Cricoid chondronecrosis: a rare but potentially life-threatening complication of endotracheal intubation.

Counterpoint: Should an Anesthesiologist Be the Specialist of Choice in Managing the Difficult Airway in the ICU? Not Necessarily

Emergency tracheal intubation: More than just technical skill

Point: Should an Anesthesiologist Be the Specialist of Choice in Managing the Difficult Airway in the ICU? Yes

Background:Different techniques have been introduced to reduce the complications of nasotracheal intubation. The aim of this study was to compare the incidence of nasotracheal intubation complications in finger-guided and conventional methods.Materials and Methods:In this double-blind randomized trial study, 70 patients who were candidates for oral and maxillofacial surgery who required nasal intubation were included in the study finally of which 33 patients with conventional method and 35 patients with finger-guided tubes in the nasopharynx were analyzed at the end of the study. Variables such as success rate, hemodynamic response, and complications of intubation were compared between the two groups.Results:There was no significant difference between the two groups in terms of hemodynamic response to intubation (P > 0.05). There was a significant difference between the two groups in terms of success in tracheal intubation (P < 0.05). There was a significant difference between the two groups in terms of epistaxis immediately after intubation (P < 0.05). There was no significant difference between the two groups in terms of nasal turbine fractures (P > 0.05). However, the frequency of submucosal intubation in the conventional method was significantly higher than the other group (P = 0.02).Conclusion:Nasotracheal intubation using the finger guiding technique in the nasopharynx is associated with a higher success rate and less complications after intubation such as epistaxis and submucosal intubation compared to the conventional method.

Objective To study the Related Facto and prevention and cure measure to the complica-tion of emergency trachea intubation. Methods Review analysis the related factor of complication of 36cases emergency trachea intubation, and the effect of treatment. Result The main cause of the complication of emer-gency trachea intubation were due to the skill and experience of the operater, the result of 29 out of 36 cases of the complication of emergency trachea intubation were survival, 7 cases were dead, (2 cases were die in the compli-cation of trachea intubation, 3 cases were die in the primary affection). 2 cases gave up treatment, 14 cases were performed tracheotomy. Conclusion Good skills in trachea intubation is the key in building complete trachea way and decreasing the complication. Key words: Emergency trachea intubation; Complication; Prevention and cure measure performed

In oral and maxillofacial surgeries, nasotracheal intubation is carried out to increase the surgeon's access to the oral cavity. During nasotracheal intubation the risk of trauma is higher than that in orotracheal intubation as there is passage of the tube through the mucosa of the nasal tract due to which bacteria might get transported into the trachea. To evaluate the effect of 2% nasal mupirocin ointment before and after nasotracheal intubation on decreasing the complications of intubation for oral and maxillofacial surgeries. In the present single blinded randomised controlled clinical trial, 44 patients were randomly assigned to two equal groups. A sterile swab was used, eight to 10 hours before nasotracheal intubation, to take a sample for culturing from the vestibule of nostrils and the anterior septum of the patients. In Group 1, 2% nasal mupirocin ointment was applied to the vestibules of both nostrils and the anterior septum. In Group 2, no intervention was carried out. After general anaesthesia and extubation, microbial cultures were prepared from the 4 cm distal end of the tube and antibiogram test was carried out. Also, the patients were compared in terms of the severity of nasal bleeding, the ease of breathing through the nose after nasotracheal intubation. Data were analysed with suitable statistical tests. In the mupirocin group, 27.2% of the subjects were carriers of Staphylococcus aureus in the nasal cavity but no S. aureus was detected at the distal end of nasotracheal tube after extubation. In the control group, 18.2% of the subjects were carriers of Staphylococcus aureus in the nasal cavity but there was no change in the number of S. aureus counts at the distal end of nasotracheal tube (p-value<0.001). After extubation, in the mupirocin and control groups, 18.2% and 22.7% of the subjects, respectively, exhibited severe bleeding (p-value=0.001). In the mupirocin and control groups, 86.4% and 59.1% of the subjects had easy extubation, respectively (p-value=0.044). In the mupirocin and control groups, 9.1% and 63.7% of the subjects immediately after regaining consciousness and 9.1% and 54.6% three hours after extubation had difficulty in breathing, respectively (p-value=0.001). Use of mupirocin before nasotracheal intubation decreased the complications of nasal intubation in addition to decreasing the risk of colonization of S. aureus and other gram-negative bacteria.

Objective To study the clinical efficacy of self-made microphone light wand in patients with difficult airway.Methods 42 patients with difficult airway scheduled for tracheal intubation were randomly divided into two groups,21 cases in each group.Self-made microphone light wand was used in group Ⅰ,while laryngoscope was used in group lⅡ.The first successful rate of intubation and the time of intubation were recorded.Hemodynamic change and the complications of intubation were observed in all patients.Results There were no difference in age,sex and weight between two groups (P＞0.05).The first successful rate of intubation in group Ⅰ was significantly higher than that in group Ⅱ (90.5％ vs 57.1％,P＜0.05),the time of intubation decreased significantly in group Ⅰ [(86±19) s vs (276±36) s,P＜0.05].Compared with group lⅡ,the complications of intubation such as hemodynamic change,oropharyngeal mucosal hemorrhage,sore throat and hoarseness in group Ⅰ were better(P＜0.05).Conclusions Self-made microphone light wand is relatively safe,effective and promising in patients with difficult airway. Key words: Self-made microphone light wand; Difficult airway; Tracheal intubation

