Difficulty Of Tracheal Intubation Research Articles

Effect of an aerosol box on tracheal intubation difficulty.

The aim of this study was to determine the effect of an aerosol box on tracheal intubation difficulty. Eighteen experienced anesthetists intubated the trachea of a manikin with a normal airway 6 times using a direct laryngoscope, a McGRATH™ MAC videolaryngoscope, or an airway scope AWS-S200NK videolaryngoscope with or without an aerosol box. Although the aerosol box prolonged the time to successful intubation and decreased the percentage of glottic opening (POGO) score when using a direct laryngoscope, the statistically significant differences were clinically irrelevant. When a McGRATH™ MAC and an AWS-S200NK were used, the times to successful intubation and POGO scores were comparable with and without the aerosol box. When using any of the laryngoscopes, there were no statistically significant differences in the Cormack–Lehane grade and peak force to maxillary incisors with and without the aerosol box. In summary, the effect of an aerosol box on tracheal intubation difficulty is not clinically relevant when an experienced anesthetist intubates the trachea in a normal airway condition.

Correlation between clinical risk factors and tracheal intubation difficulty in infants with Pierre-Robin syndrome: a retrospective study

BackgroundDifficult tracheal intubation is a common problem encountered by anesthesiologists in the clinic. This study was conducted to assess the difficulty of tracheal intubation in infants with Pierre Robin syndrome (PRS) by incorporating computed tomography (CT) to guide airway management for anesthesia.MethodsIn this retrospective study, we analyzed case-level clinical data and CT images of 96 infants with PRS. First, a clinically experienced physician labeled CT images, after which the color space conversion, binarization, contour acquisition, and area calculation processing were performed on the annotated files. Finally, the correlation coefficient between the seven clinical factors and tracheal intubation difficulty, as well as the differences in each risk factor under tracheal intubation difficulty were calculated.ResultsThe absolute value of the correlation coefficient between the throat area and tracheal intubation difficulty was 0.54; the observed difference was statistically significant. Body surface area, weight, and gender also showed significant difference under tracheal intubation difficulty.ConclusionsThere is a significant correlation between throat area and tracheal intubation difficulty in infants with PRS. Body surface area, weight and gender may have an impact on tracheal intubation difficulty in infants with PRS.

How to Predict Difficult Tracheal Intubation: The Application of Acromio-axillo-suprasternal Notch Index.

Background:The incidence of difficult laryngoscopy or tracheal intubation is high, which needs a method to predict the difficulty of tracheal intubation to decrease the rate of complications. Therefore, the aim of this study was to evaluate acromio-axillo-suprasternal notch index (AASI) method for predicting difficult tracheal intubation and difficult laryngoscopy.Materials and Methods:This cross-sectional and diagnostic value study was performed on 108 patients who had indication for endotracheal intubation in the emergency department. Before endotracheal intubation, AASI was evaluated in all patients. The sensitivity, specificity, and total accuracy for predicting the power of AASI for the difficulty of tracheal intubation were measured.Results:Based on Cormack and Lehane grading system, 54 patients had easy endotracheal intubation (33.3% Grade I and 66.6% Grade II) and 52 patients had difficult endotracheal intubation (57.7% Grade III and 32.7% Grade IV). The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AASI in cutoff point 0.515 for predicting difficulty of endotracheal intubation with 0.857 area under the receiver operating characteristic curve were 84.6%, 77.7%, 78.5%, 84%, and 81.13%, respectively.Conclusions:Our results showed that predicting difficulty of endotracheal intubation by AASI is accurate and with high sensitivity and specificity values, therefore, training this method to emergency physicians should be considered in our country or other countries. Further studies are required to confirm our findings.

The use of high‐flow nasal oxygen during airway management in a child with epidermolysis bullosa dystrophica and a difficult airway

The role of high-flow nasal oxygen in paediatric anaesthesia has been emerging in recent years. However, literature regarding its benefits in paediatric difficult airway management is limited. In this case report, we describe the use of high-flow nasal oxygen during airway management of a child with a difficult airway due to epidermolysis bullosa dystrophica in whom the use of a facemask would have been potentially harmful. Deep sedation was achieved with propofol and remifentanil while maintaining spontaneous breathing before flexible bronchoscopic tracheal intubation was attempted. However, on attempted tracheal intubation difficulty was encountered due to poor visualisation and contact bleeding. Tracheal intubation was eventually successful after converting to videolaryngoscopy. Oxygenation was maintained throughout the process despite deep sedation and a long procedure time. Moreover, no skin abrasions or mucosal injury resulted from the use of high-flow nasal oxygen. We conclude that high-flow nasal oxygen has a valuable role during airway management for a child with a predicted difficult airway when the use of a facemask would have been potentially harmful.

