Airway Management Experience Research Articles

Comparison of the GlideScope® with the Macintosh Laryngoscope in Endotracheal Intubation during Uninterrupted Mechanical Chest Compression: A Randomised Crossover Manikin Study

Background The GlideScope® (GS) has been shown to improve the first-attempt success rate of endotracheal intubation during continuous mechanical chest compressions compared with the conventional Macintosh laryngoscope (ML) in inexperienced hands. Yet, its value for operators with experience of emergency airway management has remained uncertain. We set out to compare their performance in the hands of experienced operators in a manikin receiving continuous mechanical chest compressions delivered by LUCAS®. Method This was a randomised crossover study. Thirty-five emergency physicians and intensivists performed intubation using GS and ML in 3 different scenarios: (1) normal airway without chest compressions; (2) normal airway with uninterrupted mechanical chest compressions; and (3) normal airway with cervical spine (C-spine) immobilisation and uninterrupted mechanical chest compressions. The sequence of scenarios and devices used were randomised. The primary outcome was the first-attempt success rate of intubation. Other data including demographics, the time required for successful intubation, complications during intubation, the visual analog scale of perceived difficulty of intubation and the preference on devices in each scenario were also collected and analyzed. Results In scenario 1, the first-attempt success rate with both laryngoscopes was 100%. In scenario 2, there was a higher first-attempt success rate with ML but it was not statistically significant (GS 97.14% vs ML 100%, p=1.00). In scenario 3, one participant failed to intubate in the first attempt with each of the laryngoscopes (GS 97.14% vs ML 97.14%, p=0.754). More dental compression was noted with GS but the difference was not statistically significant (GS 42.86% vs ML 22.86%, p=0.126). Overall, the median time for intubation with GS was significantly longer in all 3 scenarios (Scenario 1: GS 18.5s; interquartile range [IQR] 13.8 -22.2s vs ML 11.2s, IQR 9.5-14.2s, p<0.001; Scenario 2: GS 18.7s, IQR 13.1-25.2s vs ML 13.4s, 10.3-15.8s, p<0.001; Scenario 3: GS 20.8s, IQR 16.5-29.2s vs ML 14.0s, IQR 10.5-18.0s, p<0.001). More participants preferred GS in scenario 3, while ML remained the device of choice in the other two scenarios. Conclusion: GS is not superior to ML in terms of the first-attempt success rate of intubation and it takes significantly longer to intubate for experienced operator. Yet more participants prefer its use when the C-spine motion is limited. Further studies are warranted to explore its role in trauma resuscitation. (Hong Kong j.emerg.med. 2016;23:159-167)

İleri Derecede Kifoskolyotik Çocukta Lateral Pozisyonda Fiberoptik Entübasyon

Kyphoscoliosis is a serious anatomical abnormality in the form of lateral curvature and rotation of the spine. Kyphoscoliosis that may be accompanied by syndromes can also cause difficulty with airway management during general anesthesia. In this report, we aimed to present our experience of difficult airway management with a child patient who could not be put in the supine position due to advanced kyphoscoliosis and underwent general anesthesia for dental treatment.

Case Series of Inflation Pressures of the Endotracheal Tube Cuffs among Intubated Patients at an Accident and Emergency Department in Hong Kong

Despite the frequent use of endotracheal tubes in daily practice of emergency medicine, not much emphasis has been put on the measurement of cuff pressure. We attempted to conduct a case series study of prospectively recruited patients to illustrate the risk of inappropriate cuff inflation without manometry. It was found that the pilot balloon palpation was an inaccurate method to estimate cuff under- or over-inflation, with large discrepancies when compared with an objective measure. Such discrepancies might be independent of doctors' and nurses' working experience in airway management. Use of an aneroid manometer remains an economical and cost-effective way to obtain an instantaneous yet reasonably reliable result and should become a routine in emergency departments.

Transnasal humidified rapid‐insufflation ventilatory exchange (THRIVE) for difficult airway management: a trainee perspective

SummaryWe present the case of an 86‐year‐old female with an epiglottic mass causing airway obstruction. The use of transnasal humidified rapid‐insufflation ventilatory exchange (THRIVE) to provide apnoeic oxygenation enabled the airway to be safely and successfully managed by an anaesthetic trainee, enhancing their educational experience in difficult airway management.

