Emergency Endotracheal Intubation With a Rigid Stylet of an Infant With Severe Subglottic Stenosis

BackgroundSubglottic stenosis is a frequent complication of endotracheal intubation in children and can create a difficult airway situation for subsequent respiratory illnesses. Difficult airway algorithms are an essential aid when dealing with respiratory failure in clinical situations where ventilation or intubation is unsuccessful.Case ReportA 4-month-old infant with a history of previous endotracheal intubation required endotracheal intubation for stridor and respiratory failure due to croup. There was difficulty intubating the trachea due to severe subglottic stenosis that developed following the previous episode of endotracheal intubation. Successful intubation was facilitated by the use of a rigid endotracheal tube stylet to facilitate passage of an endotracheal tube through the stenotic segment.Why Should an Emergency Physician Be Aware of This?Difficult airway algorithms recommend the use of invasive airway access only as a last resort and noninvasive airway access should be explored prior to their use. The use of a readily available rigid stylet as an alternative method for tracheal intubation should be considered only after more conventional techniques and potential complications have been considered.     

Submental tracheal intubation is an alternative to tracheostomy in oral surgery

A prospective study was performed in 17 patients who had undergone submental tracheal intubation in facial injury, tumors of the upper jaw, and congenital and acquired deformities of the facial skeleton. The time required for intubation, and the adequacy of gas exchange and ventilation during tracheal intubation and an operation was estimated. Submental intubation was successfully carried out in all the patients. The mean time spent on tracheal intubation was 5-6 min. At surgery, there was no chance extubation or endotracheal tube damage, the parameters of ventilation and gas exchange remained to be within the normal range. A submental scar was minimal. There was inflammation and formation of a bad scar or bleeding at the site of intubation in none case. Submental orotracheal intubation is a safe and simple procedure for airway patency and it may be used as an alternative to tracheostomy in maxillofacial injury, tumors of the upper jaw, and congenital and acquired deformities of the facial skeleton.     

The intubating laryngeal-mask airway may be an ideal device for airway control in the rural trauma patient

A review of the literature on advanced airway management indicates that the intubating laryngeal-mask airway (ILMA) may be an ideal device for airway control in the rural trauma patient. The ILMA is an advanced laryngeal-mask airway designed to allow oxygenation of the unconscious patient as well as blind tracheal intubation with an endotracheal tube. The ILMA is an easy-to-use airway with a high success rate of insertion, and requires little training. For the rural physician managing a difficult airway in a trauma patient, the ILMA has been found to be reliable and successful when other techniques fail, such as fiberoptic intubation and direct laryngoscopy. The ILMA has also been reported to cause less hemodynamic change and less injury to the teeth and lips than direct laryngoscopy. Further, the ILMA was found to be easier and faster to use with a higher success rate than either the combitube or endotracheal tube for unskilled healthcare providers. Limitations and complications of the ILMA may include aspiration, esophageal intubation, damage to the larynx or other tissues during blind passage of a tracheal tube, and edema of the epiglottis.     

Evaluation of esophageal tracheal combitube in cardiopulmonary resuscitation

Prompt establishment of an airway is a primary goal in CPR of nonbreathing and unconscious patients. The esophageal tracheal combitube (ETC) is a new airway, designed for emergency intubation providing sufficient ventilation whether the airway is placed into the trachea or into the esophagus. We evaluated the effectiveness of the ETC in 31 patients during CPR. Blood gas analyses obtained during esophageal placement of the ETC showed results comparable to those of ventilation with a conventional endotracheal airway (ETA). The ETC appeared to oxygenate and ventilate patients adequately without complications. The efficacy, safety, and ease of insertion ensure rapid airway control. It is concluded that the ETC provides a sufficient alternative to the ETA whenever ideal conditions or trained staff for endotracheal intubation are not immediately available.     