A data review of airway management in patients with oral cavity or oropharyngeal cancer: a single-institution experience

BackgroundOral cavity and oropharyngeal cancer impose significant threat to airway management. Head and neck radiotherapy (HNRT) may further increase the difficulty of tracheal intubation. We hypothesized that a history of HNRT would be associated with a high rate of difficult tracheal intubation.MethodsAdult patients with a history of HNRT were identified. Non-HNRT controls were case-matched by age, sex and body mass index. The tracheal intubation status between the two patient groups (treated vs. untreated with HNRT) was compared. The t test was used to evaluate differences in continuous variables between the 2 groups. Fisher’s exact test or a chi-square test was used to test for associations between radiation status and patient characteristics that may be associated with difficult tracheal intubation. Odds ratio and its confidence interval were used to assess the effect of radiation status on intubation status.ResultsThe final cohort of 472 matched patients in age, sex and body mass index consisted of 236 patients who had HNRT before surgery and 236 who had upfront surgery without HNRT. The percentage of patients who had restricted neck range of motion in the HNRT group was significantly higher than in the control group (22.3% vs. 11.0%; p = 0.001). The proportion of patients with trismus (p = 0.11) or difficult tracheal intubation (p = 0.73) did not differ significantly between the 2 groups. 12.7% patients in the study had difficult tracheal intubation. Patients who had mallampati scores of 3 or 4 had significantly higher rate of difficult tracheal intubation than did patients with mallampati scores of 1 or 2 (17.8% vs. 8.7%; p = 0.004). Multivariate logistic regression model showed no difference between HNRT and intubation status after adjusting neck range of motion and mallampati score (OR = 0.91, 95% CI: 0.510 to1.612).ConclusionsPrevious treatment with HNRT was not associated with additional risk of difficult tracheal intubation. Mallampati score may be a sensitive measurement for difficult tracheal intubation in this patient population.

Anesthetic Care of Children With Gene Therapy for the Treatment of Aromatic L-Amino Acid Decarboxylase (AADC) Deficiency

AADC deficiency is a rare autosomal recessive disease that may lead to movement disorder and/or autonomic dysfunction. The prognosis of AADC deficiency patients is poor, and most die in childhood. Gene therapy is the only method currently available to help alleviate related symptoms. Gene therapy involves the injection of adeno-associated viral (AV) vector into the basal ganglia of patients, helping transfer the AADC gene and leading to improved AADC production and higher numbers of neurotransmitters in the brain. Moreover, as patients are unable to produce catecholamine, they may also suffer from a disorder affecting the regulatory control of the autonomic nervous system, resulting in hypoglycemia, which often causes imbalances in thermoregulation and hemodynamic and functional adjustments during surgery. Furthermore, the use of analgesics and inhalational anesthetics increase the risks of hypotension and bradycardia. Thus, in addition to assessing cardiac and respiratory system functions, it is important to evaluate the patient's airway before administering anesthesia, as structural anomalies or other situations may be present that lead to difficulties in tracheal intubation. Various airway tools, anesthesia equipment, and alternative plans should thus be prepared to protect the airway and maintain vital signs. All of the abovementioned issues increase the risks of AADC deficiency patients undergoing general anesthesia. The development of gene transfection for genetic diseases is a future trend. This paper identifies possible problems and related responses in perioperative patient care during gene therapy. The authors hope that these experiences provide references for the administration of AADC and similar gene therapies in the future.

Comparative evaluation of CMAC and Truview picture capture device for endotracheal intubation in neonates and infants undergoing elective surgeries: A prospective randomized control trial.