Percutaneous dilatational tracheostomy for ICU patients with severe brain injury

ObjectiveTo sum up our experience in percutaneous dilatational tracheostomy (PDT) in ICU patient with severe brain injury. MethodsBetween November 2011 and April 2014, PDTs were performed on 32 severe brain injury patients in ICU by a team of physicians and intensivists. The success rate, efficacy, safety, and complications including stomal infection and bleeding, paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, as well as clinically significant tracheal stenosis were carefully monitored and recorded respectively. ResultsThe operations took 4-15 minutes (mean 9.1minutes±4.2minutes). Totally 4 cases suffered from complications in the operations: 3 cases of stomal bleeding, and 1 case of intratracheal bloody secretion, but none required intervention. Paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis were not found in PDT patients. There was no procedure-related death occurring during or after PDT. ConclusionOur study demonstrats that PDT is a safe, highly effective, and minimally invasive procedure. The appropriate sedation and airway management perioperatively help to reduce complication rates. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and also an intensivist with experience in difficult airway management.

Influence of clinical experience of the Macintosh laryngoscope on performance with the Pentax-AWS Airway Scope(®), a rigid video-laryngoscope, by paramedics in Japan.

We sought to establish the clinical utility of the Pentax-AWS Airway Scope(®) (AWS) when used by paramedics to intubate the trachea, and to evaluate whether their performance was influenced by previous clinical experience with the Macintosh laryngoscope (ML). Twenty paramedics attempted tracheal intubation using the AWS in five patients each in the operating room. We recorded the success rate, the number of intubation attempts, and the time for intubation and adverse events, and compared these based on the paramedics' previous clinical experience with the ML. Ten paramedics had no prior clinical experience of the ML (group A) and 10 had used it on more than 30 occasions (group B). The intubation success rate was 99 % (99/100). Notably, 96 % (47/49) of intubations were achieved on the first attempt by the inexperienced paramedics in group A, compared with 64 % (32/50) by the experienced paramedics in group B (p = 0.0001). The time to intubation (mean ± SD) was significantly shorter in group A than in group B (37 ± 24 vs. 48 ± 21 s, p = 0.002). There were marked variations in the times taken to intubate, but no apparent improvement as the intubators gained experience between their first and fifth cases. No complications were encountered in either group. We found that paramedics could achieve a high tracheal intubation success rate using the AWS independent of previous airway management experience. Better intubation performance with the AWS was observed in paramedics without clinical experience with the ML.

Teaching tracheal intubation: Airtraq is superior to Macintosh laryngoscope.

BackgroundTracheal intubation with Macintosh laryngoscope is taught to medical students as it is a lifesaving procedure. However, it is a difficult technique to learn and the consequences of intubation failure are potentially serious. The Airtraq optical laryngoscope is a relatively novel intubation device, which allows visualization of the glottic plane without alignment of the oral, pharyngeal, and tracheal axes, possessing advantages over Macintosh for novice personnel. We introduced a teaching mode featured with a progressive evaluation scheme for preparation and performance of tracheal intubation with medical students in this prospective randomized crossover trial who had no prior airway management experience to find the superior one.MethodsTwenty-six medical students of the 8-year programme in the 6th year participated in this trial, when they did their one-week rotation in the department of anaesthesiology. Each of the students intubated 6 patients, who were scheduled for surgeries under general anaesthesia, each laryngoscope for 3 patients respectively. One hundred and forty-nine consecutive patients scheduled for surgical procedures requiring tracheal intubation were enrolled. Patients were randomly allocated to undergo tracheal intubation using Macintosh (n = 75) or Airtraq (n =74) laryngoscope. The progressive evaluation scheme was applied to each intubation attempt.ResultsIntubation success rate was significantly higher in Airtraq group than Macintosh group (87.8% vs. 66.7%, P < 0.05). Duration of glottis exposure was significantly shorter in Airtraq group compared to Macintosh group (50 ± 19 s vs. 81 ± 27 s, P < 0.001). A grade I Cormack and Lehane glottic view was obtained in 94.6% of patients in the Airtraq group versus 32% of patients in the Macintosh group (P <0.001). Duration of intubation in Airtraq group was significantly shorter (68 ± 21 s vs. 96 ± 22 s, P < 0.05) compared to Macintosh group.ConclusionsAirtraq laryngoscope is easier to master for novice personnel with a higher intubation success rate and shorter intubation duration compared with the Macintosh laryngoscope.Trial registrationTrial registration number is ChiCTR-TRC-13003987, approval date Dec 12, 2013.

