Fiberoptic Tracheal Intubation Research Articles

A Method to Improve Oxygen Delivery During Fiberoptic Tracheal Intubation Via Intubating LMA (FastrackR) in Patients With Cervical Neuropathy

s: 33rd Annual Meeting of the Society of Neurosurgical Anesthesia and Critical Care: DRUGS AND TECHNIQUES

Use of the laryngeal tube for difficult fibreoptic tracheal intubation

Use of the laryngeal tube for difficult fibreoptic tracheal intubation

The Chewing of Betel Quid and Oral Submucous Fibrosis and Anesthesia

Oral submucous fibrosis (OSMF) is a premalignant lesion of the buccal mucosa caused by chewing betel quid. It results in progressive inability to open the mouth. OSMF causes difficulty in laryngoscopy and intubation of the trachea. Patients with OSMF require anesthesia for trismus correction, resection, and reconstructive (oncoplastic) surgery for coexisting oral malignancies or other unrelated surgeries. Our review of the anesthetics of 44 patients with oral malignancies suggested that 8 had OSMF. The preoperative airway assessment, including the Mallampati score and the clinical Tumor Node Metastasis stage, were useful in predicting the need for fiberoptic intubation. Patients with oral malignancies and OSMF had increased requirement for fiberoptic endotracheal intubations (62.5%) compared with those without OSMF (44.4%). Three different techniques of airway management (tracheal intubation after direct laryngoscopy, fiberoptic tracheal intubation, and tracheostomy) in four patients with OSMF are described. OSMF contributes to the development of the malignancy, delays the diagnoses, and complicates the anesthetic management.

Airway Management in Adult Patients with Deep Neck Infections: A Case Series and Review of the Literature

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.

Continuous ventilation technique for laryngeal mask airway (LMATM) removal after fiberoptic intubation in children

Fiberoptic tracheal intubation through the laryngeal mask airway (LMA) is a simple technique to establish a safe airway in neonates and infants with a difficult airway. The technique, however, is complicated by the removal of the laryngeal mask from the patient's mouth because of the similarity in length of the LMA and the tracheal tube. Several solutions have been presented to stabilize the tracheal tube within the trachea during withdrawal of the LMA. With all these techniques ventilation of the patient is interrupted. We present a modified technique, using a double tube assembly, which allows uninterrupted ventilation of the patient during withdrawal of the LMA from the patient's mouth. The technique is simple and safe, can be performed without hurry and carries potential advantages for neonates and children with limited cardiorespiratory reserve.

Breathing or ventilation via a mouth mask for rhinoplasty operations in the early postanaesthetic period

EDITOR: Nasal packs are usually used to maintain haemostasis and stabilization of the reconstructed nose after rhinoplasty. Since the nostrils are completely blocked by the packs, breathing is only possible through the mouth once endotracheal extubation has taken place at the end of the operation. Compression of the fragile nose by a standard facemask could spoil the surgical result. Furthermore, immediately the endotracheal tube has been removed, breathing through a standard facemask is extremely difficult because the usual adult facemask is difficult to seal on the face due to the plaster splint and dressing. Nagaro and colleagues developed a method to permit fibreoptic tracheal intubation in anaesthetized patients with ventilation performed only through the mouth [1]. They applied a child's mask over the mouth (mouth mask) instead of a standard anaesthesia adult facemask. In their method, an oral airway was usually inserted to overcome any airway obstruction and the nostrils were plugged with cotton if a leak through the nares occurred. Arai and colleagues reported that fibreoptic tracheal intubation could be achieved using a mouth mask in cases of difficult tracheal intubation [2]. They used the same method as Nagaro and colleagues [1], but used an infant's or child's mask, or else a specially constructed device, as a mouth mask. Arai and colleagues concluded that the mouth mask method for fibreoptic tracheal intubation was safe, useful and practical in instances of difficult intubation. After rhinoplasty operations, in the early postanaesthetic period, we have used a silicone child's mask through which the patient is permitted to breathe only through the mouth. We prefer a child's silicone facemask (No. 2 Silicone Child Mask, GaleMed Corp., I-Lan Hsien, Taiwan) as a mouth mask because of its elasticity and pliability over the mouth. The mask is applied only over the mouth; an oral airway is inserted to overcome any upper airway obstruction (Fig. 1). Patients breathed spontaneously through the child's mask in the operating room until they regained consciousness and their cognitive functions; standard monitoring, including pulse oximetry, was maintained in the recovery room. The same child's mask was used if supplemental oxygen was necessary. In our experience, breathing is much facilitated with a mouth mask compared with a standard anaesthesia mask in these patients; we have found it helpful on occasions to assist breathing. We have been using this method after rhinoplastic surgery for 1 yr and have found it easy and safe to use.Figure 1: Application of a mouth mask after rhinoplasty surgery.H. Erbay C. O. Kara I. G. Kara E. Tomatir Departments of Anaesthesiology, Ear-Nose-Throat; Surgery, and Plastic and Reconstructive Surgery; Medicine Faculty, Pamukkale University, Denizli, Turkey

Intubation fibroscopique sous ventilation non invasive avec un masque facial endoscopique

