Airway Management In Patients Research Articles

Anaesthesiologist-provided prehospital airway management in patients with traumatic brain injury

BackgroundGuidelines recommend that patients with brain trauma with a Glasgow Coma Scale (GCS) score of less than 9 should have an airway established. Hypoxia, hypotension and hypertension as well as hypoventilation and hyperventilation may worsen outcome in these patients.ObjectivesThe objectives were to investigate guideline adherence, reasons for nonadherence and the incidences of complications related to prehospital advanced airway management in patients with traumatic brain injury.Materials and methodsWe prospectively collected data from eight anaesthesiologist-staffed prehospital critical care teams in the Central Denmark Region according to the Utstein-style template.ResultsAmong 1081 consecutive prehospital advanced airway management patients, we identified 54 with a traumatic brain injury and an initial GCS score of less than 9. Guideline adherence in terms of airway management was 92.6%. The reasons for nonadherence were the patient’s condition, anticipated difficult airway management and short distance to the emergency department. Following rapid sequence intubation (RSI), 11.4% developed oxygen saturation below 90%, 9.1% had a first post-RSI systolic blood pressure below 90 mmHg and 48.9% had a first post-RSI systolic blood pressure below 120 mmHg. The incidence of hypertension following prehospital RSI was 4.5%. The incidence of postendotracheal intubation hyperventilation was as high as 71.1%.ConclusionThe guideline adherence was high. The incidences of post-RSI hypoxia and systolic blood pressure below 90 compare with the results reported from other physician-staffed prehospital services. The incidence of systolic blood pressure below 120 as well as that of hyperventilation following prehospital endotracheal intubation in patients with traumatic brain injury call for a change in our current practice.

The Airway Management of Patients with Apert Syndrome

Introduction: The management of the Apert airway presents a rare and difficult challenge. The level of airway obstruction includes the pyriform aperture, nasal passages, posterior choanae, nasopharynx and oropharynx. Moreover, this group is prone to central apnoeas. Our aim was to study the treatment modalities of the Apert airway at our Craniofacial unit and to determine if there has been a trend away from tracheostomy.

Gastric Tubes and Airway Management in Patients at Risk for Aspiration

Gastric Tubes and Airway Management in Patients at Risk for Aspiration

Airway management in head and neck cancer patients undergoing microvascular free tissue transfer: delayed extubation as an alternative to routine tracheotomy

The aim of this study was to evaluate two practices of airway management in patients undergoing head and neck cancer (HNC) resection and microvascular free tissue transfer (MFTT), and to assess the advantages and disadvantages of the two approaches. Patients undergoing a delayed extubation approach (NO-TRACH group) and patients undergoing primary tracheotomy (PRIM-TRACH group) were retrospectively evaluated in terms of perioperative and postoperative outcome measures. Not performing routine tracheotomy was safe and no perioperative airway complications occurred. NO-TRACH patients were extubated after 1.1 ± 0.9 days (mean ± standard deviation) and secondary tracheotomy was necessary in three patients (13%). NO-TRACH patients revealed decreased duration of surgery (p <0.05) and showed trends to earlier resumption of oral feeding and decreased length of hospitalisation. Flap complication rates were similar in both groups, with an overall flap survival rate of 97.5% (n = 39/40). With appropriate postoperative care, carefully selected patients undergoing major HNC resections with MFTT can be safely managed without routine tracheotomy.

Gastric Tubes and Airway Management in Patients at Risk of Aspiration

Rapid sequence induction and intubation (RSII) and awake tracheal intubation are commonly used anesthetic techniques in patients at risk of pulmonary aspiration of gastric or esophageal contents. Some of these patients may have a gastric tube (GT) placed preoperatively. Currently, there are no guidelines regarding which patient should have a GT placed before anesthetic induction. Furthermore, clinicians are not in agreement as to whether to keep a GT in situ, or to partially or completely withdraw it before anesthetic induction. In this review we provide a historical perspective of the use of GTs during anesthetic induction in patients at risk of pulmonary aspiration. Before the introduction of cricoid pressure (CP) in 1961, various techniques were used including RSII combined with a head-up tilt. Sellick initially recommended the withdrawal of the GT before anesthetic induction. He hypothesized that a GT increases the risk of regurgitation and interferes with the compression of the upper esophagus during CP. He later modified his view and emphasized the safety of CP in the presence of a GT. Despite subsequent studies supporting the effectiveness of CP in occluding the esophagus around a GT, Sellick's early view has been perpetuated by investigators who recommend partial or complete withdrawal of the GT. On the basis of available information, we have formulated an algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents. The approach in an individual patient depends on: the procedure; type and severity of the underlying pathology; state of consciousness; likelihood of difficult airway; whether or not the GT is in place; contraindications to the use of RSII or CP. The algorithm calls for the preanesthetic use of a large-bore GT to remove undigested food particles and awake intubation in patients with achalasia, and emptying the pouch by external pressure and avoidance of a GT in patients with Zenker diverticulum. It also stipulates that in patients with gastric distension without predictable airway difficulties, a clinical and imaging assessment will determine the need for a GT and in severe cases an attempt to insert a GT should be made. In the latter cases, the success of placement will indicate whether to use RSII or awake intubation. The GT should not be withdrawn and should be connected to suction during induction. Airway management and the use of GTs in the surgical correction of certain gastrointestinal anomalies in infants and children are discussed.

