Guided tactile probing: a modified blind orotracheal intubation technique for the problem-oriented difficult airway

We present 'tactile probing', a guided approach to blind orotracheal intubation to secure a problem-oriented anticipated difficult airway in a 55-year-old male patient scheduled for elective surgical tracheostomy for a postradiotherapy translaryngeal carcinoma. Standard techniques to gain the airway were inapplicable in this case and awake flexible fiberoscopy-aided intubation had already failed.     

A new modification for safer submental orotracheal intubation

In patients in whom a tracheal tube cannot be inserted through the nostrils due to multiple facial trauma or hypoplasty of the nose, submental orotracheal intubation (SOI) is performed to avoid tracheostomy. We report a new modification for SOI to minimize the risk of apnea. A 20-year-old man was scheduled for sagittal split ramus osteotomy. As the patient had severe hypoplasia of the nose, SOI was planned. Following orotracheal intubation with a spiral tube (first tube), a submental tunnel was surgically created. A second tube that had been confirmed, in advance, to snugly fit into the proximal end of the first tube was passed into the submental tunnel via a polypropylene cylinder and connected between the first tube and the breathing circuit. After careful withdrawal of the second tube through the submental tunnel, the first tube was directly connected to the breathing circuit after removal of the second tube. Although this technique requires additional time, apnea time is minimal even in patients in whom withdrawal of the tracheal tube through the submental tunnel takes time, because the second tube forms a link between the first tube and the breathing circuit, making it possible to ventilate the patient throughout the procedure.     

A clinical evaluation of blind orotracheal intubation using Trachlight in 511 patients

We used Trachlight for blind orotracheal intubation (ordinary tracheal tube or Portex Blueline in 305 cases, and reinforced tube or Mallinckrodt Safety-Flex in 206 cases) for general anesthetic procedures, and evaluated its technical features along with related complications. With ordinary tubes, 93% of the patients could be intubated successfully at the first attempt. Unsuccessful intubation even at the third attempt occurred in 3 patients (1%). One patient was complicated with a long epiglottis and the cause was unknown in the other patients. With reinforced tubes, 83% of the patients could be intubated at the first attempt but 8 patients (4%) could not. Of them, four patients received too large reinforced tubes straightening the bending of the stylet. Each of the three patients had a narrow larynx, mandibular retraction or obese neck making transillumination difficult. In the remaining one patient, the cause was unknown. Complication found in 30% of the patients was sore throat that seemed severer than that caused by laryngoscope. One patient developed minor tracheal bleeding probably due to injury of the mucosa. The elevation of the blood pressure at intubation with this device was not as high as that by direct laryngoscopy. We conclude that Trachlight leads to intubation with a high success rate, and that care should be taken not to damage the tracheal mucosa by blind insertion.     

光棒和插管型喉罩在盲探气管插管中的比较

目的 比较光棒和插管型喉罩在盲探气管插管中的应用效果.方法 拟行气管内插管患者100例,ASA Ⅰ或Ⅱ级,随机均分为光棒组(A组)和插管型喉罩组(B组).记录诱导前、诱导后、插管即刻、插管后1、3、5 min的SBP、DBP、HR、SpO2变化及首次插管成功率和总成功率、插管时间、并发症等.结果 A、B组首次插管成功率分别为76%和80%,插管总成功率分别为96%和98,插管时间分别为(38.9±16.1)s和(76.1±18.0)s(P<0.05).结论 光棒和插管型喉罩在盲探气管插管中成功率高、并发症少,可安全用于盲探气管插管.     

Rapid-sequence orotracheal intubation: a comparison of three techniques

The authors compared tracheal intubating conditions using three techniques for rapid-sequence orotracheal intubation. Sixty patients were randomly assigned to one of three groups: priming with vecuronium (0.01 mg/kg priming dose, 4-min priming interval, 0.14-mg/kg intubating dose along with thiopental 4-6 mg iv); timing with vecuronium (0.15-mg/kg intubating dose given before thiopental and timed to weakness of hand grip); and succinylcholine (1.5 mg/kg). Blinded intubators graded intubating conditions 60 s after the induction of anesthesia with thiopental. Intubation scores in the succinylcholine group were significantly better than in the priming group (P = 0.009). Intubation scores of the succinylcholine and the timing groups were not significantly different. Use of the timing principle for rapid-sequence orotracheal intubation is a reliable alternative in cases where succinylcholine is contraindicated.     

