Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients

BACKGROUND: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients. METHODS: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation). RESULTS: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity. CONCLUSIONS: The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.     

Accuracy and Reliability of the Self-inflating Bulb to Verify Tracheal Intubation in Out-of-hospital Cardiac Arrest Patients

Background: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients.

Methods: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either bag-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETco2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation).

Results: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETco2 (60%). When the SIB test is combined with the ETco2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity.     

Airway management during spaceflight: A comparison of four airway devices in simulated microgravity

BACKGROUND: The authors compared airway management in normogravity and simulated microgravity with and without restraints for laryngoscope-guided tracheal intubation, the cuffed oropharyngeal airway, the standard laryngeal mask airway, and the intubating laryngeal mask airway. METHODS: Four trained anesthesiologist-divers participated in the study. Simulated microgravity during spaceflight was obtained using a submerged, full-scale model of the International Space Station Life Support Module and neutrally buoyant equipment and personnel. Customized, full-torso manikins were used for performing airway management. Each anesthesiologist-diver attempted airway management on 10 occasions with each device in three experimental conditions: (1) with the manikin at the poolside (poolside); (2) with the submerged manikin floating free (free-floating); and (3) with the submerged manikin fixed to the floor using a restraint (restrained). Airway management failure was defined as failed insertion after three attempts or inadequate device placement after insertion. RESULTS: For the laryngoscope-guided tracheal intubation, airway management failure occurred more frequently in the free-floating (85%) condition than the restrained (8%) and poolside (0%) conditions (both, P < 0.001). Airway management failure was similar among conditions for the cuffed oropharyngeal airway (poolside, 10%; free-floating, 15%; restrained, 15%), laryngeal mask airway (poolside, 0%; free-floating, 3%; restrained, 0%), and intubating laryngeal mask airway (poolside, 5%; free-floating, 5%; restrained, 10%). Airway management failure for the laryngoscope-guided tracheal intubation was usually caused by failed insertion (> 90%), and for the cuffed oropharyngeal airway, laryngeal mask airway, and intubating laryngeal mask airway, it was always a result of inadequate placement. CONCLUSION: The emphasis placed on the use of restraints for conventional tracheal intubation in microgravity is appropriate. Extratracheal airway devices may be useful when restraints cannot be applied or intubation is difficult.     

Strukturqualität im Notarztdienst

BACKGROUND: A survey amongst emergency physician bases in the federal state of Baden-Wuerttemberg in 2001 concerning equipment available for airway management and the treatment of acute coronary syndromes showed striking differences with respect to implementation of European norms and international recommendations. The survey was repeated in 2005 to evaluate the development of the equipment in physician-staffed ambulance systems. METHODS: A questionnaire was sent to all emergency physician bases (ground ambulance and helicopter) registered with the Ministry of Health in Baden-Wuerttemberg. Questions encompassed availability of options to verify correct tracheal tube position (e.g. capnometry), supraglottic airway devices as alternatives to mask ventilation and tracheal intubation, 12-lead ECG and fibrinolytic agents. RESULTS: In 2001, 116 out of 127 bases (91.3%) participated and in 2005, 107 out of 120 bases (89.2%) returned the questionnaire. With availability in 97.2% of bases, prevalence of supraglottic airway devices is almost state-wide (2001: 54.3%, p<0.001, Fisher's exact test). The topics verification of tracheal tube position (2005: 73.8%, 2001: 26.7%, p<0.001), 12-lead ECG (2005: 89.7%, 2001: 52.6%, p<0.001) and fibrinolytic therapy (2005: 59.8%, 2001: 12.9%, p<0.001) showed noticeable increases in the corresponding availability, however, distinct regional structural deficits were still present in 2005. CONCLUSIONS: A favourable trend could be found concerning the equipment of physician-staffed ambulances state-wide. Further efforts must be undertaken to ensure the complete implementation of legal requirements and international recommendations concerning provision of medical equipment.     

The UK helicopter ambulance tasking study

Introduction

Helicopter ambulances are a scarce and expensive resource and their use carries significant risk for crew and patients.

Aims

To establish and compare the tasking criteria, dispatch arrangements and crew configuration for all helicopter ambulance services in the United Kingdom.

Methods

Structured telephone interview of all helicopter ambulance services in the United Kingdom.

