Difficulty Of Tracheal Intubation Research Articles

Anaesthetic approach in a case of Goldenhar's syndrome

Anaesthetic approach in a case of Goldenhar's syndrome

Airway alerts: how UK anaesthetists organise, document and communicate difficult airway managment

A questionnaire on documentation and communication of airway problems during anaesthesia was sent to 271 anaesthetic department College Tutors in the UK. Their responses were compared with three published recommendations. There was a 71.9% response rate. 70.8% of respondents met the recommendations of the American Society of Anesthesiologists (ASA) Task Force on the management of the difficult airway [1]. The recommendations of the Canadian Airway Focus Group [2] and those in the textbook ‘Difficulties in Tracheal Intubation’ [3] are more stringent than the ASA guidelines and were met by only 2.1% and 1.5% of respondents, respectively. Only 21% of departments have guidelines for communication and dissemination of information regarding a difficult airway. There is universal acceptance that documentation on the anaesthetic chart is essential. However, further communication of this information is less widely practiced. Worryingly, only 40% of respondents would give written information to the patient and only 26% write to the patient's general practitioner. Benumof [4] suggested that ‘the patient's responsible doctor must guarantee communication of this difficult airway experience to future care takers so that the near death experience does not become a future death.’ The majority of departments in the UK are failing to communicate this important information. We have produced an ‘Airway Alert’ scheme. It is a paper document printed in quadruplicate. Copies are intended for the patient, their general practitioner, the case record and Anaesthetic Department. Use of this scheme will allow concise and quick documentation and communication of an episode of difficult airway management.

Morbid obesity and tracheal intubation.

The tracheas of obese patients may be more difficult to intubate than those of normal-weight patients. We studied 100 morbidly obese patients (body mass index >40 kg/m(2)) to identify which factors complicate direct laryngoscopy and tracheal intubation. Preoperative measurements (height, weight, neck circumference, width of mouth opening, sternomental distance, and thyromental distance) and Mallampati score were recorded. The view during direct laryngoscopy was graded, and the number of attempts at tracheal intubation was recorded. Neither absolute obesity nor body mass index was associated with intubation difficulties. Large neck circumference and high Mallampati score were the only predictors of potential intubation problems. Because in all but one patient the trachea was intubated successfully by direct laryngoscopy, the neck circumference that requires an intervention such as fiberoptic bronchoscopy to establish an airway remains unknown. We conclude that obesity alone is not predictive of tracheal intubation difficulties. In 100 morbidly obese patients, neither obesity nor body mass index predicted problems with tracheal intubation. However, a high Mallampati score (greater-than-or-equal to 3) and large neck circumference may increase the potential for difficult laryngoscopy and intubation.

Anaesthetic management of the airway in The Netherlands: a postal survey.

A postal survey was conducted in order to investigate current practice in airway management amongst Dutch anaesthetists and to investigate the role of recent training and the role of an 'Access to the Airway' airway management course. A questionnaire containing 27 questions was sent to all practising anaesthetists in The Netherlands. Questionnaires were returned anonymously and were analysed using the Pearson chi(2)-test (P < 0.05) with the SPSSR version 8.0 statistical software program. The response rate was 42%. Of the respondents, 78% claim often or always to assess the expected degree of difficulty in tracheal intubation as part of routine preoperative assessment. The American Society of Anesthesiologist's Difficult Airway Algorithm was used by 19% of respondents. A wide variety of airway management techniques is being used. In 36% of all general anaesthetics a laryngeal mask airway is used. In 1.1% of all general anaesthetics tracheal intubation is performed with the flexible fibrescope. Dutch anaesthetists, who commenced anaesthetic training after 1988, and those who attended the airway management course 'Access to the Airway' are significantly more likely to follow the American Society of Anesthesiologist's Difficult Airway Algorithm and to use adjunctive techniques for airway management.

