Blind Intubation Research Articles

Tracheal intubation in a simulated cervical spine immobilisation: The Macintosh laryngoscope versus supraglottic airway devices - A manikin study

BackgroundAirway management is performed with simultaneous cervical spine immobilisation in trauma patients and is regarded as the gold standard. Application of spinal stabilisation may significantly worsen direct laryngoscopy and make intubation more difficult. Supraglottic airway devices may also be used for intubation. The aim of this study was to evaluate the Macintosh laryngoscope, the Classic Laryngeal Mask Airway and the I-gel used for blind intubation by experienced paramedics. Cervical collar was used to simulate reduced cervical spine mobility. Materials and methodsFifty-five experienced and active paramedics participated in the study (F = 25, M = 30). The intubation-to-successful-ventilation time was recorded. Efficacy of intubation and the ease of use by the operator were also assessed. All devices under study were used by each participant and they were randomly chosen. All participants were trained in supraglottic airway devices insertion and intubation although they were not experts in the latter as each of the paramedics performed less than 20 intubations. ResultsThe mean intubation-to-ventilation time was the shortest when the I-gel device was used 28.2 s (±2.09). This was statistically significant when compared to both the Classic Laryngeal Mask Airway (p = 0.0344) and the Macintosh laryngoscope (p < 0.0001). Both of the studied supraglottic airway devices achieved an overall 100% successful intubation rate and required maximum 2 attempts out of 3 allowed. ConclusionThe I-gel and the Classic Laryngeal Mask Airway were superior to the Macintosh laryngoscope as they shortened the time required to intubate and successfully ventilate the patient. They also improved the rate of successful intubation.

English

Temperomandibular joint (TMJ) ankylosis is loss of joint movement that results from a union of the mandibular condyle to the base of the skull. Managing airway is considered to be one of the most difficult and challenging procedures when there is a diseased temperomandibular joint as a result of inadequate mouth opening. Although TMJ ankylosis is well known risk factors of difficult airway management, the techniques used are dependent on the expertise of the concerned anesthesiologists and available resources. Techniques used to secure airway in adults may not be ideal for children and sometimes dedicated equipment may not be available. In this case report we described a case of 14-year-old female patient diagnosed with bilateral TMJ ankylosis and who underwent surgery for left side temperomandibular ankylosis release and temperomandibular joint reconstruction under general anesthesia with a blind nasal intubation. Key words: Temporomandibular joint ankylosis, difficulty airway, blind nasal intubation.

Pre-hospital i-gel blind intubation for trauma: a simulation study.

ObjectiveThis study aimed to evaluate the efficacy of i-gel blind intubation (IGI) as a rescue device for definitive airway management in ground intubation for pre-hospital trauma patients.MethodsA prospective randomized crossover study was conducted with 18 paramedics to examine intubation performance of two blind intubation techniques through a supraglottic airway devices (IGI and laryngeal mask airway Fastrach), compared with use of a Macintosh laryngoscope (MCL). Each intubation was conducted at two levels of patient positions (ground- and stretcher-level). Primary outcomes were the intubation time and the success rate for intubation.ResultsThe intubation time (sec) of each intubation technique was not significantly different between the two positions. In both patient positions, the intubation time of IGI was shortest among the three intubation techniques (17.9±5.2 at the ground-level and 16.9±3.8 at the stretcher-level). In the analysis of cumulative success rate and intubation time, IGI was the fastest to reach 100% success among the three intubation techniques regardless of patient position (all P<0.017). The success of intubation was only affected by the intubation technique, and IGI achieved more success than MCL (odds ratio, 3.6; 95% confidence interval, 1.1 to 11.6; P=0.03).ConclusionThe patient position did not affect intubation performance. Additionally, the intubation time with blind intubation through supraglottic airway devices, especially with IGI, was significantly shorter than that with MCL.