Videolaryngoscopy has an established role in difficult airway management in adults. However, there is limited literature to support their efficacy in children. The Truview PictureCapture Device has shown promising results for endotracheal intubation in infants in the past. The CMAC videolaryngoscope has launched its novel infant Miller blade, but its performance has not been assessed clinically for routine intubation in infants and neonates. We hypothesized that the CMAC videolaryngoscope would reduce the total time to intubation as compared to the Truview PictureCapture Device in neonates and infants. After parental informed consent, 80 prospective infants posted for surgical procedures under general anesthesia were randomized to undergo intubation with either of the two. The two videolaryngoscopes were also compared in terms of time required for glottis view and intubation (primary outcome), modified Cormack and Lehane grade, first attempt and overall success rate, ease of intubation, number of attempts, and any complications. The CMAC significantly reduced the time required for glottic view [8s (5.25-9) vs 9s (6.5-12); P=0.02] and intubation [22s (18-26) vs 26s (21.5-32); P=0.003]. The median difference (95% CI) for time to tracheal intubation and time to glottic view was 4s (1-7) and 1 (0-4). It also improved the ease of intubation, the Cormack-Lehane grades, and first attempt success rate. Intubation with the CMAC was possible in 100% cases, whereas only 92.5% of patients could be intubated with the Truview. The failed intubations with the Truview could be successfully intubated with the CMAC. The CMAC Miller blade reduced the total time taken for tracheal intubation and intubation difficulty as compared to the Truview PictureCapture Device and may be a better tool for intubation in infants.

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia

The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial. To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed. Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017). Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group. Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure. Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group. This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room. ClinicalTrials.gov Identifier: NCT02080754.

Safety and efficacy of rescue flexible bronchoscopic intubation using the Bentson floppy-tip guidewire via a supraglottic airway in critically ill children.

Difficulty in tracheal intubation in paediatric intensive care patients is associated with increased morbidity and mortality. Delays to intubation and interruption to oxygenation and ventilation are poorly tolerated. We developed a safe and atraumatic tracheal intubation technique. A floppy-tipped guidewire and airway exchange catheter were placed to a pre-determined length under bronchoscopic guidance while oxygenation and ventilation was maintained via a supraglottic airway device (SAD). We performed a retrospective review of this technique on patients who were either known to have or who had an unexpected difficultly in intubation. We describe the safety and experience of this in a broad range of critically ill children. Thirteen patients, median (IQR [range]) (9.0 (5.0-10.0 [4.0-12.0]) kg and 15.4 (12.1-23.2 [3.3-49.7]) months) underwent emergency tracheal intubation using this technique, after unsuccessful attempts at intubation using standard laryngoscopy blades. All intubations were successful at the first attempt using this technique and no airway trauma or significant clinical deteriorations were recorded.

Perioperative Management of Children With Giant Encephalocele: A Clinical Report of 29 Cases.

Giant encephalocele, a rare entity, makes anesthesiologists wary of challenging anesthetic course. Apart from inherent challenges of pediatric anesthesia, the anesthesiologist has to deal with unusual positioning, difficult tracheal intubation, and associated anomalies during the perioperative course. Medical records of 29 children with giant encephalocele, who underwent excision and repair, during a period of 13 years, were retrospectively analyzed. Data pertaining to anesthetic management, perioperative complications, and outcome at discharge were reviewed. The average age at admission was 164 days. Hydrocephalus and delayed milestones were present in 19 (65.5%) and 7 (24.1%) children, respectively. Difficulty in tracheal intubation was encountered, in 15 (51.7%) children. Tracheal intubation was attempted with direct laryngoscopy, most often, in lateral position (24 [82.8%]). Intraoperative hemodynamic and respiratory complications were observed in 9 (31.0%) and 5 (17.2%) children, respectively. Intraoperative hypothermia was observed in 4 (13.8%) children. The average stay in the intensive care unit was 2.7 days and average hospital stay was 11.5 days. The condition at discharge remained same as the preoperative period in 24 children (82.7%), deteriorated in 2 (6.9%), and 3 children (10.3%) died. Management of children with giant encephalocele requires the updated knowledge on possible difficulties encountered during the perioperative period. They need specialized anesthetic care for dealing with difficult tracheal intubation, associated congenital anomalies, unusual positioning, electrolyte abnormalities, hypothermia, and cardiorespiratory disturbances. For securing the airway, we suggest the practice of direct laryngoscopy in lateral position after inhalational induction. Muscle relaxant should be administered only after visualization of the glottis.

Assessment of endotracheal tube intubation. Review of existing scales

Due to the complications associated with endotracheal intubation, contraindications should be assessed prior to initiating the procedure when possible. Several scales have been created to assess the ease of intubation. These intubation scales use numerous scoring systems combined with subjective assessments to provide a quantifiable suggestion for the patients difficulty of tracheal intubation. While there is no formal definition of what comprises a difficult intubation, some parameters include effort, number of attempts and complications. Some of the most common scales to assess this difficulty include the Mallampati score, the Cormack Lehane scale, the intubation difficulty scale, the level of difficulty of intubation, as well as the simplified airway risk index. There have been several other proposed methods as well that are less frequently used contributing to even less cohesion in the evaluation of airways.