The “Other Tube” in the Airway

The “Other Tube” in the Airway

Airway management in maxillofacial trauma: do we really need tracheostomy/submental intubation.

There are various techniques available for airway management in patients with maxillofacial trauma. Patients with panfacial injuries may need surgical airway access like submental intubation or tracheostomy, which have their associated problems. We have been managing these types of cases by a novel technique, i.e, intraoperative change of nasotracheal to orotracheal intubation. To review our experience about various techniques for the airway management in patient with maxillofacial trauma. To analyse the possibility of using nasotracheal intubation and intraoperative change of nasotracheal to orotracheal intubation in panfacial fractures. In a tertiary care centre four hundred eighty seven patients of maxillofacial injuries, operated over a period of 2 years were reviewed in relation to age, sex, mode of injury, type of facial fractures, methods of airway management and their associated complications. Young patients with male predominance is the most common affected population. Panfacial fracture is the most common type of injury (39.83%) among facial fractures. Airway was managed with intraoperative change of nasotracheal to orotracheal intubation in 33.05% of the patients whereas submental intubation or tracheostomy was done in 8.62% of the patients. Nasal route for endotracheal intubation is not a contraindication in the presence of nasal fractures, base of skull fractures and CSF leak. By changing the nasotracheal intubation to orotracheal intubation intraoperatively in cases panfacial fractures, most of the tracheostomies and submental intubations can be avoided.

Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer

Overview:Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks.Materials and Methods:A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted.Results:The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L.Conclusion:Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate.

Evaluation of submental approach for oro-endotracheal intubation in maxillofacial trauma

Introduction: In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to fractured nasal bone and simultaneous establishment of occlusion are required. We report our experience with submental intubation in the airway management of complex maxillofacial trauma patients and complication associated with it. The aim is to evaluate the outcome of airway management in patients with complex maxillofacial trauma by submental intubation. Materials and Methods: Fifteen cases reporting to the Department of Oral and Maxillofacial Surgery of a tertiary care hospital, with multiple facial trauma from September 2011 to September 2013 were selected for study. Median submental intubation was performed. Follow-up during hospitalization for wound associated complication and 3 months postoperatively was done. Results: At the end of the procedure, all 15 patients were extubated without any complications. Postoperatively, only one patient presented with superficial infection of the submental wound. Conclusion: Submental endotracheal intubation is a simple technique with very low morbidity and can be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.

Evaluation of submental approach for oro-endotracheal intubation in maxillofacial trauma

Introduction: In maxillofacial injuries, a choice has often to be made between different ways of intubation when surgical access to fractured nasal bone and simultaneous establishment of occlusion are required. We report our experience with submental intubation in the airway management of complex maxillofacial trauma patients and complication associated with it. The aim is to evaluate the outcome of airway management in patients with complex maxillofacial trauma by submental intubation. Materials and Methods: Fifteen cases reporting to the Department of Oral and Maxillofacial Surgery of a tertiary care hospital, with multiple facial trauma from September 2011 to September 2013 were selected for study. Median submental intubation was performed. Follow-up during hospitalization for wound associated complication and 3 months postoperatively was done. Results: At the end of the procedure, all 15 patients were extubated without any complications. Postoperatively, only one patient presented with superficial infection of the submental wound. Conclusion: Submental endotracheal intubation is a simple technique with very low morbidity and can be used as an alternative to tracheostomy in selected cases of maxillofacial trauma.

Difficult fiber-optic intubation in a patient with giant neck masses: The role of McCoy laryngoscope in elevating compressed laryngeal aperture

Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.

