Difficult and failed intubation management in obstetrics

Failed intubation in obstetrics remains a topical issue, a rare but potentially devastating complication of obstetric general anaesthesia. The 2015 guidelines produced following several years of collaborative work between the Difficult Airway Society (DAS) and Obstetric Anaesthetists' Association (OAA) remain the definitive text. While deaths from failed intubation have declined significantly over 30 years, the incidence of failed intubation remains fairly constant at 1:300, with the latest studies showing a rate of 1:224. This reflects the significant decline in the use of general anaesthesia for caesarean section over the last three decades; however, it also highlights a decreased exposure for trainees to tracheal intubation in the obstetric population.     

Use of a ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed tracheal intubation

We report the use of the ProSeal^TM laryngeal mask airway toestablish and maintain the airway during emergency Caesareansection when tracheal intubation had failed with conventionallaryngoscopy and mask ventilation was difficult. The ProSeal^TMlaryngeal mask allowed controlled ventilation without gas leakand facilitated drainage of the stomach. Br J Anaesth 2004; 92: 144–6     

气管导管套囊充气前后气管横径变化值与套囊压的相关性

目的 探讨超声测量气管导管(ETT)套囊充气前后的气管横径变化值(ΔTD)与ETT套囊压(CPETT)的相关性.方法 选择2020年6月-2021年8月行气管插管全身麻醉的男性患者,年龄18～60岁,BMI 18～25 kg/m2,ASA Ⅰ至Ⅲ级.研究分为两个部分.第1部分拟招募90例符合纳入标准的患者,用指压法进行...     

Management of the difficult airway A case of failed fiberoptic intubation

Background: Fiberoptic intubation is the current gold standard for the management of difficult intubation. Nevertheless, in rare circumstances even fiberoptic intubation fails.
Methods: We describe the case of a female patient suffering from neurofibromatosis Recklinghausen and a giant malignant schwannoma on the neck obstructing the pharynx and compromizing respiration. Based on the clinical presentation and the MRI findings, difficulties in airway management were anticipated and fiberoptic intubation of the awake patient was planned.
Results: After localizing the vocal cords it was not possible to advance the tube into the trachea due to the severe deviation of the glottis. A decision was made to cancel any further fiberoptic intubation attempts and a conventional tracheotomy was performed under local anaesthesia without problems.
Conclusion: This case illustrates that even awake fiberoptic intubation has its failure rate, due to inability to visualize the larynx, inability to advance the tube over the fiberscope (as in the present case), or inability to direct the tube towards the larynx. Due to the extreme deviation of the larynx other established techniques for difficult intubation were not deemed appropriate in this case. Therefore, weighing the risks and benefits, a decision was made to perfom a tracheotomy under local anaesthesia.     

Detection of oesophageal intubations using cuff pressures in a pig trachea oesophagus model

BACKGROUND: The cuff pressures may be different in oesophageal and tracheal intubations. We conducted a study to evaluate if cuff pressures of endotracheal tubes (ETTs) could provide information to distinguish tracheal or oesophageal intubations in a pig trachea-oesophagus model. METHODS: In each preparation of pig trachea-oesophagus model, the trachea and the oesophagus were intubated separately with a cuffed ETT, and the cuff pressures were measured after each 1 ml increment of air (1-10 ml) during inflation. The cuff pressures and the pressure-volume relationships in both intubations were compared. RESULTS: The cuff pressures of oesophageal intubations were significantly higher than those of tracheal intubations in all comparisons from 1 to 10 ml of cuff volumes (P < 0.05). The cuff pressure-volume curve was steeper in the oesophageal intubation group, and the difference between the two curves was the largest when the cuff volume was 4-5 ml. CONCLUSIONS: We conclude that the cuff pressures may be useful in detecting oesophageal intubations. This method is faster than other confirmation measures as it can detect inadvertent oesophageal intubations at the time of inflating the cuffs.     

瑞芬太尼在纤维支气管镜清醒气管插管中的应用进展

背景 困难气道患者的围术期气道管理是临床麻醉关注的热点问题.纤维支气管镜清醒气管插管(awake fibreoptic intubation,AFO1)技术是处理预见性困难气道的公认方法.然而实施AFOI的难点在于给患者提供充分镇静、镇痛的同时,又要保证患者有效的自主通气功能.瑞芬太尼作为一种较理想的麻醉性镇痛药,一定剂量下能有效抑制气管插管的应激反应,故已有用于AFOI的报道. 目的 概述及评价瑞芬太尼在AFOI中的有效性及安全性,为临床应用和进一步研究提供参考. 内容 分析瑞芬太尼用于AFOI的剂量对机体的影响、不同给药方案的优劣以及在特殊患者中的应用. 趋向 瑞芬太尼在AFOI中的应用具有诸多优势,但最佳方案仍需进一步临床研究.     

