Laryngoscopy and fibreoptic intubation in acromegalic patients

Acromegaly is recognized as a cause of difficulty in airway management and tracheal intubation. We evaluated prospectively the conditions for laryngoscopy and fibreoptic intubation in 15 acromegalic patients. Each patient served as his or her own control. Ventilation of the lungs with a face mask was successful in all patients. In five of 15 patients the vocal cords could not be seen using the Macintosh laryngoscope with a size 5 blade. Difficult laryngoscopy was associated significantly with the number of attempts required to see the vocal cords with the fibrescope (P < 0.01, Spearman rank correlation). The larynx could not be seen with both techniques in one patient, and the trachea was intubated blindly with the help of an introducer. Our results showed that fibreoptic intubation may prove difficult or fail in acromegalic patients. Difficulties in seeing the vocal cords with a fibrescope were present most often in patients who also had probable intubation difficulties with a rigid laryngoscope.     

Nasal fibreoptic tracheal intubation in anaesthetised patients breathing via a modified laryngeal mask airway

A modified laryngeal mask airway was used to facilitate nasotracheal intubation with a fibreoptic laryngoscope. A size 4 laryngeal mask airway was modified by creating a defect at the base of the stem and removing the bars to allow passage of the fibreoptic laryngoscope from the nasopharynx to the larynx. The laryngeal mask airway cuff was split and the cut edges were sealed with silicone. This design allowed the cuff to function normally and allowed removal of the split laryngeal mask airway after the tracheal tube had been 'railroaded' into place. Thirty-four patients were studied. The split laryngeal mask airway was easily inserted with satisfactory airway maintenance in 32 patients. Nasal airway endoscopy and laryngoscopy were successfully achieved with the split laryngeal mask airway in place in 31 of 32 patients. Railroading the tracheal tube over the fibreoptic laryngoscope with the split laryngeal mask airway in place was successful in all 31 of these patients. This prototype split laryngeal mask airway allows good airway maintenance while fibreoptic nasotracheal intubation is performed.     

Retrograde fibreoptic intubation in a child with Nager's syndrome

PURPOSE: The authors describe a retrograde fibreoptic technique for tracheal intubation in a micrognathic child with a tracheo-cutaneous fistula. CLINICAL FEATURES: A four-year-old child with Nager's syndrome presented for surgical closure of a tracheocutaneous fistula. A tracheostomy tube had been placed in the neonatal period for management of upper airway obstruction due to severe micrognathia. At 2 1/2 yr of age, after a successful mandibular advancement procedure, the tracheostomy was removed and the child allowed to breathe through the natural airway. Preoperative physical examination revealed an uncooperative child, unable to open her mouth due to limited temporo-mandibular motion. The child was first anaesthetized with ketamine, 70 mg im, then halothane by mask. The authors were unable to open the child's mouth sufficiently to allow rigid laryngoscopy. Attempts at oral and nasal fibreoptic intubation were unsuccessful. Ultimately, the authors were able to intubate nasally by passing an ultrathin Olympus LF-P laryngoscope under direct vision through the tracheocutaneous fistula in a cephalad direction, through the larynx and nasopharynx, then out the nares. An endotracheal tube was then advanced over the fibreoptic scope and positioned distal to the tracheocutaneous fistula. The surgical procedure was successfully accomplished and the trachea was extubated postoperatively without difficulty. CONCLUSION: Retrograde fibreoptic intubation may be an option for airway management of a select group of children who cannot be intubated by traditional techniques.     

Fibreoptic intubation using the cuffed oropharyngeal airway and Aintree intubation catheter

A cuffed oropharyngeal airway has recently been introduced which has larger internal dimensions than a comparable Guedel airway. This allows a ventilation/exchange bougie, the Aintree Intubation Catheter, mounted on a fibreoptic laryngoscope to pass through it. Its 15-mm connector and pharyngeal cuff suggested the possibility of using a Rüsch sealed-port angle piece to allow ventilation through the oropharyngeal airway during fibreoptic laryngoscopy. This study investigated using this equipment to intubate the trachea through the cuffed oropharyngeal airway in paralysed patients, whilst maintaining ventilation manually with a Bain system. In 20 patients, airway control was satisfactory throughout and tracheal intubation was accomplished without complications. The cuffed oropharyngeal airway was easy to manipulate to improve a suboptimal fibreoptic view of the larynx. This may give it an advantage over the laryngeal mask airway when used as a ventilation/intubation conduit.     

