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.     

Trachealruptur durch zu stark geblockte Tubusmanschette

The authors report a tracheal rupture in a 34-year-old patient who was primarily intubated following generalised seizures and loss of consciousness (Rüsch endotracheal tube). Some hours later, she developed high ventilatory airway pressures and subcutaneous and mediastinal emphysema were noted. Reintubation with a high-volume, low-pressure endotracheal tube was planned when it was noted that the ballon of the Rüsch tube was grossly overinflated. Endotracheal tube cuff pressure was measured and found to be greater than 120 cm H₂O (the maximum measurement possible with the manometer). The diagnosis of tracheal rupture was confirmed by fiberoptic bronchoscopy. The patient immediately underwent a throacotomy and a 3-cm tear of the pars membranacea of the trachea was sutured with a dural patch. To maintain low airway pressures post-operatively, she remained sedated for 2 days and received a muscle relaxant to permit pressure-controlled ventilation. In this case, it can be concluded that excessive inflation of the endotracheal tube cuff resulted in the tracheal rupture. Other possible causes and results of tracheal rupture are discussed.     

Video RIFL: a rigid flexible laryngoscope to facilitate airway management

The video RIFL (rigid flexible laryngoscope) is an airway management adjunct designed to facilitate endotracheal intubation. It is a novel stylet-based laryngoscope that incorporates a complementary metal oxide sensor distal chip imaging system and real-time articulation tip. The device combines features desired in fiberoptic bronchoscopy as well as in video laryngoscopy. Four cases involving its use in difficult airway management are presented.     

Airway access using an endotracheal tube changer for safe extubation in an infant with a difficult airway

We present a case where airway access was maintained using an endotracheal tube changer (ETC) after extubation in an infant with a difficult airway. A 4-month-old male infant with bilateral cleft lip and palate, micrognathia, schizencephaly, undescended testis, and abnormality of chromosomes 10 was scheduled for bilateral cleft lip repair. After anesthesia induction with thiamylal and vecuronium, we found that laryngoscopy was difficult (Cormack and Lehane grade III) despite external laryngeal compression. Since there was no fiberoptic bronchoscopy for an infant in our department, and the fact that epiglottis could be visualized with external laryngeal compression, three anesthesiologists attempted tracheal intubation in turn and intubation was successful at last. The surgery was concluded uneventfully; but since endotracheal intubation had been difficult, special care was taken for extubation. We used an ETC for tracheal tube passing into the endotracheal tube at the time of extubation. Although using the ETC in infant with difficult airway for extubation remains controversial, we believe that for a difficult airway, even in an infant, a flexible ETC is a useful device for temporal airway access after extubation.     

The air-Q as a conduit for fiberoptic aided tracheal intubation in adult patients undergoing cervical spine fixation: A prospective randomized study

The air-Q? intubating laryngeal airway is a supraglottic airway device which was designed to allow adequate patient ventilation and reliable blind endotracheal tube intubation.ObjectivesTo investigate the efficacy of air-Q as a conduit for fiberoptic endotracheal intubation in adult patients with limited cervical spine mobility compared with fiberoptic-guided intubation alone.DesignProspective randomized study.PatientsSixty adult (12 female) patients, ASA physical status I and II scheduled for cervical spine fixation under general anesthesia. Patients were randomized into two parallel groups. Exclusion criteria includes, history of difficult airway, mouth opening <3 cm, Mallampati class ?III and, increased risk of aspiration of gastric contents.InterventionIn the first group, endotracheal intubation was aided with the fiberoptic scope while patients in the second group were intubated with the fiberoptic scope guided with the air-Q as a conduit. The number of attempts and time to successful insertion of air-Q and endotracheal tube were recorded. The fiberoptic quality of the vocal cords view as seen through the air-Q and ease of endotracheal tube insertion were also assessed.ResultsThe air-Q was easily inserted in all patients of the second group with mean insertion time (22.6 ± 4.3 s). The air-Q provided a good fiberoptic view of the vocal cords and successful tracheal intubation in 29 (96.7%) patients of the second group on the first attempt. Time to tracheal intubation in the second group was significantly shorter than the first group (21.6 ± 5.7 and 29.8 ± 6.2 s respectively). The air-Q was easily removed without any complications.ConclusionsThe air-Q as a conduit for fiberoptic scope provided a better view of the vocal cords and, less insertion time of the endotracheal compared to fiberoptic-aided endotracheal intubation in adult patients with limited cervical spine mobility scheduled for cervical spine fixation.     