Choosing a Fellow or Fellowship

The numbers of pediatric otolaryngology fellowship programs and applicants have increased over the past 5 years. However, the qualities desired in programs and applicants have not been explored. To determine the factors that fellowship program directors and applicants believe to be most important in choosing a fellow and the factors most important to fellowship applicants in choosing a program. Cohort study using an anonymous online survey of 2012 pediatric otolaryngology fellowship program directors and applicants. Respondents were asked to rank a list of 10 qualities from most to least important for judging the strength of a fellowship applicant. Applicants also assessed the importance of factors in choosing a fellowship. Rank of each factor by members of each group. Thirty-two of 47 applicants (68%) and 15 of 31 fellowship directors (48%) completed the survey. For applicants, the most important factors when choosing a fellowship program were gaining strong experience in airway management and otology, faculty reputation, and location, whereas Accreditation Council for Graduate Medical Education (ACGME) accreditation, fellowship longevity, and salary were less important. For choosing an applicant, applicants indicated that the interview, prior applicant knowledge (trusted recommendation), and letters of recommendation, sequentially, should be given the greatest weight. Directors reported that they used the same top 3 factors to rank applicants, but knowledge or trusted recommendation of the applicant ranked first. Applicants who successfully matched interviewed at (mean, 9.5 vs 3.0; P = .003), applied at (mean, 11.6 vs 4.3; P = .02), and ranked (mean, 8.3 vs 2.3; P < .001) more fellowship programs than those who did not. United States Medical Licensing Examination scores higher than 230 and AΩA membership status did not significantly affect fellowship match. Personal knowledge or a trusted colleague's recommendation may be the most important determinant when pediatric otolaryngology fellowship programs choose an applicant. When fellows choose a program, the opportunity to gain surgical experience in both otology and airway management is crucial, but ACGME accreditation status seems less important. Successful applicants ranked and interviewed at more fellowship programs than nonmatching applicants.

Supreme Laryngeal Mask Airway achieves faster insertion times than Classic LMA during chest compressions in manikins

BackgroundAccording to the 2010 European Resuscitation Council guidelines on cardiopulmonary resuscitation (CPR), one can appreciate that the classic laryngeal mask airway (CLMA) is acceptable as an alternative airway device to endotracheal intubation for airway management in cardiac arrest victims. ObjectiveTo compare a relatively new supraglottic airway device, the Supreme Laryngeal Mask Airway (SLMA), with the CLMA in a cardiac arrest scenario. MethodsFifty healthcare professionals inexperienced in advanced airway management attempted to insert both airway devices in a manikin in 2 scenarios: in the first, chest compressions were not performed (non-CPR scenario), and in the second, uninterrupted chest compressions were performed (CPR scenario). The primary end points were insertion time and success rate at first attempt. The level of self-confidence of each participant was recorded. ResultsSLMA achieves faster insertion times both in the non-CPR (SLMA: 10.4 ± 2.7 seconds vs CLMA: 13.4 ± 3.2 seconds, P < .05) and in the CPR scenario (SLMA: 9.9 ± 2.0 seconds Vs CLMA: 11.9 ± 2.3 seconds, P < .05). The difference between first attempt success rates was not statistically significant both in the non-CPR (SLMA: 96% vs CLMA: 90%, P = .18) and in the CPR scenario (SLMA: 98% vs CLMA: 94%, P = .32). The participants are more self-confident using SLMA instead of CLMA (P < .001) and 94% of them would prefer SLMA for future use. ConclusionSLMA could be a useful alternative to CLMA during CPR in the hands of healthcare professionals with minimal experience in airway management.

Comparing the novel GlideScope Groove videolaryngoscope with conventional videolaryngoscopy: a randomized mannequin study of novice providers

Study ObjectiveTo compare the GlideScope Groove (GG) with conventional GlideScope videolaryngoscopy (GVL) and direct laryngoscopy (DL) on intubation times, intubation attempts, and glottic visualization of an airway mannequin by medical students. DesignRandomized crossover trial. SettingIntensive care unit of an academic tertiary-care hospital. Participants34 medical students with no airway management experience. MeasurementsEach participant received standardized video instruction on all three laryngoscopes and was given 10 minutes to practice with each device. The participants had two attempts using DL, and then had two attempts each with either the GG or GVL in random order. MeasurementsTime-to-intubate the mannequin in seconds was recorded. Secondary outcomes were Cormack-Lehane grade and number of intubation attempts, also recorded. Main ResultsThe median number of seconds required to successfully intubate the mannequin with DL, GVL, and GG were 17.4 seconds [interquartile range (IQR) 13.2 - 22.1)], 17.7 seconds (IQR 14.9 - 21.0), and 21.7 seconds (IQR 15.4 - 37.0), respectively. No differences in time-to-intubate was noted among the three devices (P = 0.45). A Cormack-Lehane grade 1 view was obtained for 25 of 34 participants (74%) with DL, 32 of 34 participants (94%) with GVL, and 34 of 34 participants (100%) with GG. First-attempt intubation success was 30 of 34 participants (88%) with DL, 34 of 34 participants (100%) with GVL, and 11 of 34 participants (32%) with GG. Using the GG, 6 of 24 participants (18%) required three attempts. More attempts were required for the GG than for DL (P < 0.001) or GVL (P < 0.001). ConclusionsGG was not superior to DL or GVL in time-to-intubate an airway mannequin.

