Conventional Intubation Research Articles

Direct endotracheal intubation using a novel detachable optic probe (Sunscope) by emergency medical technicians with various training backgrounds

ObjectiveEffective airway management requires both proper technique and the appropriate devices. With the widespread implementation of advanced life-support techniques in emergency medical services (EMS), orotracheal intubation is now performed not only by professional practitioners but, in many occasions, nonprofessionals. With extensively diversified skill equipped, we tested whether the Sunscope, a patented tracheal intubation device with a digital display, is able to facilitate tracheal intubation by naïve EMS personnel with various training backgrounds. MethodsWe conducted a study to determine rate of success and time required to insert an orotracheal tube into a mannequin using Sunscope. The participants were placed into the professional group (i.e., anesthesiologists and emergency medical paramedics; EMT-P) or the nonprofessional group (i.e., emergency medical technicians; EMT). Intubation required three steps: equipment preparation, vocal cord exposure, and tube insertion. The time required for each step was recorded by a senior staff member, and the data were analyzed by nonparametric statistics. ResultsEach consecutive step in the operating procedure was significantly shorter for the professional group in comparison with the nonprofessional group during the first trial: equipment preparation, 10.5 ± 2.1 vs. 11.9 ± 4.1 seconds; vocal cord exposure, 7.4 ± 7.7 vs. 12.2 ± 7.7 seconds; tube insertion, 8.8 ± 4.8 vs. 17.6 ± 9.4 seconds; and total time required for intubation, 26.7 ± 8.8 vs. 35.8 ± 19.6 seconds. The professional practitioners showed no significant improvement, in terms of time reduction, on the following three trials. On the other hand, the nonprofessional practitioners showed no significant differences, in terms of time required to expose the vocal cords and total operation time, following the third trial in comparison with the professional practitioners. ConclusionOur research demonstrates that professional practitioners are able to use the Sunscope on their first attempt. Despite a lack of training in conventional endotracheal intubation, emergency medical technicians (EMT-I and -II) were able to complete intubation on their first attempt; a significant reduction in the time required to intubate was noted after repeated practice. All levels of naïve EMTs were able to readily visualize the vocal cords through Sunscope and, thereby, reliably insert the endotracheal tube in less than 1 minute, regardless of their skills before testing.

A randomized comparative study of intraocular pressure and hemodynamic changes on insertion of proseal laryngeal mask airway and conventional tracheal intubation in pediatric patients

Objective:To assess the influence of proseal laryngeal mask airway (PLMA) insertion on intraocular pressure (IOP).Aim:We compared the effects of PLMA insertion and laryngoscopic intubation on IOP and hemodynamic response in pediatric patients.Background:Previous studies have shown that there is no hemodynamic response to PLMA insertion similar to classic LMA insertion, but there is no published report about the influence of PLMA insertion on IOP. Conventional laryngoscopic tracheal intubation evokes a rise in IOP and cardiovascular response and has been traditionally used to secure the airway in pediatric patients undergoing ophthalmic surgery.Materials and Methods:59 patients, less than 14 years of age, scheduled for elective ophthalmic surgery were randomly divided into two groups, group P, in which the patient's airway was secured with PLMA (using introducer tool technique), and group T, in which the airway was secured with laryngoscopy-guided endotracheal intubation. Heart rate, blood pressure, and IOP were measured just before insertion of the airway device and subsequently three times at intervals of 1 min after insertion of the airway device.Results:In group T, there was a significant rise in IOP as well as hemodynamic parameters recorded. In group P, there was no significant rise in hemodynamic parameters, but a significant rise in IOP was found though the rise was less than in group T.Conclusion:We conclude that the PLMA use is associated with lesser cardiovascular response and rise in IOP as compared to tracheal intubation.

The reaction of a patient with suspicious retroverted epiglottis to an anesthetic

The reaction of a patient with suspicious retroverted epiglottis to an anesthetic

The Management of Antihypertensive-Associated Angioedema: When Necessary, Conventional Tracheal Intubation can be Successful

Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists are known to be associated with angioedema. These drugs are widely prescribed for hypertension and left ventricular dysfunction, in accordance with NICE guidance. There have been several case series published pertaining to angioedema associated with antihypertensives originating from allergy clinics and emergency departments, but very few from critical care. We present a case series describing the presentation and critical care management of this group of patients. We found that 5 of 16 (31%) patients required tracheal intubation, with only one of these having an awake fibreoptic intubation. Fifteen out of 16 (94%) of these patients survived to hospital discharge. Previous authors have suggested that these patients should always be managed with awake fibreoptic intubation. Our data, although with limited numbers, challenge this approach.