Fiberoptic Bronchoscopy-Assisted Endotracheal Intubation in a Patient With a Large Tracheal Tumor

In the event of a high degree of airway obstruction, endotracheal intubation can be impossible and even dangerous, because it can cause complete airway obstruction, especially in patients with high tracheal lesions. However, a smaller endotracheal tube under the guidance of a bronchoscope can be insinuated past obstructive tumor in most noncircumferential cases. Here we report a case of successful fiberoptic bronchoscopy-assisted endotracheal intubation in a patient undergoing surgical resection of a large, high tracheal tumor causing severe tracheal stenosis. A 42-year-old Chinese man presented with dyspnea, intermittent irritable cough, and sleep deprivation for one and a half years. X-rays and computed tomography scan of the chest revealed an irregular pedunculated soft tissue mass within the tracheal lumen. The mass occupied over 90% of the lumen and caused severe tracheal stenosis. Endotracheal intubation was done to perform tracheal tumor resection under general anesthesia. After several failed conventional endotracheal intubation attempts, fiberoptic bronchoscopy-assisted intubation was successful. The patient received mechanical ventilation and then underwent tumor resection and a permanent tracheostomy. This case provides evidence of the usefulness of the fiberoptic bronchoscopy-assisted intubation technique in management of an anticipated difficult airway and suggests that tracheal intubation can be performed directly in patients with a tracheal tumor who can sleep in the supine position, even if they have occasional sleep deprivation and severe tracheal obstruction as revealed by imaging techniques.Key words: Tracheal tumors, Fiberoptic bronchoscopy, Difficulty intubation, Difficult airwayPrimary tumors of the trachea, mostly malignant, are rare, accounting for fewer than 0.1% of all tumors.¹ Surgical resection is the major option that has the potential to cure all patients with benign and low-grade tumors and most patients with malignant tracheal tumors.¹ Since surgical procedure often requires the airway to be shared by the anesthetist and the surgeon, patients who undergo tracheal tumor resection often present with a considerable degree of airway obstruction, which makes anesthetic management during surgical resection challenging.² In the event of a high degree of airway obstruction, endotracheal intubation can be impossible and even dangerous because it can cause complete airway obstruction, especially in patients with high tracheal lesions.³ However, tumors are not circumferential in most cases, and a small endotracheal tube can be insinuated past a highly obstructive tumor under the guidance of bronchoscopy.³ Here we report a case of successful fiberoptic bronchoscopy-assisted endotracheal intubation in a patient undergoing surgical resection of a large, high tracheal tumor causing severe tracheal stenosis.     

The new air-QTM intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series

The air-Q intubating laryngeal airway (ILA) is a new supraglottic airway device which may overcome some limitations inherent to the classic laryngeal mask airway for tracheal intubation. We present a case series of patients with anticipated difficult airway in whom the air-Q ILA was successfully used as a conduit for fiberoptic intubation.     

Tracheal intubation for two patients with lingual tonsil hyperplasia and prospect of difficult airway management

Lingual tonsil hyperplasia is rare, but may cause difficult or inpossible tracheal intubation. We experienced two cases of tracheal intubation for lingual tonsil hyperplasia. A 71-yr-old man was scheduled for resection and biopsy of symptomatic hypertrophied lingual tonsils. In this patient, we performed oro-tracheal intubation by rigid laryngoscopy from left oral angle, because left hypertrophied lingual tonsils are smaller than those on the right side. A 44-yr-old man was scheduled for resection of symptomatic hypertrophied lingual tonsils after lingual tonsillitis. In this patient, we performed nasotracheal intubation using fiberoptic bronchoscopy with assist of jaw-lift and tongue-extension. When an anesthesiologist can predict the abnormality of lingual tonsils, these methods might be recommended for difficult airway and intubation. However, it is necessary to prepare a difficult airway management set including laryngeal mask airway, intubating laryngeal mask airway, fiberoptic bronchos-copy and transcutaneous tracheotomy set. And most important is preliminary evaluation of airway and cautious planning of tracheal intubation.     