Objective To discuss the feasibility on putting the patients prone position by themselves after awake endotracheal intubation assisted by fiberoptic bronchoscope. Methods Thirty patients underwent general anesthesia prone position operation were selected. After awake endotracheal intubation assisted by fiberoptic bronchoscope, the patients according to their own comfort with the medical staff placed in prone position. The maximum data of systolic blood pressure, diastolic blood pressure and heart rate at basal state (T0), endotracheal intubation (T1) and making position (T2) were recorded. Reflection of tussis and complications of intubation were also recorded. Results In 30 patients, 28 patients succeeded, and 2 patients failed. The patients succeeding had no reflection of tussis obviously and no complications of intubation. There were no statistical differences in systolic blood pressure, diastolic blood pressure and heart rate at T0, T1, T2 (P>0.05). Conclusion The patients prone position by themselves after awake endotracheal intubation assisted by fiberoptic bronchoscope is a better choice in patients undergoing general anesthesia prone position operation. Key words: Bronchoscopes; Catheterization; Prone position

Ventilator-Associated Pneumonia

A case of tracheal stenosis following a short period of intubation with a low pressure cuffed portex tube is described. The possible factors responsible for the tracheal damage are discussed.

MALIGNANT HEMISPHERIC INFARCTION AFTER SUBTLE TRACHEAL RUPTURE

Aim: We aimed to compare patients who developed complications during endotracheal intubation and who did not develop any complication in the Medical Intensive Care Unit. Material and Methods: We enrolled 39 patients into the study. Patients intubated outside the intensive care unit (emergency service, prior to operation) were excluded. All intubation procedures were performed by residents in internal medicine. Data about the patient and complications were recorded by the same person. Results: At least one complication was seen in 41% of all patients. Life-threatening complications such as severe hypoxemia (12%) and severe cardiovascular collapse (7%) were found. Difficult intubation (23%), aspiration (10%), esophageal intubation (10%), dental injury (10%), and dangerous agitation (3%) were found as moderate complications. Acute respiratory failure was the most common reason for intensive care unit admission (59%) and intubation (74%). Within one hour before intubation, the highest and lowest mean heart rate was higher than those who developed complications. No complications were observed in patients who were intubed at the first attempt. All complications occurred in patients who had two or more trials. Conclusion: Complications of endotracheal intubation is an important problem in intensive care units. Intubation success on the first attempt prevents complications. As the number of endotracheal intubation with the assistance of laryngoscopy increased, it was seen that complications related to the procedure also increased. (Yogun Bakim Derg 2011; 2: 39-43)

A series of 10 consecutive cases presenting an obstructive fibrinous tracheal pseudomembrane (OFTP) as a complication of endo-tracheal intubation is presented. The patients developed a thick tubular, rubber-like, whitish pseudomembrane moulding the tracheal wall as a result of short-duration endotracheal intubation. This pseudomembrane firmly adhered to the tracheal wall at the site of the endotracheal cuff. Shortly after extubation, partial detachment of the proximal part of the pseudomembrane produced intermittent positional acute respiratory failure due to valve-manner tracheal obstruction. Immediate mechanical ablation was curative in nine patients, without secondary development of tracheal stenosis. One patient died from acute asphyxiation. The history and the pathological findings of these cases support the hypothesis that this lesion represents an early stage of ischemic tracheal wall injury related to the cuff pressure. Pulmonary physicians should be alerted on this poorly known complication of endotracheal intubation.

Objective To compare the effect of the application of tracheal intubation with SEESHEEN video intubation endoscope (ENF-20) and direct laryngoscopy in patients with missing teeth. Methods 50 patients with missing teeth were selected, and they were randomly divided into two groups, respectively after induction of general anesthesia in tracheal intubation using ENF-20 (group E) and direct laryngoscopy (SHUCMAN laryngoscopy) (group S) intubation. The time of intubation, the times of intubation and the complication of intubation were recorded. Results The success rate of intubation in group E was 92%, which was significantly higher than 64% in group S (χ2=5.711, P=0.017). The intubation time of group E was (27±12)s, which was significantly shorter than (36±13)s in group S (t=-2.620, P=0.012). The total intubation complications of group E was 12%, which was significantly lower than 48% of the group S (χ2=6.095, P=0.014). Conclusion The successful rate of tracheal intubation in patients with missing teeth by using video tracheal intubation (ENF-20) is higher and with less complication. Key words: Intubation, intratracheal; Video tracheal intubation; Direct laryngoscopy; Patients with missing teeth

Objective The purpose of this study was to assess the frequency of complications of endotracheal intubation (ETI) in neonates. Methods The newborns that were admitted and needed urgent or semi-urgent intubation were enrolled in this study over a 1 year period. Route for intubation in all cases were orotracheal. Cases were not routinely sedated or paralyzed. The patients were clinically and radiographically assessed. Results Of 233 newborn infants who were admitted to the neonatal intensive care unit (NICU) at the Children’s Medical Center, 60 infants were intubated. A total of 131 attempts were documented. Unsuccessful attempts with difficult intubation were 17(13%); successful intubation attempts were 114(87%). Complications were detected in 69 cases (61%). The most common complication was laryngeal injury (24%). Accidental extubation was the most frequent event (12%).Tube blockage 7% and endotracheal tube (ETT) malposition was 3%. The complications were less during placement of ETT (12%), but were high during maintenance (61%) and removal of the endotracheal tube (28%). 47% of patients required repeated intubation. There was a significant statistical difference between complications of medicated and unmedicated patients. There was no significant statistical difference relative to gestational age, route of delivery, sex, birth weight, and length of time the ETT remained in place. Conclusion Trauma to the larynx and vocal cords were the most common complications. Difficult and repeated intubation played a major role. Premedication for non-urgent or semi-urgent intubation was safer and more effective than awake intubation. We did not assess long-term outcomes associated with endotracheal tube intubation; this was a limitation of the present study. Operator skill and postoperative care are confounding variables that may influence the results.