Tracheal Intubation Surgical Airway Techniques Publications (4033)
Tracheal Intubation Surgical Airway Techniques Publications
Preoperative recognition of a difficult airway, detailed planning and being aware of plan B and plan C are the elementary keys to success. Providers have to be aware, that preoperative airway assessment does not always correlate with the ease of oxygenation and ventilation. Therefore, various methods have been described in the literature and several authors have adopted unique ways to manage the airways in a successful manner. With the advancement of surgical techniques over the years, anesthetic management has also evolved tremendously to match the needs. The commonly encountered conditions requiring surgical interventions include post-intubation stenosis and foreign body aspiration. In this review we will discuss the most common pathologies of tracheobronchial lesions and specific anesthetic management considerations related to them.
We conducted an observational study using a mannequin. A Leksell stereotactic headframe was placed on a mannequin in the operating room and the frame was fixed to the operating room table. Anesthesia personnel were asked to insert a #4 laryngeal mask and then to intubate the mannequin, using both direct (DL) and video laryngoscopy (VL). In addition, participants were asked to perform the same airway techniques in the mannequin without the headframe. Data were analyzed for time taken for airway management using different devices with and without the headframe. In addition, we compared the time taken to secure the airway between different participant groups.
Thirty anesthesia personnel (7 residents, 12 fellows, and 11 consultants) participated in the study. With the headframe in situ, 97% of participants were able to insert a laryngeal mask on their first attempt; 93% and 97% of participants were able to intubate the mannequin using DL and VL respectively on their first attempt. Without the stereotactic headframe, all participants were able to insert the laryngeal mask and intubate on the first attempt. The average time taken to insert a laryngeal mask and intubate the mannequin using DL and VL with the headframe in situ was 39.3, 58.6, and 54.8 seconds, respectively.
Our study showed that both laryngeal mask insertion and tracheal intubation can be performed with a stereotactic headframe in situ. A laryngeal mask is the quickest airway device to insert and can be inserted while the mannequin is in the standard surgical position. Further study is needed to validate the results in patients.
Methods This study is an observational prospective study. It was performed at the otolaryngology department and ICU new surgery hospital on 124 ICU admitted patients. We collected patients' demographic records, cause of admission, indications of tracheostomy, mechanical ventilation, and duration of ICU stay. We also gathered patientś tracheostomy records including the incidence, timing, technique, type, early and late complications, and outcome. All tracheostomized patients received follow-up for 12 months. Results The indication for tracheostomy in ICU patients was mostly prolonged intubation (80.5%), followed by diaphragmatic paralysis (19.5%). All tracheostomies were done by the open approach technique. Tracheostomy for prolonged intubation was done within 17 to 26 days after intubation with a mean of 19.4 ± 2.07 days. Complications after tracheostomy were 13.9% tracheal stenosis and 25% subglottic stenosis. Conclusion Prolonged endotracheal intubation is the man indication of tracheostomy, performed after two weeks of intubation. Although there were no major early complications, laryngotracheal stenosis is still a challenging sequel for tracheostomy that needs to be investigated to be prevented.
This prospective study was performed in patients undergoing surgery for major maxillofacial fractures in which oral intubation and/or nasal intubation have been unsuitable, impossible, or contraindicated. The technique of submandibular intubation was assessed intraoperatively and in the postoperative period. The outcomes and complications are presented.
The study included 26 patients aged between 14 and 57 years. All patients had mandibular fractures, with 19 midface fractures (73.1%), 11 nasal bone fractures (42.3%), 10 zygomatic bone fractures (38.5%), 9 naso-orbito-ethmoidal fractures (34.6%), and 9 frontobasilar fractures (34.6%). The procedure time ranged from 5 to 12 minutes (mean, 7 minutes 4.6 seconds). Delayed extubation was performed in 15 cases (57.7%) in which the tube was left in place for a period ranging from 8 to 50 hours (mean, 30 hours 24 minutes). The technique has proved to be straightforward and satisfactory. A postoperative superficial infection occurred in 2 patients, whereas hypertrophic scars occurred in another 2 patients.
Submandibular endotracheal intubation is straightforward, safe, and quick to carry out. It can be an alternative to tracheotomy as it allows operative techniques and postoperative airway protection without the risks and side effects of tracheotomy.