喷射通气辅助下经喉罩行困难气道气管插管临床研究

目的探讨在喷射通气辅助下经喉罩行困难气道气管插管的方法和可行性。方法选择麻醉前被评估为困难气道、麻醉诱导中发生气管插管困难的择期手术患者68例,随机分为2组:A组(n=34),喷射通气辅助下经LMA气管插管;B组(n=34),经ILMA盲探气管插管。观察两组患者气管导管置入情况及MAP、HR、SPO2、EtCO2、PaO2、PaCO2变化情况。结果两组患者置入LMA或ILMA情况相似,无统计学差异,但和B组相比,A组首次插管成功率明显高于B组,差异有统计学意义(P0.01);麻醉诱导前后各组MAP、HR明显下降而PaO2明显升高,差异显著(P0.05);气管插管操作完成后,B组患者MAP、HR、EtCO2、PaCO2显著升高(P0.05),PaO2显著降低(P0.05);插入导管后,A组MAP、HR、EtCO2、PaCO2明显低于B组(P0.05),PaO2明显高于B组(P0.05)。结论在存在自主呼吸条件下,应用喷射通气辅助下经喉罩行困难气道气管插管安全、有效。     

AANA journal course: update for nurse anesthetists. The SLAM Emergency Airway Flowchart: a new guide for advanced airway practitioners

Advanced airway practitioners in anesthesiology, emergency medicine, and prehospital care can suddenly and unexpectedly face difficult airway situations that can surface without warning during mask ventilation or tracheal intubation. Although tracheal intubation remains the "gold standard" in airway management, it is not always achievable, and, when it proves impossible, appropriate alternative interventions must be used rapidly to avoid serious morbidity or mortality. The SLAM Emergency Airway Flowchart (SEAF) is intended to prevent the 3 reported primary causes of adverse respiratory events (ie, inadequate ventilation, undetected esophageal intubation, and difficult intubation). The 5 pathways of the SEAF include primary ventilation, rapid-sequence intubation, difficult intubation, rescue ventilation, and cricothyrotomy. It is intended for use with adult patients by advanced airway practitioners competent in direct laryngoscopy, tracheal intubation, administration of airway drugs, rescue ventilation, and cricothyrotomy. The SEAF has limitations (eg, suitable only for use with adult patients, cannot be used by certain categories of rescue personnel, and depends heavily on assessment of Spo2). A unique benefit is provision of simple alternative techniques that can be used when another technique fails.     

Selective bilateral bronchial intubation for large, acquired tracheoesophageal fistula

The anesthetic management of patients undergoing tracheoesophageal fistula repair often involves lung separation, usually selective bronchial intubation with a double-lumen endotracheal tube. However, in patients with airway fistulas arising below the tracheal lumen, selective lung ventilation and separation may require unusual methods of airway management. In the patient described in this report, the airway fistulas involved the distal 3 cm of the trachea, approximately half of the left main bronchus 1.5 cm beyond the carina, and the proximal 0.5 cm of the right main bronchus. To separate and ventilate the lungs during the repair of these large and complex airway fistulas, 2 individual Mallinckrodt microlaryngeal endotracheal tubes were used. While lung separation was achieved, contrary to previous reports, the Mallinckrodt's larger and more tapered cuff made positioning in the left main bronchus an ongoing issue that required the use of a conventional endotracheal tube and, eventually, intubation of the bronchus from the surgical field. Future cases involving complex airway fistulas should consider endotracheal tube limitations and other methods of providing ventilation such as high-frequency jet ventilation or cardiopulmonary bypass.     