Airway Management in Patients with Subglottic Stenosis

We describe a pilot study investigating the airway techniques used in the anesthetic management of subglottic stenosis. We searched the electronic clinical information database of the University of Michigan Health System for cases of subglottic stenosis in patients undergoing surgery. Demographics, airway techniques, incidence of hypoxemia, and technique failure were extracted from 159 records. A lower incidence of hypoxemia was found between the 4 most commonly used techniques and the less common techniques. We detected no difference in outcome between individual techniques. This study suggests a larger prospective multicenter study is required to further investigate these outcomes in patients with subglottic stenosis.

Airway management in patients with brain injury

Research has highlighted potential for changes in the technique and implementation of the bag-valve-mask system, a common piece of equipment used during resuscitation attempts to ventilate patients' lungs and deliver oxygen. This article analyses a critical incident involving a patient who experienced traumatic brain injury and required airway management. In reference to a reflective model, the article discusses the technique, implementation, complications and limitations of the bag-valve-mask system, and provides implications for practice.

ERCP: The Unresolved Question of Endotracheal Intubation

The anesthesia community is still divided as to the appropriate airway management in patients undergoing endoscopic retrograde cholangiopancreatography. Increasingly, gastroenterologists are comfortable with deep sedation (normally propofol) without endotracheal intubation. There are no comprehensive reviews addressing the various pros and cons of an un-intubated airway management. It is hoped that the present review will benefit both anesthesia providers and gastroenterologists. The reasons to avoid routine endotracheal intubation and the approaches for an un-intubated anesthetic management are discussed. The special situations where endotracheal intubation is the preferred approach are mentioned. Many special techniques to manage airway are illustrated.

GlideScope video laryngoscopy use tracheal intubation in patients with ankylosing spondylitis: a series of four cases and literature review

Airway management in patients with ankylosing spondylitis (AS) is a challenging problem for anesthesiologists. The GlideScope video laryngoscope (GVL) is designed to assist tracheal intubation for patients with a difficult airway. The aim of the study was to report the successful intubation by GVL of four AS patients, and to discuss the use of GVL for tracheal intubation in patients with AS by performing a review of the literature. Four patients with chronic, severe AS were evaluated preoperatively; all had features associated with a difficult direct laryngoscopy. We performed the necessary preparations for difficult airway and intubation. Patients were kept in supine position, with their head and neck supported on pillows. Following sufficient preoxygenation, patients received i.v. remifentanil at 1 μg kg(-1), propofol at 2 mg kg(-1), and succinylcholine at 1 mg kg(-1). GVL intubation was provided after full muscle relaxation. GVL is reasonable alternative to awake fiberoptic bronchoscopy or any other device, as it appears that less training and skill is involved in the actual intubation process. Adequate laryngeal exposure was obtained in all patients were successfully intubated in the first attempt. As with any challenging airway management, it is essential to have a rescue strategy. We believe that GVL can be a good alternative for oral endotracheal intubation in patients with AS. This series is very small and the reader should be very cautious about drawing broad conclusions regarding the GVL and patients with AS.

Do Patients With Pierre Robin Sequence Have Worse Outcomes After Cleft Palate Surgery?

Pierre Robin sequence (PRS) is a congenital condition characterized by micrognathia, glossoptosis, airway obstruction, and often clefting of the soft and hard palate. The purpose of this study was to compare oronasal fistula rates, long-term speech outcomes, and rates of secondary surgery for velopharyngeal insufficiency (VPI) after primary cleft palate repair using the modified Furlow technique between nonsyndromic patients with and without PRS. This study also sought to determine if type of airway management in infancy correlated with speech outcomes in patients with PRS. A retrospective review was performed of all nonsyndromic patients with clefts of the palate only who underwent repair between 1981 and 2006 at The Children's Hospital of Philadelphia using the modified Furlow technique. Patient outcomes were evaluated by the rate of postoperative oronasal fistula, speech scores at a minimum of age 5 years using the Pittsburgh Weighted Values for Speech Symptoms Associated with VPI, and the need for secondary pharyngeal surgery for VPI. Fifty-five patients with PRS and 129 without PRS were included in this study. There was no significant difference in oronasal fistula rate between groups. Speech outcomes were worse in patients with PRS with 52.7% demonstrating a competent velopharyngeal mechanism, and 30.9% a borderline mechanism, compared to 72.1% and 19.4% in the non-PRS group, respectively (P = 0.035). In addition, only 76.3% of patients with PRS had no or mild hypernasality compared to 91.5% of patients without PRS (P = 0.01). The rates of nasal emission, articulation errors associated with VPI, and secondary surgery for VPI did not differ between groups. Of the patients with PRS, 36 were managed in infancy with positioning alone and 15 underwent surgical intervention for airway obstruction, and there were no significant differences in speech scores or rates of secondary surgery for VPI between these subgroups. Nonsyndromic patients with PRS had worse speech outcomes after modified Furlow cleft palate repair, but no significant differences were seen in the rates of secondary surgery for VPI or postoperative oronasal fistula. In addition, initial airway management in patients with PRS did not correlate with speech outcomes.