The laryngeal mask--a valuable instrument for cases of difficult intubation in children. Anesthesiologic management in the presence of Pierre-Robin syndrome

In cases of craniofacial and mandibulofacial malformations, which are mostly treated during childhood, difficult intubation conditions must generally be expected. In such cases, the laryngeal mask airway (LMA) an alternative instrument for use in endotracheal intubation is a new aid for ventilation. In certain instances, it can be used alone to induce general anaesthesia. Reports of endotracheal intubation by means of the LMA in adults have also been published. CASE REPORT: In our case, a 6-year-old boy with Pierre-Robin syndrome (triad: micrognathia, broad palatoschisis, glossoptosis) needed dental resetting. After induction of anaesthesia in this very cooperative boy with thiopentone and fluothane and relaxation with succinylcholine, it was not possible to examine the hypopharynx by laryngoscopy preparatory to nasal intubation as usual. Repeated blind attempts at nasal intubation (again with spontaneous breathing) failed, as did the attempt at fibreoptic bronchoscopic intubation, because of the narrow anatomical conditions. Finally, a laryngeal mask airway (LMA; size 2) was introduced, and as a result of this ventilation was achieved. However, endotracheal intubation was required for performance of the surgical resetting. With the fibreoptic bronchoscope, we could verify the central position of the LMA over the glottis. A tracheal tube (size 4) was inserted across the laryngeal airway without optic control. The tube connector was disconnected and a normal guide inserted into the tube to remove the LMA. The dental resetting was also performed by oral intubation. CONCLUSION: Therefore, the LMA is not only a ventilation aid, but also a valuable tool in difficult intubation conditions. In our opinion, it is necessary to provide this tool in every anaesthetic unit.     

Clinical trial of a new lightwand device (Trachlight) to intubate the trachea

BACKGROUND: Transillumination of the soft tissue of the neck using a lighted stylet (lightwand) is an effective and safe intubating technique. A newly designed lightwand (Trachlight) incorporates modifications to improve the brightness of the light source as well as flexibility. The goal of this study was to determine the effectiveness and safety of this device in intubating the trachea of elective surgical patients. METHODS: Healthy surgical patients were studied. Patients with known or potential problems with intubation were excluded. During general anesthesia, the tracheas were intubated randomly using either the Trachlight or the laryngoscope. Failure to intubate was defined as lack of successful intubation after three attempts. The duration of each attempt was recorded as the time from insertion of the device into the oropharynx to the time of its removal. The total time to intubation (TTI), an overall measure of the ease of intubation, was defined as the sum of the durations of all (as many as three) intubation attempts. Complications, such as mucosal bleeding, lacerations, dental injury, and sore throat, were recorded. RESULTS: Nine hundred fifty patients (479 in the Trachlight group and 471 in the laryngoscope group) were studied. There was a 1% failure rate with the Trachlight, and 92% of intubations were successful on the first attempt, compared with a 3% failure rate and an 89% success rate on the first attempt with the laryngoscope (P not significant). All failures were followed by successful intubation using the alternate device. The TTI was significantly less with the Trachlight compared with the laryngoscope (15.7 +/- 10.8 vs. 19.6 +/- 23.7 s). For laryngoscopic intubation, the TTI was longer for patients with limited mandibular protrusion and mentohyoid distance, with a larger circumference of the neck, and with a high classification according to Mallampatti et al. However, there was no relation between the TTI and any of the airway parameters for Trachlight. There were significantly fewer traumatic events in the Trachlight group than in the laryngoscope group (10 vs. 37). More patients complained of sore throat in the laryngoscope group than in the Trachlight group (25.3% vs. 17.1%). CONCLUSIONS: In contrast to laryngoscopy, the ease of intubation using the Trachlight does not appear to be influenced by anatomic variations of the upper airway. Intubation occasionally failed with the Trachlight but in all cases was resolved with direct laryngoscopy. The failures of direct laryngoscopy were resolved with Trachlight. Thus the combined technique was 100% successful in intubating the tracheas of all patients.     