Our primary objective was to assess whether use of videolaryngoscopy for tracheal intubation in adults requiring general anaesthesia reduces risks of complications and failure compared with direct laryngoscopy. Our secondary aim was to assess the benefits and risks of these devices in selected population groups, such as adults with obesity and those with a known or predicted difficult airway.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase on 10 February 2015. Our search terms were relevant to the review question and were not limited by outcomes. We carried out clinical trials register searches and forward and backward citation tracking. We reran the search on 12 January 2016; we added potential new studies of interest from the 2016 search to a list of 'Studies awaiting classification', and we will incorporate these studies into the formal review during the review update.
We considered all randomized controlled trials and quasi-randomized studies with adult patients undergoing laryngoscopy performed with a VLS or a Macintosh laryngoscope in a clinical, emergency or out-of-hospital setting. We included parallel and cross-over study designs.
Two review authors independently assessed trial quality and extracted data, consulting a third review author to resolve disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias.
We included 64 studies identified during the 2015 search that enrolled 7044 adult participants and compared a VLS of one or more designs with a Macintosh laryngoscope. We identified 38 studies awaiting classification and seven ongoing studies. Of the 64 included studies, 61 included elective surgical patients, and three were conducted in an emergency setting. Among 48 studies that included participants without a predicted difficult airway, 15 used techniques to simulate a difficult airway. Seven recruited participants with a known or predicted difficult airway, and the remaining studies did not specify or included both predicted and not predicted difficult airways. Only two studies specifically recruited obese participants. It was not possible to blind the intubator to the device, and we noted a high level of inevitable heterogeneity, given the large number of studies.Statistically significantly fewer failed intubations were reported when a VLS was used (Mantel-Haenszel (M-H) odds ratio (OR), random-effects 0.35, 95% confidence Interval (CI) 0.19 to 0.65; 38 studies; 4127 participants), and fewer failed intubations occurred when a VLS was used in participants with an anticipated difficult airway (M-H OR, random-effects 0.28, 95% CI 0.15 to 0.55; six studies; 830 participants). We graded the quality of this evidence as moderate on the basis of the GRADE system. Failed intubations were fewer when a VLS was used in participants with a simulated difficult airway (M-H OR, random-effects 0.18, 95% CI 0.04 to 0.77; nine studies; 810 participants), but groups with no predicted difficult airway provided no significant results (M-H OR, random-effects 0.61, 95% CI 0.22 to 1.67; 19 studies; 1743 participants).Eight studies reported on hypoxia, and only three of these described any events; results showed no differences between devices for this outcome (M-H OR, random-effects 0.39, 95% CI 0.10 to 1.44; 1319 participants). Similarly, few studies reported on mortality, noting no differences between devices (M-H OR, fixed-effect 1.09, 95% CI 0.65 to 1.82; two studies; 663 participants), and only one study reporting on the occurrence of respiratory complications (78 participants); we graded these three outcomes as very low quality owing to lack of data. We found no statistically significant differences between devices in the proportion of successful first attempts (M-H OR, random-effects 1.27, 95% CI 0.77 to 2.09; 36 studies; 4731 participants) nor in those needing more than one attempt. We graded the quality of this evidence as moderate. Studies reported no statistically significant differences in the incidence of sore throat in the postanaesthesia care unit (PACU) (M-H OR, random-effects 1.00 (95% CI 0.73 to 1.38); 10 studies; 1548 participants) nor at 24 hours postoperatively (M-H OR random-effects 0.54, 95% CI 0.27 to 1.07; eight studies; 844 participants); we graded the quality of this evidence as moderate. Data combined to include studies of cross-over design revealed statistically significantly fewer laryngeal or airway traumas (M-H OR, random-effects 0.68, 95% CI 0.48 to 0.96; 29 studies; 3110 participants) and fewer incidences of postoperative hoarseness (M-H OR, fixed-effect 0.57, 95% CI 0.36 to 0.88; six studies; 527 participants) when a VLS was used. A greater number of laryngoscopies performed with a VLS achieved a view of most of the glottis (M-H OR, random-effects 6.77, 95% CI 4.17 to 10.98; 22 studies; 2240 participants), fewer laryngoscopies performed with a VLS achieved no view of the glottis (M-H OR, random-effects 0.18, 95% CI 0.13 to 0.27; 22 studies; 2240 participants) and the VLS was easier to use (M-H OR, random-effects 7.13, 95% CI 3.12 to 16.31; seven studies; 568 participants).Although a large number of studies reported time required for tracheal intubation (55 studies; 6249 participants), we did not present an effects estimate for this outcome owing to the extremely high level of statistical heterogeneity (I(2) = 96%).
Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VLS reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VLS affects time required for intubation.
Large lesions in the spine may require pre-operative therapy with denosumab, a human monoclonal antibody to RANKL, to facilitate surgery. It is highly unusual for GCT arising in cervical spine to present with acute asphyxia (requiring tracheostomy).
We report a patient with large C7 GCT that caused tracheal compression with almost complete airway obstruction requiring emergency intubation.
The tumor responded to subcutaneously administered denosumab with marked decrease in size and relief of symptoms. Increased tumor mineralization in response to therapy facilitated subsequent successful surgical tumor resection. The patient remains symptom-free 2 years following surgery without tumor recurrence.
Denosumab can shrink the size of large GCTs, providing symptom relief prior to surgery and facilitate tumor resection.
Four fresh frozen cadavers underwent oesophageal intubation by an emergency medicine specialist with confirmation by a second specialist. Hand ventilation with room air via a self-inflating resuscitation bag was provided at 12 breaths per minute for 2 min or until ETCO2 was zero for 10 consecutive breaths. ETCO2 and waveform morphology were examined and video recorded. The oesophagus was then extubated and the process was repeated for tracheal intubation.
In no case was oesophageal ETCO2 detected. For two cadavers, life-like ETCO2 waveforms were achieved immediately after tracheal intubation, with maximum ETCO2 achieved by the second breath. In these cases waveform morphology was normal and persistent.
Cadaveric oesophageal intubation did not result in a capnography waveform, simulating live patients. When present, ETCO2 following tracheal intubation showed normal morphology which was sustained for 2 min. However, ETCO2 was not present following tracheal intubation in all cadavers. These results represent instrumentation on the cadavers for the first time after thawing and further work should assess the repeatability of the findings with subsequent intubations.
We started with routine tracheal intubation but during surgery our tracheal tube was hindering surgical repair. So we used intermittent ventilation by passing the tracheal tube distal to the fistula and then pulling it back and providing clear surgical field during apnoea. It was done several times until the repair was completed successfully. Different airway management techniques are described in literature with the most common being oral intubation and placement of cuff distal to the fistula. However it may need to be modified according to the situation. We used a different technique for ventilation and will discuss it's pros and cons.
This was a single-blind, randomized clinical trial, in which 121 patients who had undergone CABG were divided into two groups: those who gargled distilled water and those who gargled a green tea solution. An hour after extubation, the patients of the intervention group were asked to gargle 30 cc of green tea, and the patients of the control group were asked to gargle 30 cc of distilled water, every 6 hours for up to 24 hours (four times per patient). A sore throat questionnaire was filled out 6, 12, and 24 hours after endotracheal extubation.
The results showed that there were no significant differences between the two groups with regard to patient age, sex, body mass index, smoking background, and duration of anesthesia. There was no significant difference between the two groups in terms of sore throat before the intervention (P = 0.461) and 6 hours after the intervention (P = 0.901). However, a significant difference was observed between the two groups in terms of sore throat 12 hours (P = 0.047) and 24 hours (P < 0.001) after removing the endotracheal tube.
Gargling a green tea solution, an anti-inflammatory, natural, and harmless substance, can reduce the pain of sore throat in patients after endotracheal extubation.
The procedure was performed in ten selected adult patients with maxillofacial/mandibular fractures associated with a fracture of skull base or nasal bone. All of them were medically stable with no need of intensive care or mechanical ventilation in post-operative period.
Submandibular intubation in all ten patients of panfacial fractures allowed uninterrupted surgical techniques with a secured airway. All patients were reverted to oro-tracheal tube at the end of surgery as immediate maxillomandibular fixation was not necessary. The patients were extubated after recovery from anaesthesia before they left the operating theatre. One patient in the post-operative period had a superficial infection of incision site that responded well to local treatment. No other complications were encountered in the intra-operative or post-operative period.
In complex maxillofacial injuries, when oral or nasal intubation hampers surgeon's field of view, submandibular intubation offers an effective alternative to short-term tracheostomy along with small risk potential. There is a need to emphasise its regular application in such cases so that technique can be mastered by both surgeons and anaesthesiologist.