Comparison of fastrach LMA and ILMA methods for airway management

The aim of this study is to compare the hemodynamic responses, durations of intubation, intubation success rates and postoperative upper airway complications between the intubation performed with direct laryngoscopy and blind intubation performed with LMA-Fastrach application in normotensive patients. This present study was performed with the approval of ethical committee and in the surgery rooms between the date March 2010-August 2010. The study was performed on 80 patients aged between 18 and 60 and had American Anesthetists Assosiation (ASA) classification I-II. Endotracheal intubation was essential in their elective abdomen surgeries. The patients were divided into 2 groups as ILMA-Fastrach Group (Group I, n=40) and laryngoscopy group (Group L, n=40). 80 patients aged between 18 and 60. Of those, 54 (67.5%) were female and 26 (32.5%) were male. The age average of the patients was 46.3 ± 10.7. There was not a statistically significant difference between the demographic parameters of the patients. When compared to the onset value of SAP in Group I and Group L, a statistically significant difference was not detected in the groups in terms of SAP 1st minute and 5th minute values. When compared to the SAP onset value of the cases, the decrease in the 1st minute was statistically significant and when compared to the 1st minute value, the decrease in the 5th minute was not statistically significant. In the groups, a statistically significant difference was not observed in terms of DAP outset 1st and 5th minute values. When compared to the DAP onset value of the patients in Group L, the increase in the 1st minute was statistically significant. When compared to the 1st minute value, the decrease in the 5th minute was statistically significant. When compared to the onset value of MAP in Group L, the increase in the 1st minute was statistically significant. In terms of HR onset 1st and 5th minute values a statistically significant value was not detected. In conclusion, patients performed endotracheal intubation with LMA-Fastrach was more stabile than the ones intubated with direct laryngoscopy in terms of hemodynamics. Fewer complications were observed in LMA-Fastrach group and there was not any difference in terms of success rates.

Emergency Tracheal Intubation in an Ankylosing Spondylitis Patient in a Sitting Position Using an Airway Scope Combined with Face-to-Face and Digital Intubation

BackgroundEmergency intubation in a patient with advanced ankylosing spondylitis (AS) who presents with severe thoracic kyphosis deformity, rigid cervical flexion deformity of the neck, and an inability to achieve the supine position is particularly challenging to emergency physicians. Case ReportThis study reports on an AS patient presenting with these difficult airway characteristics and acute respiratory failure who was successfully intubated using video laryngoscope-assisted inverse intubation (II) and blind digital intubation (BDI). By using Pentax AirwayScope-assisted inverse intubation, the tracheal tube tip was passed through the glottic opening, but an unexpected resistance occurred during tube advancement, which was overcome by subsequent BDI. By using laryngoscope-assisted II complemented by the BDI technique, the patient was successfully intubated without complications. Why Should an Emergency Physician Be Aware of This?Our case demonstrated that these two emergency airway management techniques are valuable backup methods and complement each other when applied to certain unstable airways, especially when the traditional patient position is not easily accomplished. Unexpected difficulty is not rare during airway management; emergency physicians should always be well prepared both mentally and practically.

Airway management of patients with temporomandibular joint disorder: A 12-year retrospective review in ABUTH Zaria

Background: Temporomandibular joint (TMJ) ankylosis is a condition associated with restricted mouth opening. Following induction of general anesthesia, airway obstruction may occur leading to “can't ventilate and can't intubate scenario.” The anticipation of difficult airway and choice of appropriate intubation techniques usually prevent anesthetic morbidity and mortality. Patients and Methods: Both the surgeons' and the anesthetic review, as well as the anesthetic chart of the 36 patients managed at Ahmadu Bello University Teaching Hospital between January 2006 and December 2017, were studied. Data collected were bio-data of the patients, extent of mouth opening, and the techniques of intubation used. Results: The mean age of the patients was 26.9 ± 1.64, with a male to female ratio of 1:1.1. There were more male 19 (52.8%) than female 17 (47.2%). Tracheal intubation was achieved with the aid of nasal fiberoptic technique in 22 (61.1%) patients, 8 patients (22.2%) were intubated by tracheostomy, 4 patients (11.1%) were intubated by blind nasal intubation, while 2 patients (5.6%) required endotracheal intubation through conventional oral laryngoscopy. The interincisor gap was between 0 and <1 cm in all the patients which indicated significantly restricted mouth opening, with an average of zero interincisor gap. Conclusion: Fiberoptic intubation was the most used approach of achieving tracheal intubation in patients with TMJ disorder.

