Alternative techniques for tracheal intubation

Conventional direct laryngoscopy with the curved Macintosh blade is a fundamental skill for all anaesthetists and has been the cornerstone of airway management for many years. This technique relies on the operator aligning the oro-pharyngo-laryngeal structures and inserting an endotracheal tube into the trachea under direct vision. There is a recognized failure rate with this technique and thus alternative techniques for tracheal intubation should be available for use in difficult situations. Awake fibreoptic intubation (AFOI) remains the ‘gold standard’ method for securing the airway in an anticipated difficult intubation. Advances in optical technology over recent years have lead to the development of several rigid indirect devices, which improve glottic visualization by enabling the operator to ‘see around the corner’. With improved views at laryngoscopy these videolaryngoscopes are emerging as important tools in airway management and useful teaching and training aids.     

Alternative techniques for tracheal intubation

Conventional direct laryngoscopy with the curved Macintosh blade is a fundamental skill for all anaesthetists and has been the cornerstone of airway management for many years. This technique relies on the operator aligning the oro-pharyngo-laryngeal structures and inserting an endotracheal tube into the trachea under direct vision. There is a recognized failure rate with this technique and thus alternative techniques for tracheal intubation should be available for use in difficult situations. Awake fibreoptic intubation (AFOI) remains the ‘gold standard’ method for securing the airway in an anticipated difficult intubation. Advances in optical technology over recent years have lead to the development of several rigid indirect devices, which improve glottic visualization by enabling the operator to ‘see around the corner’. With improved views at laryngoscopy these videolaryngoscopes are emerging as important tools in airway management and useful teaching and training aids.     

Laryngeal tube II : alternative airway for children?

Difficult airway situations both expected and unexpected, present major challenges to every anesthesiologist, especially in pediatric anesthesia. However, the integration of extraglottic airway devices, such as the laryngeal mask, into the algorithm of difficult airways has improved the handling of difficult airway situations. A device for establishing a supraglottic airway, the laryngeal tube (LT), was introduced in 1999. The LT is an extraglottic airway designed to secure a patent airway during either spontaneous breathing or controlled ventilation. The design of the device has been revised several times and a further development is the LTS?II/LTS-D, which provides an additional channel for the insertion of a gastric drain tube. This article reports on the successful use of the LTS?II in 12 children aged from 2 days to 6 years when endotracheal intubation, alternative mask or laryngeal mask ventilation failed. Use of the LTS?II was associated with a high level of success, securing the airway when other techniques had failed. The potential advantage of the LTS?II over the standard LT is an additional suction port, which allows gastric tube placement and can be used as an indirect indicator of correct placement. With a modified insertion technique using an Esmarch manoeuvre, placement was simple and fast to perform. In emergency situations when direct laryngoscopy fails or is too time-consuming the LTS?II tube is recommended as an alternative device to secure the airway. As with all extraglottic airway devices, familiarity and clinical experience with the respective device and the corresponding insertion technique are essential for safe and successful use, especially in emergency situations.     

视频喉镜在气道管理中应用的进展

视频喉镜是能够提供上呼吸道间接视野的新型气管插管设备。在困难气道管理处理方面．与直接喉镜相比．视频喉镜能够改善声门显露的Cormack—Lehane分级,并能在较短时间内达到相同或更高的气管插管成功率。尽管视频喉镜可获得非常好的声门显露．但是应用视频喉镜时插入和推进气管导管有时可发生失败。到目前为止,尚无确切证据表明在正常或困难气道患者视频喉镜应取代直接喉镜。     

Infraglottic airway devices and techniques

Infraglottic airway management techniques, such as intubation of the trachea with a cuff-sealed endotracheal tube, offer significant advantages for the anaesthetized patient, especially for patients in critical condition.There are numerous ways of intubation of the trachea; the most common and popular is direct laryngoscopy. The variety of laryngoscope blades offers choices to solve difficult intubations, but all different techniques and devices need experience in routine clinical use.In case of failure, unsuccessful attempts to intubate the trachea should be limited to three, in order to use different—e.g. supraglottic or fibreoptic—techniques.Nasotracheal intubation causes an inherent risk of severe epistaxis, which may severely compromise airway management options and endangers the patient's life. Prior to passing the tube through the nose, direct laryngoscopy should be performed to estimate the Cormack–Lehane score.Rigid intubation fibrescopes—as flexible ones—do improve the view of the larynx and permit tracheal intubation with less head and cervical spine movement than direct laryngoscopy. Success with these devices requires considerable experience and clinical practice.The use of retrograde intubation has reduced during recent years, mainly due to the availability of flexible and rigid intubation fibrescopes.The EasyTube—a relatively new device—combines the advantages of both an endotracheal tube with a supraglottic airway device.The Combitube is a well-established emergency airway used widely for solving unanticipated and anticipated difficult airways. International guidelines recommend the use of Combitube following the number of studies and reports associated with its use.     

