Application of Gum Elastic Bougie to Nasal Intubation

Gum elastic bougie (GEB), a useful device for difficult airway management, has seldom been used for nasotracheal intubation. Among 632 patients undergoing dental procedures or oral surgery, GEB was used successfully in 16 patients in whom conventional nasal intubation had failed because of anatomical problems or maldirection of the tip of the tracheal tube. We recommend that GEB should be applied from the first attempt for nasal intubation in patients with difficult airways.     

Successful nasal intubation using airway scope with gum elastic bougie in a case of difficult airway

AWS (Airway Scope, Pentax, Tokyo), a new videolaryngoscope, was originally designed to facilitate oral laryngoscopy and tracheal intubation. We describe a successful case of nasal intubation with a combination of AWS and GEB (gum elastic bougie). A 50-year-old man with a past history of difficult intubation was scheduled to undergo subtotal esophagectomy. As the patient was scheduled to be ventilated overnight after the operation in the intensive care unit, nasal intubation with a combination of AWS and GEB was planed. Anesthesia was induced with intravenous propofol 100 mg, fentanyl 200 microg and vecuronium 7 mg and endotracheal tube was inserted through the nostril. Oral insertion of AWS showed full view of the glottis and nasal insertion of GEB was easily advanced into the trachea through an endotracheal tube, allowing tracheal intubation while utilizing GEB as a stylet. No complication occured in this case. In conclusion, nasal intubation using AWS combination with GEB is useful for patients with difficult airways and is easy to perform.     

Awake tracheal intubation using the Airtraq® laryngoscope: a case series

The Airtraq^® laryngoscope (AL) is a new single use indirect laryngoscope designed to facilitate tracheal intubation in anaesthetised patients either with normal or difficult airway anatomy. It is designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axes. We report four cases of successful awake tracheal intubation using the AL. The first case is a patient with severe ankylosing spondylitis and the other three cases with anticipated difficult airway. An awake intubation under sedation and topical airway anaesthesia was chosen. We consider that the AL can be used effectively to accomplish an awake intubation in patients with a suspected or known difficult airway and may be a useful alternative where other methods for awake intubation have failed or are not available.     

Fastrach laryngeal mask and difficult intubation

OBJECTIVE: To evaluate the success rate of intubation through the intubating laryngeal mask airway (LMA-Fastrach) in patients with predictive signs of difficult airway or after intubation failure. STUDY DESIGN: Open prospective study. PATIENTS: The study included 33 adults, 21 with predictive signs of difficult airway and 12 after intubation failure. METHODS: After induction of anaesthesia, the intubating LMA was inserted. Proper insertion was confirmed by easy bag ventilation and capnography. Intubation through the intubating LMA was then carried out with an armoured endotracheal tube. If intubation failed, a second attempt was carried out after a gentle manipulation of the intubating LMA. After two attempts, if intubation remained impossible, fibrescopic intubation through the intubating LMA was carried out. In case of failure the usual tracheal intubation algorithms were used. RESULTS: Tracheal intubation through the intubating LMA was successful in all patients, in 32 on the first attempt and in one on the second. Successful tracheal intubation was possible on the first attempt in 25 patients (76%), on the second in four (12%) and after fibrescopic intubation through the intubating LMA in the four remaining (12%). CONCLUSION: The results of this study confirm that tracheal intubation through the intubating LMA can be recommended in patients with a difficult airway, whether foreseen or not.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Dual bougie technique for nasotracheal intubation

We read with great interest the anesthetic technique of using a gum elastic bougie (GEB) for nasal intubation in a recent issue of Anesthesia Progress. The authors recommend the use of GEB for the first attempt of nasotracheal intubation in patients with a difficult airway. We agree that this is an excellent alternative. We also have found an excellent variation of this method that utilizes a double bougie technique for insertion of a nasotracheal tube if the difficult airway can be secured initially with an orotracheal tube.     