TRACHEAL INTUBATION

Introduction: Haemodynamic response to direct laryngoscopy and tracheal intubation has always been concern especially in cardiac patients. The use of fiberoptic bronchoscope for endotracheal tube placement may reduce the haemodynamic changes associated with intubation. Objectives: To compare haemodynamic changes (pulse and mean arterial pressure) following tracheal intubation, using direct laryngoscopic technique with fiberoptic bronchoscopic technique. Study Design: Randomized Controlled Trial (RCT). Settings and Duration: Department of Anaesthesiology, Intensive Care and Pain management Military hospital Rawalpindi. The study was of six months duration starting from April 2008 to October 2008. Subject and Methods: ASA-I and II patients (n=160) undergoing surgery meeting the inclusion and exclusion criteria.Informed consent was taken from all the patients undergoing the study. Patients were divided in two groups. Patients assigned to Group A got endotracheal intubation through direct laryngoscopic technique and Group B through fiberoptic bronchoscopic technique after induction of general anaesthesia. Pulse and Mean arterial pressure were recorded before induction of anaesthesia and three minutes after the intubation. Results: One hundred and sixty patients were studied. Eighty patients intubated through direct laryngoscopy (Group A) and eighty patients intubated through fiberoptic bronchoscope and it was observed that fiberoptic bronchoscopic intubation is haemodynamically safer as compared to conventional laryngoscopic intubation. Conclusion: The study concluded that bronchoscopic intubation provides better haemodynamic stability than direct laryngoscopic intubation.

Atemwegsmanagement – Videoassistierte Verfahren

Endotracheal intubation remains the "goldstandard" in airway management. If with use of conventional techniques intubation of the patient fails, or if an anticipated difficult airway is present, video-assisted techniques may help to increase intubation success. Video-assisted techniques give the possibility to indirectly visualise the laryngeal structures with fibreoptical or camerachip-technique, and to display the videopicture on an external or integrated monitor. For the anticipated difficult airway, awake flexible fibreoptical intubation still is the first choice. However, if Oxygenation and Ventilation can be established with bag-mask ventilation or supraglottic airways, the use of an endoscopic optical stylet or a videolaryngoscope may be alternatives. If the algorithm for the unanticipated difficult airway can be safely administered, the latter techniques may also be used as emergency intubation devices.

Anesthesia Literature Review

Anesthesia Literature Review

Solution for the Problem of Difficult Respiratory Tract in Planned Orthopaedic Surgery

Methods to solve the situation of difficult intubation in planned orthopaedic surgery are presented. Total number of 101 patients with problematic conventional tracheal intubation due to various orthopaedic pathology (Bekhterev's disease, abnormality of development or posttraumatic instability of cervical spine, etc.) was studied. In 49 patients tracheal intubation was performed using laryngeal mask LMA C-Trach with videovisualization (main group), in 52 patients - using fiberoptic bronchoscope (control group). The results achieved showed high efficacy of LMA C-Trach technology for solving difficult intubation problem. Application of laryngeal mask was successfully performed even in patients with Hallo-apparatus fixed cervical spine. Unlike fiber bronchoscope insertion placing of laryngeal mask was atraumatic in relation to stomatopharynx and enabled to perform adequate pulmonary ventilation till tracheal intubation. Videovisualization ensured accurate localization of trachea and its intubation with atraumatic reinforced tube under visual control. Only in 2 patients use of that technology failed and it was related to the bleeding from tonsils after multiple unsuccessful attempts of trachea intubation using direct laryngoscopy. Above described technique is not only a highly effective method for solving the problem of difficult intubation but decreases psychologic strain of the anesthesiologic team.

