Retrograde nasotracheal intubation with a new tracheal tube: a feasibility study

We have assessed the feasibility of retrograde nasotracheal intubation using a flexometallic tracheal tube with a detachable pilot balloon and connector in a study of 20 consecutive adult patients undergoing oropharyngeal surgery. The technique consisted of: (1) laryngoscope- guided orotracheal intubation; (2) insertion of an 18-gauge Foley catheter through the nose and retraction into the mouth; (3) detachment of the anaesthesia circuit, pilot balloon and connector; (4) insertion of the Foley catheter tip into the proximal end of the tracheal tube and inflation of the Foley catheter cuff; (5) withdrawal of the Foley catheter and attached tracheal tube back through the nose; (6) deflation of the Foley catheter cuff; and (7) re-attachment of the pilot balloon, connector and anaesthesia circuit. The technique was successful at the first attempt in all patients. Mean time taken to insert the Foley catheter and retract it into the mouth was 19 (range 12-30) s. Mean time taken from disconnection to reconnection of the anaesthesia circuit was 8 (6-10) s. Heart rate increased after intubation, but there were no significant changes in arterial pressure. Nasal bleeding, airway problems and hypoxic events did not occur. No anatomical abnormalities or nasal trauma were detected at rhinoscopy. We conclude that retrograde nasotracheal intubation is feasible using a flexometallic tracheal tube with a detachable pilot balloon and connector.      

Submental intubation for cancrum oris: a case report

Cancrum oris (Noma) is a devastating gangrenous disease that leads to severe tissue destruction in the face. We describe the anesthetic management of a 12-year-old girl with cancrum oris sequelae in a Rural Secondary level Hospital in Central India (Padhar Hospital). She presented with a large defect in her upper lip on the left side that extended into the columella and the floor of the left nostril. She was scheduled to undergo reconstructive surgery and the surgeons planned to use an Abbé flap based on the lower lip. For this, access to both the mouth and the nose was required. We considered a tracheostomy but decided to attempt the submental route for orotracheal intubation. Following intravenous induction the patient's trachea was intubated with a cuffed oral tracheal tube. This was passed through the submental incision and then reconnected. The surgery proceeded uneventfully and the patient was extubated before transfer. She made a satisfactory recovery and the submental scar healed without complication or scarring. We describe briefly the features of cancrum oris and review the technique of submental intubation (described in adults with midfacial trauma). The use of submental intubation in children and for cancrum oris sequelae has not been previously reported.     

Orotracheal fibreoptic intubation for rapid sequence induction of anaesthesia

We assessed whether flexible fibreoptic-guided orotracheal intubation could be rapidly and successfully achieved during a simulated rapid sequence induction in 30 anaesthetised and paralysed patients. Rapid sequence induction was simulated by applying practised cricoid pressure. Using a flexible fibreoptic laryngoscope with camera and closed circuit television, an anaesthetist experienced with the technique performed orotracheal endoscopy and intubation with a cuffed 7.0-mm Portex tracheal tube through a VBM Bronchoscope Airway. Fibreoptic intubation was successful at the first attempt in 28 patients (93%); two patients required two attempts. Mean (SD) time from removal of the facemask from the patient's face to the appearance of carbon dioxide in the expired breath after intubation was 111 (46) s (median 100 s; range 54-195 s). There were one or more difficulties in 13 patients (43%). These difficulties were largely avoidable and included problems with fibreoptic equipment, the Bronchoscope Airway, copious secretions, cricoid pressure or railroading of the tracheal tube. Flexible fibreoptic-guided orotracheal intubation may have a place in the management of failed intubation during a rapid sequence induction.     

Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening

Submental intubation is useful for airway management during maxillofacial surgery when both nasal and orotracheal intubation are deemed unsuitable and to avoid a tracheostomy, especially when long-term ventilatory support is not required in the postoperative period. Adequate mouth opening is a prerequisite for all the techniques described for submental intubation, as the initial step is orotracheal intubation. Hence, this procedure has never been reported in a patient with the inability to open the mouth. We describe the technique of retrograde submental intubation with the help of a pharyngeal loop assembly for the first time in a patient with maxillofacial trauma and restricted mouth opening in whom oral and nasal intubations were not possible and tracheostomy was the only alternative. In this case report, with successful retrograde submental intubation, the potential complications associated with a short-term tracheostomy were avoided, as there was no indication for keeping a tracheostomy during the postoperative period.     

Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures

BACKGROUND: The submental route for endotracheal intubation has been proposed as an alternative to tracheotomy in the surgical management of patients with maxillofacial trauma. The purpose of this study was to review our experience with this procedure. METHODS: Medical records of 25 patients who had surgical reduction of midfacial or panfacial fractures while securing their airway with submental intubation were reviewed. After standard orotracheal intubation, a passage was created by blunt dissection with a hemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed with minimal interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. RESULTS: Mean duration of surgery was 7.9 hours (range, 2-16 hours). Mean duration of postoperative mechanical ventilation was 5.2 days (range, 1-24 days). Fourteen of these patients required prolonged (>24 hours) postoperative mechanical ventilation because of associated injuries. Two patients later required a tracheotomy because of prolonged respiratory failure. One patient died of multiple organ failure. One complication of the submental intubation was observed: a superficial infection of the submental wound. CONCLUSION: Submental intubation is a simple technique associated with a low morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of maxillofacial trauma.     

Effect of orientation of a standard polyvinyl chloride tracheal tube on success rates during awake flexible fibreoptic intubation

We conducted a randomised study in 70 patients to assess the effect of orientation of a standard polyvinyl chloride tracheal tube on the ease of railroading the tube during awake fiberoptic orotracheal intubation. Conventional orientation of the tube (with the bevel of the tube directed to the patient's left) was compared with orientation of the tube with the bevel facing posteriorly. The success rate of intubation at the first attempt was higher with the bevel oriented posteriorly (35/35; 100%) than with the conventional orientation (21/35; 60%; p = 0.0001), and the intubating time was shorter (median (range) 7 (5-11) s and 11 (5-60) s, respectively; p = 0.0001). We recommend that the tracheal tube should be aligned in this manner when railroading it over the fibrescope during awake fibreoptic orotracheal intubation.     

An assessment of the ability of impedance respirometry distinguish oesophageal from tracheal intubation

Accidental oesophageal intubation is still an important cause of anaesthetic morbidity and mortality. This study investigated the use of impedance respirometry to determine the position of a tracheal tube. Seventy-nine patients undergoing general anaesthesia requiring tracheal intubation with muscle relaxation were recruited to the study. After pre-oxygenation, tracheal tubes were placed in both the oesophagus and trachea; a breathing system was attached to one tube chosen randomly. A blinded observer was required to correctly identify the position of the tube within six tidal ventilations. The position of every tube connected to the breathing system was correctly identified. The median time to correctly identify tracheal and oesophageal tubes was 3 and 5 s, respectively. The median number of breaths to identify tracheal and oesophageal tubes was two for both groups. Every tube position was identified within the required six breaths. Impedance respirometry is a reliable method for diagnosing tracheal tube position.     

Case report: Nasotracheal intubation — look before leaping to assess the laryngeal view

PURPOSE: To describe an airway management plan, including oral to nasal endotracheal tube exchange, when nasal intubation is required in the unanticipated difficult airway. CLINICAL FEATURES: A nasal intubation was required for a patient undergoing oropharyngeal surgery. Following loss of consciousness and paralysis, a Cormack-Lehane class 3 view was obtained, and pressure over the thyroid cartilage failed to reveal the vocal cords. An Eschmann bougie was inserted into the oropharynx and blindly entered the trachea. An orotracheal tube was advanced into the trachea over the bougie, and the patient was ventilated with 100% O2 following the bougie's removal. An endotracheal tube was then guided through the right nostril into the hypopharynx. An Eschmann bougie was inserted into the nasal tube, and advanced towards the glottic opening under laryngoscopic view. Digital pressure applied to the oral tube at the base of the tongue brought the vocal cords into view. The oral endotracheal cuff was deflated, and the bougie (inserted into the nasal tube) was advanced into the trachea alongside the orotracheal tube. The orotracheal tube was withdrawn, and the nasal tube was advanced into the trachea over the bougie. The patient's O2 saturation and end-tidal CO2 concentration remained at 99-100% and 30-33 mmHg, respectively, during these maneuvers, which required only a few minutes to perform. CONCLUSION: When nasotracheal intubation is required, a plan of airway management is required to safely secure the airway. We emphasize the importance of direct laryngoscopy prior to insertion of an endotracheal tube through the nose, and describe a strategy for oral to nasal tracheal tube exchange.     