The use of AIR-Q as conduit for fiberoptic endotracheal intubation in adult paralyzed patients

BackgroundThe AIR-Q Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical) is a supraglottic device present in the market since 2004. It has different sizes for pediatric and adult use. This device proved to be of utmost importance in the management of difficult airway [1]. The study evaluates the different adult sizes of the Air Q when used for intubation regarding the ease of insertion, the laryngeal view grade, their efficacy as conduit for standard cuffed endotracheal tubes using fiberoptic bronchoscope. The study also records the time of intubation, the ease and time of removal of the AIRQ over a removal stylet without dislodgement of the tube from trachea. Any complications related to the use of AIRQ were also recorded such as laryngeal oedema, blood streaked mucous, trauma to the airway, laryngeal spasm or aspiration.MethodsSixty adult patients aged 20–50 years, ASA I, II undergoing elective surgeries requiring general anesthesia, were enrolled in the study. The patients were divided into 2 equal groups according to their body weight. The body weight of the first group ranged from 50 to 70 kg and used the Air Q 3.5 for intubation with an endotracheal tube (ETT) 7 mm ID, while the body weight of the second group ranges from 70 to 100 kg and used the Air Q 4.5 for intubation with a tube 7.5 mm ID. The number of attempts of insertion, the seal pressure, the laryngeal view grade, the time and the number of attempts of intubation, time of removal of the AIRQ over the tube without dislodgement, and any complications related to the use of AIRQ were recorded such as laryngeal oedema, blood streaked mucous, trauma to the airway, laryngeal spasm or aspiration.ResultsThe insertion and removal of the AIRQ were easy and successful in all patients of both groups. The endotracheal intubation by fiberoptic bronchoscope through the Air Q was successful and easy in both groups. Grade 5 laryngeal view was seen with AIRQ 4.5 in some patients with higher body weight.ConclusionThe insertion of AIRQ in adult patients is easy and provides an effective conduit for the standard cuffed endotracheal tubes using fiberoptic bronchoscope. The removal of the AIRQ over the removal stylet is easy without dislodgement of the tube. Because of higher incidence of down folding of the epiglottis in some obese patients, they are better intubated under direct vision with the use of fiberoptic bronchoscope.     

Failed intubation in obstetrics

Failed intubation in obstetric practice is rare, however it can have a devastating impact on the mother and fetus if not managed appropriately.Over the last 20 years there have been significant changes in anaesthetic management and training; in addition The European Working Time Directive has led to a reduction in junior doctors' hours. As a result, trainees now have less exposure to airway management, specifically endotracheal intubation.Acquiring skills in obstetric general anaesthesia is increasingly difficult as the majority of women will be suitable for regional anaesthesia.Training must be targeted at the differences between the airway in the non-pregnant and pregnant woman, and it is essential that all training opportunities in obstetric general anaesthesia should be taken. Use of simulation and animal models is an effective way of improving teamwork and confidence to deal with emergency situations such as failed intubation.     

新型气管插管器具发展的新特点

背景自上世纪40年代Macintosh和Miller喉镜片问世以来,各种新的气管插管器具被商业性推广。目的综述与目前临床实践相关的新型气管插管器具。内容重点阐述新型气管插管器具与传统直接喉镜性能的比较、新型气管插管器具的并发症、新型气管插管器具在清醒气管插管方法中的应用以及新型气管插管器具气管插管失败的预测等。趋向在预知的和未预知的困难气管插管或者气管插管失败的情况下,应用新型气管插管器具可获得极高的气管插管成功率。然而更重要的是,操作者应用各种新型气管插管器具的经验和技能是保证其在不同临床情况下成功应用的关键。     

Failed intubation in obstetrics

Failed intubation in obstetrics remains a topical issue, a rare but potentially devastating complication of obstetric general anaesthesia. The 2015 guidelines produced following several years of collaborative work between the Difficult Airway Society (DAS) and Obstetric Anaesthetist's Association (OAA) remain the definitive text. While deaths from failed intubation have declined significantly over 30 years, the incidence of failed intubation remains fairly constant at 1:300, with latest studies showing a rate of 1:224. This reflects the significant decline in the use of general anaesthesia for caesarean section over the last three decades; however it also highlights a decreased exposure for trainees to tracheal intubation in the obstetric population.     