Results

Replies were received from all 16 UK air ambulance services. Crew configuration varies between services. Nine services had paramedic only crew, 3 had physician/paramedic crew and 4 had a paramedic crew with variable physician input.Only 2 of the 16 services used a paramedic in the dispatch process.There were 67 different tasking criteria used for air ambulance dispatch across all air ambulances with a range from 4 to 23 for individual air ambulance services.

Conclusion

Given the financial burden and physical risk of air ambulance use, there should be a more standardised approach to the tasking, dispatch and crew configuration of air ambulances in the UK.     

Airway Management during Spaceflight: A Comparison of Four Airway Devices in Simulated Microgravity

Background: The authors compared airway management in normogravity and simulated microgravity with and without restraints for laryngoscope-guided tracheal intubation, the cuffed oropharyngeal airway, the standard laryngeal mask airway, and the intubating laryngeal mask airway.

Methods: Four trained anesthesiologist-divers participated in the study. Simulated microgravity during spaceflight was obtained using a submerged, full-scale model of the International Space Station Life Support Module and neutrally buoyant equipment and personnel. Customized, full-torso manikins were used for performing airway management. Each anesthesiologist-diver attempted airway management on 10 occasions with each device in three experimental conditions: (1) with the manikin at the poolside (poolside); (2) with the submerged manikin floating free (free-floating); and (3) with the submerged manikin fixed to the floor using a restraint (restrained). Airway management failure was defined as failed insertion after three attempts or inadequate device placement after insertion.

Results: For the laryngoscope-guided tracheal intubation, airway management failure occurred more frequently in the free-floating (85%) condition than the restrained (8%) and poolside (0%) conditions (both, P < 0.001). Airway management failure was similar among conditions for the cuffed oropharyngeal airway (poolside, 10%; free-floating, 15%; restrained, 15%), laryngeal mask airway (poolside, 0%; free-floating, 3%; restrained, 0%), and intubating laryngeal mask airway (poolside, 5%; free-floating, 5%; restrained, 10%). Airway management failure for the laryngoscope-guided tracheal intubation was usually caused by failed insertion (> 90%), and for the cuffed oropharyngeal airway, laryngeal mask airway, and intubating laryngeal mask airway, it was always a result of inadequate placement.     

A United Kingdom national obstetric intubation equipment survey

BackgroundFailed intubation is relatively common in the obstetric patient. Overall, there has been a decline in experience of general anaesthesia in obstetrics. The level of anaesthetic preparedness in the event of a difficult obstetric intubation is unknown.MethodsWith approval from the Obstetric Anaesthetists’ Association, a national postal survey of obstetric units in the United Kingdom was conducted. The survey addressed airway equipment availability and existence of difficult airway algorithms and formal difficult airway drills. The number of deliveries, general anaesthetic cases and failed intubations in each unit was also ascertained.ResultsOne hundred and eighty-seven units completed the national obstetric intubation equipment survey questionnaire (78% response rate). All obstetric units possessed a laryngoscope with a normal handle and adult Macintosh blade, a bougie and a laryngeal mask airway. A 7.0 internal diameter endotracheal tube was most often used for securing the airway, and 90% of units stored all airway equipment on a designated difficult airway trolley. A fiberoptic bronchoscope was not readily available and on average it would take >10 min to obtain. A failed intubation incidence of 1:309 was reported. Only one third of units promoted difficult airway training.ConclusionEssential airway equipment was readily available in the event of a difficult obstetric intubation, with the exception of a fiberoptic bronchoscope. Few units conduct difficult airway training.     

The laryngeal mask airway in obstetrical anaesthesia

The laryngeal mask airway (LMA) has been used extensively to provide a safe airway in spontaneously breathing patients who are not at risk from aspiration of gastric contents. The role of the LMA in the event of a failed intubation in an obstetrical patient, and its place in a failed intubation drill remains unclear. Two hundred and fifty consultant obstetric anaesthetists in the United Kingdom were asked to complete an anonymous questionnaire regarding their views about using the laryngeal mask airway (LMA) in obstetrical anaesthesia. The LMA was available in 91.4% of obstetric units. Seventy-two per cent of anaesthetists were in favour of using the LMA to maintain oxygenation when tracheal intubation had failed and ventilation using a face mask was inadequate. Twenty-four respondents had had personal experience with the LMA in obstetrical anaesthesia, eight of whom stated that the LMA had proved to be a lifesaver. We believe that the LMA has a role in obstetrical anaesthesia when tracheal intubation has failed and ventilation using a face mask proves to be impossible, and it should be inserted before attempting cricothyroidectomy.     

