A modified method for intubation of a patient with ankylosing spondylitis using intubating laryngeal mask airway (LMA-Fastrach)--a case report

We present an instance of successful use of an intubating laryngeal mask airway (LMA-Fastrach) and a Cook airway exchanger (CAE) for ventilation and intubation in a patient with severe ankylosing spondilitis (AS) receiving total hip arthroplasty. This measure may serve as an effective alternative for airway management in patients with difficult airway. A 61-year-old male was scheduled for right total hip arthroplasty because of degenerative osteoarthritis. He had been suffering from extensive ankylosing spondylitis, with the cervical spine markedly fixed in anterior flexion. Besides he could not open his mouth widely (35 mm when fully open) also because of ankylosis of jaw. Although we advised an awake fiberoptic tracheal intubation for anesthesia but he refused owing to a previous painful experience. After induction of anesthesia with glycopyrrolate, fentanyl, thiamylal sodium and succinylcholine, we inserted a # 5 Fastrach ILMA for primary airway maintenance. Then through the lumen of the ILMA we introduced the CAE as a guide for endotracheal tube (ETT) intubation. After applying the RAPI-FIT adapter to the CAE, we connected it to the capnography monitor for the confirmation of airway. We finally inserted an endotracheal tube into the trachea using the CAE as a guide. The whole procedure was uneventful and smooth. In sum, the modified Fastrach intubation method may facilitate tracheal intubation in patients with severe ankylosing spondilitis. It may be an alternative way for successful airway management in patients with difficult airway.     

The intubating laryngeal mask airway in failed fibreoptic intubation

PURPOSE: Prediction of difficult tracheal intubation is not always reliable and management with fibreoptic intubation is not always successful. We describe two cases in which blind intubation through the intubating laryngeal mask airway (ILMA FasTrach) succeeded after fibreoptic intubation failed. CLINICAL FEATURES: The first patient, a 50 yr old man, was scheduled for elective craniotomy for intracerebral tumour. Difficulty with intubation was not anticipated. Manual ventilation was easily performed following induction of general anesthesia, but direct laryngoscopy revealed only the tip of the epiglottis. Intubation attempts with a styletted 8.0 mm endotracheal tube and with the fibreoptic bronchoscope were unsuccessful. A #5 FasTrach was inserted through which a flexible armored cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. The second patient, a 43 yr old man, presented with limited mouth opening, swelling of the right submandibular gland that extended into the retropharynx and tracheal deviation to the left. He was scheduled for urgent tracheostomy. Attempted awake fibreoptic orotracheal intubation under topical anesthesia showed gross swelling of the pharyngeal tissues and only fleeting views of the vocal cords. A #4 FasTrach was easily inserted, a clear airway obtained and a cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. CONCLUSION: The FasTrach may facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.     

A comparative study of tracheal intubation using an intubating laryngeal mask (Fastrach) alone or together with a lightwand (Trachlight)

Study Objective: To determine if the Trachlight^TM lightwand can facilitate Fastrach^TM intubation by guiding the tip of the endotracheal tube into the trachea.

Design: Open-label, prospective, randomized, comparative study.

Setting: General operating suites of a tertiary teaching hospital.

Patients: 172 elective surgical patients requiring general anesthesia with endotracheal intubation.

Interventions: With general anesthesia, the Fastrach™, which is a new intubating laryngeal mask airway, was inserted into the oropharynx. Ventilation was ensured before the insertion of an endotracheal tube via the Fastrach™. Tracheal intubation was then performed randomly (coin toss) using either the endotracheal tube alone (Fastrach™ group), or endotracheal tube with the Trachlight, a lightwand (Fastrach/Trachlight™ group). The time to place the Fastrach™ and endotracheal tube, to remove the Fastrach™, and the total time to intubate were recorded. The number of attempts, failures, trauma, sore throats, and hemodynamic changes were also recorded. Data were analyzed using unpaired t-test, ANOVA with repeated measures, or Chi-squares contingency table where appropriate.

Measurements and Main Results: Although there were no differences in the times to place the Fastrach™, and endotracheal tube, the hemodynamic changes, and postoperative complications, there were significantly more attempts and failures in the Fastrach™ group compared to the Fastrach™/Trachlight™ group. There were no differences in the incidence of sore throat and trauma in between the groups.

Conclusions: Although tracheal intubation is effective using a Fastrach™ alone (76% success rate), it is more effective when the Fastrach™ is used in conjunction with the Trachlight™ (95%). These results suggest that the lightwand is a useful adjunct for Fastrach™ intubation. However, the role of Fastrach™ intubation together with the Trachlight™ in the management of patients with a potential difficult airway remains to be determined.     