广东省困难气道处理清醒插管现状调查及分析

目的 对广东省部分二级以上医疗机构困难气道管理清醒插管技术的现状进行调查,为改进和完善气道管理提供参考. 方法 采用邮寄调查问卷的方法,对全省66家医院进行调查,按照医院等级分为三甲和二甲两组.问卷内容包括困难气道时麻醉方式的选择,是否常规沟通,是否准备鼻腔、收缩鼻腔的药物,是否应用抗胆碱药物,常用哪种抗胆碱药物,表面麻醉药物的种类,表面麻醉的工具,是否做环甲膜穿刺表面麻醉,常用的镇痛镇静药物,在镇痛镇静药物的基础上是否复合表面麻醉等.以医院等级为分组变量,采用校正x2检验进行分析比较. 结果 选择清醒表面麻醉插管处理者分别为三甲30％,二甲18％(P＜0.01),镇静镇痛慢诱导插管处理者三甲28％、二甲23％,清醒插管前会与患者充分沟通的比例均仅为53％,经口不做鼻腔准备的三甲为13％、二甲为23％(P＜0.01).常规使用抗胆碱药物的三甲为36％、二甲为22％(P＜0.01),选择2％利多卡因溶液做表面麻醉的三甲为46％、二甲为34％(P＜0.01).镇静镇痛慢诱导插管时,选用丙泊酚复合芬太尼诱导的最多,三甲为20％,二甲为28％(P＜0.05). 结论 清醒表面麻醉插管应用率不高,清醒插管的各种准备措施不足,对于清醒镇静下的气道管理仍需不断改善.     

Airway management behaviour, experience and knowledge among Danish anaesthesiologists – room for improvement

BACKGROUND: Problems with managing the airways in relation to anaesthesia causes severe morbidity and mortality. A large proportion of these adverse respiratory events is preventable. Still patients continue to die from airway disasters related to anaesthesia, also in Scandinavia. The goal of this study is to identify which efforts are likely to improve this situation. METHODS: A questionnaire asking about experience, behaviour and availability of various items of equipment was mailed to all members of the Danish Society of Anaesthesiologists and were returned anonymously. RESULTS: More than 65% of respondents have sufficient access to a flexible fibrescope, but still 17% of specialists have no access and the vast majority (>67%) has little (1-10 times) or no experience in its use for awake intubation. A total of 52-70% knew the basic principles of the ASA difficult airway algorithm, but despite this only 25-50% would perform awake intubation if a difficult intubation was expected. More than 20% of respondents had experienced preventable airway management mishaps. In all, 18-46% did not know how to oxygenate via the cricothyroid membrane. CONCLUSION: There is room for improvement regarding airway management skills among Danish anaesthesiologists. It is likely that airway management can be improved by: A) Better knowledge of an appropriate plan, algorithm, for airway management. B) Awake intubation used more often. C) More experience in fibreoptic intubation. D) All anaesthesiologists accepting that previous difficult intubation is an indicator of future difficulties. E) All anaesthesiologists knowing, and practising on manikins, how to oxygenate via the cricothyroid membrane. F) Always having a laryngeal mask airway immediately available when inducing anaesthesia.     

Fibreoptic-guided tracheal intubation through i-gel® and LMA® ProtectorTM supraglottic airway devices - a randomised comparison

Fibreoptic-guided tracheal intubation using a supraglottic airway device as a conduit is a technique that can be used in anticipated and unanticipated difficult airway management. Although the i-gel^® supraglottic airway device has been examined for this purpose, the LMA^® Protector^TM, a recently introduced second-generation supraglottic airway device, has not been evaluated for this use in clinical trials. This prospective, randomised clinical trial compared fibreoptic-guided tracheal intubation via i-gel and LMA Protector supraglottic airway devices in two UK hospitals. Patients who were ASA physical status 1 or 2 and undergoing elective surgery requiring tracheal intubation were recruited to the study. A block randomisation list was generated for each study site. The primary outcome measure was time to successful tracheal intubation and secondary outcomes were tracheal intubation success rate, glottic view through flexible fibrescope, ease of tracheal intubation using operator visual analogue score, supraglottic airway device insertion time and insertion success rate. Ninety patients were randomly allocated to each device, and final data analysis was carried out for 92 patients in the i-gel group and 86 patients in the LMA Protector group. Mean (SD) tracheal intubation time in the i-gel and LMA Protector groups were 54.3 (13.8) s and 52.0 (13.0) s, respectively (p = 0.240). There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups. This study demonstrates that the LMA Protector supraglottic airway device is comparable to the i-gel supraglottic airway device as a conduit for fibreoptic-guided tracheal intubation.     

