Airway Sonography in Live Models and Cadavers

Sonography using cadavers is beneficial in teaching and learning sonoanatomy, which is particularly important because imaging of the airway can be challenging due to the cartilaginous landmarks and air artifacts. In this exploratory study, we have attempted to compare the airway sonoanatomy of cadavers and live models. Our observations support the use of cadavers as teaching tools for learning airway sonoanatomy and practicing procedures involving airway structures, such as superior laryngeal nerve blocks, transtracheal injections, and needle cricothyroidotomy, before performance on patients in clinical situations. We believe this process will improve patient safety and enhance the competency of trainees and practitioners in rare procedures such as needle cricothyroidotomy.     

插管型喉罩用于困难气道的临床研究

目的:观察插管型喉罩(intubating laryngeal mask airway,ILMA)在困难气道中应用的可行性。方法:25例Cormack与lehaneⅢ-Ⅳ级预测为困难气道的择期手术患者(Difficut组,简称D组),另匹配25例Cormack与lehaneⅠ-Ⅱ级的择期手术患者(Control组,简称C组),在静脉诱导后行ILMA插管。观察喉罩置入时间和次数、气管插管时间和次数、插管并发症以及成功率。结果:D组24例(96％)成功经ILMA插入气管导管,其中1次插管成功16例,成功率64％;2次插管成功6例;1例操作失败。C组25例(100％)全部经ILMA成功插入气管导管,其中1次插管成功23例,成功率92％。2次插管成功1例。D组和C组喉罩置入加插管总时间分别为(90．24±8．50)s和(81．26±7．20)s,插管时间分别为(41．73±7．86)s和(40．80±6．93)s。两组在气管导管插入时间、总的ILMA置入时间,成功率、术后并发症等方面无显著差异。结论:插管型喉罩是处理困难气道的有效应用工具之一。     

Use of Sonography for Airway Assessment

Objective. The purpose of this study was to evaluate the feasibility of sonography in identifying the anatomic structures of the upper airway and to describe their appearance on sonography. Methods. We enrolled 24 healthy volunteers, placed them supine with their head extended and neck flexed (the “sniffing” position), and performed a systematic sonographic examination of their upper airway from the floor of the mouth to the suprasternal notch. Results. We were able to visualize all relevant anatomic structures in all of the participants using either a linear or curved transducer oriented in 1 of 3 planes: sagittal, parasagittal, and transverse. Bony structures (eg, the mandible and hyoid) were brightly hyperechoic with an underlying hypoechoic acoustic shadow. Cartilaginous structures (eg, the epiglottis, thyroid cartilage, cricoid cartilage, and tracheal rings) were hypoechoic, and their intraluminal surface was outlined by a bright air‐mucosa interface. The vocal cords were readily visualized through the thyroid cartilage. However, the posterior pharynx, posterior commissure, and posterior wall of the trachea could not be visualized because of artifacts created by an intraluminal air column. Conclusions. Sonography of the upper airway is capable of providing detailed anatomic information and has numerous potential clinical applications.     

食管引流型喉罩和经典型喉罩的临床应用对比观察

目的比较经典型喉罩（CLMA）和食管引流型喉罩（PLMA）在骨科全麻手术中的应用,为临床安全有效选择喉罩提供参考依据。方法选择ASA分级Ⅰ～Ⅱ级,拟在全身麻醉下择期行骨科手术的患者100例,年龄18—60岁,体重指数（BMI）18-30kg／m2,随机分为CLMA组和PLMA组,每组50例。PLMA组沿食管引流孔插入14号胃管,观察两组喉罩一次置入成功率,尝试时间,头位,漏气率,胃胀气情况,记录患者入室,置入喉罩前,置入喉罩后以及离室四个时间点的平均动脉压,心率,血氧饱和度,并在术后2h,12～24h两个时间点随访患者是否咽喉痛,下颌痛,恶心呕吐,吞咽困难,声音嘶哑。结果两组患者的一般资料没有显著差异。喉罩置入时间,一次成功率,插罩方法,术中漏气需调整例数,以及通气失败需更换气管插管的例数,两组相比较均无显著差异（P〉0．05）,两组患者各时点生命体征组间比较差异无显著性（P〉0．05）。术中胃胀气以及插入喉罩时需调整头位为嗅花位的患者例数两组相比较,PLMA组明显低于CLMA组,有统计学差异（P〈0．05）,术后随访各并发症发生率均无统计学差异（P〉0．05）。结论与经典型喉罩相比较,食管引流型喉罩的机械通气效果和密封性更好,置入喉罩时简单伸展位即可顺利操作,成功率更高。     