Intubation via LMA in pediatric patients with difficult airways

PURPOSE: To report two cases of successful tracheal intubation in difficult pediatric airways using a conventional laryngeal mask airway (LMA) with an extended polyvinyl chloride (PVC) tube after laryngeal assessment with a fibreoptic device. CLINICAL FEATURES: Two cases, Dandy-Walker and Pierre Robin syndromes, were scheduled for surgery. They were premedicated with 0.5 mg x kg(-1) promethazine p.o. 90 min before surgery. Both patients arrived in the operating room sedated, with dry mouth, and without evidence of increased intracranial tension or airway obstruction. Inhalational induction with isoflurane 0.5-3% was commenced. Conventional tracheal intubation was impossible in both cases. In each an LMA was inserted to maintain ventilation, anesthesia, and to facilitate intubation. Fibreoptic bronchoscopy was used to assess the larynx, followed by blind intubation via the LMA using extended PVC tracheal tube (TT). Anesthesia was maintained during intubation using Mapleson F anesthesia circuit attached to a connector with fibreoptic bronchoscope adapter. CONCLUSION: This report describes the assessment of the airway with fibreoptic bronchoscopy after LMA insertion facilitated blind tracheal intubation in two children with difficult airways.     

Awake fibrecapnic intubation: a novel technique for intubation in head and neck cancer patients with a difficult airway

Awake fibreoptic intubation is the gold standard for difficult airway management but failures are reported in the literature in up to 13% of cases. In case of failure, a tracheotomy is often indicated. We describe a novel technique for intubation in head and neck cancer patients with a difficult airway that we call awake fibrecapnic intubation. The aim of this study was to investigate the feasibility of this technique. We studied prospectively 15 consecutive intubations in head and neck cancer patients before diagnostic or therapeutic surgical procedures. After topical anaesthesia, a fibrescope was introduced into the pharynx. Spontaneous respiration was maintained in all patients. Through the suction channel of the fibrescope a special suction catheter was advanced into the airway for carbon dioxide measurements. When four capnograms were obtained, the fibrescope was railroaded over the catheter and after identification of tracheal rings, a tracheal tube was placed. Tracheal intubation was successful in all patients without bleeding or complications, with a median (range) time to intubation of 3 (2-15) min. Identification of the vocal cords and glottis was difficult in four patients due to extensive anatomical abnormalities or poor visibility; even in these patients, a capnogram was obtained within 4 s.     

Use of the McGrath video laryngoscope in awake patients

Reported are three cases of successful tracheal intubation using the McGrath Video Laryngoscope in awake patients. All three patients had predicted difficult direct laryngoscopy and signs of upper airway obstruction.     

Use of gum elastic bougie for tracheal intubation: comparison of different tracheal tubes

BACKGROUND: Gum elastic bougie (GEB) is one of the most useful devices for patients whose tracheas are difficult to intubate during anesthetic induction. But no previous study has evaluated the effects of the types of the tracheal tube. We hypothesized that wire-reinforced tracheal tubes were superior to standard tracheal tubes in the success rate of tracheal intubation when using GEB. We compared these two different types of tracheal tubes in using GEB. METHODS: Forty patients were subjected and randomly allocated into two groups; patients intubated with standard tracheal tubes (Group , n = 20) and those with wire-reinforced tracheal tubes (Group S, n = 20). Measured variables were intubation time defined as elapsed time from mouth opening to removal of GEB from tracheal tube, heart rate (HR), and systolic blood pressure(SBP). We also compared trial times of intubation and pharyngeal or laryngeal bleeding as a minor side effect. RESULTS: Trachea was successfully intubated in the frist attempt in 37 patients (92.5%), and the rest of the patients were all intubated at second trial. Intubation times of Group P and Group S were 41.5 +/- 13.9s and 41.3 +/- 11.1s, respectively. There were no significant differences in HR and SBP between the groups. CONCLUSIONS: The type of tracheal tube would not affect the success rate and time of intubation when using gum elastic bougie.     

Comparison of the GlideScope video laryngoscope vs. the intubating laryngeal mask for females with normal airways

BACKGROUND AND OBJECTIVE: In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope in terms of successful intubation times. METHODS: Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded. RESULTS: Time to successful intubation was longer (mean 68.4 s +/- 23.5 vs. 35.7 s +/- 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 +/- 16.3 vs. 7.3 +/- 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group. CONCLUSION: The GlideScope improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.     