Angioedema of the Upper Aerodigestive Tract: Risk Factors for Intubation and Review of Management Algorithm

Objectives: To define the risks associated with angioedema related airway obstruction and intervention, and to delineate the treatment algorithm used at our institution for airway management in patients with angioedema. Methods: Retrospective chart review of consecutive otolaryngology consultations for angioedema in the emergency department (ED) from 1999-2003. All patients were evaluated by an otolaryngologist and underwent fiberoptic laryngoscopy. Results: 177 patients were included in our study. 32 (18%) patients required intubation, 25 (14%) on initial presentation and 7 (4%) patients progressed from an initially stable airway to requiring intervention after reevaluation. ANOVA analysis demonstrated a statistically significant variance between location of edema and rate of intubation, with higher rates in the pharynx and larynx versus the lip and face. There was no difference between pharyngeal and laryngeal edema in rate of intubation, and there was no difference between oral cavity edema and other subsite in rate of airway intervention. Patients who required intubation after progression between serial evaluations were more statistically more likely to have edema that involved deeper portions of the aerodigestive tract. Patients who required intubation were statistically more likely to be older (average age 61.8 vs 55.1, P=0.03). Conclusions: In this large series of patients managed for aerodigestive angioedema we demonstrate risk factors associated with airway intervention and risk factors associated with clinical progression on serial examination to airway intervention. In addition, we demonstrate a successful management algorithm for patients with aerodigestive angioedema.

Outcomes following prehospital airway management in severe traumatic brain injury

Prevention of hypoxia and thus secondary brain injury in traumatic brain injury (TBI) is critical. However there is controversy regarding the role of endotracheal intubation in the prehospital management of TBI. To describe the outcome of TBI with various airway management methods employed in the prehospital setting in the Cape Town Metropole. The study was a cohort descriptive observational analysis of 124 consecutively injured adult patients who were admitted for severe TBI (Glasgow Coma Score ≤8) to Groote Schuur and Tygerberg hospitals between 1 January 2009 and 31 August 2011. Patients were categorised by their method of airway management: rapid sequence intubation (RSI), sedation-assisted intubation, failed intubation, basic airway management, and intubated without drugs. Good outcomes were defined by a Glasgow Outcome Score of 4 - 5. There was a statistically significant association between airway management and outcome (p=0.013). Patients who underwent basic airway management had a higher proportion of a good outcome (72.9%) than patients who were intubated in the prehospital setting. A good outcome was observed with 61.8% and 38.4% of patients who experienced sedation-assisted intubation and RSI, respectively. Patients intubated without drugs had the poorest outcome (88%), followed by rapid sequence intubation (61.5%) and by the sedation assisted group (38.2%). Prehospital intubation did not demonstrate improved outcomes over basic airway management in patients with severe TBI. A large prospective, randomised trial is warranted to yield some insight into how these airway interventions influence outcome in severe TBI.

Awake endotracheal retrograde intubation in restricted mouth opening: a ‘J’-tipped guide wire technique—a retrospective study

Airway management in patient with restricted mouth opening is a great challenge, owing to the difficulty in laryngoscopy and visualisation of the vocal cords during the procedure of intubation. The term retrograde intubation refers to a technique in which a guide wire is passed into the trachea and then into the mouth or nose. A tracheal tube is then passed down over the guide until it enters the trachea. A retrospective audit was undertaken to determine the success and complication associated with retrograde intubation. The results show that in a sample of 20 patients in which retrograde intubation was done, only three developed sore throat and cough, one had bronchospasm and one developed infection at the site of insertion of a J-tipped catheter. Retrograde tracheal intubation was easy to perform and had a high success rate and a low incidence of complications.

Airway Management in Cervical Spine Injury

Airway management in patients with cervical spine injury is a difficult and challenging task. Attention to head positioning and stabilization during the initial evaluation and airway management is critical in the care of these patients in order to minimize the risk of secondary neurologic insult. Awareness that these patients are at risk for airway obstruction is critical. A systemic approach and development of an individualized airway plan is necessary for optimal management of patients with cervical spine injury.