Asymptomatic vallecular cyst: airway management considerations

Airway problems are easiest to manage when they are anticipated. Difficult intubation might, however, occur in patients with no obvious signs or symptoms suggesting airway difficulty. We describe a case where laryngeal inlet was obscured by a large vallecular cyst that was discovered during rapid-sequence induction of general anesthesia, causing difficulty in tracheal intubation. Once the patient was allowed to recover from general anesthesia, the trachea could be safely intubated using a fiberoptic bronchoscope.

New equipment and techniques for airway management in trauma

A patent, unobstructed airway is fundamental in the care of the trauma patient, and is most often obtained by placing a cuffed tube in the trachea. The presence of shock, respiratory distress, a full stomach, maxillofacial trauma, neck hematoma, laryngeal disruption, cervical spine instability, and head injury all combine to increase tracheal intubation difficulty in the trauma patient. Complications resulting from intubation difficulties include brain injury, aspiration, trauma to the airway, and death. The use of devices such as the gum-elastic bougie, McCoy laryngoscope, flexible and rigid fiberscopes, intubating laryngeal mask, light wand, and techniques such as rapid-sequence intubation, manual in-line axial stabilization, retrograde intubation, and cricothyroidotomy, enhance the ability to obtain a definitive airway safely. The management of the failed airway includes calling for assistance, optimal two-person bag-mask ventilation, and the use of the laryngeal mask airway, Combitube, or surgical airway. The simulation of airway management using realistic simulator tools (e.g. full-scale simulators, virtual reality airway simulators) is a promising modality for teaching physicians and advanced life support personnel emergency airway management skills.

A survey of tracheal intubation difficulty in the operating room: a prospective observational study.

The purpose of this study is to describe all degrees of endotracheal intubation difficulty among patients attended by eight anesthesiologists during routine surgery over a six-month period. Airway characteristics were routinely assessed preoperatively, according to the anesthesiologists' usual practice. Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS), a quantitative score based on seven variables. An IDS value of 0 is consistent with a procedure without difficulty, and an IDS > 5 with a procedure involving moderate to major difficulty. For 1171 patients undergoing tracheal intubation, IDS was 0 in 55%, and greater than 5 in 8% of cases. External laryngeal pressure, repositioning the patient and added use of a stylet were the most frequent methods chosen to facilitate tracheal intubation. There was a high incidence (37%) of minor difficulties encountered during routine surgery.

Use of the Laryngeal Mask Before Tracheal Intubation in a Patient with a Cancerous Nose

To the Editor: We report a new indication for the laryngeal mask airway. A 61-year-old man (weight 60 kg) with adenocarcinoma of the nose was scheduled for resection of the tumor and skin flap to the region. The tumor had penetrated the nose skin and was prone to bleeding if pressure was applied. Surgeons requested us not to apply a face mask during the induction of anesthesia to avoid spreading of cancerous exudate to the airway. Preoperatively, there were no pathological changes to the oropharynx. No difficulty in tracheal intubation or in insertion of the laryngeal mask was predicted. In the operating room, while oxygen was given by "open drop" method, lidocaine 50 mg was injected IV. Anesthesia was induced by propofol 3.3 mg/kg and maintained by continuous infusion of propofol, starting with the rate of 10 mg [middle dot] kg (-1) [middle dot] h-1. Immediately after the induction of anesthesia, thrusting the jaw forward did not cause body movements, indicating that the depth of anesthesia was adequate for insertion of the laryngeal mask [1]. The laryngeal mask was inserted without difficulty. While adequate ventilation via the laryngeal mask was being obtained, vecuronium 8 mg was given. A few minutes later, the mask was removed, and the trachea was intubated using a laryngoscope. During this procedure, arterial oxygen hemoglobin saturation remained >98%, and there was no bleeding from the lesion. Both anesthesia and operation proceeded uneventfully. It is possible to insert the laryngeal mask without airway complications immediately after the induction of anesthesia using propofol [1,2]; thus, interruption of ventilation of the lungs is usually <1 min. Therefore, if application of a face mask is undesirable during the induction of anesthesia-for example, in a patient with pathological changes to the tissues around the mouth-the laryngeal mask allows adequate ventilation until a muscle relaxant takes its effect and the trachea is intubated. Takashi Asai, MD, PhD Sachiko Johmura, MD Koh Shingu, MD Department of Anesthesiology; Kansai Medical University; Moriguchi City, Osaka 570-8507, Japan