Inestabilidad cervical: punto de vista del anestesiólogo

The experience in airway management permits the anesthesiologist to participate in cases of cervical spine instability in the operating room when the patient is subjected to surgical procedures, or in cases of difficulty to access or keep the airway open in emergencies. This article reviews the epidemiology, definition, etiology, diagnostic criteria, methods of approach to airway management, and current recommendations on handling cervical instability in different scenarios. There is no approach to the airway that ensures complete immobility of the cervical spine, but there are methods that are better adapted to specific contexts; at the end, the reader will be able to identify the virtues and defects of the various options that the anesthesiologists have to address the airway in cases of cervical instability.

Survey of Airway Management Strategies and Experience of Non-Consultant Doctors in Intensive Care Units in the UK

Background Airway problems continue to occur in intensive care setting. Management strategies, staffing, and availability of equipment can all have an influence. Methods We undertook a standardized telephone survey of airway management strategies, staffing, and airway equipment availability in general intensive care units (ICUs) in the UK, before the reporting of the Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. Results All 257 UK general ICUs were contacted and 77% replied. At the time of the survey, 6.3% of all ICU patients were judged by respondents to have an increased risk of airway complications. While 38% of respondents reported using individualized airway management plans for patients with higher risk airways, only 19% of the patients identified as ‘at risk’ had such a plan in place. Action plans for the management of unanticipated tracheal tube and tracheostomy displacement were available in 7% and 10% of ICUs, respectively, although 27% of respondents reported no training in recognition and management of these events. Few respondents could describe the equipment available for emergency transtracheal access on their ICU and 13% had no training in its use. More than half of the respondents (56%) routinely used continuous waveform capnography for patients with artificial airways. A fibrescope was available to all ICUs: immediately in 63% and after >5 min in 14%. In 33% of ICUs, the most junior doctor providing out-of-hours cover had not always obtained the Royal College of Anaesthetists initial assessment of competency in anaesthesia. One-third of ICU residents also had commitments outside the ICU. An additional anaesthetist for managing airway emergencies was available in all ICUs with 80% being on-site. Conclusions There remains room for improvement in airway management strategies and resources in ICUs in the UK.

Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study

IntroductionAirway management is an important component of cardiopulmonary resuscitation (CPR). Recent guidelines recommend keeping any interruptions of chest compressions as short as possible and not lasting more than 10 seconds. Endotracheal intubation seems to be the ideal method for establishing a secure airway by experienced providers, but emergency medical technicians (EMT) often lack training and practice. For the EMTs supraglottic devices might serve as alternatives.Methods40 EMTs were trained in a 1-hour standardised audio-visual lesson to handle six different airway devices including endotracheal intubation, Combitube, EasyTube, I-Gel, Laryngeal Mask Airway and Laryngeal tube. EMTs performances were evaluated immediately after a brief practical demonstration, as well as after 1 and 3 months without any practice in between, in a randomised order. Hands-off time was pair-wise compared between airway devices using a repeated-measures mixed-effects model.ResultsOverall mean hands-off time was significantly (p<0.01) lower for Laryngeal tube (6.1s; confidence interval 5.2-6.9s), Combitube (7.9s; 95% CI 6.9-9.0s), EasyTube (8.8s; CI 7.3-10.3s), LMA (10.2s; CI 8.6-11.7s), and I-Gel (11.9s; CI 10.2-13.7s) compared to endotracheal intubation (39.4s; CI 34.0-44.9s). Hands-off time was within the recommended limit of 10s for Combitube, EasyTube and Laryngeal tube after 1 month and for all supraglottic devices after 3 months without any training, but far beyond recommended limits in all three evaluations for endotracheal intubation.ConclusionUsing supraglottic airway devices, EMTs achieved a hands-off time within the recommended time limit of 10s, even after three months without any training or practice. Supraglottic airway devices are recommended tools for EMTs with lack of experience in advanced airway management.