Double-lumen endotracheal tube for one-lung ventilation through a fresh tracheostomy stoma: a case report

For one-lung ventilation in many surgical cases, double-lumen endotracheal tubes are the first-line choice for airway management. For most cases, double-lumen endotracheal tubes are faster, easier to place, cheaper, and less prone to malposition than today's bronchial blocker devices. This report describes an elective tracheostomy and the use of a double-lumen endotracheal tube directly through the fresh stoma site for a 55-year-old man with a known difficult airway who had undergone a left-sided radical neck dissection and postoperative radiation 10 years earlier. The 11-hour operation, in supine and lateral positions, occurred uneventfully. This report documents one-lung ventilation of a 4-hour duration using a double-lumen endotracheal tube directly through a fresh tracheostomy site without supplemental continuous positive airway pressure to maintain an oxyhemoglobin saturation of more than 97% as measured by pulse oximetry. During the past decade, unique modifications of the use of bronchial blockers and their use with tracheostomies have been reported. Complications have been reported with double-lumen endotracheal tubes and with more recent classic and modified uses of the bronchial blockers. This article discusses appropriate preoperative patient selection and intraoperative airway management plans for the modified use of one-lung anesthesia airway devices with an emphasis on use with tracheostomies.     

Clinical review: Management of difficult airways

Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainly at induction of anesthesia. Nevertheless, claim reports emphasize that airway emergencies, tracheal extubation and/or recovery of anesthesia phases are still associated with death or brain damage, indicating that additional educational support and management strategies to improve patient safety are required. The present brief review analyses specific problems of airway management related to difficult tracheal intubation and to difficult mask ventilation prediction. The review will focus on basic airway management including preoxygenation, and on some oxygenation and tracheal intubation techniques that may be performed to solve a difficult airway.     

Complications of emergency tracheal intubation: immediate airway-related consequences: part II

Airway management in the stable, elective operating room patient is typically exceptionally safe. Conversely, the acute deterioration of an intensive care unit or floor patient being rescued by a clinician unfamiliar with the patient's past and current history combined with an incomplete physical examination places the critically ill patient in a precarious, potentially life-threatening position. Emergency airway management in remote locations outside the confines of the operating room is complex and stressful due to immense airway challenges coupled with the high risk of hemodynamic and airway complications. Despite the commonality of difficulties with mask ventilation, laryngoscopy, and tracheal intubation in this population, relatively sparse literature deals with these subjects. Consequences of airway management should be openly discussed as a first step toward improving airway safety. This is the second of 2 reviews, "Complications of Emergency Tracheal Intubation," and focuses on the immediate airway-related consequences during emergency tracheal intubation in the remote location.     

A new tracheal tube and methods to facilitate ventilation and placement in emergency airway management

The “jet endotracheal tube” (JET) has been designed to facilitate emergency intubation in apnoeic or paralyzed patients with a difficult airway. We investigated the efficiency of jet ventilation to maintain adequate oxygenation and ventilation using the initially designed JET, either with its distal tip positioned above vocal cord and pointed directly at or 45° to the right of the vocal cord opening midline in 10 adult paralyzed pigs. The effectiveness of using end tidal carbon dioxide pressure (PetCO₂), chest rise and breath sounds to facilitate tracheal placement of the JET blindly in a simulated difficult airway was studied. All complications of using the JET were noted. Jet ventilation with the distal tip of the JET pointed directly at, not 45° to the right of vocal cord opening midline, provides adequate oxygenation and ventilation during intubation. In a simulated difficult airway, PetCO₂, chest rise and breath sounds were all effective methods to assist placement of the JET blindly, and the combination of all three methods works the best. No serious complications were detected with the use of the JET. Our results suggest that a correctly positioned JET guided by monitoring PetCO₂, chest rise and breath sound provides adequate oxygenation and ventilation during intubation in apnoeic pigs, and facilitates the intubation blindly in a simulated difficult airway. No serious complications were observed using the JET in this study. In patients requiring emergency intubation, a JET with PetCO₂ monitoring catheter and the instructions for use may be a useful addition to the airway management devices.     