清醒气管插管气道局部麻醉技术的研究进展

对于术前评估为困难气道的患者应当采用清醒镇静表面麻醉下实施气管插管。实施清醒气管插管的关键技术是完善的气道局部麻醉。清醒气管插管是麻醉科医师必须掌握的技能之一。本文通过回顾近十年的文献,旨为麻醉科医师提供清醒气管插管气道局部麻醉技术相关理论参考。     

Videolaryngoscopy vs. direct laryngoscopy use by experienced anaesthetists in patients with known difficult airways: a systematic review and meta‐analysis

Experienced anaesthetists can be confronted with difficult or failed tracheal intubations. We performed a systematic review and meta‐analysis to ascertain if the literature indicated if videolaryngoscopy conferred an advantage when used by experienced anaesthetists managing patients with a known difficult airway. We searched PubMed, MEDLINE, Embase and the Cochrane central register of controlled trials up to 1 January 2017. Outcome parameters extracted from studies were: first‐attempt success of tracheal intubation; time to successful intubation; number of intubation attempts; Cormack and Lehane grade; use of airway adjuncts (e.g. stylet, gum elastic bougie); and complications (e.g. mucosal and dental trauma). Nine studies, including 1329 patients, fulfilled the inclusion criteria. First‐attempt success was greater for all videolaryngoscopes (OR 0.34 (95%CI 0.18–0.66); p = 0.001). Use of videolaryngoscopy was associated with a significantly better view of the glottis (Cormack and Lehane grades 1 and 2 vs. 3–4, OR 0.04 (95%CI 0.01–0.15); p < 0.00001). Mucosal trauma occurred less with the use of videolaryngoscopy (OR 0.16 (95%CI 0.04–0.75); p = 0.02). Videolaryngoscopy has added value for the experienced anaesthetist, improving first‐time success, the view of the glottis and reducing mucosal trauma.     

Prospective randomized comparison of the EasyTube and the esophageal-tracheal Combitube airway devices during general anesthesia with mechanical ventilation

Study Objective

To evaluate the ease of use of two airway devices, the EasyTube (EzT) versus the esophageal-tracheal Combitube (ETC).

Design

Prospective, randomized controlled trial.

Setting

University hospital.

Subjects

80 adult, ASA physical status 1 and 2 patients scheduled for elective surgery.

Interventions

Patients’ tracheas were intubated with the EzT or the ETC in randomized fashion.

Measurements

Difficulty of insertion, time to achieve an effective airway, insertion success rate, maneuvers to achieve an effective airway, oropharyngeal leak pressure, intracuff pressure, ventilatory parameters, success rate of gastric tube insertion, and frequency of adverse effects were compared.

Main Results

Insertion was easier in the EzT than in ETC; insertion of the EzT was rated easy in 36 7cases and moderately difficult in 4 cases versus 26 and 14 cases, respectively, for the ETC (P = 0.014). Less time was required to achieve an effective airway with the EzT than the ETC: 19.4 ± 5.3 sec versus 30.6 ± 4.1 seconds, respectively (P < 0.001). Oropharyngeal leak pressure was higher with the EzT than the ETC (34.3 ± 5.95 vs 31.6 ± 2.42 cm H₂O; P = 0.011). Peak airway pressures for the EZT and the ETC were 22.2 ± 0.99 cm H₂0 and 33.7 ± 1.82 cm H₂O, respectively (P < 0.001). Gastric tube insertion was successful with both devices; however, the EzT allowed insertion of gastric tubes of wider diameter. No severe perioperative adverse events were recorded for either device.

Conclusion

The EzT has distinct advantages over the ETC in airway management, including shorter time to achieve an effective airway and easier insertion.     

Cisto hidático na medula cervical complicada por via aérea difícil com potencial risco de vida: relato de caso

Hydatid cyst in the cervical region is an extremely rare condition that can create challenges for anesthesiologists. Timely recognition of difficult airway and preparing the management plan is crucial to avoid life‐threatening complications such as hypoxic brain damage. We describe a case of difficult airway management in a patient with massive cervical hydatid cyst. We used a low‐dose ketamine‐propofol sedation and lidocaine spray for local oropharyngeal anesthesia. Muscular relaxants were not used, and spontaneous breathing was maintained during intubation. Recognition, assessment, and perioperative planning are essential for difficult airway management in patients with cervical hydatid cyst.     

腰椎手术失败综合征的再手术治疗

[目的]探讨腰椎手术失败综合征（FBSS）再手术治疗的方式和注意事项。[方法]对20例再手术治疗的腰椎手术失败综合征（FBSS）患者进行回顾性研究，综合分析FBSS患者的病史、体征、影像学表现以及术中探查结果等资料。术中行硬膜囊和神经根减压以及自体骨植骨融合，其中12例腰椎失稳的患者辅以椎弓根钉系统固定，术后进行一定的康复锻炼。[结果]术中损伤神经根1例，术后暂时性的脑脊液漏3例。治疗效果参照Ragab的评估标准进行综合评估。本组20例患者，治疗效果优12例，良5例，可2例，差1例；优良率为85％。[结论]FBSS是一多病因多表现的综合征，术前应当综合分析患者的临床表现，寻求病因，制订适宜的手术方案。