Rapid sequence induction with oral endotracheal intubation in the multiply injured patient

The charts of 1798 consecutive admissions at this level one trauma center to evaluate the practice of emergency airway control were reviewed. A total of 335 patients required endotracheal intubation, 320 oral endotracheal, 12 nasotracheal, and three surgical. A technique of rapid sequence induction (RSI) with oral endotracheal intubation was the method of airway control in 260 spontaneously breathing patients. Prior cervical spine evaluation was not obtained. In all instances airway control was prompt and accurate. There were no hemodynamic nor neurologic complications secondary to RSI or oral endotracheal intubation. It is believed that RSI with oral endotracheal intubation is a reasonable alternative to nasotracheal intubation in the spontaneously breathing patient.     

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。     

Problems and complications in airway management by endotracheal intubation and laryngeal mask airway

The endotracheal intubation and laryngeal mask airway confer many advantages for surgical patients. However, a number of problems and complications with airway management by endotracheal intubation and laryngeal mask airway have been documented. In this report, several problems by using endotracheal intubation (e.g. hoarseness, arytenoids dislocation) and laryngeal mask airway (e.g. aspiration, oropharyngeal leak, gastric distension) are summarized.     

Indirekte Laryngoskopie

Endotracheal intubation remains the gold standard for securing the airway in emergency medicine. However, difficult endotracheal intubation and complications are common during emergency intubation. In contrast to conventional direct laryngoscopy, the new generation of devices does not require direct visualization of the vocal cords for endotracheal tube placement. These devices allow a better glottic view and successful endotracheal placement of the tube, especially if direct laryngoscopy is difficult. Recent studies showed that utilization of these devices can be easily learned. The technique of indirect laryngoscopy is currently used for securing the airway in daily anesthesia routine as well as for managing the difficult airway in the operating room. This article gives an overview of available devices for indirect endotracheal intubation as well as the current literature.     

Use of the intubating laryngeal mask for airway management and light-guided tracheal intubation in the lateral position

Sudden accidental loss of the airway during surgery is potentially hazardous especially when the patient is lying in any position which prevents easy intubation of the trachea. We describe two patients lying in the lateral position who required urgent airway management and endotracheal intubation. In both cases endotracheal intubation was achieved successfully using a light-guided technique--with a prototype illuminated flexible catheter--through an intubating laryngeal mask airway.     

The use of the intubating laryngeal mask endotracheal tube with intubating devices

IMPLICATIONS: Despite adequate visualization of the vocal cords using specialized airway devices, anatomical factors and the physical characteristics of the tube may cause difficulty when performing endotracheal intubation. The endotracheal tube designed for use with the intubating laryngeal mask airway may facilitate intubation in these circumstances.     

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.     

Pediatric airway management : cuffed endotracheal tube and other devices for tracheal intubation

Uncuffed endotracheal tubes have been commonly used in pediatric patients, but cuffed pediatric endotracheal tubes are recently introduced and stirred up a controversy. Uncuffed tubes may require multiple laryngoscopies, pollute the environment, and cause pulmonary aspiration as well as unstable ventilation. A recent study revealed that the contours of the airway and the tracheal tube are different, so that the pressure exerted on some parts of the cricoid mucosa may not be appropriate. Cuffed endotracheal tubes overcome these shortcomings if anesthesiologists pay close attention to the insertion length of the tube and cuff pressure. Laryngeal mask airway has worked well, with few complications, as a ventilatory device in pediatric patients whose tracheas cannot be intubated and/or whose lungs cannot be ventilated with conventional techniques. It is also used for a conduit for fiberoptic intubation and emergent airway with patients in the prone position. The lightwand (Trachlight) is another device for pediatric intubation and is recommended as the first-line option in patients who can be ventilated but in whom laryngoscopic intubation has failed. AirWayScope (Pentax-AWS) is a novel intubation device which combines an airway, camera and monitor It can be an epoch-making intubation device for infants and children if a smaller size is available in the future.     