The status and influencing factors of the methods used by nurses verifying the blinded inserted nasogastric tube placement

Objective To investigate the status and influencing factors of the methods used by nurses verifying the nasogastric tube placement blinded inserted in adult, and to explore the best practice of nursing staff to verify the nasogastric tube placement. Methods We designed the questionnaire and conducted survey to the clinical nursing staff in accordance with the American Association of Critical-Care Nurses practice alert. Results Air bolus auscultation (70.53%, 675/957) and aspirate appearance(68.97%, 660/957) were the most used method during insertion procedure. There was insufficient in the cognition of X-ray as the gold standard and the use in clinical.The department, work years, specialist nursesand hospitallevel impact X-ray use (all P <0.05) .Age, education,title,hospital level, specialist nurses and department impact the cognition of X-ray as the gold standard (all P <0.05) . Conclusions Nurses still use the traditional methods to verify the nasogastric tube placement. There is a certain gap between clinical practice and AACN practice alert in themethods used to verify nasogastric tube placement.As the gold standard to verify gastric tube placement, the use and cognition of X-ray are impacted by many factors, including the department, specialist nurses, hospital level, et al. Therefore, hospital should establish a knowledge sharing platform, which will help to spread the advantages and disadvantages of various methods used in verifying the nasogastric tube placement, and then to strengthen the cognition with different people. Furthermore, based on potential influencing factors, it is necessary to further explore new bedside effective method of verifying the nasogastric tube placement and seek the best practice to validate the method of blind intubation of nasogastric tube. Key words: Nurses; Nasogastric tube; Intubation

Chest Computed Tomography Image for Accurately Predicting the Optimal Insertion Depth of Left-Sided Double-Lumen Tube

The main objective of this study was to assess the feasibility and accuracy of measuring the distance between the vocal cord and carina using chest computer tomography (CT) as a guide for the intubation of a left-sided double-lumen tube (LDLT). Single-center, prospective, randomized study. Local hospital in China. Sixty adult patients undergoing elective thoracic surgery requiring an LDLT for one lung ventilation were enrolled in this study. Patients were randomly allocated to the following 2 groups: blind intubation group (B group, n = 30) or chest computed tomography-guided group (C group, n = 30). The placement of the LDLT was accomplished using 1 of the 2 intubation methods. After intubation, an independent anesthesiologist evaluated the position of the LDLT and carina and bronchial injuries using fiber optic bronchoscopy. The number of optimal positions, the time for LDLT intubation, the time for fiber optic bronchoscope confirmation, and carina and bronchial injuries were recorded. Sixteen of 30 intubations in the B group were in optimal position, whereas 27 of 30 intubations in the C group were in optimal position; the difference was statistically significant (p < 0.01). The time for intubation of the LDLT took 118.0 ± 26.2 seconds in the B group and 71.5 ± 8.7 seconds in the C group (p < 0.01). The time for position confirmation using fiber optic bronchoscope took 40.8 ± 15.8 seconds in the B group and 18.7 ± 7.9 seconds in the C group (p < 0.05). The incidences of carina and bronchial injuries were obviously lower in the C group (occurred in 3 of 30 cases) than in the B group (11 of 30 cases) p < 0.05. The incidences of postoperative sore throat and hoarseness showed no significant differences between the 2 groups (p > 0.05). This study demonstrated that the method of measuring the distance between the vocal cord and carina according to the chest CT as a guide for the intubation of LDLT is more effective and more accurate than the blind intubation method.

Retrograde intubation through nasal route in patients with limited mouth opening undergoing oral and maxillofacial surgery

BackgroundPatients with limited mouth opening (LMO) often associated with difficult intubation. Retrograde intubation is an alternative technique of establishing definitive airway in these patients when blind nasal intubation fails and fiberoptic bronchoscope is not available. We tested the retrograde intubation through nasal route in patients with LMO less than 2cm. Materials and methodsThe procedure was performed with some modification with regard to retrograde guide on 18 patients requiring maxillofacial surgical procedures to increase mouth opening. Indications for this technique were mandibular fracture (n=6), oral submucous fibrosis (OSMF; n=6), temporomandibular joint (TMJ) ankylosis (n=4) and internal derangement of TMJ (n=2). All patients were assessed for preoperative interincisal opening; during intubation through specific parameters and; also postoperative findings were observed. ResultsMean time taken for successful intubation was 5.6min±1.66. One patient had subcutaneous emphysema which was managed conservatively. Postoperatively, four patients had sore throat which resolved in few days. No other complications were encountered. ConclusionIn conclusion, retrograde nasotracheal intubation is an effective and useful technique for airway control in patients with LMO and with only a small risk potential.