Use of the intubating laryngeal mask for airway management and light-guided tracheal intubation in the lateral position

Sudden accidental loss of the airway during surgery is potentially hazardous especially when the patient is lying in any position which prevents easy intubation of the trachea. We describe two patients lying in the lateral position who required urgent airway management and endotracheal intubation. In both cases endotracheal intubation was achieved successfully using a light-guided technique--with a prototype illuminated flexible catheter--through an intubating laryngeal mask airway.     

Fiber-optic bronchoscopic guidance for intubating a neonate with Pierre-Robin syndrome

The Pierre-Robin anomalad features micrognathia, glossoptosis, and frequently a cleft palate. Tracheal intubation may be challenging and sometimes impossible. Reported is a case in which a tracheal guide wire was passed via the suction port of a flexible pediatric bronchoscope. The bronchoscope was then removed, and an endotracheal tube was threaded over the wire. The technique is safe and allows rapid endotracheal intubation in pediatric patients with difficult upper airways.     

Failed intubating laryngeal mask airway-guided blind endotracheal intubation in a severe postburn contractured neck patient

Securing the airway in patients with severe post burn contracture of the neck is often challenging for attending anesthesiologists. Fiberoptic bronchoscope (FOB)-guided endotracheal intubation is considered safe and reliable in this situation. Intubating Laryngeal Mask Airway (ILMA) is an alternative in case of FOB unavailability. We report a case of 30 year old female with mentosternal contracture, where the use of ILMA allowed easy ventilation but failed to enable successful ILMA-guided blind intubation despite multiple attempts, the use of recommended Chandey's maneuver and muscle relaxation. Subsequent FOB revealed marked anterior dislocation of laryngotracheal structures, leading to a slippage of the endotracheal tube back to the esophagus.     

Soft-tip intubating stylet

Endotracheal intubation using a laryngoscope is the most rapid and usually the easiest means to ensure a patent airway. It has therefore earned its popularity in anesthesia and other acute health care practices. However, intubation by conventional technique is not always successful as at times direct vision of the glottis/vocal cords is impossible during laryngoscopy. Thus, acute airway obstruction remains a constant problem in all acute health care practices. To deal with this challenge, we have developed a new technique incorporating a modified Satin-Slip intubating stylet (Mallinckrodt Medical, St. Louis, MO, USA). First, cut the plastic sheath of the stylet at its distal end and push the sheath forward about one and a half inches. The soft plastic tip of the malleable stylet is then allowed to protrude from the endotracheal tube (ETT). When visualization of the glottic aperture is not possible, one simply places the soft plastic tip of the stylet under the epiglottis and advances it forward, and the tip will eventually enter the larynx. The ETT is then advanced off the stylet into the trachea. This new technique works very well in our experiences. It can be performed quickly with readily available inexpensive equipment. Our favorable experience leads us to believe it is one of the most promising additions to the current recommended alternatives.     

Acoustic reflectometry profiles of endotracheal and esophageal intubation

BACKGROUND: Acoustic reflectometry can be used to create a "one-dimensional image" of a cavity, such as the airway and lung, with the image displayed as an area-length curve. This pilot study was undertaken to determine whether acoustic reflectometry could be used to distinguish between an endotracheal and an esophageal intubation. METHODS: Ten adult patients underwent general endotracheal anesthesia and neuromuscular blockade. The reflectometer wavetube was attached to an endotracheal tube, and a reflectometric profile was obtained of the endotracheal tube and the airway and lung cavity. After confirmation of tracheal intubation, a second endotracheal tube was placed in the esophagus. After four breaths were administered, a reflectometric profile of the endotracheal tube-esophagus cavity was obtained. RESULTS: The acoustic reflectometric profiles for tracheal and esophageal intubation profiles were distinctive and characteristic. For an endotracheal tube-airway cavity, the profile shows a constant cross-sectional area throughout the length of the endotracheal tube, followed by a rapid rise in the area past the carina. For an esophageal intubation, the profile shows constant cross-sectional area throughout the length of the endotracheal tube, followed by a sudden decrease in the cross-sectional area to zero. CONCLUSIONS: In this pilot study, acoustic reflectometry within seconds, and without resort to capnography, was able to generate characteristic and distinctive area-length profiles for both endotracheal and esophageal intubation. Acoustic reflectometry may have a role in the emergency imaging of the airway, and in the immediate detection of esophageal intubations, particularly in cases of cardiopulmonary arrest in which the usual techniques for confirmation of breathing tube placement fail.     