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 ...

Unexpectedly difficult airway

Introduction: Difficult airway is defined as ‘clinical situation where an experienced anesthesiologist has difficulty in ventilation patient’s facial mask difficulty in tracheal intubation or loth’ The assessment of the airway is one of the first and key step in anesthetit preoperative examination, and determined strategy to plan positioning of patients, equipment, technology and medicine. There are few difficult airway predictors: obesity, deformities of the jaw and neck, macroglossia, interincisor small space, prominent chest, large breasts, small tireomental distance. The most commonly used Mallampati, wherein the class 3 and 4 predictors of difficult intubation. The most useful is a combination of tests, there is no perfect predictor for assessing airway difficulties, unexpected difficult intubation in practice occur from time to time. Objective: Case report of unanticipated difficult intubation, analysis procedures and measures taken. Materials and method: A descriptive method, the data from the anesthetic records. Case report: A 62 year old female patient, weighing 50 kg and a height of 160 cm, is preparing for the planned operation, with the diagnosis: Tumor ovarii dextri per magna. Without significant comorbidity. In assessing the airway, patient had sufficient mobility of the neck, tireomental distance, Mallampati class 2, not obese, only interincisor space limits of about 3 cm. The possibility for difficult ntubation is not anticipated. After premedication, the patient is positioned in a horizontal position. After the introduction of anesthesia, ventilation facial mask was good. After aplication short acting depolarizing muscle relaxants, access to laryngoscopy. It is observed that a large epiglottis is impossible to raise, and plicae vocalis were unavailable for visualization. Endotracheal intubation was attempted in 3 times. After the failure, the supraglottic device laryngeal mask was placed. Laryngeal mask was not positioned satisfactorily to achiev the correct ventilation. Because insufflation of air in the stomach and unsatisfactory ventilation, we made a decision to postpone the surgery for a few days. The patient wakes up, breathe spontaneously. All data, with detailed descriptions were recorded in the anesthetic card. Confronted with the unanticipated difficult intubation, anesthetic team is thoroughly prepared for delayed surgery, and changes the strategy for airway management. The patient is placed in the anti-Trendeleburg position, the head is elevated, thus the axes of the upper airway and allows a better visualization of anatomical structures. One anesthesiologist approach to direct laryngoscopy, and other performed BURP maneuver (Backward, Upward, Rightward Pressure), approaching structures of the larynx, and allows visualization of the successful intubation. Discussion and conclusion: The Guide Association for difficult airway from 2015 emphasis on careful planning and detailed knowledge of the entire team with the strategy of securing the airway. The positioning of the head and neck must be optimized from the start to make the first intubation attempt successful. Equipment for difficult intubation must be easily accessible. All the difficulties must bedetaily noted in the medical records, which is of great importance for the anesthesiologist and patient with possible following surgery.

Comparative evaluation of Airtraq™ optical Laryngoscope and Miller's blade in paediatric patients undergoing elective surgery requiring tracheal intubation: A randomized, controlled trial.

Background and Aims:The Airtraq™ optical laryngoscope is the only marketed videolaryngoscope for paediatric patients besides the fibre-optic bronchoscope. We hypothesized that intubation would be easier with Airtraq™ compared to Miller blade. Hence, we compared Airtraq™ with the Miller laryngoscope as intubation devices in paediatric patients.Methods:This prospective, randomized study was conducted in a tertiary care teaching hospital. Sixty children belonging to American Society of Anesthesiologists' Grade I–II, aged 2–10 years, posted for routine surgery requiring tracheal intubation were randomly allocated to undergo intubation using a Miller (n = 30) or Airtraq™ (n = 30) laryngoscope. The primary outcome measure was time of intubation. We also measured ease of intubation, number of attempts, percentage of glottic opening score (POGO), haemodynamic changes and airway trauma. Student t test was used to analyse parametric data.Results:Intubation time was comparable between Miller's laryngoscope (15.13 ± 1.33s) compared to Airtraq™ (11.53 ± 0.49 s) (P = 0.29) The number of first and second attempts at intubation were 25 and 5 for the Miller laryngoscope and 29 and 1 for the Airtraq™. Median visual analogue score (VAS) for ease of intubation was 5 in Miller group compared to 3 in Airtraq™ group. The median POGO score was 75 in the Miller group and 100 in the Airtraq™ group (P = 0.01). Haemodynamic changes were maximum and most significant immediately and 1 min after intubation. Airway trauma occurred in three patients (9.09%) in Miller group and one patient (3.33%) in Airtraq™ group.Conclusion:The Airtraq™ reduced the difficulty of tracheal intubation and degree of haemodynamic stimulation compared to the Miller laryngoscope in paediatric patients.