喉罩通气道与气管内插管在急救复苏中重建有效通气道的对比研究

目的检测喉罩通气道用于急救复苏中重建有效通气道的优越性.方法L组20例系各种因素导致呼吸衰竭或呼吸停止的患者,选择合适3～4型号的喉罩盲探插入正确位置,进行控制呼吸.E组20例手术麻醉患者,在静脉快诱导明视下行气管内插管机械通气,观察2组插管困难程度、插管成功次数、插管时间、插管后PetCO2波形、气道顺应性、SPO2、胸廓起伏状况、双肺呼吸音.结果L组盲探下插管全部1次成功,E组诱导明视下插管1次成功16例,3次以上4例.插管时间L组全部在30s内完成,E组在30s内完成16例,其余长达1min30s～3min20s(P＜0.05),相比差异有显著性.插管后两组气道顺应性,PetCO2、SPO2、双肺呼吸音判断导管位置均正确无误.结论应用喉罩通气道于急救复苏,与使用喉镜明视下快诱导行气管内插管相比,具有体位要求不高,操作简单,可盲探插管,为抢救此类患者赢得宝贵的抢救时间.     

Successful Tracheal Intubation through an Intubating Laryngeal Airway in Pediatric Patients with Airway Hemorrhage

Background

This case report describes the use of the air-Q intubating laryngeal airway (air-Q ILA; Cookgas LLC, St. Louis, MO) for airway rescue and a conduit for blind tracheal intubation in two pediatric patients with failed rapid sequence intubation and difficult airways secondary to airway bleeding in the emergency department (ED).

Objectives

To describe the use of a new supraglottic rescue device in the management of the pediatric patient’s difficult airway in the emergency setting.

Case Report

Case 1 was a 5-year-old boy who presented to the ED for bleeding one day after his tonsillectomy. After a rapid sequence intubation, direct laryngoscopy was difficult, with copious bleeding in the oropharynx and inability to visualize the glottis. After two failed direct laryngoscopic attempts to intubate, a size-2 air-Q ILA was inserted. A cuffed 5.0-mm inner diameter (ID) endotracheal tube (ETT) was blindly inserted through the lumen of the air-Q ILA into the trachea successfully. Case 2 was a 13-year-old boy who presented to the ED with a large nasopharyngeal laceration from a motor vehicle accident. After a rapid sequence intubation, direct laryngoscopy showed copious blood with no glottic visualization. A size 3 Laryngeal Mask Airway Classic™ (cLMA; LMA North America Inc., San Diego, CA) was inserted with a large airway leak, and blind ETT insertion via the cLMA was unsuccessful. Subsequently, a size-2.5 air-Q ILA was inserted and adequate ventilation was restored. A cuffed 6.0-mm ID ETT was blindly inserted through the air-Q ILA into the trachea successfully.

Conclusion

Two cases of failed laryngoscopy in pediatric patients with blood in the airway are described. In each case, insertion of an air-Q ILA was followed by successful blind tracheal intubation via the lumen of the air-Q ILA.     

Impact of Emergency Medicine Faculty and an Airway Protocol on Airway Management

OBJECTIVE: To determine the impact of emergency medicine (EM) faculty presence and an airway management protocol on success rates of tracheal intubation in the emergency department (ED). METHODS: A retrospective observational study of prospectively collected data on rates of successful intubations between June 1997 and December 2001 in the ED of a large urban teaching hospital. The authors compared success rates of the first attempt at intubation and times to intubation prior to and after EM faculty presence and the institution of an airway management protocol. RESULTS: Prior to EM faculty presence and the airway management protocol, tracheal intubation was achieved on the first attempt 46% of the time; more than six attempts were required 2.9% of the time. The mean time to intubation was 9.2 minutes (+/-13.2 SD). Following EM faculty presence and the airway protocol, the success rate on the first attempt was 62%, more than six attempts were required 1.1% of the time, and the mean time to intubation was 4.6 minutes (+/-6.2 SD). CONCLUSIONS: First-attempt intubation success rates and decreased mean time to successful intubation improved following EM faculty presence and the introduction of an airway management protocol.     