人工智能在气道管理中的应用

人工智能技术的发展促进了气道管理方法和设备的更新,具有优化、解决气道管理中延迟插管、气道困难和气管导管位置的评估等问题的潜力。本文总结了气道管理领域常用的人工智能模型,从患者气管插管需求的预测、困难气道患者的识别、气管导管定位、气管插管设备的自动化和智能化进行总结阐述,为围术期气道管理工作提供参考。     

Awake intubating laryngeal mask airway placement in a morbidly obese patient with ankylosing spondylitis and unstable thoracic spine

Intubating laryngeal mask airways can be used to provide continuous ventilation throughout intubation. This is a case of a morbidly obese (body mass index = 58) 65-year-old woman with T10 and T11 compression fractures. Optimal positioning for airway management was hindered by her unstable spine, minimal neck range of motion, and extreme pain with any movement. An intubating laryngeal mask airway was placed in the awake, topically anesthetized patient, and the laryngeal mask airway and endotracheal tube combination was left in place throughout surgery.     

Intubation in a patient with lingual tonsil hypertrophy using an intubating laryngeal mask airway in combination with fiberoptic intubation

A 66-yr-old man was scheduled for colon resection under general anesthesia. There were no findings suggesting difficulty of airway management. After induction of anesthesia, manual ventilation via a facemask was suboptimal, but increased fresh gas flow improved it. At direct laryngoscopy after achieving muscular relaxation, the arytenoids and epiglottis could not be seen even by an expert anesthesiologist. Intubating laryngeal mask airway (ILMA) was inserted to patient's larynx and ventilation could be continued. Tracheal intubation through ILMA was impossible because of hard resistance for inserting the endotracheal tube. Fiberoptic bronchoscopy revealed that the hypertrophied lingual tonsil obstructed the aperture of ILMA. Several attempts were made for intubation using fiberoptic tracheal intubation technique through ILMA and finally the patient's trachea was intubated without any bleeding or swelling of laryngeal tissues. The effectiveness of ILMA for the patient with lingual tonsil hypertrophy is still unknown, but the insertion of ILMA might be considered for safe airway management in combination with a fiberscope.     

A modified intubating laryngeal mask for endotracheal tube exchange

Implications: It is often necessary to change a patient's breathing tube (endotracheal tube). This can be a risky procedure. This report describes a technique for changing an endotracheal tube by using a modified "intubating laryngeal mask" (a commonly used airway and breathing device) and a fiberoptic bronchoscope.     

Indirekte Laryngoskopie

Endotracheal intubation remains the gold standard for securing the airway in emergency medicine. However, difficult endotracheal intubation and complications are common during emergency intubation. In contrast to conventional direct laryngoscopy, the new generation of devices does not require direct visualization of the vocal cords for endotracheal tube placement. These devices allow a better glottic view and successful endotracheal placement of the tube, especially if direct laryngoscopy is difficult. Recent studies showed that utilization of these devices can be easily learned. The technique of indirect laryngoscopy is currently used for securing the airway in daily anesthesia routine as well as for managing the difficult airway in the operating room. This article gives an overview of available devices for indirect endotracheal intubation as well as the current literature.     

Pediatric airway management : cuffed endotracheal tube and other devices for tracheal intubation

Uncuffed endotracheal tubes have been commonly used in pediatric patients, but cuffed pediatric endotracheal tubes are recently introduced and stirred up a controversy. Uncuffed tubes may require multiple laryngoscopies, pollute the environment, and cause pulmonary aspiration as well as unstable ventilation. A recent study revealed that the contours of the airway and the tracheal tube are different, so that the pressure exerted on some parts of the cricoid mucosa may not be appropriate. Cuffed endotracheal tubes overcome these shortcomings if anesthesiologists pay close attention to the insertion length of the tube and cuff pressure. Laryngeal mask airway has worked well, with few complications, as a ventilatory device in pediatric patients whose tracheas cannot be intubated and/or whose lungs cannot be ventilated with conventional techniques. It is also used for a conduit for fiberoptic intubation and emergent airway with patients in the prone position. The lightwand (Trachlight) is another device for pediatric intubation and is recommended as the first-line option in patients who can be ventilated but in whom laryngoscopic intubation has failed. AirWayScope (Pentax-AWS) is a novel intubation device which combines an airway, camera and monitor It can be an epoch-making intubation device for infants and children if a smaller size is available in the future.     