The laryngeal tube for difficult airway management: a prospective investigation in patients with pharyngeal and laryngeal tumours

BACKGROUND AND OBJECTIVE: Since the introduction of the laryngeal mask into clinical practice, various additional supraglottic ventilatory devices have been developed. Although it has been demonstrated that the laryngeal tube is an effective airway device during positive pressure ventilation no clinical study has been performed thus far regarding its use in patients with predicted ventilation and intubation difficulties. METHODS: The aim of this study was to prospectively evaluate the use of the laryngeal tube for temporary oxygenation and ventilation in adult patients with supraglottic airway tumours scheduled to undergo a pharyngeal-laryngeal oesophagoscopy and bronchoscopy under general anaesthesia. In addition to our standard airway management with face mask ventilation and rigid bronchoscopy, all patients were temporarily ventilated with an laryngeal tube. Also, in patients requiring laryngeal biopsies, endotracheal intubation was performed with a 6.0 mm microlaryngeal tracheal tube. Minute ventilation volumes, tidal volumes, ventilation pressures, end-expiratory CO2 concentration, oxygen saturation and arterial blood gas samples were measured. RESULTS: From 54 enrolled patients only patients with relevant tumour masses were evaluated (n = 23). Mask ventilation was performed without difficulty in 15 of 23 patients. Mechanical ventilation with the laryngeal tube was possible in 22 of 23 patients with an audible leak present in three. Conventional endotracheal intubation was successfully performed in 19 of 23 patients. During face mask ventilation, minute volume, tidal volume, ventilation pressure, end-tidal CO2, oxygen saturation and arterial PO2 were significantly lower and PCO2 significantly higher (P < 0.05, paired t-test). No statistically significant differences were noted between the laryngeal tube and the microlaryngeal tracheal tube. CONCLUSIONS: The possibility of difficult ventilation and intubation must always be considered, in patients with supraglottic airway tumours. In these cases, the laryngeal tube can be considered for routine airway management and may be useful in the 'cannot-intubate' situation although difficulties should be anticipated in patients with previous irradiation, specifically of the throat area.     

Iatrogenic tracheal rupture after endotracheal intubation

Tracheobronchial rupture after tracheal intubation is rare in clinical practice. Possible contributory factors are multiple vigorous attempts at intubation, overinflation of the cuff, anatomic alterations, and predisposing individual factors. These lesions can be detected by bronchoscopy, which is the most effective method to confirm the diagnosis and determine the exact location and extent of the tear. We report the case of a woman with membranous tracheal rupture after endotracheal intubation. Subcutaneous emphysema, pneumomediastinum and bilateral pneumothorax were noted after extubation. The diagnosis was confirmed by fiberoptic bronchoscopy and computed tomography scan, and the patient required emergency surgical repair.     

Air-Q the Intubating Laryngeal Airway: Comparative study of hemodynamic stress responses to tracheal intubation via Air-Q and direct laryngoscopy

Background: Tracheal intubation is the gold standard for securing airway. Tracheal intubation through DLS produces marked hemodynamic stress responses. The Air-Q is a new supraglottic airway device. The purpose of this study was to determine whether endotracheal intubation through Air-Q is associated with lesser hemodynamic stress responses.Methods: 60 patients scheduled for elective surgery under general anesthesia requiring endotracheal intubation were randomly assigned into two groups. Direct laryngoscopy group and Air-Q group. Blood pressure and heart rate were recorded before, after induction, immediately after intubation and every minute for 4 min after intubation. The intubation time was recorded. Upon removal of the Air-Q, trauma to the upper airway was reported.Results: The intubation time was shorter in the DLS group compared with the Air-Q group (P value < 0.05). A significant reduction in BP was evident after the induction of anesthesia in both groups. Immediately after intubation, there was a significant increase in BP compared with the preintubation values. A decline was inspected between 1 and 4 min postintubation in both groups with significant difference immediately, at 1 and 2 min postintubation between the two groups. There were significant increase in HR immediately, at 1 and 2 min postintubation compared with the preintubation values, but there was no significant difference at each time point between two groups. Sore throat was more in the Air-Q group (P value <0.05).Conclusion: The hemodynamic stress response to intubation by Air-Q is less than that of DLS despite the longer duration of the former.     