Patientsʼ experience of awake versus anaesthetised orotracheal intubation: a controlled study

We investigated patients' self-reported experience following awake flexible fibreoptic tracheal intubation and compared this to the experience of matched patients who had undergone conventional tracheal intubation under general anaesthesia for the same type of surgical procedure. Patients suspected of having, or known to have, a difficult airway underwent flexible fibreoptic orotracheal intubation with topical anaesthesia and sedation. A matched group of patients who underwent tracheal intubation conventionally following induction of general anaesthesia were identified in our database and questionnaires were mailed to the patients at a median of 15 months after the procedure. One hundred and ten patients completed the questionnaire. Feelings of discomfort, sensation of suffocation and hoarseness were reported by 14.6, 12.5, and 37.5%, respectively in the awake group and 0, 1.6, and 17.7%, respectively in the conventionally intubated group. No significant differences were reported between the groups with regard to sleeping disorders and the incidence of nightmares. Temporary discomfort is encountered more frequently following awake orotracheal intubation than after conventional intubation, but we did not find a difference in long-term problems such as sleeping disorders or nightmares.

Intubation with Airtraq® and bronchial blocker compared with conventional intubation with double-lumen tube in thoracic surgery: Impact on the hemodynamic response

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Airway Management

Endotracheal intubation with Airtraq® optical laryngoscope in the pediatric patients

Pediatric AnesthesiaVolume 21, Issue 6 p. 703-704 CORRESPONDENCE Endotracheal intubation with Airtraq® optical laryngoscope in the pediatric patients Fu Shan Xue, Fu Shan Xue Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, China Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorHe Ping Liu, He Ping Liu Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, ChinaSearch for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorYu Jing Yuan, Yu Jing Yuan Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorJian Hua Liu, Jian Hua Liu Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this author Fu Shan Xue, Fu Shan Xue Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, China Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorHe Ping Liu, He Ping Liu Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, ChinaSearch for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorYu Jing Yuan, Yu Jing Yuan Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorJian Hua Liu, Jian Hua Liu Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this author First published: 25 April 2011 https://doi.org/10.1111/j.1460-9592.2011.03568.xCitations: 8Read the full textAboutRelatedInformationPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume21, Issue6June 2011Pages 703-704 RelatedInformation RecommendedAwake tracheal intubation using the Airtraq® laryngoscope: a case seriesV. K. DIMITRIOU, I. D. ZOGOGIANNIS, D. G. LIOTIRI, Acta Anaesthesiologica ScandinavicaComparison of Bullard laryngoscope and short‐handled Macintosh laryngoscope for orotracheal intubation in pediatric patients with simulated restriction of cervical spine movementsANITHA NILESHWAR MD, FRCA, VISHAL GARG MD, Pediatric AnesthesiaPerformance of the Airtraq™ laryngoscope after failed conventional tracheal intubation: a case seriesE. MALIN, J. de MONTBLANC, Y. YNINEB, E. MARRET, F. BONNET, Acta Anaesthesiologica ScandinavicaThe use of nasotracheal Airtraq® laryngoscope with reinforced endotracheal tube: our experienceFabio Ferrari, Giuliano Marchetti, Sergio Giuseppe Picardo, Pediatric Anesthesia

Nasotracheal intubation using the Airway Scope and an Endotrol tracheal tube

The Airway Scope® (AWS; Hoya-Pentax, Tokyo, Japan) videolaryngoscope, designed for orotracheal intubation, has been shown to be useful in patients with a difficult airway [1]. The AWS has been reported as a useful and safe device for nasotracheal intubation [2]. During conventional nasotracheal intubation using the Macintosh laryngoscope, Magill’s forceps are often required to introduce the tracheal tube through the glottis. However, when the AWS is used for nasotracheal intubation, the AWS blade may obstruct Magill’s forceps. We have previously reported a method for combining the use of the AWS with the fibreoptic bronchoscope [3], and a gum-elastic bougie may also be used to introduce the tracheal tube into the glottis [2, 4]. Herein, we report a new method in which the Endotrol® tracheal tube (Mallinckrodt Medical, Athlone, Co Westmeath, Ireland) is used for nasotracheal intubation with the AWS. The Endotrol tracheal tube has a wire hook that can be used to control the curve of the tube, and has been used successfully in blind intubation [5]. The combination of the Endotrol tracheal tube and a lightwand has been used successfully for nasotracheal intubation [6]. We report the use of this tube with the AWS for nasotracheal intubation. After induction of anaesthesia and establishing mask ventilation, we insert the Endotrol tracheal tube into the patient’s nostril, and the AWS into the patient’s mouth. When the glottis is seen on the monitor, the tube is advanced to the glottis. The tube’s tip may then be directed upward by pulling the wire hook. In our experience with seven cases of nasotracheal intubation using the AWS, the tube can be successfully advanced through the glottis in this manner. We believe the combination of the Endotrol tracheal tube and the AWS is effective for nasotracheal intubation. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: A randomized control trial*