Familial occurrence of temporal arteritis

The incidence of difficulty in tracheal intubation in the presence of goiter was investigated. Data were collected in a series of 4742 consecutive adult patients undergoing general anesthesia. The prevalence of goiter was 6.8%. Fifteen anesthesiologists performed the preoperative airway assessment using standardized guidelines. Seven individual risk factors were correlated with the potential for difficult tracheal intubation. Whenever evidence of goiter or airway pathology was observed, the evaluation was completed by indirect laryngoscopy and radiologic examination to establish the presence of any anatomical deviation. Difficult intubation was defined as inadequate exposure of the glottis by direct laryngoscopy. There was no difference in probability of difficulty in tracheal intubation between patients who presented for thyroidectomy and patients with goiter estimated as a random finding. Statistical analysis revealed an increased risk of difficult intubation amongst goiter patients compared with patients with no evidence of any risk factor (6.8% vs 0.9%, P < 10(-8), relative risk = 7.4). We conclude that goiter, when accompanied by airway deformity, constitutes an aggravating factor for difficult intubation.     

Comparative randomized controlled study between human follicle- stimulating hormone (FSH-HP) and human menopausal gonadotropins (hMG) in in vitro fertilization

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.     

Management of difficult airway during induction of anesthesia in a patient with Hallermann-Streiff syndrome

An 18-year-old female with Hallermann-Streiff syndrome underwent the fixation of prolapsus recti. She had significant microgenia, mental retardation and pharyngeal airway stenosis. During induction of anesthesia with halothane and nitrous oxide, severe upper airway obstruction and respiratory depression occurred. The mask ventilation with jaw lift maneuver was impossible. Lowering anesthetic level restored her spontaneous breathing and airway patency. Although the direct laryngoscopic view under light anesthesia with halothane was limited to the epiglottic tip, blind orotracheal intubation using stylet was accomplish after several attempts. At the end of anesthesia, the tracheal tube was extubated after the patient had become fully awake and had recovered completely from neuromuscular blockade monitored by electromyography.     

Induction of anesthesia and tracheal intubation with sevoflurane in adults

BACKGROUND: The speed, quality, and cost of mask induction of anesthesia and laryngeal mask airway insertion or tracheal intubation were studied in young non-premedicated volunteers given high inspired concentrations of sevoflurane (6 to 7%). METHODS: Twenty healthy persons who were 19 to 32 years old participated three times, received 6 l/min fresh gas flow, and were randomized to receive 6 to 7% sevoflurane in 66% nitrous oxide/28% oxygen by face mask until tracheal intubation (treatment 1) or until laryngeal mask airway insertion (treatment 3), or 6 to 7% sevoflurane without nitrous oxide to tracheal intubation (treatment 2). Participants exhaled to residual volume and took three vital capacity breaths of the gas mixture; thereafter ventilation was manually assisted. The time of exposure to the inhaled gas was varied for consecutive participants. It was either increased or decreased by 30-sec increments based on the failure or success of the preceding volunteer's response to laryngoscopy and intubation after a preselected exposure time. Failure was defined as poor jaw relaxation, coughing or bucking, or inadequate vocal cord relaxation. RESULTS: Loss of the lid-lash reflex in unpremedicated young volunteers was achieved in 1 min and did not differ among groups. Average time (and 95% confidence interval) for acceptable conditions for LMA insertion was achieved in 1.7 (0.7 to 2.7) min, and all participants had an immediate return of spontaneous ventilation. The time for acceptable tracheal intubating conditions after manual hyperventilation by mask was 4.7 (3.7 to 5.7) min and 6.4 (5.1 to 7.7) min in treatments 1 and 2, respectively. There were no cases of increased secretions or laryngospasm. The incidence of breath holding and expiratory stridor ("crowing") was 7.5% and 25%, respectively, during treatment 1 and 15% and 40%, respectively, during treatment 2. CONCLUSIONS: The induction of anesthesia to loss of lid reflex in young non-premedicated adults approaches the speed of intravenous induction techniques. No untoward airway responses were noted during mask induction of anesthesia with a three-breath technique. In response to intubation, no adverse airway responses, including jaw tightness, laryngospasm, and excessive coughing or bucking, occurred in participants whose duration of mask administration of sevoflurane met the appropriate times (as determined in this study).     