Fibreoptic-guided tracheal intubation through i-gel® and LMA® ProtectorTM supraglottic airway devices - a randomised comparison

Fibreoptic-guided tracheal intubation using a supraglottic airway device as a conduit is a technique that can be used in anticipated and unanticipated difficult airway management. Although the i-gel^® supraglottic airway device has been examined for this purpose, the LMA^® Protector^TM, a recently introduced second-generation supraglottic airway device, has not been evaluated for this use in clinical trials. This prospective, randomised clinical trial compared fibreoptic-guided tracheal intubation via i-gel and LMA Protector supraglottic airway devices in two UK hospitals. Patients who were ASA physical status 1 or 2 and undergoing elective surgery requiring tracheal intubation were recruited to the study. A block randomisation list was generated for each study site. The primary outcome measure was time to successful tracheal intubation and secondary outcomes were tracheal intubation success rate, glottic view through flexible fibrescope, ease of tracheal intubation using operator visual analogue score, supraglottic airway device insertion time and insertion success rate. Ninety patients were randomly allocated to each device, and final data analysis was carried out for 92 patients in the i-gel group and 86 patients in the LMA Protector group. Mean (SD) tracheal intubation time in the i-gel and LMA Protector groups were 54.3 (13.8) s and 52.0 (13.0) s, respectively (p = 0.240). There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups. This study demonstrates that the LMA Protector supraglottic airway device is comparable to the i-gel supraglottic airway device as a conduit for fibreoptic-guided tracheal intubation.     

Flexible lightwand-guided tracheal intubation with the intubating laryngeal mask Fastrach in adults after unpredicted failed laryngoscope-guided tracheal intubation

BACKGROUND: The authors determined the efficacy of using the intubating laryngeal mask airway Fastrach (ILM) as a ventilatory device and aid to flexible lightwand-guided tracheal intubation in patients with unpredicted failed laryngoscope-guided tracheal intubation when managed by experienced anesthetists. METHODS: During a 27-month period, 16 experienced anesthetists agreed to use the ILM as an airway device and airway intubator in patients (aged > 18 yr) with predicted normal airways who were subsequently found to be difficult to intubate (three failed attempts at laryngoscopy). Intubation via the ILM was performed with a flexible lightwand. The number of attempts at ILM placement, the number of adjusting maneuvers, the number of attempts at tracheal intubation via the ILM,and any episodes of hypoxia (oxygen saturation < 90%) were recorded. RESULTS: Forty-four of 11,621 patients (0.4%) met the inclusion criteria. ILM insertion and ventilation was successful at the first attempt in 40 of 44 patients (91%) and at the second attempt in 4 of 44 (9%). Flexible lightwand-guided tracheal intubation via the ILM was successful in 38 of 44 patients (86%) at the first attempt, 3 of 44 (7%) at the second attempt, 2 of 44 (5%) at the third to fifth attempts, and failed in 1 of 44 (2%). The median number of adjusting maneuvers before successful intubation was 1 (range, 0-4). Hypoxia occurred in 5 patients before ILM insertion (range, 52-82%), but none after ILM insertion. No patient developed hypoxia during or after intubation via the ILM. CONCLUSION: The ILM is an effective ventilatory device and aid to flexible lightwand-guided tracheal intubation in adult patients with predicted normal airways in whom laryngoscope-guided tracheal intubation subsequently fails when managed by experienced anesthetists.     

Awake intubation using lightwand technique under conscious sedation with remifentanil

We experienced two cases of difficult airway due to deformities in the oral cavities. The first patient was a 62-year-old woman with a large benign soft palate tumor and the second was a 64-year-old woman with macroglossia secondary to acromegaly. Both patients were evaluated difficult to ventilate via face mask and presenting serious risks for tracheal intubation under general anesthesia. The tracheal intubation was planned using the lightwand (Trachilight) under conscious sedation with continuous administration of remifentanil. Remifentanil (0.1-0.25 microg x kg(-1) x min(-1)) maintained the patients' spontaneous ventilation and increased their tolerance to the pain and discomfort caused by insertion of the lightwand. In both patients, remifentanil mildly suppressed the coughing reflex as well as the autonomic responses to stimuli to the airway. Tracheal intubation was managed successfully in both cases and the operations were completed under general anesthesia. Although the patients were aware of being intubated, they could not recall the procedures postoperatively. The awake intubation technique using the lightwand under conscious sedation with remifentanil can be safely applied to a patient with difficult airway.     

