingham, UK. PATIENTS: 20 patients scheduled to undergo routine elective surgery requiring the use of an LMA for anesthesia. INTERVENTIONS: Blind placement of a gum elastic bougie through an LMA in two head positions. MEASUREMENTS AND MAIN RESULTS: Final position of the gum elastic bougie after removal of the LMA as determined by fiberoptic laryngoscopy. The gum elastic bougie was correctly sited in the trachea in the classical intubating position in 4/20 (20%) and in the neutral position in 0/20 (0%). There was no difference in the success of this technique between the two head positions. CONCLUSIONS: This technique cannot be recommended as an alternative to direct laryngoscopy following a failed intubation.     

Gum elastic bougie, capnography and apnoeic oxygenation

BACKGROUND AND AIM: This study assessed the accuracy of using capnography with a modified, hollow gum elastic bougie in predicting tracheal intubation, and its effectiveness as a method of apnoeic oxygenation. METHODS: Patients were randomly allocated to having the gum elastic bougie inserted, under anaesthesia, in the trachea or the oesophagus. End-tidal carbon dioxide measurements were made at 10 and 20 s. The position of the gum elastic bougie was correctly predicted in 89.2% of patients. We tested the apnoeic oxygenation on an anaesthetic simulator model, which is housed in the Scottish Anaesthesia Simulator Centre, Stirling, UK. RESULTS: The time taken for the oxygen saturation to fall to 90% was significantly prolonged when the gum elastic bougie was used for apnoeic oxygenation. CONCLUSION: The modification of the gum elastic bougie allows a more objective assessment of correct placement than the previous tactile method. The current design of bougie is unsuitable but can be modified.     

The rigid nasendoscope as a tool for difficult tracheal intubation: a manikin study

We examined the use of the 30 degrees rigid nasendoscope in aiding difficult tracheal intubations. A Cormack and Lehane grade 4 difficult intubation (no view of glottis or epiglottis) was set up on a manikin. After 10 s of tuition, 40 anaesthetists attempted to pass a standard gum elastic bougie between the cords, with and without the nasendoscope, in randomised order. A bougie curved to an 'optimal curve' was also tested. Using the standard bougie 13/40 (33%) passed the bougie between the cords without the nasendoscope, compared with 31/40 (78%) when using the nasendoscope (p < 0.001). The 'optimal curve' bougie resulted in 29/40 (73%) and 39/40 (98%) success rates without and with the nasendoscope, respectively (p = 0.004). The nasendoscope is a simple and easy to use tool in grade 4 intubation, and results are improved further by the use of an 'optimal curve' bougie.     

Use of a gum elastic bougie to facilitate blind nasotracheal intubation in children: a series of three cases

Management of a difficult paediatric airway is challenging, and the unavailability of a paediatric fibreoptic bronchoscope, a common limitation in developing countries, adds to these difficulties. Children with bilateral temporomandibular joint ankylosis have limited mouth opening and therefore direct laryngoscopy and intubation is not usually possible. In the absence of sophisticated fibreoptic equipment, blind nasal intubation remains the only non-surgical option for control of the airway. Blind nasal intubation in paediatric anaesthesia is difficult. We describe a novel method of blind nasal intubation in paediatric patients using a gum elastic bougie. We have used this method successfully in three patients in whom tracheal intubation using a conventional blind nasal approach was unsuccessful. In view of its reliability and the absence of any soft tissue injury, we propose the use of this novel technique as an alternative to conventional blind nasal intubation, when more sophisticated fibreoptic equipment is not available.     

Survey of the use of the gum elastic bougie in clinical practice

Data were collected prospectively on the use of the gum elastic bougie in 200 patients. The bougie was successfully inserted into the trachea and tracheal intubation was accomplished in 199 cases. The bougie was inserted into the trachea at the first attempt in 178 cases. In nine cases (4.5%) a second, more experienced, clinician was required. In 173 cases, the grades of view were recorded before and after the application of laryngeal pressure; pressure improved the view in 80 cases (46%), had no effect in 89 (51%) and worsened the view in four cases (2%). Various recommendations for optimal external laryngeal pressure and use of the bougie were not followed on 15-64% of occasions. There is a need for better education in these techniques.     

Rigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie

We describe a technique by which a gum elastic bougie (GEB) is used to facilitate an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy. After placing the GEB through the lumen of the rigid bronchoscope, the GEB-suction catheter assembly was used to safely withdraw the bronchoscope in a manner mimicking the withdrawal of an intubating laryngeal mask airway (LMA) over the endotracheal tube using a stabilizer rod. The rationale for management and potential advantages of this approach versus use of an airway exchange catheter (including increased stability of an intubation guide) are discussed. IMPLICATIONS: We describe a technique of using a gum elastic bougie to facilitate an endotracheal intubation in a patient undergoing rigid bronchoscopy, which can be useful in a variety of clinical situations when the rigid bronchoscope is used in patients with abnormal airway.     

Successful difficult intubation

The reliability of two signs of tracheal placement of a gum elastic bougie was studied. These signs were clicks (produced as the tip of the bougie runs over the tracheal cartilages) and hold up of the bougie as it is advanced (when the tip reaches the small bronchi). Ninety-eight simulated and two genuine Grade 3 difficult intubations were attempted with the aid of a gum elastic bougie. Seventy-eight tracheal and 22 oesophageal placements of the bougie resulted. No clicks or hold up occurred with the bougie in the oesophagus. Clicks were recorded in 89.7% of tracheal placements of the bougie. Hold up at between 24-40 cm occurred in all tracheal placements. We conclude that these signs are reliable and that they should be taught as part of any difficult intubation drill in which the gum elastic bougie is used.     

Dual bougie technique for nasotracheal intubation

We read with great interest the anesthetic technique of using a gum elastic bougie (GEB) for nasal intubation in a recent issue of Anesthesia Progress. The authors recommend the use of GEB for the first attempt of nasotracheal intubation in patients with a difficult airway. We agree that this is an excellent alternative. We also have found an excellent variation of this method that utilizes a double bougie technique for insertion of a nasotracheal tube if the difficult airway can be secured initially with an orotracheal tube.     

Use of the video laryngoscopy for Combitube exchange in a difficult airway

Following failed intubation attempts via conventional direct laryngoscopy, an Esophageal Tracheal Combitube was successfully placed in the esophagus of a 51-year-old man with a subdural hematoma and uncleared cervical spine. The decision was made to change the Combitube for an endotracheal tube (ETT). After deflation of the large oropharyngeal cuff of the Combitube, video laryngoscopy was performed with the Direct Coupled Interface (DCI) video intubation system, and the Combitube was exchanged for an ETT with the assistance of a gum elastic bougie.     

Use of a gum elastic bougie for tracheal intubation with Pentax-AWS airway scope

Pentax-AWS laryngoscope (Pentax, Tokyo, Japan) consists of a disposable anatomically shaped blade, a 12-cm cable with a charge-coupled device (CCD) camera and a 2.4-inch liquid crystal device (LCD) color monitor display. A tracheal tube can be attached to the right side of the blade. The device may be useful in patients with difficult airways. One limitation of the device is that intubation may be difficult if it is difficult to position the glottis to the target symbol on the monitor display. We experienced such a difficulty in four patients, and the use of a gum elastic bougie enabled intubation. In a 57-year-old woman with a difficult airway, tracheal intubation using either a Macintosh laryngoscope or a fiberscope had failed. By inserting the AWS laryngoscope, the glottis was easily seen on the monitor display. Nevertheless, it was difficult to position the glottis to the target symbol, and advancing a tracheal tube collided with the tissue around the glottis. A bougie was passed through the tracheal tube, and it became possible to insert the bougie into the trachea by adjusting the angle of its tip. The tracheal tube was then easily passed over the bougie into the trachea. We successfully used the same technique in other three patients. We believe that the gum elastic bougie can be useful for tracheal intubation using the Pentax-AWS laryngoscope.     

Airtraq喉镜联合弹性插管探条在预计困难气道支气管插管中的应用

目的 比较Airtraq喉镜联合弹性插管探条(gum elastic bougie,GEB)和纤维支气管镜(fiberoptic bronchoscope,FOB)在预计困难气道患者支气管插管中的效果.方法 择期行右侧单肺通气的胸外科手术患者48例,张口度大于3 cm,Mallampati分级Ⅲ或Ⅳ级,随机数字表法分为两组(每组24例):Airtraq喉镜联合GEB组(A组)和FOB组(F组).记录插管首次成功率、置管时间、支气管对位用时和气道损伤情况,记录麻醉诱导前和支气管对位成功后2 min时点的SBP、DBP、HR和血浆去甲肾上腺素(norepinephrine,NE)浓度.结果 插管首次成功率A组与F组差异无统计学意义(91.7％比95.8％,P＞0.05);A组置管时间[(91±17)s]短于F组[(105±19) s](P＜0.05);A组支气管对位用时[(132±34)s]长于F组[(55±12)s](P＜0.05);气道损伤并发症两组之间差异无统计学意义(P＞0.05).两组SBP、DBP、HR和血浆NE浓度在插管完成后2 min均较麻醉诱导前明显升高(P＜0.05),且A组高于F组(P＜0.05).结论 Aiaraq喉镜联合GEB用于预计困难气道支气管插管与FOB一样安全有效,但支气管对位较慢,心血管应激反应较大.     