Survey of airway management strategies and experience of non-consultant doctors in intensive care units in the UK

Airway problems continue to occur in intensive care setting. Management strategies, staffing, and availability of equipment can all have an influence. We undertook a standardized telephone survey of airway management strategies, staffing, and airway equipment availability in general intensive care units (ICUs) in the UK, before the reporting of the Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. All 257 UK general ICUs were contacted and 77% replied. At the time of the survey, 6.3% of all ICU patients were judged by respondents to have an increased risk of airway complications. While 38% of respondents reported using individualized airway management plans for patients with higher risk airways, only 19% of the patients identified as 'at risk' had such a plan in place. Action plans for the management of unanticipated tracheal tube and tracheostomy displacement were available in 7% and 10% of ICUs, respectively, although 27% of respondents reported no training in recognition and management of these events. Few respondents could describe the equipment available for emergency transtracheal access on their ICU and 13% had no training in its use. More than half of the respondents (56%) routinely used continuous waveform capnography for patients with artificial airways. A fibrescope was available to all ICUs: immediately in 63% and after >5 min in 14%. In 33% of ICUs, the most junior doctor providing out-of-hours cover had not always obtained the Royal College of Anaesthetists initial assessment of competency in anaesthesia. One-third of ICU residents also had commitments outside the ICU. An additional anaesthetist for managing airway emergencies was available in all ICUs with 80% being on-site. There remains room for improvement in airway management strategies and resources in ICUs in the UK.

The normal and the challenging pediatric airway

Management of a child's airway is one of the main sources of stress for anesthetists who do not routinely anesthetize children. Unfortunately, trainees are gaining less experience in pediatric airway management than in the past, which is particularly difficult at a time when some beliefs about airway management are being challenged and airway management is less standardized. Fortunately, most children have an easily managed, normal airway. Nevertheless, it is of vital importance to teach our trainees the basic airway skills that are probably the most important skill in an anesthetists' repertoire when it comes to a difficult airway situation. This review focuses on the airway management in children with a normal and a challenging airway. Different choices of airway management in children, and their advantages and disadvantages are discussed. Furthermore, the three broad causes of a challenging airway in children and infants are highlighted - the difficulty obtaining a mask seal, difficulty visualizing the vocal cords, and the third cause in which the larynx can be visualized but the difficulty lies at or beyond that level. Guidelines are given how to deal with these patients as well as with the feared but rare scenario of 'cannot ventilate, cannot intubate' in children.

Airway Management in Critical Care - New Guidelines, Old Problems

Intensive care training in the UK is undergoing change. Traditionally, the majority of intensive care medicine (ICM) clinicians were from an anaesthetic background with trainees and consultants receiving specific training and experience in basic and advanced airway management. As ICM becomes a stand-alone specialty with intake of trainees from other acute medical backgrounds, these airway skills can no longer be taken for granted. Advanced ICM trainees require only six months of training in anaesthesia, which could mean that the management of the difficult airway from intubation through to successful extubation will become increasingly challenging for those without advanced airway skills. The recent Royal College of Anaesthetists NAP4 audit aimed to identify and study major complications of airway management in the UK. It described many of these events as likely to have been avoidable, with a disproportionately high number of adverse airway incidents occurring in the intensive care unit (ICU) and emergency department. 1 When compared with ‘anaesthetic’ airway incidents, ICU airway events were more likely to be managed by doctors with less airway experience, occur out of hours and lead to more frequent permanent harm and death. Similar findings are echoed in the report written on behalf of the UK National Patient Safety Agency. 2

Comparison of GlideScope® versus Macintosh laryngoscope for the removal of a hypopharyngeal foreign body: A randomized cross-over cadaver study

ObjectiveThis study aimed to evaluate whether GlideScope® is an effective and acceptable method for the removal of a hypopharyngeal foreign body. MethodsThis was a prospective study conducted in 28 first year emergency residents with little prior airway management experience. Participants extracted hypopharyngeal foreign bodies using a Macintosh laryngoscope and GlideScope® with Magill and Sponge forceps. The primary endpoints were extraction time and success rate with each device. Participant preferences were also assessed. ResultsThe cumulative success rate in relation to time to extraction was significantly higher with the Macintosh laryngoscope than with the GlideScope® (p<0.001) regardless of the extraction device. Significantly fewer attempts were required for the first successful extraction with the Macintosh laryngoscope versus GlideScope® with Magill forceps (p=<0.001) and Sponge forceps (p=<0.001). The time for successful foreign body extraction using GlideScope® was significantly lower when using Magill (median 46s, IQR 28–75s) forceps than Sponge forceps (median 79s, IQR 41–88s). ConclusionsIn this cadaver model, the Macintosh laryngoscope appeared to be more efficient and preferred than GlideScope® for extracting hypopharyngeal airway foreign bodies that are associated with fatal asphyxiation.