Performance of the Airtraq™ laryngoscope after failed conventional tracheal intubation: a case series

Background: The Airtraq^™, a new disposable indirect laryngoscope, was evaluated in patients with difficult intubation.
Methods: The Airtraq^™ was used in 47 patients with predicted or unpredicted difficult intubation after failed orotracheal intubation performed by two senior anaesthesiologists with the Macintosh laryngoscope.
Results: Tracheal intubation with Airtraq^™ was successful in 36 patients (80%). The Cormack and Lehane score was IIb–III in 35 patients, and IV in 12 patients, with the Macintosh laryngoscope, while Cormack and Lehane score was I–IIa in 40 patients, IIb–III in three and IV in four with Airtraq^™. A gum elastic bougie was used to facilitate tracheal access in one-third (11/36) of the cases. Orotracheal intubation was not possible with Airtraq^™ in nine cases, five of whom had a pharyngeal, laryngeal or basal lingual tumour.
Conclusion: In patients with difficult airway, following failed conventional orotracheal intubation, Airtraq^™ allows securing the airway in 80% of cases mainly by improving glottis view. However, the Airtraq^™ does not guarantee successful intubation in all instances, especially in case of laryngeal and/or pharyngeal obstruction.     

Non-conventional uses of the Aintree Intubating Catheter in management of the difficult airway

We present 14 cases, of which three have been previously reported, in which non-conventional use was made of the Aintree Intubating Catheter (AIC). In seven cases the AIC was used via a ProSeal Laryngeal mask airway (PLMA). Two patients had anticipated difficult intubation, two unexpected difficult intubation and two required rescue of an obstructed airway prior to AIC-assisted intubation. In two cases of tracheal stenosis the AIC was used as a 'long narrow tracheal tube' during fibre-optic intubation: the AIC facilitated passage through the narrowed trachea and smooth railroading of a tracheal tube. In two cases the AIC was used in an awake patient. In three cases the AIC was used successfully despite gross laryngeal oedema. In three cases attempted AIC deployment failed: two patients had undergone radiotherapy to the mouth and PLMA placement failed; in the third, supraglottic oedema prevented visualisation of the larynx. The AIC via an LMA Classic was successful in one of these cases. In all cases where the larynx was visualised the AIC was rapidly successful without complications. In eight cases the anaesthetist had no experience of the technique outside workshops. These cases demonstrate general utility of the technique and successful use of the AIC via the PLMA, in awake patients, as an adjunct to fibre-optic intubation and in patients with an oedematous larynx. Finally, cases where the combination of the PLMA and AIC was unsuccessful demonstrate the technique, like many, is not always successful.     

Flexible Lightwand-guided Tracheal Intubation with the Intubating Laryngeal Mask FastrachTM in Adults after Unpredicted Failed Laryngoscope-guided Tracheal Intubation

Background: The authors determined the efficacy of using the intubating laryngeal mask airway FastrachTM (ILMTM) as a ventilatory device and aid to flexible lightwand-guided tracheal intubation in patients with unpredicted failed laryngoscope-guided tracheal intubation when managed by experienced anesthetists.

Methods: During a 27-month period, 16 experienced anesthetists agreed to use the ILMTM as an airway device and airway intubator in patients (aged > 18 yr) with predicted normal airways who were subsequently found to be difficult to intubate (three failed attempts at laryngoscopy). Intubation via the ILMTM was performed with a flexible lightwand. The number of attempts at ILMTM placement, the number of adjusting maneuvers, the number of attempts at tracheal intubation via the ILMTM,and any episodes of hypoxia (oxygen saturation < 90%) were recorded.