Brief review: The LMA Supreme? supraglottic airway

Purpose

This article is a review of the efficacy and safety of the Laryngeal Mask Airway (LMA) Supreme? as a stand-alone supraglottic airway during general anesthesia and as a conduit for tracheal intubation. Relevant articles were obtained using MEDLINE (1948-July 2011) and EMBASE (1980-July 2011). Only original studies with adult human patients and published in English were selected.

Principal findings

The LMA Supreme was found to be comparable with the LMA Proseal? with regard to success rate, insertion time, and complications. However, in three studies, oropharyngeal leak pressure was higher with the LMA Proseal than with the LMA Supreme. The LMA Supreme was superior to the LMA Classic? with regard to insertion time and oropharyngeal seal pressure. The LMA Supreme was also used successfully in two difficult airway cases, and it has been used as a conduit for tracheal intubation by utilizing an intubation introducer (gum elastic bougie) and subsequently railroading an endotracheal tube over the bougie into the trachea. Techniques for achieving tracheal intubation include the use of the Aintree Intubation Catheter?, a guidewire-exchange catheter, a gum elastic bougie, and a small (<6.0?mm internal diameter) endotracheal tube.

Conclusion

The LMA Supreme has been shown to be a safe and efficacious device as a stand-alone supraglottic airway and may also be used as a conduit for tracheal intubation. Further trials are needed to determine the efficacy of the LMA Supreme compared with other supraglottic airways in both elective and emergent airway management situations.     

Awake intubation: a new technique

A 46-year-old male with a known history of difficult intubation presented for elective surgery. It was considered prudent to perform an awake intubation and a size 3 laryngeal mask was introduced under topical anesthesia. A gum elastic bougie was then passed, enabling the laryngeal mask to be removed and a tracheal tube to be inserted.     

A comparison of the Seeing Optical Stylet and the gum elastic bougie in simulated difficult tracheal intubation: a manikin study

Management of the difficult airway is one of the major challenges that anaesthetists face. The flexible fibreoptic scope is widely available but its use requires a level of skill, training and continued practice that is not universally found in all anaesthetists, particularly trainees. The Seeing Optical Stylet is a new, semirigid fibreoptic stylet 'scope. We compared the Seeing Optical Stylet with a gum elastic bougie in a simulated Cormack and Lehane Grade 3 laryngoscopy in a manikin. Forty-four anaesthetists were timed while intubating the manikin's trachea with both devices. The mean (SD) time taken with the Seeing Optical Stylet was 20.8 (9.3) s and with the bougie 30 (19.8) s (p = 0.001). Oesophageal intubation occurred six times with the bougie but did not occur with the Seeing Optical Stylet (p = 0.011). We conclude that the Seeing Optical Stylet may be superior to the bougie in difficult tracheal intubation. We feel that the results of this manikin trial are sufficiently encouraging to proceed to a clinical trial in patients.     

Use of Eschmann's gum elastic bougie in difficult orotracheal intubation, an audit over eight years of clinical practice

Objectives

The objective was to check on the effectiveness of difficult orotracheal intubation by Eschmann's gum elastic bougie in our institution.

Study design

Retrospective observation study led for eight years.

Patients and methods

All the orotracheal intubations during the inductions in the surgical unit of the hospital of Laon were listed from 1998 to 2005, whether they were achieved in a classical way, with a fibrobronchoscope or with Eschmann's gum elastic bougie.

Results

Out of 15,657 intubations, 301 of them were difficult. Eschmann's gum elastic bougie was used 276 times with a rate of success of 99%.

Conclusion

Our study confirms the figures of publications, particularly the anglo-saxon ones and proves the interest of the Eschmann's gum elastic bougie in orotracheal intubations and this in first intention.