Laryngoscopy and Fibreoptic Intubation in Acromegalic Patients

Acromegaly is recognized as a cause of difficulty in airway management and tracheal intubation. We evaluated prospectively the conditions for laryngoscopy and fibreoptic intubation in 15 acromegalic patients. Each patient served as his or her own control. Ventilation of the lungs with a face mask was successful in all patients. In five of 15 patients the vocal cords could not be seen using the Macintosh laryngoscope with a size 5 blade. Difficult laryngoscopy was associated significantly with the number of attempts required to see the vocal cords with the fibrescope (P

Fibreoptic assessment of laryngeal aperture in patients with difficult laryngoscopy.

To determine the relationship between the area of the laryngeal aperture (LA) seen fibreoptically during laryngoscopy and the difficulty of tracheal intubation in patients with difficult laryngoscopy In 587 adult patients after induction of general anesthesia and muscle relaxation, the best laryngoscopic view of the larynx using a Macintosh 3 blade was classified according to Cormack. When the LA could not be seen, with laryngoscope blade in place, the LA view provided by a fibreoptic bronchoscope (FOB)-camera passed nasally was photographed. Then, the laryngoscopist attempted to intubate the trachea using the Macintosh blade. Tracheal intubation requiring more than three attempts was defined as difficult. After the third attempt, the trachea was intubated orally aided by FOB. The LA view after jaw thrust during FOB-aided intubation was photographed. Laryngoscopy was difficult in 17 of 587 patients. In four, intubation was difficult. In the remaining 13 patients the trachea was easy to intubate. The LA area obtained by the FOB in the difficult group (median, 0.19; intra-quartile range, 0.14 to 0.39 cm2) was smaller than that in the easy group (2.43; 1.84 to 2.93 cm2)(P = 0.003). In contrast, the LA area provided by jaw thrust during the FOB-aided intubation in the difficult group (2.28; 1.99 to 2.73 cm2) was similar to that during laryngoscopy in the easy group. Inability of the laryngoscope to provide an adequate LA view is one cause of difficult intubation with the Macintosh laryngoscope in patients with difficult laryngoscopy.

Laryngeal function may be impaired in patients with cervical osteophytes

Sir: Tracheal intubation may be difficult in patients with cervical osteophytes [1-3]. We suggest that, in these patients, the laryngeal function may be impaired and cricoid pressure may be ineffective. A 79-year-old man with Forestier's disease was scheduled for surgical removal of cervical osteophytes. He complained of difficulty in swallowing and frequent choking during drinking. A lateral X-ray showed large osteophytes extending anteriorly from the 2nd to the upper edge of the 5th cervical vertebrae (Fig. 1). Computed tomography revealed that the larynx, including the upper edge of the cricoid cartilage, was displaced anteriorly by the osteophytes and both the hypopharynx and the upper segment of the oesophagus were splinted open (Fig. 2).Fig. 1: The X-ray shows large osteophytes bridging between the 2nd and 5th cervical vertebrae. The larynx, including the cricoid cartilage, was displaced anteriorly and the upper segment of the oesophagus was splinted open (arrow).Fig. 2: Computed tomography shows that the oesophagus is splinted open (arrow) just below the level of the cricoid cartilage.Cinegraphy (video swallow) showed that on swallowing there was marked pooling of the liquid in the valleculae and pyriform fossae, and a considerable amount of liquid entered the larynx (Fig. 3). The 'Mallampati score' was class 1 with wide mouth opening. It was possible to move the larynx to the lateral side, but not towards the cervical vertebrae.Fig. 3: Cinegraphy (video swallow) shows that during swallowing, there is pooling of a contrast medium in the valleculae (upper arrow) and pyriform fossae, and medium has entered the larynx (lower arrow). Note a large cervical osteophytes.As reported previously [1-3], there was some difficulty in tracheal intubation. It was noted that the oesophagus was splinted open. The risk of pulmonary aspiration would be likely to be high in this patient had he had a full stomach, because cricoid pressure is unlikely to compress the hypopharynx effectively, and because regurgitated material may pool in the hypopharynx and be aspirated. We suggest that large cervical osteophytes may impair the pharyngo-laryngeal reflexes and might splint the oesophagus open, rendering cricoid pressure ineffective. Awake tracheal intubation should be considered in these patients. K. BARCLAY T. ASAI Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff, UK