Effect of Head Position on the Success Rate of Blind Intubation through Air Q Laryngeal Mask in Morbidly Obese Patients

Aim: To evaluate the effect of head positioning whether neutral or sniffing position on the conduct of intubation through air Q in morbidly obese patients. Patients and method: This study was conducted on 90 patients with body mass index equal or above 40 who were scheduled for surgery under GA and were randomly divided into 2 equal groups: Group N (Gn) in which blind intubation through air Q was done in neutral position. Group S (Gs) in which blind intubation was done in sniffing position. Proper airway assessment of the patients was done. Basic monitoring was attached; Induction of anaesthesia was achieved by Fentanyl 2 ug/kg, Propofol 1.5 - 2.5 mg/kg and Atracurium 0.5 mg/kg. Maintenance of anaesthesia was achieved by Sevoflurane, Atracurium, oxygen and air. When neuromuscular blockade was complete, the head of the patient was adjusted according to their group. The supraglottic device was inserted and connected to capnography, thereafter a well lubricated proper sized ETT was passed through the air Q. We recorded a baseline reading of HR, SBP, DBP, MBP, and oxygen saturation. A second reading was taken after induction of anesthesia, just before intubation. The third reading was recorded after intubation while further readings were measured 1, 3, 5, 10, 15 min after intubation. After ETT removal, we observed the patients in the recovery room at 0, 3 & 24 hours for possible postoperative complications. Results: There was no statistical difference between the two groups regarding the demographic data. Although the intubation in sniffing position has a higher success rate from the first time than the neutral position, the results were statistically insignificant, regarding the mean duration of blind intubation trials through the Air Q and postoperative complications. Conclusion: Although the sniffing position improves glottic visualization, the change of head position had no effect on the success rate of blind intubation through air Q in obese patients.

Blind Intubation through Self-pressurized, Disposable Supraglottic Airway Laryngeal Intubation Masks: An International, Multicenter, Prospective Cohort Study.

Supraglottic airway devices commonly are used for securing the airway during general anesthesia. Occasionally, intubation with an endotracheal tube through a supraglottic airway is indicated. Reported success rates for blind intubation range from 15 to 97%. The authors thus investigated as their primary outcome the fraction of patients who could be intubated blindly with an Air-Qsp supraglottic airway device (Mercury Medical, USA). Second, the authors investigated the influence of muscle relaxation on air leakage pressure, predictors for failed blind intubation, and associated complications of using the supraglottic airway device. The authors enrolled 1,000 adults having elective surgery with endotracheal intubation. After routine induction of general anesthesia, a supraglottic airway device was inserted and patients were ventilated intermittently. Air leak pressure was measured before and after full muscle relaxation. Up to two blind intubation attempts were performed. The supraglottic airway provided adequate ventilation and oxygenation in 99% of cases. Blind intubation succeeded in 78% of all patients (95% CI, 75 to 81%). However, the success rate was inconsistent among the three centers (P < 0.001): 80% (95% CI, 75 to 85%) at the Institute of Anesthesia and Pain Therapy, Kantonsspital Winterthur, Winterthur, Switzerland; 41% (95% CI, 29 to 53%) at the Department of Anesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland; and 84% (95% CI, 80 to 88%) at the Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland. Leak pressure before relaxation correlated reasonably well with air leak pressure after relaxation. The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate.

Blind Nasal Intubation with the Miller straight blade as an adjunct- A Case Report

Blind Nasal Intubation with the Miller straight blade as an adjunct- A Case Report

Comparison of a Supraglottic Airway Device (v-gel®) with Blind Orotracheal Intubation in Rabbits