Tracheal intubation

Tracheal intubation is the placement of a tube into the trachea. It provides the gold standard for airway protection ensuring the trachea and lungs are protected from the aspiration of stomach contents. The tube can be used for ventilation permitting oxygen delivery and the removal of carbon dioxide; it also has a role in delivering drugs. If the tracheal tube is misplaced and not recognized, then hypoxia will occur which may be fatal.Tracheal intubation was first recorded in 1543, but few advances were made until the First World War when its importance was recognized. Sir Ivan Whiteside Magill was predominantly involved in the development of tracheal intubation and he designed several pieces of equipment we still use in our clinical practice today.Prior to intubation the required equipment should be assembled and checked and the indication for tracheal intubation confirmed. An experienced and trained assistant is required and an anaesthetist with advanced airway skills should be available. Following tracheal intubation, correct placement of the tube should be confirmed by clinical signs and capnography. The tube should be carefully secured to avoid displacement.     

Tracheal intubation

Tracheal intubation is the placement of a tube into the trachea. It provides the gold standard for airway protection ensuring the trachea and lungs are protected from the aspiration of stomach contents. The tube can be used for ventilation permitting oxygen delivery and the removal of carbon dioxide; it also has a role in delivering drugs. If the tracheal tube is misplaced and not recognized, then hypoxia will occur which may be fatal.Tracheal intubation was first recorded in 1543, but few advances were made until the First World War when its importance was recognized. Sir Ivan Whiteside Magill was predominantly involved in the development of tracheal intubation and he designed several pieces of equipment we still use in our clinical practice today.Prior to intubation the required equipment should be assembled and checked and the indication for tracheal intubation confirmed. An experienced and trained assistant is required and an anaesthetist with advanced airway skills should be available. Following tracheal intubation, correct placement of the tube should be confirmed by clinical signs and capnography. The tube should be carefully secured to avoid displacement.     

Difficult airway equipment in English emergency departments

The need for tracheal intubation in the emergency department is often unpredictable and precipitous in nature. When compared with the operating room, a higher incidence of difficult intubation is observed. There are currently no accepted guidelines with respect to the stocking of difficult airway equipment in the emergency department. We have conducted a telephone survey to determine the availability of equipment for the management of the difficult airway in English emergency departments. Overall, the majority of units held a curved laryngoscope blade (100%), gum elastic bougie (99%) and surgical airway device (98%). Of alternative devices for ventilation, a laryngeal mask airway was kept by 65% of departments, a needle cricothyroidostomy kit by 63% and an oesophageal-tracheal twin-lumen airway (Combitube) by 18%. Of alternative devices for intubation, fewer than 10% held a retrograde intubating kit, intubating laryngeal mask, bronchoscope or lighted stylet. Seventy-four per cent of departments held an end-tidal carbon dioxide detector.     

The use of end-tidal carbon dioxide monitoring to confirm endotracheal tube placement in adult and paediatric intensive care units in Australia and New Zealand

The use of end-tidal carbon dioxide monitoring to assist in confirming endotracheal tube placement is currently not mandatory in intensive care units (ICUs) in Australia and New Zealand. Early detection of failed tracheal intubation is vital to optimize management and to prevent complications. Questionnaires were sent to the lead clinician/head of department of all 66 intensive care units approved for training purposes by the Joint Faculty of Intensive Care Medicine in Australia and New Zealand. The methods used to confirm correct endotracheal tube placement, the availability of end-tidal carbon dioxide monitoring and its role in confirming endotracheal tube placement in the intensive care unit were explored. Completed questionnaires were received from 61 of the 66 centres (92.4%). Wide variation in the method of confirmation of endotracheal tube position was demonstrated, with 23 (37.7%) of units using sub-optimal methods. Sixty (98.3%) of units had end-tidal carbon dioxide monitoring available. Thirty-eight (62%) units shared monitors between several beds; and 22 (36%) had one monitor per bed. End-tidal carbon dioxide monitoring was used routinely to confirm endotracheal tube placement in 42 (68.8%) units. Fifty-two respondents (83.3%) felt that end-tidal carbon dioxide monitoring was superior to other methods for confirming endotracheal tube placement in critically ill patients. Thirty-eight respondents (62.3%) thought that end-tidal carbon dioxide monitoring should be mandatory to confirm tracheal intubation in the intensive care unit. If it were available, 42 respondents (68.8%) would use end-tidal carbon dioxide monitoring for confirmation of every intubation. Mandatory end-tidal carbon dioxide confirmation of endotracheal tube placement was policy in 33 (54.1%) of the intensive care units.     