Laryngoscopy and fibreoptic intubation in acromegalic patients

Acromegaly is recognized as a cause of difficulty in airway management and tracheal intubation. We evaluated prospectively the conditions for laryngoscopy and fibreoptic intubation in 15 acromegalic patients. Each patient served as his or her own control. Ventilation of the lungs with a face mask was successful in all patients. In five of 15 patients the vocal cords could not be seen using the Macintosh laryngoscope with a size 5 blade. Difficult laryngoscopy was associated significantly with the number of attempts required to see the vocal cords with the fibrescope (P < 0.01, Spearman rank correlation). The larynx could not be seen with both techniques in one patient, and the trachea was intubated blindly with the help of an introducer. Our results showed that fibreoptic intubation may prove difficult or fail in acromegalic patients. Difficulties in seeing the vocal cords with a fibrescope were present most often in patients who also had probable intubation difficulties with a rigid laryngoscope.

Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index

Several clinical multifactorial indexes have been described for predicting difficult laryngoscopy or intubation, or both, mostly in general surgery, and less frequently in ENT surgery. The objective of this study was to develop and validate a single clinical index for prediction of difficulty in tracheal intubation in both ENT and general surgery. We studied a population of 1200 consecutive ENT and general surgical patients. Clinical criteria were tested using univariate and multivariate analysis. Difficult intubation was defined as requiring unusual techniques. Logistic regression identified seven criteria as independent predictors of difficult tracheal intubation; previous history of difficult intubation; pathologies associated with difficult intubation; clinical symptoms of pathological airway; inter-incisor gap and mandible luxation; thyromental distance; head and neck movement; and Mallampati's modified test. Point values were assigned to each of these factors in proportion to regression coefficients representing the relative weight of each predictive intubation difficulty factor, the sum comprising the score. The best predictive threshold was chosen using a receiver operating characteristic curve. We then prospectively studied and validated the score in a population of 1090 consecutive ENT and general surgery patients. The sensitivity and specificity of the predictions were 94% and 96% in general surgery, 90% and 93% in non-cancer ENT surgery, and 92% and 66% in ENT cancer surgery, respectively.

A New Scale for Intubation Difficulty

Numerous scoring systems and subjective assessments have been proposed to quantify the difficulty of tracheal intubation. Lack of standardization makes