Achieving a secure airway in rabbits is generally considered more difficult than in cats or dogs. Their relatively large tongue, small oropharyngeal cavity and glottis limit direct visualization. A rabbit-specific supraglottic airway device (SGAD) may offer benefits over blind orotracheal intubation. Fifteen adult New Zealand white rabbits were randomized to SGAD or orotracheal intubation (ETT). All animals were sedated with dexmedetomidine (0.1 mg kg-1 IM) and midazolam (0.5 mg kg-1 IM), followed by induction with alfaxalone (0.3 mg kg-1 IV). Two CT scans of the head and neck were performed, following sedation and SGAD/ETT placement. The following were recorded: time to successful device insertion, smallest cross-sectional airway area, airway sealing pressure, and histological score of tracheal tissue. Data were analyzed with a Mann-Whitney test. Two rabbits were excluded following failed ETT. Body masses were similar [ETT; n = 6, 2.6 (2.3-4.5) kg, SGAD; n = 7, 2.7 (2.4-5.0) kg]. SGAD placement was significantly faster [33 (14-38) s] than ETT [59 (29-171) s]. Cross-sectional area (CSA) was significantly reduced from baseline [12.2 (6.9-3.4) mm2] but similar between groups [SGAD; 2.7 (2.0-12.3) mm2, ETT; 3.8 (2.3-6.6) mm2]. In the SGAD group, the device tip migrated into the laryngeal vestibule in 6/7 rabbits, reducing the CSA. ETT airway seals were higher [15 (10-20) cmH2O], but not significant [SGAD; 5 (5-20) cmH2O, p = 0.06]. ETT resulted in significantly more mucosal damage [histological score 3.3 (1.0-5.0)], SGAD; 0.67 (0.33-3.67). The SGAD studied was faster to place and caused less damage than orotracheal intubation, but resulted in a similar CSA.

Evaluation of the Intubating Laryngeal Mask Airway (ILMA) as an intubation conduit in patients with a cervical collar simulating fixed cervical spine

Background: Cervical spine immobilisation with a semi-rigid cervical collar imposes difficulty in tracheal intubation. There is increasing use of the Intubating Laryngeal Mask Airway (LMA- FastrachTM) for intubation in patients with difficult airways. The present study was conducted to assess its potential role for tracheal intubation in simulated fixed cervical spine patients.Method: After obtaining approval from the ethics committee and patients’ consent, this observational study was performed on 35 adult patients of either sex of ASA physical status I and II scheduled to undergo surgery under general anaesthesia requiring tracheal intubation. A two-piece semi-rigid cervical collar of appropriate size was positioned around the neck of patients. A standard anaesthesia protocol comprising glycopyrrolate, propofol and vecuronium was used for induction of anaesthesia. ILMA placement and blind tracheal intubation through this was attempted by using dedicated silicone tube provided with the ILMA set. Success ...

Comparison of Ambu® AuraGain™ laryngeal mask and air-Q™ intubating laryngeal airway for blind tracheal intubation in adults: A randomized controlled trial

BackgroundThis study has been designed to compare the performance of Ambu® AuraGain™ laryngeal mask with the air-Q™ as a conduit for blind tracheal intubation in adult patients.MethodsIn this prospective randomized controlled trial blind endotracheal intubation success rates were compared between Ambu® AuraGain™ and air-Q™ intubating laryngeal airway in 90 adult patients. Patients were randomized in two equal groups: Group Ambu® AuraGain™ (n = 45) and Group air-Q™ (n = 45).ResultsTime to insert the laryngeal airway was similar between Ambu® AuraGain™ and air-Q™ (median [IQR] 13[12–14] s versus 14[12–16] s) and in all cases laryngeal mask insertion was possible in first attempt. Intubation success rate at first attempt was significantly higher in air-Q™ group compared to in Ambu® AuraGain™ group (68.9% versus 35.6%; p = 0.002). Overall blind intubation success rate was significantly higher in air-Q™ group in comparison to Ambu® AuraGain™ (80% versus 53.3%; p = 0.007). Intubation time was significantly higher with Ambu® AuraGain™ (p < 0.0001; median difference 4.0 s, 95% CI 2.7, 5.3 s). Blind intubation was significantly easier in air-Q™ group compared to in Ambu® AuraGain™ (42.2% intubation was graded as easy in air-Q™ instead of 22.2% in Ambu® AuraGain™, p = 0.04). Comparison of fibreoptic bronchoscopic glottis view was similar between the two devices (p = 0.07). Reported complications were infrequent and similar between the two devices.ConclusionWe conclude that air-Q™ laryngeal airway is superior to Ambu® AuraGain™ when used as a conduit for blind endotracheal intubation in adult patients.Trial registrationClinical Trial Registry of India (CTRI/2015/02/005553).