Difficult airway management due to obesity and lingual tonsillar hyperplasia

We experienced anesthesia for a female patient of BMI 39.2 with unanticipated lingual tonsillar hyperplasia. At the induction of anesthesia, both mask ventilation and tracheal intubation were difficult due to the lingual tonsillar hyperplasia. However, tracheal intubation was performed by Intubating LMA with the fiberoptic bronchoscopy. After the placing of TE (the catheter for tracheal tube exchanger), the tracheal tube was extubated without any airway trouble. Following the extubation, the opening of the respiratory tract was evaluated by TE and the fiberoptic bronchoscopy. In this case we confirmed that the ASA difficult airway algorithm was also useful in the presence of lingual tonsillar hyperplasia.     

An unusual case of airway obstruction at the tip of an endotracheal tube caused by insertion of a nasogastric tube

We report an unusual case of ventilatory impediment caused by the obstruction of an endotracheal tube (ETT) by a nasogastric (NG) tube. A 72-year-old woman with bronchial asthma was scheduled for colostomy closure. An ETT of 7.5-mm internal diameter (ID) could not be advanced, and finally a 5.0-mm ID ETT was placed, because she had post-intubation tracheal stenosis. When an NG tube was inserted after endotracheal intubation, ventilation suddenly became nearly impossible. She was treated for an asthmatic attack, but her respiratory condition did not recover. We then exchanged the ETT for a laryngeal mask airway (LMA) and removed the NG tube. It was suspected that the cause of the airway obstruction was that the NG tube in the esophagus compressed the membranous portion of the stenotic trachea and the tip of the ETT was obstructed.     

Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study

Background: Air‐Q^TM intubating laryngeal airway (ILA) has been used successfully as a conduit for tracheal intubation in pediatric difficult airway. However, its use as an airway device and conduit for intubation in infants is not yet evaluated. Aims: The primary objective was to evaluate ILA as a conduit for tracheal intubation in infants, and secondary objectives were to evaluate ILA in terms of ease of insertion and ventilation, oropharyngeal leak pressure (OLP), glottic view, and complications. Methods: Twenty infants with normal airway were included. After induction of general anesthesia and neuromuscular blockade, ILA (size 1.0/1.5) was inserted. Fiberoptic bronchoscope (FOB)–guided intubation and removal of ILA with the stabilizing stylet was attempted. Results: The mean age and weight of the infants were 7.5 ± 2.3 months and 7.3 ± 1.8 kg. The ILA sizes 1.0 and 1.5 were inserted in 10 infants each according to the weight of the infants. The mean OLP was 18.5 ± 1.8 cm H₂O, and mean time for insertion of ILA was 13.3 ± 3.9 s. Glottic view was grade I in 6, grade II in 1, grade III in 4, and grade IV in nine infants. Tracheal intubation was successful in 19/20 infants. The mean endotracheal tube (ETT) insertion time and mean total time (ILA insertion to the confirmation of ETT placement) were 95.6 ± 32.3 s and 306.42 ± 120.2 s respectively. Conclusion: The ILA is a safe and easy‐to‐use supraglottic airway device for intubation with FOB in infants with normal airway. Insertion and removal of ILA are easy with satisfactory oropharyngeal seal and ventilation.     

Anesthetic management of a patient with tracheal bronchus with one lung ventilation]

A 56-year-old-male with malignant pleural mesothelioma of the left lung underwent pneumonectomy and pleurectomy. Fiberoptic bronchoscopy was not done preoperatively. Anesthesia was induced rapidly and a double-lumen endobronchial tube was inserted. When we checked the position of the tube with a fiberoptic bronchoscope, we found that the normal right upper lobe bronchus was absent and that the inflated tracheal cuff had obstructed the right upper lobe bronchus originating above the carina. Then we changed the double-lumen endobronchial tube to a endotracheal tube with the blocker. Thereafter, the surgery was completed safely and his postoperative course was uneventful. Routine bronchoscopy is essential just after intubation and before extubation of the endobronchial tube in safe airway management. How to use a fiberoptic bronchoscope to check the position of a double-lumen endobronchial tube is also discussed.     