Predictors of Difficult Tracheal Intubation on Adult Elective Patients in a Teaching Hospital

Background: During routine preoperative assessment of patients one of the commonest practices is predicting difficulty of tracheal intubation from various factors detected. Whether the factors reliably predict the difficulty is subject of argument. This study was conducted to assess the predictors of difficult tracheal intubation in adult patients. Methods: In this prospective observational study, we studied 120 consecutive elective adult patients admitted for general, gynecologic and orthopedic surgeries. Socio-demographic parameters and test variables such as BMI, TMD, SMD, IIG and Mallampati class were collected during preoperative evaluation. CL grade and difficulty of intubation were observed while the anesthetist in duty performs the laryngoscopy. While the former obtained from the preoperative anesthesia note, the latter were filled to questionnaire based on what the anesthetist reports during or after laryngoscopy. The prevalence of difficult intubation and the sensitivity, specificity, PPV and NPV of the tests were analyzed. SPSS-20 and different formulas were used during analysis. Chi square test was used and P&lt;0.05 was considered as statistically significant. Result: The overall prevalence of difficult tracheal intubation was 2.5%. The sensitivity, specificity, PPV &amp; NPV of the tests were 0%, 98.3%, 0% &amp; 97.46% for BMI; 0%, 97.5%, 0% &amp; 100% for SMD; 100%, 96.64%, 20% &amp; 100% for TMD; 0%, 99.17%, 0%, &amp; 100% for IIG; and 100%, 99.14%, 75% &amp; 100% for Mallampati test. Conclusion: The incidence is not quite small that anesthetists should use necessary tests to predict the difficult intubation. Probably combining the tests being the best option, Mallampati test alone can predict the difficult intubation in adult patients.

Difficult tracheal intubation in a patient with maternal uniparental disomy 14.

BackgroundMaternal uniparental disomy 14 (UPD(14)mat) is an imprinting disorder. It is a rare disease, but there is the possibility that more undiagnosed patients might exist because the clinical features of UPD(14)mat resemble those of the Prader-Willi syndrome or other congenital diseases. We performed anesthetic management for an 8-year-old girl with UPD(14)mat.Case presentationsShe was admitted to undergo correction surgery due to symptomatic scoliosis. Preoperative examination revealed that she had a restricted mouth opening and retrognathia, as well as some typical characteristics of UPD(14)mat, such as small hands, growth retardation, and precocious puberty. We induced general anesthesia using sevoflurane without any problems. However, the tracheal intubation was difficult because of the restricted mouth opening. We used the McGRATHR MAC videolaryngoscope to overcome this problem.ConclusionsWe speculate that the craniofacial deformity in case of UPD(14)mat patients may lead to difficulty in tracheal intubation.

Suitability of a preserved human cadaver model for the simulation of facemask ventilation, direct laryngoscopy and tracheal intubation: a laboratory investigation

BackgroundUsing fresh or formalin-embalmed cadavers has not been generally accepted for the purposes of teaching airway management. We investigated whether cadavers ‘preserved according Thiel’s embalming method’ (PATEM) are suitable for the simulation of facemask ventilation and tracheal intubation by direct laryngoscopy. MethodsThis observational cluster sampling, controlled simulation study, included eight PATEM cadavers and eight manikins in two clusters. Twenty experienced anaesthetists were randomly assigned to execute 80 facemask ventilations and 80 tracheal intubations in both groups. The ease of facemask ventilation was the primary endpoint. The secondary endpoint was the composite outcomes of laryngoscopy and tracheal intubation. ResultsThe success rate at the first attempt at mask ventilation was 74% (59/80 attempts) on cadavers and 41% (33/80 attempts) on manikins (P<0.0001). Twenty one subjects received an oral airway in both groups and succeeded in facemask ventilation 20 times on cadavers and four times on manikins (P+0.004). Two-handed technique mask ventilation was required 24 times on manikins and once on cadavers (P+0.0016). In one attempt on a manikin the mask ventilation was impossible. Poor laryngeal view (Cormack-Lehane grade 3) occurred 14 times among cadavers (17.5%) and once in manikins (1.25%) (P+0.007), whereas difficulties in tracheal intubation were encountered 16 times in cadavers (20%) vs 17 times in manikins (21.25%) (P+0.84). In a subjective evaluation the participants preferred the cadaver model over the manikins (P<0.0001). ConclusionsPATEM cadavers were better suited for facemask ventilation and provided a more realistic environment for laryngoscopy and tracheal intubation than the studied manikins.