Acoustic reflectometry profiles of endotracheal and esophageal intubation

BACKGROUND: Acoustic reflectometry can be used to create a "one-dimensional image" of a cavity, such as the airway and lung, with the image displayed as an area-length curve. This pilot study was undertaken to determine whether acoustic reflectometry could be used to distinguish between an endotracheal and an esophageal intubation. METHODS: Ten adult patients underwent general endotracheal anesthesia and neuromuscular blockade. The reflectometer wavetube was attached to an endotracheal tube, and a reflectometric profile was obtained of the endotracheal tube and the airway and lung cavity. After confirmation of tracheal intubation, a second endotracheal tube was placed in the esophagus. After four breaths were administered, a reflectometric profile of the endotracheal tube-esophagus cavity was obtained. RESULTS: The acoustic reflectometric profiles for tracheal and esophageal intubation profiles were distinctive and characteristic. For an endotracheal tube-airway cavity, the profile shows a constant cross-sectional area throughout the length of the endotracheal tube, followed by a rapid rise in the area past the carina. For an esophageal intubation, the profile shows constant cross-sectional area throughout the length of the endotracheal tube, followed by a sudden decrease in the cross-sectional area to zero. CONCLUSIONS: In this pilot study, acoustic reflectometry within seconds, and without resort to capnography, was able to generate characteristic and distinctive area-length profiles for both endotracheal and esophageal intubation. Acoustic reflectometry may have a role in the emergency imaging of the airway, and in the immediate detection of esophageal intubations, particularly in cases of cardiopulmonary arrest in which the usual techniques for confirmation of breathing tube placement fail.     

Acesso às vias aéreas guiado por ultrassom

Ultrasound has increasingly growing applications in anesthesia. This procedure has proven to be a novel, non‐invasive and simple technique for the upper airway management, proving to be a useful tool, not only in the operating room but also in the intensive care unit and emergency department. Indeed, over the years mounting evidence has showed an increasing role of ultrasound in airway management. In this review, the authors will discuss the importance of ultrasound in the airway preoperative assessment as a way of detecting signs of difficult intubation or to define the type and/or size of the endotracheal tube as well as to help airway procedures such as endotracheal intubation, cricothyrotomy, percutaneous tracheal intubation, retrograde intubation as well as the criteria for extubation.     

Rigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie

We describe a technique by which a gum elastic bougie (GEB) is used to facilitate an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy. After placing the GEB through the lumen of the rigid bronchoscope, the GEB-suction catheter assembly was used to safely withdraw the bronchoscope in a manner mimicking the withdrawal of an intubating laryngeal mask airway (LMA) over the endotracheal tube using a stabilizer rod. The rationale for management and potential advantages of this approach versus use of an airway exchange catheter (including increased stability of an intubation guide) are discussed. IMPLICATIONS: We describe a technique of using a gum elastic bougie to facilitate an endotracheal intubation in a patient undergoing rigid bronchoscopy, which can be useful in a variety of clinical situations when the rigid bronchoscope is used in patients with abnormal airway.     

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.     

Ist die Kehlkopfmaske ein minimal invasives Instrument zur Sicherung der Atemwege? Ergänzende Bemerkungen zum Beitrag „Schäden und Gefahren durch Einsatz der Kehlkopfmaske” von V. Hempel Anaesthesist (1999) 48:399–402

Minor laryngopharyngeal complaints following anaesthesia considerably determine postoperative patient comfort. They cannot be eliminated but reduced by experience and careful preparation and insertion technique. The incidence of minor laryngopharyngeal symptoms following the use of the laryngeal mask airway is similar to that following endotracheal intubation. However, there seems to be a distinct pattern of complaints: discomfort with swallowing is more frequent after LMA, whereas dysphonia is more often observed following endotracheal intubation. The significance of LMA cuff pressures in the pathogenesis of postoperative throat complaints remains unclear. There is sound evidence that cuff pressure is not a representative measure for the effective pressure load upon the pharyngeal mucosa. Measurement of cuff pressure is not obligatory, instead reduction of cuff volume to a "just seal" situation seems to be a reasonable approach. The laryngeal mask airway has definitely changed anaesthesiology airway management. Whether this is due to its supposedly less invasiveness compared to endotracheal intubation has not been proven by scientific investigations.     

Airway access using an endotracheal tube changer for safe extubation in an infant with a difficult airway

We present a case where airway access was maintained using an endotracheal tube changer (ETC) after extubation in an infant with a difficult airway. A 4-month-old male infant with bilateral cleft lip and palate, micrognathia, schizencephaly, undescended testis, and abnormality of chromosomes 10 was scheduled for bilateral cleft lip repair. After anesthesia induction with thiamylal and vecuronium, we found that laryngoscopy was difficult (Cormack and Lehane grade III) despite external laryngeal compression. Since there was no fiberoptic bronchoscopy for an infant in our department, and the fact that epiglottis could be visualized with external laryngeal compression, three anesthesiologists attempted tracheal intubation in turn and intubation was successful at last. The surgery was concluded uneventfully; but since endotracheal intubation had been difficult, special care was taken for extubation. We used an ETC for tracheal tube passing into the endotracheal tube at the time of extubation. Although using the ETC in infant with difficult airway for extubation remains controversial, we believe that for a difficult airway, even in an infant, a flexible ETC is a useful device for temporal airway access after extubation.     

Difficult endotracheal intubation as a result of penetrating cranio-facial injury by an arrow.