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.     

Comparative study between Air-Q and Intubating Laryngeal Mask Airway when used as conduit for fiber-optic

This study compared Air-Q and Intubating LMA when used as a conduit for endotracheal intubation.MethodsOne hundred patients scheduled for surgical operations under general anesthesia were randomly allocated into two equal groups (n = 50). Group I: Air-Q and group II: Intubating Laryngeal Mask Airway (ILMA) in both groups intubation was done by Fiberoptic bronchoscope (FOB) through study device. After induction of anesthesia, patients were ventilated with Air-Q or ILMA. Then, endotracheal tube (ETT) was inserted through study device. Recorded measurements were as follows: number of attempts and duration of insertion of device, peak airway pressure and fiberoptic grading of laryngeal view. Also, we recorded number of attempts and duration of insertion of ETT and the incidence of blood stain on device and sore throat grading.ResultsDuration of insertion of Air-Q was 13.300 ± 3.471 s, whilst that of ILMA was 19.640 ± 4.737 s (p < 0.001). In group I, peak airway pressure was 26.400 ± 2.176 cmH₂O, whilst, in group II, it was 25.260 ± 1.468 cmH₂O (p < 0.01). Full view of vocal cords amounted to 78% and 26% of Groups I and II patients, respectively (p < 0.001). Time of insertion of ETT was 33.5 ± 6.795 s in group I, whilst in group II, it was 39.5 ± 6.566 s (p < 0.001). Blood stain was found on supraglottic device in 46% and 22% of cases in Groups I and II, respectively (p < 0.01).ConclusionAir-Q proved to be an excellent conduit for endotracheal intubation compared to the ILMA.     

Fastrach intubation in patients with cervical disease

The Fastrach laryngeal mask for intubation is a new device designed for blind orotracheal intubation in patients with criteria predictive of difficult airway control. The new device looks like the conventional laryngeal mask but offers a series of design changes that allow orotracheal intubation to be accomplished without visualization of the glottis. The rigid metal tube is bent and incorporates a metal handle; the two fixed bars that prevent the epiglottis from falling and blocking the opening have been replaced by a moveable bar that rises with the passage of the endotracheal tube and the exit of the V-shaped metal tube guides the endotracheal tube that was specially designed for this use. We describe three patients with cervical disease, one with advanced ankylosing spondylitis, one with traumatic luxation of the C6-C7 articulation and one diagnosed of two cervical disk hernias. All their tracheas were intubated without difficulty through the Fastrach mask with the patients' heads in neutral position. Although fiberoptic bronchoscopy is the method of choice in patients with cervical problems, the non-availability of the technique and the need for training in its use make the Fastrach mask an alternative worth considering for such patients.     

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.     

Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy.

During a period of 11 1/2 months, 41 of 217 adult burn patients admitted to the U.S. Army Institute of Surgical Research Burn Center required endotracheal intubation or tracheostomy for management of the airway and/or ventilatory assistance. Permanent upper airway sequelae were recorded and related to presence of inhalation injury, duration of tube placement, cuff pressure, and pulmonary compliance. An "inhalation injury scoring system" based upon history, physical examination, bronchoscopic findings, and abnormalities at 133xenon lung scan correlated well with postinjury alteration in compliance and subsequent sequelae. Significant inhalation injury was found in 35 patients. Seventeen of the study patients survived (Group I) and 24 patients expired (Group II). Group I patients were screened for permanent airway sequelae by fiberoptic bronchoscopy, xeroradiograms, and spirometry undertaken an average of 11 weeks after extubation or decannulation. Four patients developed tracheal stenosis and five patients had significant tracheal scar granuloma formation. Sequelae were generally more frequent and more severe after tracheostomy than after translaryngeal intubation, and duration of tube placement and presence of a tracheal stoma were the most important etiological factors in permanent damage. For initial respiratory support, we favor the use of translaryngeal (nasotracheal) tubes for periods up to 3 weeks. Fiberoptic bronchoscopic examination is the most reliable follow-up method for detecting anatomic damage in such patients. Spirometry can be used as a noninvasive screening test and xeroradiograms are helpful in assessing the degree of tracheal stenosis.