Acoustic Reflectometry Profiles of Endotracheal and Esophageal Intubation

Background: Acoustic reflectometry can be used to create a "one-dimensional image" of a cavity, such as the airway and lung, with the image displayed as an area-length curve. This pilot study was undertaken to determine whether acoustic reflectometry could be used to distinguish between an endotracheal and an esophageal intubation.

Methods: Ten adult patients underwent general endotracheal anesthesia and neuromuscular blockade. The reflectometer wavetube was attached to an endotracheal tube, and a reflectometric profile was obtained of the endotracheal tube and the airway and lung cavity. After confirmation of tracheal intubation, a second endotracheal tube was placed in the esophagus. After four breaths were administered, a reflectometric profile of the endotracheal tube-esophagus cavity was obtained.

Results: The acoustic reflectometric profiles for tracheal and esophageal intubation profiles were distinctive and characteristic. For an endotracheal tube-airway cavity, the profile shows a constant cross-sectional area throughout the length of the endotracheal tube, followed by a rapid rise in the area past the carina. For an esophageal intubation, the profile shows constant cross-sectional area throughout the length of the endotracheal tube, followed by a sudden decrease in the cross-sectional area to zero.     

Developmental anatomy of the airway

The airway develops from the primitive foregut and a number of congenital anomalies may result when this process is abnormal. The anatomy of the neonatal airway is significantly different from older children and adults. The larynx is cephalad, the epiglottis large and the cricoid cartilage is the narrowest part of the upper airway. The technique of endotracheal intubation is significantly different in neonates compared with older children and adults. A straight-bladed laryngoscope and an uncuffed endotracheal tube are usually used. During the first years of life the anatomy gradually becomes more like that of adults. By the age of 8–10 years normal children have an airway that is anatomically adult in most ways other than absolute size. The technique used for endotracheal intubation in adults is appropriate, including the use of a Macintosh laryngoscope blade and a cuffed endotracheal tube.     

Use of a tracheoscopic ventilation tube for endotracheal intubation in the difficult airway

Difficult endotracheal intubation is a clinical challenge for anesthesiologists and other practitioners of airway management. The use of a tracheoscopic ventilation tube, a novel airway device, for endotracheal intubation during general anesthesia in two patients with difficult airways after unsuccessful direct laryngoscopy is presented.     

Life-Threatening Stridor due to Membranous Tracheitis as a Rare Complication of Endotracheal Intubation: Report of a Case

This report describes a rare case of acute life-threatening stridor due to membranous tracheitis that occurred as a complication of endotracheal intubation, performed for video-assisted thoracotomy. An obstructive fibrin clot was found in the subglottic region by bronchofiberscopy, and removal provided complete relief of the airway obstruction. The mechanism of the development of this fibrin membrane may have interacted with local tracheal trauma from the endotracheal tube. Membranous tracheitis should be considered in the differential diagnosis of stridor and airway obstruction after endotracheal intubation because it is a life-threatening complication of this procedure. Received: April 8, 2002 / Accepted: September 3, 2002 Reprint requests to: I. Takanami     

Intubation through intubating laryngeal mask with and without a lightwand: a randomized comparison.

The combined use of a lightwand and the intubating laryngeal mask airway (ILMA) was compared with the use of the ILMA alone to determine whether the combination was a more efficient method of endotracheal intubation. One hundred healthy patients were randomly assigned to two groups. After induction of anaesthesia, Group A patients were intubated blindly through the ILMA while in Group B, intubation was guided by a lightwand. A sequence of standard manoeuvres was followed it attempts at intubation failed. The number of manoeuvres used, the time taken for successful intubation and complications associated with intubation were recorded. Intubations were successful in all patients, but the mean endotracheal intubation time was longer in Group A than in Group B (38.3 +/- 10.4 s versus 26.4 +/- 9.1 s, P < 0.001). The number of patients who needed one or more manoeuvres was significantly higher in Group A than in Group B (76% versus 42%, P = 0.001). We conclude that the lightwand is a useful adjunct in endotracheal intubation through an ILMA.     

Malposition of the epiglottis after tracheal intubation via the intubating laryngeal mask

The intubating laryngeal mask has been reported to be a successful method of tracheal intubation although advancement of the tracheal tube via the laryngeal inlet into the trachea cannot be seen. Damage to the larynx or other tissues may occur during blind passage of a tracheal tube. We report a case in which the tracheal tube, advanced blindly, tucked the epiglottis into the laryngeal inlet, resulting in oedema of the epiglottis. This case illustrates the potential for airway obstruction after extubation when using the intubating laryngeal mask as a blind intubation guide.