Comparison of Intubating Supraglottic Airways LMA Fastrach™ and ILTS-D® under Normal and Simulated Difficult Airways — a Manikin Study

Objectives. The goal of study was to compare the effectiveness of using Fastrach ™ and iLTS-D® on a manikin by novices 1st year resident-anesthesiologists under normal and simulated difficult airways. Material and Methods. At the first stage the participants conducted four consecutive trials on a manikin. Each trial included insertion, ventilation and blind intubation the manikin using iLTS-D® and Fastrach™. ‘Time to ventilation’, ‘time to tracheal ventilation’, success rates and number of attempts were recorded for the both devices. At the second stage participants performed one attempt of ventilation and blind intubation under simulated difficult airways (midline head stabilization and limited mouth opening 3 cm). It was estimated the difference between devices in ‘time to ventilation’ and ‘time to tracheal ventilation’; differences in success rates at trial 4 and at the second stage. Results. There was no difference in ‘time to ventilation’ between either device in trial 4 (median: Fastrach: 14.7 s, iLTS-D: 13.2 s, p = 0.14). Also there was no difference in ‘time to tracheal ventilation’ between either device in trial 4 (median: Fastrach: 15.4 s., iLTS-D: 13.9 s, p = 0.55). Both devices were equally effective in a simulated difficult airway, ventilation and intubation at the first attempt was successful in all cases, there was no significant difference in ‘time to ventilation’ (Fastrach: 12.3 s, iLTS-D: 13.5 s, p = 0.14) and ‘time to tracheal ventilation’ (Fastrach: 12.6 s, iLTS-D: 12.5 s, p = 0.77).

Bougie assisted endotracheal intubation using the Air-Q™ Intubating Laryngeal Airway: A prospective randomized clinical study

BackgroundAir-Q™ Intubating Laryngeal Airway is an extraglottic airway device used as a primary airway tool or as an adjunct to tracheal intubation. The bougie is a simple flexible device that might increase the success rate of endotracheal intubation either blindly or through a supraglottic device. We hypothesized that using bougie guided intubation through air-Q™ can improve the success rate with minimal complications.MethodsOne hundred and forty patients of either sex, >18 years old, ASA I-II scheduled for elective surgical procedures under general anesthesia with intubation were randomly allocated to one of two groups of 70 patients each. Blind tracheal intubation was performed through air-Q™ with bougie assistance (Group B) or without (Group Q). In both groups, 3 attempts were allowed for successful device insertion. After obtaining normal capnographic wave, 3 more attempts were tried for intubation with or without bougie guidance. Lung ventilation through air-Q™ was permitted between intubation attempts. If tracheal intubation through air-Q™ was unsuccessful, it was performed by direct laryngoscopy.ResultsAir-Q™ time, ease, attempts number of insertion and ventilation grade were comparable between both groups. Total intubation time was significantly longer in group-B (P = 0.001) while overall success rate for intubation was comparable (64.3%). Group-B showed significant (P = 0.001) higher incidence of complications (trauma (P = 0.023), sore throat (P = 0.001), dysphonia (P = 0.023) and dysphagia (P = 0.001)) as compared with group-Q. In spite of significant decrease in both heart rate and mean arterial pressure in both groups after air-Q™ insertion, yet there was significant increase in both parameters after intubation compared to baseline values (P < 0.05) which was more prominent in group-B than in group-Q. Significant increase in HR and MAP was elicited after bougie placement in group-B (P < 0.01).ConclusionBougie guided tracheal intubation through air-Q™ didn’t improve overall success rate with significant longer time, hemodynamic derangement and traumatic sequelae.

Comparison of the Macintosh laryngoscope and blind intubation via the iGEL for Intubation With C-spine immobilization: A Randomized, crossover, manikin trial

