Ultrasound evaluation of the impact of cricoid pressure versus novel ‘paralaryngeal pressure’ on anteroposterior oesophageal diameter

To assess the degree to which cricoid pressure (Sellick manoeuvre) actually compresses the oesophagus, we measured the effect of cricoid pressure and paralaryngeal pressure on the outer anteroposterior diameter of the upper oesophagus with ultrasound in 39 healthy volunteers. The mean (SD) outer anteroposterior oesophageal diameter was 0.77 (0.11) cm with no pressure, 0.79 (0.13) cm with the application of cricoid pressure of 30 N and 0.68 (0.12) cm with the application of paralaryngeal pressure of 30 N (p < 0.0001). If cricoid pressure does not reduce the anteroposterior diameter of the oesophagus, it is difficult or impossible to explain the efficacy of the Sellick manoeuvre. However, paralaryngeal pressure decreases this diameter and has the potential to occlude the upper oesophagus.     

经颌下置管全麻在复杂全面部骨折中的应用

目的：介绍特殊全面部骨折手术中一种经颌下置管全麻的方法并探讨其适应症及注意事项。方法：7例全面部骨折、无法实施鼻插全麻患者,口插全麻并稳定后制备口底与颌下间隧道并将气管导管导出颌下、固定。手术结束后将导管导回口腔。结果：所有患者口腔插管和口底导出均顺利,导管位置无改变,双肺呼吸音对称。术中麻醉平稳,管理方便,不影响手术操作。术后局部无气肿、感染、气道阻塞、神经损伤。结论：在无法鼻插全麻前提下,经颌下置管全麻避免了气管切开,同时满足了颌骨骨折术中咬合对位的要求,是特殊全面部骨折麻醉手段的有效方法。     

一例曾两次拔管后喉痉挛患者成功拔管的体会

喉痉挛（laryngospasm）指喉部肌肉反射性痉挛收缩,使声带内收,声门部分或完全关闭而导致病人出现不同程度的呼吸困难甚至完全性的呼吸道梗阻,本文遇到一例曾两次拔管后出现严重喉痉挛、声门闭合、接近心跳骤停意外,第三次成功拔管患者,现将救治经过与体会介绍如下。1病例介绍患者,刘XX,男,60岁,汉族,以＂咳嗽,咳痰三年伴呼吸困难一年,加重三天＂为主诉于2014年4月9日入ICU,诊断为慢性阻塞性肺疾病,呼吸衰竭,酸碱平衡紊乱，入院时血气分析PH7．31PC0275 mmHg PO245 mmHg HC03-37．8mmol／L，给予抗炎、平喘、呼吸兴奋剂治疗，于4月14日患者呼吸困难加重给予评吸兴奋剂治疗效果不佳，行呼吸机辅助呼吸，曾两次拔出气管插管后出现严重喉痉挛，复插管。于4月24日第三次拔出气管插管，25日转至呼吸内科病房。     

Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations

Purpose

In hospital-based studies, patients intubated by physicians while in an inclined position compared to supine position had a higher rate of first pass success and lower rate of peri-intubation complications. We evaluated the impact of patient positioning on prehospital endotracheal intubation in an EMS system with rapid sequence induction capability. We hypothesized that patients in the inclined position would have a higher first-pass success rate.

Removal methods of rigid stylets to minimise adverse force and tracheal tube movement: a mathematical and in-vitro analysis in manikins

This study investigated displacement of the tracheal tube caused by different methods of intubating stylet removal, using in-vitro experiments and mathematical analysis. In the first in-vitro experiment, we measured the distance travelled by the tube tip during stylet extraction. Then, we investigated the ideal technique for stylet extraction using mathematical analysis, which would cause minimal tube displacement. Then, using a training manikin, we measured the force applied to the vocal cords and stylet extraction force during tracheal intubation. When the stylet was extracted along a straight path towards the stylet end, the distance travelled by the tube tip significantly increased as the bending angle increased. Mathematical analysis revealed that the stylet should be diagonally extracted (in the sagittal plane) at an appropriate angle, rather than along a straight path towards the direction of the stylet end. In simulated tracheal intubation, extraction force and force applied to the vocal cords both significantly increased as the bending angle increased. Compared with the ‘hockey stick’-shaped stylet, the arcuate-shaped stylet resulted in reduced force. Our results indicate the potential risk for vocal cord injury when using hockey stick-shaped stylets with large bending angles.     