The intubating laryngeal mask airway in failed fibreoptic intubation

PURPOSE: Prediction of difficult tracheal intubation is not always reliable and management with fibreoptic intubation is not always successful. We describe two cases in which blind intubation through the intubating laryngeal mask airway (ILMA FasTrach) succeeded after fibreoptic intubation failed. CLINICAL FEATURES: The first patient, a 50 yr old man, was scheduled for elective craniotomy for intracerebral tumour. Difficulty with intubation was not anticipated. Manual ventilation was easily performed following induction of general anesthesia, but direct laryngoscopy revealed only the tip of the epiglottis. Intubation attempts with a styletted 8.0 mm endotracheal tube and with the fibreoptic bronchoscope were unsuccessful. A #5 FasTrach was inserted through which a flexible armored cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. The second patient, a 43 yr old man, presented with limited mouth opening, swelling of the right submandibular gland that extended into the retropharynx and tracheal deviation to the left. He was scheduled for urgent tracheostomy. Attempted awake fibreoptic orotracheal intubation under topical anesthesia showed gross swelling of the pharyngeal tissues and only fleeting views of the vocal cords. A #4 FasTrach was easily inserted, a clear airway obtained and a cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. CONCLUSION: The FasTrach may facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.     

A comparison of two tracheal intubation techniques with Trachlight and Fastrach in patients with cervical spine disorders

Optimal airway management strategies in patients with an unstable cervical spine remain controversial. A newly designed lightwand device (Trachlight) or an intubating laryngeal mask (Fastrach) may avoid hyperextension of the neck. However, there are few objective data that guide us in selecting the appropriate devices. We conducted a prospective randomized study in 148 patients who received general anesthesia for whom the operations were related to the clinical and/or radiographic evidence of cervical abnormality. Trachlight or Fastrach was used for tracheal intubation with the head and neck held in a neutral position. In the Trachlight group, intubation was successful at the first attempt in 67 of 74 (90.5%) cases and at the second attempt in 5 (6.8%) cases. In contrast, in the Fastrach group, 54 of 74 (73.0%) patients were intubated within our protocol. The mean time for successful tracheal intubation at the first attempt was significantly shorter in the Trachlight group than in the Fastrach group. The Trachlight may be more advantageous for orotracheal intubation in patients with cervical spine disorders than the Fastrach with respect to reliability, rapidity, and safety. IMPLICATIONS: The Trachlight may be more advantageous for orotracheal intubation in patients with cervical spine disorders than the Fastrach with respect to reliability, rapidity and safety.     

Flexible, tapered-tip tube facilitates conventional orotracheal intubation by novice intubators

Orotracheal intubation is the standard technique for airway management, but several untoward airway complications are possible with this method. To avoid airway trauma caused by the tube tip during intubation, the Parker Flex-Tip tube (PFT), which has a flexible, tapered tip, was developed. It has been reported that the PFT facilitates fiberoptic orotracheal intubation and introducer-guided tracheal intubation. In this study, we compared the PFT to a standard endotracheal tube (SET), regarding the time of intubation during conventional orotracheal intubation and the incidence of postoperative sore throat and hoarseness. One hundred and thirty-four patients scheduled for elective anesthesia using orotracheal intubation were randomized to either the PFT or SET and 132 completed the study. The intubators were classified into three groups: staff anesthesiologists, inexperienced anesthesiologists, and anesthesia trainees. The tube was selected by another anesthesiologist and the time required for intubation was measured. PFT did not shorten the time required for intubation and did not reduce the incidence of sore throat and hoarseness. However, a detailed analysis revealed that the PFT decreased the time required for intubation in the anesthesia trainee group. The PFT may help novice intubators to conduct a smooth intubation.     