Survey of use of end-tidal carbon dioxide for confirming tracheal tube placement in intensive care units in the UK

The use of end-tidal carbon dioxide monitoring to confirm the correct placement of a tracheal tube immediately after intubation is mandatory in the operating theatre. Tracheal intubation in critically ill patients can be challenging. Quick and accurate confirmation of tracheal tube placement is essential to minimise complications. This survey explored the use of end-tidal carbon dioxide monitoring to confirm tracheal tube placement in intensive care units in the UK. Questionnaires were sent to either the lead clinician or clinical director of randomly selected general adult intensive care units. One hundred and twenty-seven replies were received from the 215 questionnaires sent (response rate 59%). Twenty per cent of the units did not have an end-tidal carbon dioxide monitor, 20% had one end-tidal carbon dioxide monitor per bed and 60% had one end-tidal carbon dioxide monitor between several beds. Only 50% of the units having an end-tidal carbon dioxide monitor use it to confirm correct tracheal tube placement. Of these 50%, only about a third use it for every intubation. Seventy-two per cent of respondents felt that end-tidal carbon dioxide is well suited to confirm correct placement of tracheal tube in critically ill patients, but 50% did not think that confirmation using end-tidal carbon dioxide should be mandatory for intubations outside the operating theatre. Half of the units not having end-tidal a carbon dioxide monitor cited lack of resources as a reason. In summary, although four in every five intensive care units surveyed have end-tidal carbon dioxide monitors, only a small proportion use them to confirm correct placement of tracheal tube after intubation.     

A French survey of paediatric airway management use in tonsillectomy and appendicectomy

BACKGROUND: There are no epidemiological data describing tracheal intubation and laryngeal mask airway (LMATM) use in paediatric anaesthesia. This analysis focused on the factors leading to the indication for an airway management procedure, i.e. tracheal intubation and laryngeal mask airway vs face mask during general anaesthesia for tonsillectomy and appendicectomy. METHODS: The data were recorded in the French survey of Practical Anaesthesia performed in 1996. Two main types of surgical procedures were selected: tonsillectomy and appendicectomy because of the number of patients and the need to use an invasive airway management technique. RESULTS: During a 1-year period, 627 anaesthetics for appendicectomy and 653 anaesthetics for tonsillectomy were recorded in the sample under consideration. Tracheal intubation or laryngeal mask airway was undertaken in 66% of tonsillectomies and 84% of appendicectomies. Univariate analysis showed that tracheal intubation/laryngeal mask were used significantly more often in older children, with long duration of anaesthesia, in nonambulatory procedures and in procedures performed at an academic centre. When these variables were included in a multivariate analysis, the duration of anaesthesia over 30 min was a factor linked to the use of tracheal intubation/laryngeal mask airway for the two types of surgery (P < 0.0001). For tonsillectomy, inpatients were 2.9 times more likely to be intubated (or have an laryngeal mask airway) than were outpatients. For appendicectomy, older children were 3.4 times more likely to be intubated (or have an laryngeal mask airway) than younger children. CONCLUSIONS: This large French survey shows that the use of tracheal intubation/laryngeal mask airway in this country is primarily related to a predicted long duration of anaesthesia.     

Equipment for airway management

Airway management provides gas exchange, protects the lungs from injury and permits treatment. This requires safe, effective and reliable use of equipment, often in combination. A management plan with backups is essential, but a sequence of logical plans forming an airway management strategy is better. Correct equipment use needs correct knowledge, skill and attitudes. There are five approaches to airway management in which equipment is used: facemask ventilation with adjuncts, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes (including the flexible fibreoptic bronchoscope), front of neck (transtracheal) access using cricothyroidotomy or tracheostomy and airway clearance with suction or foreign body removal. Tracheal tubes and aids for placement are described.     