Brief report: Tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway

BACKGROUND: The Bonfils intubation fibrescope (BIF), a rigid, straight and reusable fibreoptic device, is being used increasingly to facilitate endotracheal intubation after direct laryngoscopy has failed. We tested the hypothesis that, with the BIF compared to direct laryngoscopy, the rate of failed endotracheal intubation could be reduced in patients with a difficult airway, simulated by means of a rigid cervical immobilization collar. METHODS: Seventy-six adults undergoing elective gynecological surgery under general anesthesia were randomly assigned to have endotracheal intubation, facilitated with either a standard size 3 Macintosh laryngoscope blade, or the BIF. A rigid cervical immobilization collar was used to simulate a difficult airway, by reducing mouth opening and limiting neck extension. If endotracheal intubation could not be achieved within two attempts, the cervical collar was removed, and direct laryngoscopy was performed thereafter, using a Macintosh blade in all subjects. The success rate of endotracheal tube placement was the primary outcome variable. RESULTS: Patient characteristics were similar in the two groups. After neck immobilization, the inter-incisor distance was reduced to 2.6 +/- 0.7 cm (Macintosh) and 2.6 +/- 0.8 cm (BIF). Tube placement was successful in 15/38 (39.5%) patients with a Macintosh blade, and in 31/38 patients with the BIF (81.6%; P = 0.0003). Time required for tube placement was 53 +/- 22 sec (Macintosh) and 64 +/- 24 sec (BIF; P = 0.15). CONCLUSION: The Bonfils intubation fibrescope is a more effective intubating device for patients with immobilized cervical spine and significantly limited inter-incisor distance, when compared to direct laryngoscopy.     

The use of a laryngeal mask airway after a prolonged suspension laryngoscopy to preserve a vocal cord fat graft

A 62-yr-old man presented for a microdirect laryngoscopy and vocal cord fat grafting under jet ventilation. After a prolonged laryngoscopy, the patient developed hypercapnea and upper airway obstruction secondary to traumatic epiglottitis. The placement of a laryngeal mask airway provided ventilation and allowed for direct visualization of the patient's inflamed epiglottis without disruption of the patient's fat graft. Because of its placement above the cords and its effectiveness in providing adequate ventilation, we propose intermittent laryngeal mask airway ventilation as a bridge, in lieu of endotracheal intubation, in microdirect laryngoscopy cases in which ventilation during emergence may be difficult and the insertion of an endotracheal tube would disrupt the surgical procedure.     

Alternative techniques for tracheal intubation

Conventional direct laryngoscopy with the curved Macintosh blade is a fundamental skill for all anaesthetists and has been the cornerstone of airway management for many years. This technique relies upon the operator aligning the oro-pharyngo-laryngeal structures and inserting a tracheal tube into the trachea under direct vision. However, there is a recognized failure rate with this technique, thus alternative techniques for tracheal intubation are available and should be considered. Awake fibreoptic intubation remains the ‘gold standard’ method for securing the airway in an anticipated difficult airway. Advances in optical technology over recent years have led to the development of several rigid indirect devices, which improve glottic visualization by enabling the operator to ‘see around the corner’. With improved views at laryngoscopy these devices have emerged as important tools in airway management and are useful teaching and training aids.     

Direct laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury

Perioperative airway management in trauma victims presenting with penetrating thoracic spine injury poses a major challenge to the anesthesiologist. To avoid further neurological impairment it is essential to ensure maximal cervical and thoracic spine stability at the time of airway manipulation (e.g., direct laryngoscopy and endotracheal intubation). Airway management in the prone position additionally increases the incidence of cervical/thoracic spine injury, difficult ventilation, and difficult airway instrumentation. Although awake fiberoptic intubation of the trachea is considered the gold standard for airway instrumentation in patients with posterior thoracic/cervical trauma, this technique requires the patient's cooperation, special equipment, and extensive training, all of which might be difficult to accomplish in emergency situations. We herein present the first reported case of an adult trauma patient who underwent direct laryngoscopy and endotracheal intubation under general anesthesia in the prone position. Although the prone position is not the standard position for airway instrumentation with direct laryngoscopy and endotracheal intubation under general anesthesia, our experience indicates that this technique is possible (and relatively easy to perform) and might be considered in an emergency situation.     

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。     

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.     

Video-laryngoscopes in the adult airway management: a topical review of the literature

The aim of the present paper is to review the literature regarding video-laryngoscopes (Storz V-Mac and C-Mac, Glidescope, McGrath, Pentax-Airway Scope, Airtraq and Bullard) and discuss their clinical role in airway management. Video-laryngoscopes are new intubation devices, which provide an indirect view of the upper airway. In difficult airway management, they improve Cormack-Lehane grade and achieve the same or a higher intubation success rate in less time, compared with direct laryngoscopes. Despite the very good visualization of the glottis, the insertion and advancement of the endotracheal tube with video-laryngoscopes may occasionally fail. Each particular device's features may offer advantages or disadvantages, depending on the situation the anaesthesiologist has to deal with. So far, there is inconclusive evidence indicating that video-laryngoscopy should replace direct laryngoscopy in patients with normal or difficult airways.     