The optical Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) has been shown to have advantages when compared with direct laryngoscopy in difficult airway patients. Furthermore, it has been suggested that it is easy to use and handle even for inexperienced advanced life support providers. As such, we sought to assess whether the Airtraq may be a reliable alternative to conventional intubation when used in the prehospital setting. Prospective, randomized control trial in emergency patients requiring endotracheal intubation provided by anesthesiologists or emergency physicians responding with an emergency medical service helicopter or ground unit associated with the Department of Anesthesiology, General Hospital, Wiener Neustadt, Austria. During the 18-month study period, 212 patients were enrolled. When the Airtraq was used as first-line airway device (n=106) vs. direct laryngoscopy (n=106), success rate was 47% vs. 99%, respectively (p<.001). Reasons for failed Airtraq intubation were related to the fiber-optic characteristic of this device (i.e., impaired sight due to blood and vomitus, n=11) or to assumed handling problems (i.e., cuff damage, tube misplacement, or inappropriate visualization of the glottis, n=24). In 54 of 56 patients where Airtraq intubation failed, direct laryngoscopy was successful on the first attempt; in the remaining two and in one additional case of failed direct laryngoscopy, the airway was finally secured employing the Fastrach laryngeal mask. There was no correlation between success rates and body mass index, age, indication for airway management, emergency medical service unit, or experience of the physicians. Based on these results, the use of the Airtraq laryngoscope as a primary airway device cannot be recommended in the prehospital setting without significant clinical experience obtained in the operation room. We conclude that the clinical learning process of the Airtraq laryngoscope is much longer than reported in the anesthesia literature.

Comparison of two different methods of fiber-optic nasal intubation: conventional method versus facilitated method (NASAL-18)

Objectives. As the conventional fiber-optic nasal intubation technique has several potential difficulties, we compared in this study another technique (NASAL-18) with the conventional one in attempting fiber-optic nasal intubation with a possible higher rate of success.Methods. A randomized controlled trial was carried out at a teaching hospital. Forty-eight patients aged 25–45 years with American Society of Anesthesiologists (ASA) classes I and II undergoing elective faciomaxillary surgery were allocated to two groups of fiberscopic nasal intubation using either the NASAL-18 technique or the conventional method (control). In the NASAL-18 group, a nasal tube was gently inserted into the nasopharynx till mark 18, then a fiberscope with 41 cm length was glided over it and advanced through the nasal cavity till the glottis could be visualized. Finally the nasal tube was rolled over the fiberscope instead of one-step passage of the nasal tube after visualization of glottis in the controls. Times from the start of insertion of the fiberscope into nares till visualization of vocal cord (T1) and from here to complete intubation (T2) were recorded. These times were compared between the two groups.Results. T1 values in NASAL-18 and control groups were 65.2 ± 33.2 and 151.0 ± 56.5 seconds, respectively (P < 0.0001). T2 durations were measured as 25.1 ± 18.5 and 21.8 ± 10.1 seconds in control and NASAL-18 groups, respectively (P = 0.45). The NASAL-18 group had a success rate of 83% compared to 66.7% in the control group.Conclusions. The NASAL-18 method reduces the time needed for successful fiber-optic intubation. This method can be added to the list of techniques in facilitating fiber-optic intubation.