Light-guided intubation using Trachlight

BACKGROUND: A new intubating transilluminated device (Trachlight) has been recently proposed as an alternative to tracheal intubation with direct laryngoscopy. OBJECTIVE: 1) To evaluate Trachlight device in orotracheal intubation and to assess its operation and complications. 2) To compare the time consumption of transillumination intubation in respect to direct laryngoscopy on the same patients. METHODS: The first study was performed on 50 patients undergoing elective surgery and submitted to Trachlight intubation alone; speed of intubation, number of attempts and all complications were recorded and related to Mallampati classes. In the second study 16 patients undergoing to elective surgery were enrolled. Each patient was classified according to both the Mallampati classes and the Cormack classes. Each patient was submitted to two tracheal intubations: the first with the Trachlight and the second with conventional direct laryngoscopy performed by the same anesthesiologist. The time to intubation and the number of attempts were recorded and related to the Mallampati and Cormack classes. RESULTS: In the first study time of intubation with Trachlight was 20.93 +/- 13.02s (mean +/- SD) without statistical differences in respect to the Mallampati classes. In the second study the times to intubation were without any statistical difference independently of the technique of intubation and of the Mallampati or Cormack classes. CONCLUSIONS: Orotracheal intubation using Trachlight appears to be an effective and easy to learn technique, being also easy, safe and fast to carry out. The comparison with direct laryngoscopy showed the same speed and effectiveness even on patients with difficult intubation.     

Usefulness of the intubating laryngeal mask airway for cases with predicted difficult intubation

We evaluated the usefulness of the intubating laryngeal mask airway (ILMA) in patients who were predicted to have possible difficult airway. Patients with possible difficult airway were defined as those with limited head extension, Mallampati's classification of grade IV, thyro-mental distance < 4 cm, or Cormack grade III-IV on the laryngoscopy. The control group was consisted of the patients without these conditions or impaired mouth opening. Insertion of the ILMA was successfully performed in all patients of both groups. In the group of possible difficult airway, 83% of patients were intubated through the ILMA successfully, and in the control group, 86%. We conclude that the ILMA may become an additional tool in patients with difficult intubation.     

Airway control during percutaneous dilatational tracheostomy: pilot study with the intubating laryngeal mask airway

Percutaneous dilatation tracheostomy has become a common procedure for bedside insertion of tracheostomy tubes in the intensive care unit. Management of the airway during the procedure using the laryngeal mask airway (LMA) and other methods has been described. The intubating laryngeal mask airway has several potential benefits for airway management during percutaneous dilatation tracheostomy compared with the LMA. These include the use of both the fibreoptic bronchoscope and tracheal tube if necessary. We report the results of a pilot study of 10 patients that illustrates these advantages.     

The intubating laryngeal mask airway: an initial assessment of performance

A new prototype of the laryngeal mask airway (LMA), the intubating laryngeal mask airway (ILMA), was used to facilitate tracheal intubation in 100 fasted patients presenting for elective surgery. Alignment of the ILMA with the larynx was assessed fibreoptically before intubation without the investigator performing the intubation being aware of the view score. Ease of intubation correlated with the view obtained and with the degree of manipulation of the ILMA needed to achieve tracheal intubation. Intubation was successful in 93 patients. Of the seven intubation failures, five occurred in the first 20 patients. Conventional connection to the breathing system and ventilation of the lungs of the patients were possible throughout the intubation procedure.     

Use of adenosine in patients hospitalized in a university medical center

A 54-year old woman was scheduled for thoracotomy for excision of a tumor of the left upper lobe. Reduced thyromental distance and thyroid enlargement were identified by the preoperative physical examination and inability to visualize the larynx was encountered during direct laryngoscopy. A 37-Fr left sided double lumen tube was inserted in trachea with great difficulty after three failed attempts. One lung anesthesia underwent uneventfully and postoperatively it was decided to exchange the double lumen tube to a single lumen tracheal tube. After the extubation, five failed attempts of reintubation were performed. A laryngeal mask airway (LMA) size 3 was passed easily achieving an airtight airway. The patient underwent an uneventful prolonged (105 min) weaning via the LMA which was left in place until the patient regained full consciousness. Peripheral oxygen saturation remained greater than 95% throughout the airway manipulation. LMA insertion is an easy non-invasive technique and should be considered whenever airway management proves difficult.     