Artificial lung ventilation using separate intubation of two main bronchi in patients with acute respiratory failure

Two-luminal endotracheal tubes are used for one-lung or selective ventilation. However, in some cases there is a need for not only to isolate the lung, but also to exclude the trachea from ventilation, for example, in injuries of its distal portions. The use of a two-luminal endobronchial tube under these conditions does not always permit isolation of an affected area since the tracheal cuff is frequently above the site of an injury. For the treatment of such complications and for selective ventilation, it is proposed to use separate intubation of two main bronchi under guidance of fibrobronchoscopy. For this, two single-luminal bronchial tubes having different inlet openings are simultaneously used; one tube is inserted translaryngeally, the other is placed through the tracheostomic opening. The tube having a cut in the bronchial cuff with an opening for ventilation of the right upper lobar bronchus is employed for the right main bronchus. There are examples how to use separate intubation of the main bronchi in patients with acute respiratory failure. This procedure may be the method of choice for treating tracheal distal injuries and, if required, for performing selective artificial ventilation. The effects of the latter are analyzed.     

Ivan Magill: Forceps for intratracheal anesthesia

Nasal tracheal intubation is a standard airway management technique in emergency medicine. Although possessing a number of advantages, this procedure, when performed under laryngoscopic visualization, possesses all the complications of oral endotracheal intubation. In addition, a number of complications are specific to this airway technique, including epistaxis, perforation of the posterior pharyngeal wall, trauma to the adenoids, rupture of the endotracheal tube balloon, and transient bacteremia. The procedure was first described in 1920 by two anesthesiologists, Stanley Rowbotham and Ivan Magill. Each developed a device to aid the insertion of the tip of the endotracheal tube into the glottis. Magill's forceps are still the instrument of choice for nasal tracheal intubation carried out under laryngoscopic visualization.     

Mainstream Time-Capnography: An Aid to Select an Appropriate Uncuffed Endotracheal Tube in Small Children

Uncuffed endotracheal tubes are commonly used in children in an attempt to decrease the potential for pressure induced tracheal injury. However, uncuffed endotracheal tube may increase the risk of aspiration and lead to erratic delivery of preset tidal volume during mechanical ventilation. Therefore, it is desirable to intubate trachea with an appropriate but not an oversized endotracheal tube. In children, for selecting an endotracheal tube, a variety of formulas and techniques are used to find the endotracheal tube size that minimizes both pressure induced tracheal injury and aspiration potential or variable ventilation. Air-leak following tracheal intubation can be recognized by the presence of audible leak, by auscultation over the trachea, by palpation over the trachea and by observing effects of positive end-expiratory pressure on inspiratory expiratory tidal volume difference during mechanical ventilation. We describe mainstream time-capnograph as an aid to recognize leak around the endotracheal tube and its utility to determine appropriate endotracheal tube size in small children. Neema PK, Jayant A, Manikandan S, Rathod RC. Mainstream time-capnography: An aid to select an appropriate uncuffed endotracheal tube in small children.     

Critically injured patients, inaccessible airways, and laryngeal mask airways

Managing the airway of a critically injured trauma patient in the prehospital environment is challenging, especially when access to the patient's airway is limited as is often the case in vehicle entrapment incidents. This paper reports the use of the laryngeal mask airway as an adjunct to airway management when attempts using simple airway management techniques have failed to provide adequate oxygenation and ventilation and limited access to the patient precluded endotracheal intubation.     

Disposcope内镜在气管插管中的应用进展

随着可视化技术的进步,越来越多的可视化工具被应用于气管插管领域,其拥有定位准确、创伤小、插管成功率高及并发症少等优点,增加了麻醉医师气道管理安全性和有效性。帝视内镜(DE)是一款可视管芯类气管插管工具,具有可视、镜身可弯曲和无线传输等特点。该文就目前DE在气管插管中的应用进展进行综述。     

An Unusual Cause of Intubating Laryngeal Mask Obstruction Preventing Successful Intubation in the Emergency Department