The Airway Management of One Case of Closed Tracheal Rupture Caused by a Car Accident

Difficulty of tracheal intubation is caused by many reasons and among them tracheal rupture is an infrequent factor. Tracheal rupture leads to higher mortality and poorer prognosis especial for closed tracheal rupture which is hard to early diagnose and is generally fatal. We described a case of a 34-year-old narcose man after a car accident that accepted twice unsuccessful tracheal intubation with visualized laryngoscope and was diagnosed tracheal rupture through tracheotomy. We reviewed some of the present literature about the diagnosis of tracheal rupture and anaesthesiologic treatment in order to better guide the clinical practices.

Airway management for patients with ossification of the anterior longitudinal ligament of the cervical spine.

Ossification of the anterior longitudinal ligament (OALL), also called Forestier’s disease or diffuse idiopathic skeletal hyperostosis, is characterized by anterior bridging osteophytes of unknown etiology. OALL may cause dysphagia, dyspnea, dysphonia, and acute airway obstruction. We report difficulty in tracheal intubation during anesthesia induction in two OALL patients. In an 82-year-old man, anterior bridging osteophytes (of the cervical region) were observed on preoperative lateral radiograph after several attempts of tracheal intubation for the operation of the anterior fusion of cervical spine. During the same procedure in another 69-year-old man, fiberoptic-assisted awake intubation was extremely difficult because of posterior hypopharyngeal wall protuberance by osteophytes of cervical spine; although tracheal intubation for anesthesia was uneventful on two previous occasions over the months. OALL is usually asymptomatic, but it has been found in 12 % of autopsies and may exaggerate with age. Dysphagia, difficulties with tracheal and/or gastric intubation, acute respiratory compromise, and sleep apnea result from the presence of cervical osteophytes. Anesthesiologists should be aware that tracheal intubation for such patients may be difficult, and thus the preoperative evaluation and airway management need careful consideration.

Facilitating Endotracheal Intubation in Difficult Cases Using an External Magnet

Difficult airway is conventionally defined as a medical scenario in which a trained examiner faces difficulty in either facemask ventilation or tracheal intubation (1). Unlike difficult intubation, the incidence of difficult mask ventilation in adults is considerable (2, 3). Anesthesiologists and those who practice intubation should be familiar with the management of airway and be able to recognize and identify potentially difficult airways including congenital craniofacial deformities with micrognathia (e.g. Pier Robin, Treacher Collins, Goldenhar's, and Crouzon's syndromes) and metabolic diseases causing the deposition of accumulated by-products (e.g., Hurler's, Morquio's, and Beckwith-Wiedemann syndromes). Cormack and Lehane grades 3 and 4 at laryngoscopy are an indication for advanced techniques for intubation. Laryngeal mask airway (LMA) and fiberscope with a directable tip are useful and important modalities in handling difficult airway and intubation (5). Even normal pediatric airway could become critical due to the anatomical and physiological differences between pediatric and adult airway; this particularly becomes a concern in infants, i.e. children younger than one year old. This hazard is augmented in the presence of congenital or acquired difficulties affecting airway. Consequently, proper preoperative assessment is considered as the cornerstone of pediatric difficult airway management. Every anesthetic plan should be tailored according to patients considering the scenario and also the expertise of the practitioner. Opting for spontaneous respiration maintenance and intervening in a step-wise manner are strongly suggested (6) . Multiple airway devices have been and are developed that all of which can be placed under direct vision or blindly; most of these devices consistently both provide and maintain safe oxygenation and ventilation. Furthermore, a wide range of ancillary devices have also been introduced to be of assistance in the management of difficult airway; most of them are available in varied sizes suitable for use in children and incorporate a variety of different types of endotracheal tubes, supraglottic devices, fiber-optic, video, optical, and mechanical technologies. Some of these devices (e.g. video laryngoscope) are expensive and not suitable for developing countries with limited financial reserve; some others need high levels of experiences or learning courses which is not possible for anesthesiologist that are not working in university hospitals or are less experienced. Some of these devices cannot be used in small children or neonates. Therefore, we were encouraged to look for a device that is easy to use and carry, inexpensive, small in size, and available in all sizes for children, and also does not need special training.