Evaluation of the SCOTI device for confirming blind nasal intubation

The sonomatic confirmation of tracheal intubation (SCOTI) is a new device used to confirm the correct placement of tracheal tubes. It utilises a sonic technique for recognition of a resonating frequency for detection of tracheal intubation. We compared its predictive value with that of the clinical auscultatory method and a capnograph to confirm 132 blind nasal intubations using three different tracheal tubes [red rubber (n = 82), polyvinyl chloride (n = 33) and RAE preformed nasal (n = 17)]. SCOTI correctly identified 70.8% of intubations and chest auscultation did so 99.2% of times. All results were confirmed using a capnograph. The SCOTI device gave a false-negative value in 37 patients (28%) and a false-positive result in two patients (1.5%). The response time for confirming intubations was 2.5 (1.5) s for the SCOTI, 4.1 (1.1) s for a capnograph and 40 (9.4) s for the auscultatory method. The erroneous results shown by the SCOTI device were highest when polyvinyl chloride tubes with a Murphy's eye were used for intubation. This study shows that this device is not very useful for ascertaining the correct placement of tracheal tubes after blind nasal intubation.     

Tooth injuries during intubation: a new preventive device

This study analyses 126 cases of dental injuries occurring during endotracheal intubation, reported to the service of litigations of the hospitals in Lyon over a ten-year period, and giving rise to a complaint. The overall rate was 1 out of 4,000 cases of intubation. The true incidence may be greater. As expected, the upper jaw teeth are most often involved, especially the left incisors. Among them 24.3% of the involved teeth were normal. Dental fractures were the most common lesion, together with total or partial dislocations. A questionnaire was sent to 534 anaesthetists to assess the main difficulties which they encounter when carrying out endotracheal intubation. The results of this enquiry demonstrated that anaesthetists were very aware of dental risks when carrying out intubation, and that there was a lack of efficient protective measures. Among them 81.2% claimed they would use a protective device from time to time, and 17.4% routinely, if one were available. Therefore we designed such a device. It is gutter-shaped, made with two different plastics, the more rigid one being on the outside. It fits over the upper jaw teeth. There is an indentation in the front, to check whether the device is placed correctly. The inner surface is made of foam which dulls the pressure which may be exerted on the device during intubation. This device was tested in 108 patients. Intubation was easy with the device in place in 73.2% of patients; mouth opening was reduced by a mean of 4.2 +/- 0.5 mm. The device made intubation more difficult, and even impossible, in patients whose mouth opened no more than 3.5 cm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Tracheal rupture a complication of orotracheal intubation

One of the most frequent anesthesiological manoeuvres is orotracheal intubation (OTI). Many complications can occur during OTI, one of these is the rupture of the trachea (TR) and/or of the bronchi. The aim of this study is to highlight the risk of TR during OTI. Over a period of three years of activity (1997-1999) in the Cardiothoracic Department of Pisa University nine patients we treated, eight of which were women ranging from 35 to 95 years of age. In the majority of the cases clinical signs like subcutaneous emphysema of the face and neck, hemoptysis and dyspnoea, variably combined were present. An X-ray of the thorax carried out on six patients did not permit the diagnosis. Bronchoscopy was the diagnostic examination in all nine patients. Seven cases were treated by senior anaesthesiologists, without stilet and OTI was easy. Predictive elements for difficult intubation were not observed in any case. Only one patient had a voluminous intrathoracic goitre dislocating the trachea. The nine patients were all treated surgically as they were all symptomatic and with important transmural lacerations that caused pneumothorax or pneumomediastinum. The survival percentage in the third month is 100%. Although rare TR must be suspected when clinical signs are present; bronchoscopy is the examination which permits diagnosis and a correct therapy.     

全身麻醉诱导后经多功能插管型喉罩盲探气管插管的临床观察

目的 观察全身麻醉患者经多功能插管型喉罩盲探行气管插管的可行性及安全性. 方法 选择ASA分级Ⅰ、Ⅱ级,年龄18～77岁择期行全身麻醉下手术的患者100例.麻醉诱导使用芬太尼4μg/kg、丙泊酚1.5～2.0 mg/kg、罗库溴铵0.6 mg/kg,诱导后先置入多功能插管型喉罩,通气行纤维支气管镜检查并定位后,经喉罩盲探插入配套的鹰嘴气管导管,观察放置喉罩及气管插管的次数和时间,记录诱导前、放置喉罩前后、气管插管前后的BP和HR.结果 置入喉罩和气管插管均1～2次成功,置入喉罩时间平均(11.0±3.2)s,气管插管时间平均(10.5±6.2)s,插管成功退出喉罩后即刻SBP、DBP和HR与诱导前比较,差异均无统计学意义(P＞0.05). 结论 经多功能插管型喉罩盲探气管插管,安全、快捷、有效,患者舒适、刺激小,比经典的插管型喉罩盲探插管更具有优势.