Equipment for airway management

Airway management provides gas exchange, protects the lungs from injury and permits treatment. This requires safe, effective and reliable use of equipment, often in combination. A management plan with backups is essential, but a sequence of logical plans forming an airway management strategy is better. Correct equipment use needs correct knowledge, skill and attitudes. There are five approaches to airway management in which equipment is used: facemask ventilation with adjuncts, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes (including the flexible fibreoptic bronchoscope), front of neck (transtracheal) access using cricothyroidotomy or tracheostomy and airway clearance with suction or foreign body removal. Tracheal tubes and aids for placement are described.     

Management choices for the difficult airway by anesthesiologists in Canada

PURPOSE: This study assessed difficult airway management, training and equipment availability among Canadian anesthesiologists. METHODS: A postal survey of active members of the Canadian Anesthesiologists' Society was conducted in 2000. Respondents chose an induction condition and intubation technique for each of ten difficult airway scenarios. Availability of airway devices in their workplaces was assessed. Chi square analyses were used to compare groups. A P value of < 0.05 was considered statistically significant. RESULTS: Eight hundred and thirty-three of 1702 (49%) surveys were returned. Staff comprised 88%, and residents 12%. Fifty-five percent had attended a difficult airway workshop within five years and 30% received mannequin airway training during residency. Direct laryngoscopy (48%) or fibreoptic bronchoscopy (34%) were the preferred techniques for intubation. For laryngeal, subglottic and unstable cervical spine scenarios, awake intubation with fibreoptic bronchoscope was most widely chosen. Asleep intubation with direct laryngoscopy was most commonly selected for trauma scenarios. Availability of difficult airway equipment varied between regions and types of hospital. Cricothyroidotomy equipment and difficult airway carts were not universally available. CONCLUSIONS: Our survey assessed current preferences, training and equipment availability for the difficult airway amongst Canadian anesthesiologists. Direct laryngoscopy and fibreoptic bronchoscopy were the preferred technique for intubation despite widespread availability of newer airway equipment. Lack of certain essential airway equipment and difficult airway training should be addressed.     

Difficult airway management in the neonate: a simple method of intubating through a laryngeal mask airway

Tracheal intubation through a laryngeal mask airway is one option for securing an airway in the patient with a difficult airway. A variety of techniques and equipment have been used to stabilize the position of the tracheal tube while removing the laryngeal mask airway. We have shown that if a fibreoptic bronchoscope is used to place an tracheal tube through a laryngeal mask in neonates, additional equipment is not needed to remove the laryngeal mask airway without endangering tracheal tube placement. This is possible even in small neonates.     

Equipment for airway management

Airway management provides gas exchange, protects the lungs from injury and permits treatment. This requires safe, effective and reliable use of equipment, often using several items in combination. An airway management plan with backup plans is vital, and correct equipment use needs correct knowledge, skill and attitudes to form an airway management strategy; a sequence of logical plans. There are five approaches to airway management in which equipment is used: facemask ventilation with or without adjuncts, airway clearance with suction or foreign body removal, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes (including the flexible fibreoptic bronchoscope (FFOB)), and transtracheal access using cricothyroidotomy or tracheostomy. Tracheal tubes and aids for placement are described.     

ProSeal喉罩用于体外循环心内直视术患儿气道管理的效果

目的 评价ProSeal喉罩用于体外循环心内直视术患儿气道管理的效果.方法 择期拟行心内直视术患儿76例,年龄3月～8岁,体重3.3～34.5 kg,性别不限,ASA分级Ⅱ级,心功能分级Ⅰ或Ⅱ级,随机分为2组(n=38):气管导管组(T组)和ProSeal喉罩组(P组).麻醉诱导后,T组置入气管导管,P组置入ProSeal喉罩,行机械通气.记录气管导管和喉罩的置入情况、置入时间、最高气道压、术中低氧血症、心动过速、心动过缓、低血压和高血压的发生情况、术后喉头水肿、吞咽困难、呛咳、呼吸困难、声音嘶哑的发生情况.结果 气管导管和ProSeal喉罩全部置入成功.两组术中均未见低氧血症、心动过速、心动过缓、低血压和高血压的发生.与T组比较,P组置入时间缩短,喉头水肿和吞咽困难的发生率降低(P＜0.05),最高气道压、呛咳、呼吸困难和声音嘶哑的发生率差异无统计学意义(P＞0.05).结论ProSeal喉罩置入简单易行,可有效保证通气,对咽喉部刺激较小,用于体外循环心内直视术患儿的气道管理安全可靠.