Difficulties in Tracheal Intubation, Second Edition

Professor and Vice Chairman for Research, Department of Anesthesiology, The Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157–1009.James C. Eisenach, M.D., EditorDifficulties in Tracheal Intubation, Second Edition. Edited by I. P. Latto, R. S. Vaughan, London, W.B. Saunders Company, Ltd., 1997. Pages: 393. Price:[pound sterling] 40.00.The second edition of Difficulties in Tracheal Intubation provides a considerably expanded view of the topic relative to that provided by the first (1984) edition. Lacking the first edition's chapter on case reports, the second edition contains new chapters on pediatric intubation, emergency airway access, cervical spine injuries, difficulties presenting at extubation, the Combitube[registered sign], predicting difficult intubation, fiberoptic techniques, the laryngeal mask airway, and legal aspects of intubation.There is much to like about this textbook. The chapters are generally well written and of a consistent length and breadth. The illustrations are appropriately numerous. A list of key points is provided at the end of each chapter. On the other hand, this second edition has more “science” than the first edition, a change which is not always for the better. For example, although studies may present conflicting data, few would agree with the comments that “inhaling enflurane at concentrations between 0.85 and 3.2% has no effect on cerebral blood flow”(p 35), or that rocuronium had a “much shorter duration of action” than vecuronium (p 38). Some topics are needlessly repeated in two or more places. There is no need to illustrate the Combitube (R) in chapter 13 when chapter 14 is devoted exclusively to this topic. And, as is often the case, line drawings might have been a better choice than many of the photographs.One aggravating aspect of the book is the repeated statement that a particular practice is “common in North America.” Curiously, many of the described common practices were new to me. For example, I was unaware that there were many centers where “awake fiberoptic intubations are carried out on all patients requiring intubation by the nasal route”(p 367).Nevertheless, this is a book with a very high ratio of wheat to chaff and, given the importance of the topic, can be recommended to all who practice anesthesia.John Butterworth, M.D.Professor and Vice Chairman for Research; Department of Anesthesiology; The Wake Forest University School of Medicine; Winston-Salem, North Carolina 27157–1009

Difficulties in Tracheal Intubation. 2nd ed

Difficulties in Tracheal Intubation. 2nd ed

Difficulties in Tracheal Intubation. 2nd ed

Difficulties in Tracheal Intubation. 2nd ed

Book Review: Difficulties in Tracheal Intubation.

Book Review: Difficulties in Tracheal Intubation.

The Effect of Goiter on Endotracheal Intubation

The incidence of difficulty in tracheal intubation in the presence of goiter was investigated.Data were collected in a series of 4742 consecutive adult patients undergoing general anesthesia. The prevalence of goiter was 6.8%. Fifteen anesthesiologists performed the preoperative airway assessment using standardized guidelines. Seven individual risk factors were correlated with the potential for difficult tracheal intubation. Whenever evidence of goiter or airway pathology was observed, the evaluation was completed by indirect laryngoscopy and radiologic examination to establish the presence of any anatomical deviation. Difficult intubation was defined as inadequate exposure of the glottis by direct laryngoscopy. There was no difference in probability of difficulty in tracheal intubation between patients who presented for thyroidectomy and patients with goiter estimated as a random finding. Statistical analysis revealed an increased risk of difficult intubation amongst goiter patients compared with patients with no evidence of any risk factor (6.8% vs 0.9%, P < 10-8, relative risk = 7.4). We conclude that goiter, when accompanied by airway deformity, constitutes an aggravating factor for difficult intubation. (Anesth Analg 1997;84:611-2)

The effect of goiter on endotracheal intubation.

The incidence of difficulty in tracheal intubation in the presence of goiter was investigated. Data were collected in a series of 4742 consecutive adult patients undergoing general anesthesia. The prevalence of goiter was 6.8%. Fifteen anesthesiologists performed the preoperative airway assessment using standardized guidelines. Seven individual risk factors were correlated with the potential for difficult tracheal intubation. Whenever evidence of goiter or airway pathology was observed, the evaluation was completed by indirect laryngoscopy and radiologic examination to establish the presence of any anatomical deviation. Difficult intubation was defined as inadequate exposure of the glottis by direct laryngoscopy. There was no difference in probability of difficulty in tracheal intubation between patients who presented for thyroidectomy and patients with goiter estimated as a random finding. Statistical analysis revealed an increased risk of difficult intubation amongst goiter patients compared with patients with no evidence of any risk factor (6.8% vs 0.9%, P < 10(-8), relative risk = 7.4). We conclude that goiter, when accompanied by airway deformity, constitutes an aggravating factor for difficult intubation.