Assessment and management of the predicted difficult airway in babies and children

Although it is essential to take a history and examine every child prior to airway management, preoperative anticipation of a difficult airway is not totally reliable and therefore it is wise to be prepared for the unexpected difficult airway. Information about the airway can be gained from previous medical records, current history, physical examination and other tests. A natural consequence of airway assessment is development of an airway plan. Important anatomical and physiological features may be identified in an airway assessment which can then have a direct influence on the subsequent airway plan. Managing the predicted difficult airway is usually elective. This allows proper preparation of equipment, assistants, expertise and the environment required for the airway plan. This article will discuss paediatric airway assessment, outline those features that contribute to airway difficulty, and identify indications and risk factors associated with various airway techniques. Key objectives for an airway management plan are to maintain oxygenation and avoid trauma. This involves adopting techniques that avoid hypoxia and provide a high success rate with minimum attempts.     

Tips and tricks to increase the success rate of blind tracheal intubation through the Air-Q™ versus the intubating laryngeal mask airway Fastrach™

BackgroundThe Air-Q intubating laryngeal airway is a new supraglottic airway device which overcomes some of the limitations inherent to the intubating laryngeal mask airway (ILMA Fastrach^™) for tracheal intubation. Previous studies showed lower success rate of the Air-Q^™ versus ILMA Fastrach^™. This study was conducted to illustrate new maneuvers for increasing the success rate of Air-Q^™ versus ILMA Fastrach^™ and compare between both devices.MethodsOne-hundred and seventy adult patients, ASA I or II, aged >16 years old undergoing elective surgery under general anesthesia were divided randomly into 2 equal groups (85 each). Group A: using Air-Q ILA size 3.5 or size 4.5 Group B: using ILMA size 4 or size 5 according to the manufacturer’s recommendations for body weight in both groups. The time and the total success rate of blind intubation through them in 2 attempts only were recorded. In Group A, extension of the head with cricoid pressure was applied. The hemodynamic response to devices insertion and the complications related to both devices were compared.ResultsIn Group A, the total success rate in 2 attempts was 94.12%, while in Group B, it was 96.47%. However, this difference was not statistically significant. The first attempt success rate was 81.18% in Group A, while it was 82.35% in Group B. The total time to intubate the hemodynamic response to device insertion and the incidence of complications (sore throat, trauma and hoarseness of voice) showed no statistically significant difference between both groups.ConclusionThis study showed that extension of the head with cricoid pressure greatly increases the success rate of blind intubation through the Air-Q to 94.12% versus the ILMA Fastrach 96.47% with no statistically significant difference between both devices.     

序贯性建立人工气道在重症脑损伤患者救治中的应用

目的探讨序贯性建立人工气道对重症脑损伤患者救治中的安全性的影响。方法选取2010-04-2014-03入住重症医学科(ICU)时APACHE-Ⅱ评分≥15分、4分≤GCS≤8分、ICU住院时间≥3d、估计气管插管超过3~7d者的重症脑损伤患者44例,随机分为2组,分别按不同方法实施气道开放,试验组采用序贯气道开放法,即在气管切开导管置入气管内之前仍保留气管插管,待气切导管完全正确放置,再拔除气管插管,全过程始终使用呼吸机辅助通气,常规组在气管切开造口过程中不使用呼吸机辅助通气,仅吸氧4~8L/min;观察2组患者的操作时间、APACHE-Ⅱ评分、生命体征、术后24h NSE水平、血气分析以及随访3个月的GOS评分。结果 (1)2组患者入科时、气管切开术前APACHE-Ⅱ、HR、RR、Bp、SpO2比较差异无统计学意义(P0.05);气管切开造口术后与入科时APACHE-Ⅱ、SpO2相比差异均有统计学意义(P0.05);同时气管切开术后APACHE-Ⅱ、HR、RR、Bp、SpO2在2组患者间的差异均有统计学意义(P0.05)。(2)2组患者入科时以及气管切开前血气分析中的pH、PaO2、PaCO2和术后NSE水平差异均无统计学意义(P0.05);气管切开造口术后与入科时相比升高,差异有统计学意义(P0.05);对比2组患者的气管切开术后pH、PaO2、PaCO2和术后NSE水平差异具有统计学意义(P0.05)。(3)2组患者3个月后生存质量相比差异有统计学意义(P0.05)。结论重症脑损伤患者因长期呼吸机辅助通气,采取序贯性人工气道开放法能确保其安全性,改善预后,提高抢救成功率。