Results: Forty-four of 11,621 patients (0.4%) met the inclusion criteria. ILMTM insertion and ventilation was successful at the first attempt in 40 of 44 patients (91%) and at the second attempt in 4 of 44 (9%). Flexible lightwand-guided tracheal intubation via the ILMTM was successful in 38 of 44 patients (86%) at the first attempt, 3 of 44 (7%) at the second attempt, 2 of 44 (5%) at the third to fifth attempts, and failed in 1 of 44 (2%). The median number of adjusting maneuvers before successful intubation was 1 (range, 0-4). Hypoxia occurred in 5 patients before ILMTM insertion (range, 52-82%), but none after ILMTM insertion. No patient developed hypoxia during or after intubation via the ILMTM.     

Successful use of videolaryngoscopy in an adult patient with acute epiglottitis: a case report

Acute epiglottitis is a potentially life-threatening infection of the supraglottic structures, which can lead to sudden, fatal airway obstruction. Different techniques have been described to facilitate tracheal intubation in acute epiglottitis. We describe the successful intubation, with the help of the videolaryngoscope, of a 60-year-old female with acute epiglottitis. On admission the patient was ill and severely distressed, sitting in the upright position, drooling saliva, showing severe inspiratory stridor, hyperventilation, but no trismus. Intubation was performed in OR conditions with difficult intubation equipment including fiberoptic bronchoscope, videolaryngscope, laryngeal mask airway and surgical tracheostomy ready for use. After pre-oxygenation for three minutes with 100% oxygen with the patient still in the sitting position, induction was performed with 250 mg propofol i.v. The patient was subsequently positioned supine. Face mask ventilation was successful with capnographic tracing and 100 mg succinylcholine was administered. Videolaryngoscopy was performed and a red, swollen epiglottitis with pin point lumen was seen. Intubation with a 5 mm microlarynx tube was successful at the first attempt. This is the first case describing intubation using videolaryngoscopy in an adult patient with acute epiglottitis. Videolaryngoscopy has already proven to be an excellent intubation device in normal and difficult airways. Direct laryngoscopy in patients with epiglottitis may be difficult due to the swelling and distortion of the airway. This case report shows that videolaryngoscopy is a good alternative intubation device option in adults with acute epiglottitis. Nevertheless, all other precautions (difficult airway trolley, surgical tracheostomy) need to be ready for immediate use.     

Lightwand intubation: I — A new lightwand device

Tracheal intubation under direct vision using a laryngoscope can be challenging and difficult even in experienced hands. Transillumination of the soft tissues of the neck using a lightedstylet (lightwand) is one of many effective alternative intubating techniques developed during the past several decades. While many versions of lightwand have been available, each has its limitations. A newly developed lightwand (Trachlight?) has incorporated many design modifications. It has a brighter bulb, permitting intubation under ambient light in most cases. A retractable stiff wire within the wand adds flexibility to facilitate both oral and nasal intubation. The flexible wand also allows visual (transillumination) guide to proper placement of the tip of the tracheal tube in the trachea. The Trachlight? does have some limitations. It is a light-guided technique in which there is no direct visualization of the upper airway structures. It should be avoided in patients with known anatomical abnormalities of the upper airway and used with caution in patients in whom transillumination of the anterior neck may not be achieved adequately. As with any intubating technique, successful intubation using the Trachlight? relies on the preparation of the patient and the operator’s skill and experience.     

Awake videolaryngoscopy-assisted tracheal intubation of the morbidly obese

Awake videolaryngoscopy may be useful for the tracheal intubation of the morbidly obese. This prospective, observational study enrolled 50 patients undergoing bariatric surgery. After sedation and topical anaesthesia of the airway, awake tracheal intubation was attempted, assisted by videolaryngoscopy, and terminated if there was severe gagging, coughing, or inadequate laryngeal view. After three attempts the procedure was considered a failure. Twenty-seven intubations were successful on the first attempt, fifteen on the second, six on the third and two were not successful, giving a success rate of 96% (95% CI 86-100%). In one failure, inserting the tracheal tube caused severe gagging in spite of an adequate view of the larynx, and the trachea was intubated with the videolaryngoscope after induction of anaesthesia. The second failure was due to gagging, with subsequent tracheal intubation successful using fibreoptic bronchoscopy. When managing the morbidly obese airway, awake tracheal intubation using videolaryngoscopy may be considered.