Laryngospasm in an unsedated patient during elective cannula cricothyroidotomy

We report a case of laryngospasm during performance of a cannula cricothyroidotomy in a conscious patient who may have been at increased risk of this complication. A 61-year-old woman presented for mandibular eminectomy. Clinical examination suggested that intubation and ventilation might be difficult, so an awake intubation was proposed. The patient declined this procedure, but did consent to placement of a cricothyroid cannula before intravenous induction of anaesthesia. Therefore, after pre-oxygenation, we performed an awake cricothyroidotomy with a 14-G Insyte™ cannula (Becton Dickinson UK Ltd, Oxford, UK) but following this, the patient coughed and developed severe laryngospasm. We immediately performed intravenous induction of anaesthesia and found that the patient’s lungs could be easily ventilated. Conventional intubation was possible and surgery proceeded uneventfully. Nothing was injected through the cannula at any stage. At the end of surgery, we viewed the cannula with fibreoptic laryngoscopy and found it to be positioned well below the vocal cords with the tip pointing caudally, suggesting no direct contact with the cords. When the episode of laryngospasm was discussed with the patient afterwards, she described experiencing similar, self-terminating ‘attacks’ of an inability to breathe that typically would wake her from sleep and occurred several times per year. Such episodes are consistent with paroxysmal laryngospasm, in which patients experience bouts of sudden-onset, forceful adduction of the vocal cords [1]. The primary risk factor is laryngopharyngeal reflux of gastric acid, which precipitates a highly irritable, ‘spasm-ready’ airway [2]. The patient was therefore referred to an ear, nose and throat specialist who identified characteristic acid damage to the larynx with nasendoscopy. In view of the history and this finding the specialist concurred with the diagnosis of paroxysmal laryngospasm. We postulate that this patient had an irritable larynx due to silent acid reflux and that the stimulus of the cannula touching the wall of the airway was sufficient to trigger laryngospasm. Given that other disease processes, such as upper respiratory tract infections, may also precipitate an irritable larynx [2, 3], and that many of the symptoms of laryngopharyngeal reflux are non-specific, the spasm-prone patient may well not declare themselves pre-operatively. With this in mind, we suggest conscious patients should be pre-oxygenated before placement of cricothyroid cannulae and the anaesthetist should be prepared to manage laryngospasm by immediately inducing anaesthesia if necessary. No external funding and no competing interests declared. Published with the written consent of the patient. Previously presented as a poster at the Difficult Airway Society Annual Meeting, November 2010.

Modified gastric intubation in the emergency patients with poisoning-induced coma

Objective To explore the effectiveness of modified gastric intubation in the emergency patients with poisoning-induced coma.Methods 40 comatose patients were randomly divided into modified intubation group and conventional intubation group.The effectiveness was then compared the two groups.Results The success rate was greater in the modified intubation group than in the conventional intubation group and the time from the insertion to the placement of the tube was shorter.Conclusions Under the guidance of pharyngoscopy and the guided wire of the tracheal catheter,modified intubation could prevent intubation failure or damage to the mucosa due to blind insertion and prevent suffocation or inspired pneumonia by quickly sucking out the vomit in the mouth,and clear the gastric poisons promptly to save the patients.It is worth popularizing in the primary hospitals. Key words: Gastric intubation; Emergency; Poisoning-induced coma

Passagere Koniotomie im Airway-Management

Extended tumors of the oral cavity, pharynx or larynx can severely compromise the performance of a necessary endotracheal intubation. Both transnasal fiberoptic intubation under spontaneous breathing as well as tracheotomy under local anesthesia require a great deal of cooperation from the awake patient. In cases with dyspnea due to a recurrent tumor the situation is much more difficult. These patients are often in a reduced general condition, show a lack of cooperation and often have postoperative or radiogenic scars of the pharyngeal and laryngeal structures. In response to these problems cricothyrotomy was performed in 16 selected patients under local anesthesia. Analgesia and sedation had been adapted to the needs of the individual patient. The cricothyrotomy was performed alternately by an anesthesiologist and an ENT surgeon. General anesthesia has been carried out immediately after secured ventilation and oxygenation had been determined. In all patients except one the airway was finally secured by tracheotomy and the larynx incision was closed in all cases. The possibility of conventional intubation was judged retrospectively by the anesthesiologist concerned and was found to be simple in one case and nearly impossible in 10 cases. There were no complications due to the surgical procedure apart from a brief episode of disturbance in wound healing and the potentially life-threatening situation of cannot ventilate-cannot intubate could be avoided. In selected cases with extended tumors of the upper airway, temporary cricothyrotomy is an effective and convenient procedure to secure the respiratory tract.