A new method for separate lung ventilation

Separate lung ventilation is obtained with selective intubation of the main bronchus by an appropriate cuffed tube inserted through a standard orotracheal tube. Ventilation is carried out separately through the bronchial tube on one side and the residual tracheal tube lumen on the other side. This method, used in 144 patients, greatly simplifies the technique of bronchial intubation and offers many advantages over commercially available double-lumen tubes.     

Intubation sub-mentale chez un patient victime d’un traumatisme maxillo-facial

Maxillo-facial traumas are frequent and most often occur in young patients. Naso-tracheal or orotracheal intubation may be contraindicated in case of combined occlusal fracture and nasal or ethmoido-nasal fracture. This study was carried out a clinical case of a patient treated at the Lille University Hospital for a maxillofacial trauma associating fracture of nose and maxilla. The purpose was to assess the reliability of submental intubation as an alternative to tracheotomy. Submental intubation is a reliable single and safe technique allowing an one-stage surgical treatment in case of complex association of fractures without using tracheotomy. Its use should be implemented on a larger scale.     

Selective bronchial intubation for one lung anaesthesia in thoracic surgery

A new method for one lung anaesthesia in thoracic surgery is described. Separate lung ventilation is obtained with selective main bronchus intubation, by means of an appropriate cuffed tube inserted through a standard orotracheal tube. Ventilation is carried out separately through the bronchial tube on one side and the residual tracheal tube lumen on the other side. This method greatly simplifies the technique of bronchial intubation and offers many advantages over commercially available double-lumen tubes.     

Light-guided tracheal intubation using a Trachlight: causes of difficulty and skill acquisition]

We studied the reasons why tracheal intubation using a lighted stylet (Trachlight) was sometimes difficult for unexperienced intubators. We also examined light-guided intubation skill acquisition in inexperienced anesthesiologists. Two anesthesiologists, with no prior experience in using a Trachlight, performed orotracheal intubation using a Trachlight in 60 anesthetized patients (30 patients each). During intubation, an assistant observed the advancement of the tracheal tube using a fiberscope passed nasally and recorded the reason for difficulty in intubation. The time to successful intubation was also measured. Data were divided into epochs of 10 cases, and the intubation time and the incidence of difficult cases were compared between the groups. Tracheal intubation was successful using the Trachlight in 59 of 60 patients. The incidence of difficult cases, defined as cases requiring two or more attempts, was 31.7%. Fiberscopy showed that when the tube tip was located in the vallecula or in the esophagus, it was sometimes difficult to determine the position of the tube tip by transillumination of the soft tissues of the neck, and this results in the need for multiple attempts. Both the intubation time and the incidence of difficult cases decreased significantly between the first and last epoch. The present study confirms that light-guided intubation is sometimes difficult when the tube tip is advanced to the vallecula or to the esophagus. An acceptable level of skill in light-guided intubation is achieved within 30 uses.     

ORAL INTUBATION V. NASAL INTUBATION IN ADULT CARDIAC SURGERY

Time for intubation, incidence of mechanical complications,occurrence of bacteraemia caused by intubation, and postoperativediscomfort were assessed in relation to nasal and oral trachealintubation in adult cardiac surgery. The time for placementof the tube was 2.5 times longer for nasal intubation. Nasalbleeding was observed in 45.3% of patients intubated throughthe nose. In patients in whom a naso-tracheaf tube was passed,9.4% (v. 2.3% of patients intubated via the mouth), exhibitedpositive blood cultures just after intubation; however, thedifference was not significant. Postoperative discomfort wassimilar in both groups. It can be concluded that nasal trachealintubation offers no advantage over oral tracheal intubationin adult cardiac surgery.     