Penetrating injury of the face and airway may make endotracheal intubation difficult or impossible. We report the case of a patient who attempted to commit suicide with a crossbow. Surgery under general anesthesia was required to remove the arrow. The oral intubation route was impossible, and a fiberoptic nasal intubation under local anesthesia was performed. IMPLICATIONS:We report a case of a 42-yr-old patient who underwent surgery for a penetrating craniofacial injury caused by an arrow. Because of the median vertical trajectory of the arrow (from the chin to the frontal skull), only the right nasal approach was accessible for endotracheal intubation. Fiberoptic nasal intubation and securing the airway under local anesthesia are described.     

Life-Threatening Stridor due to Membranous Tracheitis as a Rare Complication of Endotracheal Intubation: Report of a Case

This report describes a rare case of acute life-threatening stridor due to membranous tracheitis that occurred as a complication of endotracheal intubation, performed for video-assisted thoracotomy. An obstructive fibrin clot was found in the subglottic region by bronchofiberscopy, and removal provided complete relief of the airway obstruction. The mechanism of the development of this fibrin membrane may have interacted with local tracheal trauma from the endotracheal tube. Membranous tracheitis should be considered in the differential diagnosis of stridor and airway obstruction after endotracheal intubation because it is a life-threatening complication of this procedure. Received: April 8, 2002 / Accepted: September 3, 2002 Reprint requests to: I. Takanami     

Developmental anatomy of the airway

The airway develops from the primitive foregut and a number of congenital anomalies may result when this process is abnormal. The anatomy of the neonatal airway is significantly different from older children and adults. The larynx is cephalad, the epiglottis large and the cricoid cartilage is the narrowest part of the upper airway. The technique of endotracheal intubation is significantly different in neonates compared with older children and adults. A straight-bladed laryngoscope and an uncuffed endotracheal tube are usually used. During the first years of life the anatomy gradually becomes more like that of adults. By the age of 8–10 years normal children have an airway that is anatomically adult in most ways other than absolute size. The technique used for endotracheal intubation in adults is appropriate, including the use of a Macintosh laryngoscope blade and a cuffed endotracheal tube.     

Acoustic Reflectometry Profiles of Endotracheal and Esophageal Intubation

Background: Acoustic reflectometry can be used to create a "one-dimensional image" of a cavity, such as the airway and lung, with the image displayed as an area-length curve. This pilot study was undertaken to determine whether acoustic reflectometry could be used to distinguish between an endotracheal and an esophageal intubation.

Methods: Ten adult patients underwent general endotracheal anesthesia and neuromuscular blockade. The reflectometer wavetube was attached to an endotracheal tube, and a reflectometric profile was obtained of the endotracheal tube and the airway and lung cavity. After confirmation of tracheal intubation, a second endotracheal tube was placed in the esophagus. After four breaths were administered, a reflectometric profile of the endotracheal tube-esophagus cavity was obtained.

Results: The acoustic reflectometric profiles for tracheal and esophageal intubation profiles were distinctive and characteristic. For an endotracheal tube-airway cavity, the profile shows a constant cross-sectional area throughout the length of the endotracheal tube, followed by a rapid rise in the area past the carina. For an esophageal intubation, the profile shows constant cross-sectional area throughout the length of the endotracheal tube, followed by a sudden decrease in the cross-sectional area to zero.     

Endotracheal intubation as an alternative to tracheostomy after intraoral or oropharyngeal surgery

Patients who undergo oral or oropharyngeal surgery usually require a tracheostomy for postoperative airway maintenance. However, the development in recent years of soft endotracheal tubes now provides the alternative of short-term endotracheal intubation, with minimal sequelae. Our favorable experience with the use of short-term intubation in children with epiglottitis prompted us to apply the technique to adults. Over a 2-year period at the University of Chicago Medical Center, we successfully used postoperative endotracheal intubation for 19 adult and pediatric patients who underwent major intraoral procedures, thus avoiding the possible complications, discomfort, and anxiety associated with tracheostomy. The patients were given intravenous steroids and antibiotics concomitantly, so that tissue edema and inflammation were minimized. No complications related to intubation and no postextubation airway compromise were noted in any of the patients.     

Nasotracheal intubation: look before you leap

Nasotracheal intubation is frequently used for airway managementduring maxillofacial surgery. Complications such as haemorrhageoccur more frequently with this route of intubation than withthe orotracheal route. This case report describes a male patientaged 51 yr who developed severe epistaxis after the tube hadpassed the nares. As an additional complication laryngoscopyand endotracheal intubation failed because of difficult airway(Cormack–Lehane grade 4). Attempts using an intubatinglaryngeal mask airway and a Bonfils intubating fibrescope didnot succeed. The airway was finally managed by cricothyroidotomy.A modified sequence of nasotracheal intubation is proposed toavoid similar life-threatening complications.