Erfolgreicher Einsatz des Intubationsendoskops nach Bonfils in der präklinischen Notfallmedizin

Background

The Bonfils intubation endoscope has been available for securing difficult airways for several years. However, very little is known about its use in a prehospital setting. The aim of this study was to examine the use of the Bonfils intubation fibrescope for endotracheal intubation in a physician-led prehospital emergency medical service.

Material and methods

The Bonfils intubation endoscope was used to secure the airway in patients requiring endotracheal intubation in a prehospital setting. The success rate, total time for securing the airway and possible complications during the procedure were evaluated.

Results

A total of 30 patients were included in this study and in 26 patients (87%) endotracheal intubation was successful at the first attempt. In 3 cases (10%) intubation was successful after the second attempt and endotracheal intubation was unsuccessful in 1 patient due to a technical problem. The median total time until the airway was secured was 17 s (min.: 7 s, max.: 30 s). Vision was limited in 3 cases (10%) due to post-traumatic oropharyngeal bleeding.

Summary

The Bonfils intubation endoscope can be used with a high success rate for securing the airway in a prehospital physician-led emergency medical system. Our data suggests that the Bonfils intubation endoscope might be an alternative device to direct laryngoscopy.     

Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate? <?6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S_pO₂? <?90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)? <?9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)? <?90?mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate ?>?29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.     

Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate ?29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.     

喉罩在长时间支撑喉镜检查后保护声带脂肪移植物中的应用

一例62岁男性患者在喷射通气下行直接显微喉镜检查和声带脂肪移植。长时间喉镜检查后,患者因为创伤性会厌炎出现过度通气和上呼吸道梗阻。放置喉罩后可进行通气,并可直视下观察患者会厌炎症,且不损伤脂肪移植物。因为喉罩放置在声带上方并能保证有效通气,所以我们认为,直接显微喉镜检查后,患者苏醒期间可能出现通气困难,而气管内插管可能会影响手术操作,宜选择间断性喉罩通气替代气管内插管作为一种有效的过渡性通气方式。     

Difficult laryngoscopy made easy with a “BURP”

Displacement of the larynx by backward, upward and rightward pressure on the thyroid cartilage or “BURP” may improve visualization of the glottis in some cases of difficult direct laryngoscopy. In a patient with the Treacher-Collins syndrome in whom conventional laryngoscopy had proved impossible and tracheal intubation extremely difficult, this manoeuvre exposed the entire glottis and made tracheal intubation under direct vision easy. In a patient with protruding upper incisors and a prominent premaxilla which precluded a view of the glottis by conventional laryngoscopy, “BURP” again revealed the glottic opening and simplified the placement of an endotracheal tube. This experience suggests that “BURP” be considered as a potential aid in the management of difficult direct laryngoscopy.     

Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.     

Soft palate trauma induced during GlideScope intubation

The GlideScope (GVL; Saturn Biomedical Systems, Burnaby, British Columbia, Canada) is a rigid indirect video laryngoscope device that facilitates exposure of the larynx for placement of the endotracheal tube. This blade also reduces the requirement for anterior displacement of the tongue. A unique feature is the acutely angled blade which provides an improved glottic view. Herein, we present 2 instances of soft palate trauma, a rare oropharyngeal complication linked to GlideScope use. In the first case, the GlideScope was used for pedagogical purposes for intubation in a knee surgery. In the second case, GlideScope was used to secure the airway of an obese patient with a Mallampati class 3 airway and, therefore, presumed difficult intubation.Use of the GlideScope requires less lifting force (approximately 0.5-1.5 kg) than direct laryngoscopy to achieve visualization of the glottis, so less traction is applied to soft tissue. However, meticulous care must be taken even by experienced operators to ensure correct use to decrease the incidence of oropharyngeal injuries, especially in patients with difficult airways. Increased vigilance makes the GlideScope an invaluable tool despite its potential complications.     

A new method for endotracheal intubation with the Bullard laryngoscope]

The Bullard laryngoscope is an anatomically shaped rigid fiber optic instrument designed for indirect laryngoscopy and intubation. It requires no neck extension nor flexion to perform laryngeal intubation. This characteristic is especially useful in the case of difficult airway. The Bullard laryngoscope, however, with which it is easy to visualize the cords, has not been popular yet, because using the intubating forceps mechanism requires a certain amount of skill. The intubation method developed by us with Bullard laryngoscope has been tried on 26 patients with difficult airway and ten patients with normal airway. An endotracheal tube is inserted through nostril, and intubation is performed viewing the tube and larynx during all the processes of intubation. Three kinds of endotracheal tubes, i.e. Magill type plain tubes, styletted tubes, and directional tip tubes, are compared. The method using a directional tip tube (Endotrol) is concluded as the best among them. The Endotrol tube itself has such a suitable shape for nasal intubation that it can be introduced to the larynx with little directional change. Therefore, our method is mastered with a shorter training period than the intubation method with fiber-optic laryngoscopes. In conclusion, our intubation method with the Bullard laryngoscopes using the directional tip tubes (Endotrol) is useful for patients with difficult airways, and is also nontraumatic and easy to perform.