162例气管插管患者的气道管理

笔者通过报道162例气管插管患者的气道管理，阐述痰痂形成的原因：(1)气道干燥，湿化不够。(2)吸痰管插入深度不够，吸痰不彻底。管理措施：(1)用金霉素眼膏润滑吸痰管，使之易于插入，保证吸痰管插入深度超过插管远端3-5cm。(2)预防气道干燥，注重湿化效果，重视吸痰环节。认为气囊不需定时放气，只需不定时调整气囊压力。     

急诊昏迷患者紧急人工气道支持的护理

目的探讨急诊昏迷患者紧急人工气道支持的护理。方法回顾分析2010年1-12月在金华市中心医院急诊科行紧急人工气道支持治疗的50例急诊昏迷患者的临床资料,总结其护理经验。结果经治疗及护理,转神经外科急诊手术15例、神经内科住院治疗21例;重症监护病房住院治疗5例、急诊留观治愈5例。患者中自动出院2例、死亡2例,其余患者均好转出院。结论医护人员应高度认识急诊昏迷患者早期呼吸道护理的重要性,提高护理技能和实践能力,不断改进早期呼吸道管理的质量与水平。     

King Airway Use by Air Medical Providers

Background. In cases of difficult or failed endotracheal intubation (ETI), alternate airways are designed to provide adequate oxygenation andventilation until a definitive airway can be established. The King Laryngeal Tube Disposable (LTD) is a new superglottic alternate airway. Objective. To describe the use, rates of success, andoutcomes of the King airway by highly skilled prehospital providers. Method. In this retrospective analysis, we examined prehospital King airway use by a large regional air medical service for the period from March 2006 to December 2006. Rescuers used alternate airways after three unsuccessful ETI attempts or in situations of anticipated ETI difficulty. We identified clinical characteristics, described airway difficulties, anddetermined the success of airway placement. Where available, we evaluated the hospital course andoutcomes. Results. Of 575 ETI, alternate airways were used in 27 cases, including 26 King airway placements (4.5%, 95% CI: 3.0–6.6%). All were successfully placed; 24 required one attempt, andtwo required more than one attempt. No immediate complications were observed. No prehospital surgical airways were performed. Follow-up data were available for 15 of 26 patients. Five patients were in cardiac arrest anddid not survive to hospital admission. Many of the patients required specialized efforts from anesthesia or surgery for definitive airway management with 40% (4/10) requiring emergent tracheostomy. Conclusion. In this series of critically ill patients, air medical providers successfully used the King airway as an alternate airway device. Definitive airway management was complicated andrequired specialized efforts from surgery andanesthesia.     

Trauma Airway Management

Background

Airway management in a trauma patient can be particularly challenging when both a difficult airway and the need for rapid action collide. The provider must evaluate the trauma patient for airway difficulty, develop an airway management plan, and be willing to act quickly with incomplete information.

Discussion

Thorough knowledge of airway management algorithms will assist the emergency physician in providing optimal care and offer a rapid and effective treatment plan.

Conclusions

Using a case-based approach, this article reviews initial trauma airway management strategies along with the rationale for evidence-based treatments.     

A Significant Cervical Spine Fracture: Think of the Airway

Background

Airway compromise is a potential complication of significant cervical spine injury.

Objectives

To alert emergency physicians to be aware of possible airway collapse after serious cervical spine injury.

Case Report

We report a case of an 87-year-old man who presented to the emergency department with an unstable cervical spine fracture after a fall. He subsequently developed complete upper airway obstruction from prevertebral soft tissue swelling, requiring a cricothyrotomy after a failed intubation attempt.

Conclusion

Patients with significant blunt cervical spine trauma can be at high risk for upper airway compromise.