Orotracheal fibreoptic intubation in children under general anaesthesia

Orotracheal fibreoptic intubation under general anaesthesia in children was studied in eleven consecutive patients of three months to eight-years-of-age without anticipated intubation difficulties. One case report is also included. Three fibrescopes with a different diameter were used in the study. The fibrescope used was chosen so that it fitted snugly in the tracheal tube. The fibreoscopy was prolonged in one patient due to mucus and two tries were needed. Resistance to the tracheal tube upon intubation was encountered in five patients, only one of these patients was older than two years. Fibreoptic intubation succeeded in nine patients. Two patients were intubated with the Macintosh laryngoscope. The problems encountered in children during orotracheal fibreoptic intubation under general anaesthesia are the same as with adults: easy fibreoscopy is not always followed by easy tracheal intubation, there may be prolonged fibreoscopy and failed intubations. Manipulation of the tracheal tube can lead to successful tracheal intubation and resistance to the tube is more common in smaller children.     

Post-intubation tracheal rupture: poor healing of the tracheal wall

Purpose

To describe tracheal rupture after orotracheal intubation assisted by a tracheal tube introducer.

Clinical features

A 73-yr-old morbidly obese female patient with a history of hypertension underwent a total knee replacement. There were no anticipated signs of difficult intubation. Orotracheal intubation was attempted twice by direct laryngoscopy, and a Boussignac bougie was used as a tube exchanger for the second attempt. Seven hours after tracheal extubation, the patient became dyspneic and showed a large subcutaneous emphysema. A chest x-ray and computerized tomography scan revealed rupture of the posterior tracheal wall. The distal part of the injury was 26.5 cm from the patient’s teeth and 0.5 cm from the carina (i.e., beyond the normal location of the tracheal tube tip) and extended to the origin of the right main bronchus, where the tip of the Boussignac bougie was probably pushed. Formation of an endotracheal sac occurred during the first two weeks after intubation, accompanied by dyspnea and alveolar hypoventilation, but symptoms resolved favourably with conservative management.

Conclusion

The tracheal rupture was attributed to airway manipulations, and the distal location of the lesion suggests that the cause was the Boussignac bougie rather than the tracheal tube. Long-term healing of the injury was satisfactory, although the patient continued to complain of dyspnea one year after the rupture.     

Submental tracheal intubation in oromaxillofacial surgery

Background:

Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying.

Materials and Methods:

The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only.

Results:

The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.

Conclusion:

In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.     

Retromolar fibreoptic orotracheal intubation in a patient with severe trismus undergoing nasal surgery

Purpose

A considerable challenge arises when passage of an endotracheal tube between the teeth is impossible because of severe trismus and the presence of concomitant contraindications to nasotracheal intubation. We report a novel technique to circumvent the need for tracheostomy by using the retromolar space for oral fibreoptic intubation.

Clinical features

A 50-yr-old female with a history of pharyngeal cancers treated with surgery and radiotherapy presented for right dacryocystorhinostomy. She had undergone left dacryocystorhinostomy after nasotracheal intubation one week earlier. This time, orotracheal intubation was requested since surgery would involve the right nostril and left nasal intubation might dislodge the recently placed nasolacrimal tube. Due to severe trismus, the patient’s interincisor distance was only 9 mm, and it was impossible to pass a 6.0 mm endotracheal tube through that gap. A flexible bronchoscope loaded with a 6.0 mm tracheal tube was inserted through the retromolar space into the pharynx and maneuvered through the vocal cords for endotracheal intubation.

Conclusions

The retromolar space is located between the last molar and the ascending ramus of the mandible. Even with complete mandibular occlusion, it is usually able to accommodate a 7.0 mm endotracheal tube. Despite its hidden location, it can be used successfully for orotracheal fibreoptic intubation. With practice, the expertise achieved in performing this technique will confer a much needed option for securing the airway in this challenging situation.