BackgroundThe intubating laryngeal mask airway (ILMA) allows providers to blindly intubate through the device. We report a case of foreign material obstructing passage of an endotracheal tube (ET) through an ILMA.Case ReportA 45-year-old man with unknown past medical history was found obtunded with an apparent intentional drug and alcohol overdose, and required tracheal intubation. We opted to use an ILMA to optimize preoxygenation prior to intubation. His upper dentures were removed and an ILMA was inserted without complication; ventilation was easily performed. Blind tracheal intubation was attempted; the ET was inserted through the ILMA and was unable to be advanced past 15 cm despite multiple attempts, including repositioning the ILMA and rotating the ET. The ILMA was removed to prepare for video laryngoscopy. He was subsequently successfully intubated using a standard geometry video laryngoscope, which showed no anatomical abnormalities. After the case, the ILMA was inspected and the bowl of the ILMA was found to be occluded with denture adhesive.Why Should an Emergency Physician Be Aware of This?This case report demonstrates that it is possible that foreign material within the ILMA can make successful intubation impossible, despite successful placement and ventilation through the device. Maneuvers may be performed to attempt successful ET intubation, but when unsuccessful, removal of the ILMA and alternate airway management must be performed.     

Anesthetic management of thoracoscopic pulmonary wedge resection with a giant tracheal diverticulum in the carina: a case report and review of the literature

A tracheal diverticulum (TD) is a rare disease that is usually diagnosed as an incidental finding on thoracic computed tomography or bronchoscopy. TDs can be classified as congenital or acquired. In patients undergoing surgery, TDs can result in difficult intubation, difficult ventilation, pneumothorax, and other complications. We herein report a case of anesthetic management of thoracoscopic pulmonary wedge resection in a patient with a giant TD in the carina. Intraoperative double-lumen intubation and single-lung ventilation were challenging to perform. Fiberoptic-guided intubation was helpful, and intraoperative management was tailored to avoid diverticulum rupture. In this report, we also review complications related to TD in surgical patients undergoing mechanical ventilation. Ventilation is one of the most prominent anesthetic challenges. The close collaboration of the entire medical team was a key factor in the successful management of this rare case.     

Preoxygenation in critically ill patients requiring emergency tracheal intubation

OBJECTIVE: To determine the effectiveness of preoxygenation with 100% oxygen in the critically ill patient in preparation for emergency tracheal intubation. DESIGN: Nonrandomized, controlled trial. SETTING: Large, level 1 trauma center, tertiary care intensive care unit. PATIENTS: Critically ill patients failing noninvasive respiratory support techniques who require tracheal intubation followed by mechanical ventilation. INTERVENTIONS: A baseline arterial blood gas was obtained on noninvasive therapy and 4 mins post-100% oxygen therapy with a bag-mask assembly. Best effort to achieve a tight-fitting mask seal was pursued coupled with other mask ventilation maneuvers to optimize noninvasive oxygenation and ventilation. MEASUREMENTS AND MAIN RESULTS: A total of 42 patients consecutively intubated during the 15-month study period were studied. The baseline Pao2 (mean +/- sd) with concurrent noninvasive support was 67 +/- 19.6 mm Hg (range, 43-88 mm Hg) and increased a mean of 37 mm Hg to 103.8 +/- 63.2 mm Hg after 4 mins of preoxygenation with 100% oxygen. A total of 36% of patients had minimal changes (+/-5%) in their baseline Pao2, and only 19% increased their baseline Pao2 by at least 50 mm Hg after preoxygenation maneuvers. CONCLUSIONS: The critically ill patient has little reserve to tolerate interruption of oxygen delivery and, thus, is at risk for hypoxemia during emergency airway management. Preoxygenation efforts as described in this clinical trial appear to be marginally effective in regard to providing a reasonable safeguard against hypoxemia during laryngoscopy and endotracheal intubation.     

Is field intubation useful?

The establishment and maintenance of an adequate airway is often the single most important initial therapy provided to a victim of severe injury. This may be accomplished by simple techniques such as placement of an oral or nasopharyngeal airway as well as bag-mask ventilation techniques. More advanced techniques such as endotracheal intubation require a higher level of training and expertise for both prehospital and hospital providers. Although paramedics routinely practice endotracheal intubation in the field, there are increasing reports on the many potential risks associated with these procedures as well as increased morbidity and mortality in both pediatric and adult patients. These data have important implications for field airway management in the critically ill trauma patient.