The learning curve for laryngoscopy: Airtraq versus Macintosh laryngoscopes

Airtraq use by inexperienced personnel has been evaluated in simulator studies, but little is known about the learning process in real patients. This prospective study was designed to compare learning curves for laryngoscopy with the Airtraq or Macintosh laryngoscopes in patients under general anesthesia. Ten medical students with no prior experience in airway management were recruited on a voluntary basis and underwent training in Macintosh and Airtraq laryngoscopy. Patients with no difficult intubation criteria were enrolled after consent. Each student performed laryngoscopy with either device on ten consecutive patients. Success was defined as Cormack-Lehane grading ≤2. We also recorded subjective difficulty scores on an 11-point numerical rating scale. Learning curves were drawn using cumulative success rates and 95% confidence intervals calculated with bootstrap procedures. The mean (95% CI) success rates for the procedures were 86.0% (76.7-93.3%) for the Airtraq and 64.0% (52.0-75.0%) for the Macintosh laryngoscope. Differences in success rate were significant from the fourth attempt and were 22.0% (8.2-36.5%) after the tenth. Seven students achieved success rates ≥90% using the Airtraq, versus one using the Macintosh (P=0.022). Median (25th-75th percentile) difficulty scores were 2 (1-4) and 4 (2-6), respectively (P<0.001). Students achieved higher success rates using the Airtraq laryngoscope during early training on live patients. The Airtraq may be a useful choice for teaching advanced airway management, especially to professionals who will not perform laryngoscopy on a regular basis.

Anesthetic Management of Direct Laryngoscopy and Dilatation of Subglottic Stenosis in a Patient with Severe Myasthenia Gravis

We describe the anesthetic management of a patient with severe myasthenia gravis and tracheal stenosis; the patient was scheduled for direct laryngoscopy and dilatation. The combination of myasthenia gravis and tracheal obstruction presents several difficulties for anesthetic management. The airway is shared; therefore, any complications are also shared by the anesthesiologist and bronchoscopists. The potential for respiratory compromise in patients undergoing the two procedures requires that anesthesiologists be familiar with the underlying disease state, as well as the interaction of anesthetic and nonanesthetic drugs in a case involving myasthenia gravis. We reviewed the literature and report our experience in this case. There is no strong evidence for choosing one approach to general anesthesia over another for bronchoscopy. Careful preoperative planning and experience in airway management and jet ventilation are crucial to prevent an adverse outcome and obtain favorable results.

Two Complications of Tracheal Intubation in a Neonate

AN infant delivered in a private hospital after 33 weeks' gestation weighed 2,050 g, had persistent tachypnea, and had associated hypoxia requiring intubation. After three esophageal intubations, the neonate's trachea was successfully intubated. Despite mechanical ventilation, the infant had persistent tachycardia, hypoxemia (80–90% oxygen saturation) and a distended abdomen. A preoperative radiograph of this child shows the endotracheal tube tip in the right main bronchus (arrow A ), atelectasis of the entire left lung (arrow B ), pneumoperitoneum (white arrows ), and increased abdominal gas. At surgery, a 1.5-cm perforation of the anterior wall of the lesser curvature of the stomach was identified and repaired.The radiograph emphasizes critical complications that can occur during airway management of a neonate. Inadvertent esophageal intubation is one of the most common causes of neonatal intubation failure, which can lead to catastrophic consequences.1This condition can be rapidly detected by using end-tidal carbon dioxide monitoring, because it is the single most useful method in confirming endotracheal tube position.2In this neonate, gastric perforation likely occurred as a result of distension associated with positive pressure ventilation after esophageal intubation. Endobronchial intubation is another common problem associated with airway management in a neonate. This child's atelectasis likely developed after main stem intubation, when the endotracheal tube depth was noted to be 11 cm. As a guide to proper tracheal placement of an endotracheal tube, 1-, 2-, or 3-kg babies are intubated to a depth of 7, 8, or 9 cm, respectively.3These two complications reinforce the need for specialized training and experience in neonatal airway management.