A description of two surgical and anesthetic management techniques used for a patient with fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare and debilitating genetic disorder of skeletal malformations and progressive heterotopic ossification. Flare-ups are episodic, with bone formation in skeletal muscle and connective tissue leading to ankylosis of major joints of the axial and appendicular skeleton. This report outlines the management of a patient with FOP who had ankylosis of the temporomandibular joint and progressive ossification of the neck structures. The patient underwent two different surgical and anesthetic procedures within a 10-year period to manage his oral pain. The authors compare the surgical techniques, osteotomy versus the more conservative buccal approach, anesthesia techniques, and conventional intubation versus sedated fiberoptic intubation. This report emphasizes the importance of a less invasive surgical technique and an appropriate anesthetic management that reduces the risks, cost, and morbidity associated with routine surgical management of patients with FOP.

Management of the airway in multitrauma

The primary purpose of this article is to highlight the latest airway research in multitrauma. Management of the airway in multitrauma patients is a critical resuscitation task. Prehospital airway management is difficult with a high risk of failure, complications, or both. In-hospital performed conventional oral intubation with manual in-line stabilization, cricoid pressure, and a backup plan for a surgical airway is still the most efficient and effective approach for early airway control in multitrauma patients. Selective utilization of airway maintenance, instead of ultimate airway control in the field, has been suggested as a primary prehospital strategy. Properties of videolaryngoscopes complement standard laryngoscopes. When compared with a Macintosh laryngoscope, the Airtraq and Airwayscope diminish cervical spine motion during elective orotracheal intubation. Penetrating neck injuries are the most frequent indication for awake intubation, whereas patients with maxillofacial injuries have the highest rate of initial surgical airway. Risks and benefits of ultimate prehospital airway control is a controversial topic. Utilization of videolaryngoscopes in multitrauma remains open for research. Standardization of training requirements, equipment, and development of prehospital and in-hospital airway algorithms are needed to improve outcomes. Rational utilization of available airway devices, development of new devices, or both may help to promote this goal.

The influence of lung transplantation on end of life care in pediatric pulmonary medicine

Our objective was to investigate the capacity of a pumpless extracorporeal lung membrane (iLA) (Novalung; Novalung GmbH, Hechingen, Germany) to provide adequate respiratory support and the impact on morbidity/mortality during complex airway reconstruction.Only patients unable to be ventilated via conventional intubation were eligible for the study. A larynx mask or orotracheal tubes were placed above the airway defect and the iLA was attached via femoral vessels (arteriovenous), providing extracorporeal gas exchange, apneic hyperoxygenation, and total tubeless airway reconstruction. Haptoglobulin, plasmin–antiplasmin complex, P-selectin activation, and interleukin 6 were measured before, during, and after iLA use and 72 hours postoperatively.Fifteen consecutive patients (age, 42 ± 17 years) underwent elective (n = 7) or emergency (n = 8) reconstruction of the airway owing to a variety of disorders or defects. The iLA was left in place for 185 ± 61 minutes, diverted 1.70 ± 0.48 L/min of the cardiac output, and provided an arteriovenous carbon dioxide removal and oxygen transfer of 173 ± 94 and 144 ± 83 mL/min, respectively. The arterial oxygen tension/inspired oxygen fraction (314 ± 31 mm Hg), and arterial carbon dioxide tension (40 ± 6 mm Hg) remained stable throughout the entire operations. The following procedures were performed: redo slide tracheoplasties (n = 3), redo tracheoesophageal fistula repair (n = 1), sleeve lobectomies (n = 2), main carina reconstructions (n = 7), and anastomotic stenting and myocutaneous coverages (n = 2). Three patients required prolonged (9 ± 2 days) postoperative iLA support. Two (13%) patients died during the hospital stay. The use of iLA was associated with significant (P < .05) but clinically nonrelevant and yet nonpathologic increases of haptoglobulin (hemolysis), plasmin–antiplasmin complex (coagulation activation), and P-selectin activation (platelet activation). Data normalized within 48 hours postoperatively.Data suggest that iLA provides complete intraoperative respiratory support in patients who cannot receive conventional intubation/ventilation without relevant effects on cellular trauma, coagulatory response, and inflammatory response.