Difficult intubation and brain-stem anaesthesia

PURPOSE: To present a case of difficult intubation with brainstem anaesthesia after retrobulbar block with bupivacaine and lidocaine and sedation with midazolam and to point out that close monitoring and timely treatment is important in preventing an unfavourable outcome. CLINICAL FEATURES: An 82-yr-old man with treated hypertension and stable angina was scheduled for cataract extraction. Physical examination revealed a class 2 airway. He had a retrobulbar block after topical tetracaine drops, with bupivacaine 0.5% and lidocaine 2% with hyaluronidase under sedation with 1 mg midazolam. Five minutes after the block, respiration slowed, he became unresponsive and oxygen saturation decreased to 80%. Immediate ventilation with mask without additional oxygen improved saturation. Attempted tracheal intubation failed: the epiglottis could not be visualized despite flaccid jaw and extremities. A laryngeal mask airway was placed which was leaking and adequate ventilation could not be achieved but a second laryngeal mask airway was placed successfully. CONCLUSION: This case emphasizes the need for dose monitoring and personnel capable of managing the difficult airway when intra-orbital anaesthesia is used.     

Experience with the McCoy laryngoscope in difficult laryngoscopy

We report our experience with the McCoy levering laryngoscope in 48 patients who were a Cormack and Lehane grade 3 or grade 4 view at direct laryngoscopy. The view with the blade in neutral position was grade 3 in 39 patients and grade 4 in nine patients. Elevation of the levered tip of the blade in the grade 3 group improved the view to grade 2 in 17 patients (44%), in 17 patients (44%) the view remained unchanged and in five patients (12%) the view deteriorated to grade 4. In the patients initially grade 4, the view improved to grade 3 in one patient and remained unchanged in eight patients. The McCoy laryngoscope is a useful tool to aid intubation in about half of patients who are a grade 3 view at laryngoscopy. Our experience indicates it is unlikely to improve a grade 4 view.     

A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis

This prospective, nonrandomized, observational study of 76 infants with pyloric stenosis was conducted at an academic children's hospital and compared awake versus paralyzed tracheal intubation in terms of successful first attempt rate, intubation time, heart rate (HR) and arterial hemoglobin oxygen saturation (SpO2) changes, and complications. Three groups were determined by intubation method: awake (A) with an oxygen-insufflating laryngoscope, after rapid-sequence induction (R), or after modified rapid-sequence induction (M) including ventilation through cricoid pressure. Successful first attempt intubation rate was 64% for Group A versus 87% for paralyzed Groups R and M (P = 0.028). Median intubation time was 63 s in Group A versus 34 s in Groups R and M (P = 0.004). Transient, mild decreases in mean HR and SpO2 and incidences of significant bradycardia and decreased SpO2 did not vary by group. Complications, including bronchial or esophageal intubation, emesis, and oropharyngeal trauma, were few. Senior anesthesiologists intervened in four tracheal intubations. We advocate anesthetized, paralyzed tracheal intubation because struggling with conscious infants takes longer, often requires multiple attempts, and prevents neither bradycardia nor decreased SpO2. After induction, additional mask ventilation with O2 confers no advantage over immediate tracheal intubation in preserving SpO2. Implications: In our children's hospital, awake tracheal intubation was not superior to anesthetized, paralyzed intubation in maintaining adequate oxygenation and heart rate or in reducing complications, and should be abandoned in favor of the latter technique for routine anesthetic management of otherwise healthy infants with pyloric stenosis.     

Tracheal intubation in a manikin: comparison of supine and left lateral positions

Tracheal intubation in the left lateral position may be necessary in some circumstances. Using a manikin we demonstrated that anaesthetic trainees found tracheal intubation in the left lateral position was more difficult and took longer than in the supine position. However, the time to successful tracheal intubation decreased with practice, indicating the presence of a learning curve. We suggest that tracheal intubation in the left lateral position should become part of training in the management of the difficult airway.