IntroductionEndotracheal intubation (ETI) using a Macintosh laryngoscope (MAC) requires the head to be positioned in a modified Jackson position, slightly reclined and elevated. Intubation of trauma patients with an injured neck or spine is therefore difficult, since the neck usually cannot be turned or is already immobilized in order to prevent further injury. The iGEL supraglottic airway seems optimal for such conditions due to its blind insertion without the need of a modified Jackson position. MethodsProspective, randomized, crossover study in 46 paramedics. Participants performing standard intubation and blind intubation via iGEL supraglottic airway device in three airway scenarios: Scenario A – normal airway; Scenario B - manual inline cervical immobilization, performed by an independent instructor; scenario C: cervical immobilization using a standard Patriot cervical extraction collar. ResultsIn Scenario A, nearly all participants performed ETI successfully both with MAC and iGEL (100% vs. 95.7%). The time to intubation (TTI) using the MAC and iGEL amounted to 19 [IQR, 18–21]s vs. 12 [IQR, 11–13]s (P<0.001). Head extension angle as well as tooth compression were significantly better with the iGEL compared to the MAC (P<0.001). In scenario B and C, the results with the iGEL were significantly better than with MAC for all analyzed variables (TTI, success of first intubation attempt, head extension angle, tooth compression and VAS scores). ConclusionWe showed that blind intubation with the iGEL supraglottic airway was superior to ETI performed by paramedics in a simulated cervical immobilization scenario in a manikin in terms of success rate, time to definite tube placement, head extension angle, tooth compression, and rating.

Blind Nasal Intubation Revisited: No Longer a Blind Technique?

BackgroundAdvancements in airway management have made the practice of blind nasal intubation obsolete. We report on successful blind nasal intubation performed with the help of capnography and real-time ultrasonography in two patients with tempormandibular joint ankylosis. Case ReportBlind nasal intubation was performed in a 12-year-old patient and a 17-year old patient under general anesthesia with spontaneous respiration. Capnography was used as an aid during insertion and dynamic ultrasonography was performed to guide and confirm proper tracheal tube placement.Use of capnography helps in following the correct path toward the glottic opening, with quick detection of any obstruction, and with confirmation of final placement of the tracheal tube. Ultrasonography aids with entry into the glottis and with identifying the correct placement.We recommend the use of this modified blind nasal intubation in patients with limited mouth opening when equipment, such as a fiberoptic scope, is not available or is nonfunctional in the emergency department. Why Should an Emergency Physician Be Aware of This?Adapting this technique will add to the armamentarium available for airway management in emergency medicine, particularly in maxillofacial injuries with limited mouth opening.

In vivo study of hepatic oxidative stress and mitochondrial function in rabbits with severe hypotension after propofol prolonged infusion.

In humans, prolonged sedations with propofol or using high doses have been associated with propofol infusion syndrome. The main objective of this study was to evaluate the effects of prolonged high-dose administration of a specific propofol emulsion (Propofol Lipuro) and an improved lipid formulation (SMOFlipid) in liver mitochondrial bioenergetics and oxidative stress of rabbits, comparatively to a saline control. Twenty-one male New Zealand white rabbits were randomly allocated in three groups that were continuously treated for 20 h. Each group of seven animals received separately: NaCl 0.9 % (saline), SMOFlipid (lipid-based emulsion without propofol) and Lipuro 2 % (propofol lipid emulsion). An intravenous propofol bolus of 20 mg kg−1 was given to the propofol Lipuro group to allow blind orotracheal intubation and mechanical ventilation. Anesthesia was maintained using infusion rates of: 20, 30, 40, 50 and 60 mg kg−1 h−1, according to the clinical scale of anesthetic depth and the index of consciousness values. The SMOFlipid and saline groups received the same infusion rate as the propofol Lipuro group, which were infused during 20 consecutive hours. At the end, the animals were euthanized, livers collected and mitochondria isolated by standard differential centrifugation. Mitochondrial respiration, membrane potential, swelling and oxidative stress were evaluated. Data were processed using one-way ANOVA (p < 0.05). The animals revealed a significant decrease in cardiovascular parameters showing bradycardia and severe hypotension. No statistical differences were observed when using pyruvate as substrate, however, when using succinate as respiratory substrate, significant decrease in ADP-stimulated respiration rate was observed for SMOFlipid group (p = 0.002). Lipid peroxides (p < 0.01) and protein carbonyls (p = 0.01) showed a statistically significant difference between propofol Lipuro and the SMOFlipid groups. These results suggest that lipid-based emulsions can be involved in the regulation of different pathways that ultimately lead to a decrease of state 3 mitochondrial respiration rate. The infusion of propofol Lipuro during prolonged periods, in addition to marked hypotension and hypoperfusion, also showed to have higher anti-oxidant activity and lower impairment of the mitochondrial function comparatively to the improved lipid formulation, SMOFlipid, using the rabbit as animal model.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-2970-2) contains supplementary material, which is available to authorized users.