Objectives: To assess the feasibility and safety of a new technique of fiberoptic bronchoscopy (FOB) tracheal intubation (TI) with noninvasive ventilation (NIV) via an endoscopic full facial mask with two openings, in case of acute respiratory failure (ARF) temporally improved by NIV, but requiring a mechanical ventilation. Study design: Clinical, prospective, open, non-comparative trial of feasibility with direct individual profit. Patients: Sixteen patients with ARF (age : 60 ± 17 years, PaO 2 = 59 ± 16 mmHg, PaCO 2 = 64 ± 26 mmHg, PaO 2/FIO 2 = 142 ± 70 before NIV) (m ± SD), requiring TI. Including were : TI necessity (SpO 2 < 90 % or hypercapnic despite NIV, dependence of NIV, exhaustion, septic syndrome), clinical and SpO 2 improvement with NIV. Methods: After IV injection of 5 mg midazolam and topical anesthesia (TA) of the nose, the endoscopic mask (modified Fibroxy™, Péters) was applied to the face, fixed with elastic straps, then connected to the ventilatory support system with IPAP=20 cmH 2O, EPAP = 5 to 12 cmH 2O, FIO 2 = 1. A tube was slid on the FOB. As soon as SpO 2〚〚〚nbsp〛 94 %, the extremity of the FOB, was inserted through the lower opening of the mask, slid in the nostril, positioned in front of the glottis for AL, then pushed in the trachea authorizing AL and IV injection of 0.15 mg.kg –1 of etomidate (Ramsay〚〚〚nbsp〛3). The tube was then slid in the trachea, then, FOB was removed from trachea. Results: The FOB intubation was easy at the patientˈs, without any failure or any complication. The procedure was 6.7 ± 2 min. SpO 2 significantly improved during TI, from 84 ± 5 % (FIO 2 = 0,6 ± 3) to 97 ± 1 ( FIO 2 = 1 ± 0), without decrease in oxygen saturation off 90 %. Arterial pressure decreased only after the 5 th min. The quantities of midazolam and of etomidate used were 4.6 ± 2 mg and 12 ± 4 mg. Three patients benefited from EPAP > 10 cmH 2O. Conclusion: Fiberoptic tracheal intubation with NIV via an adapted endoscopic facial mask is a safe technique in patient with ARF temporally improved by NIV. This procedure requires TA and conscious sedation.

Fibreoptic nasal intubation in children with anticipated and unanticipated difficult intubation.

The establishment of a tracheal airway with direct laryngoscopy can be either a very difficult or an impossible task in children with congenital or acquired facial malformations. Out of 46 patients categorized as difficult tracheal intubation, fibreoptic laryngoscopy was used successfully in 44 children anaesthetized by mask with sevoflurane and oxygen or by an intravenous infusion of propofol and mask oxygenation. There were two failures (4.3%). One was due to excessive bleeding and secretions produced by the multiple attempts to intubate with direct laryngoscopy and the other failure in a patient with Pierre Robin syndrome and very small nasal passages that precluded the introduction of the endoscope. Fibreoptic laryngoscopy was successful in 37 cases (80.4%) on the first attempt to intubate and in seven (15.2%) on a second or third attempt. We conclude that fibreoptic laryngoscopy in anaesthetized children with difficult anticipated or unanticipated tracheal intubation in trained hands is a safe technique that can be lifesaving. Therefore, we urge all anaesthesia trainees to become proficient in fibreoptic tracheal intubation.

Intubating laryngeal mask for fibreoptic intubation-particularly useful during neck stabilization.

Intubating laryngeal mask for fibreoptic intubation-particularly useful during neck stabilization. Asai T, Eguchi Y, Murao K, Niitsu T, Shingu K. Can J Anaesth 2000;47:843–848. Manual in-line stabilization is often recommended to prevent cervical spine movement during laryngeal intubation. It is generally recognized that this precaution can make laryngoscopy more difficult. The authors of this study attempted to ascertain whether the use of an intubating laryngeal mask facilitated fibreoptic intubation of the trachea in patients when manual in-line stabilization was employed. A total of 124 patients were studied. In 84 patients, the patient's head and neck were placed in a neutral position with the neck on a firm pad approximately 7 cm in height. In 40 additional patients, manual in-line stabilization was performed during intubation. Pillows and pads were removed and an assistant held the sides of the neck at the mastoid processes. The patients were all ASA physical status 1 or 2 undergoing elective surgery and patients with Mallampati class 3 or 4 airways were excluded. All patients received an intravenous induction of general anesthesia using 2.0 to 2.5 mg/kg propofol, 50 to 100 μg fentanyl, and 1.0 mg/kg of vecuronium. Ventilation by mask was described as easy in all subjects, and no antisialagogues were administered. Those patients who had their heads positioned on the 7 cm pad (84 patients) were further subdivided into 2 groups using block randomization. In one group, tracheal intubation was attempted using only a fibreoptic bronchoscope, whereas in the other group, fibreoptic intubation through an intubating laryngeal mask was attempted. A fibrescope with an outer diameter of 3.5 mm was employed in both groups, and a Mallinckrodt reinforced tracheal tube (Athlone, Ireland) was used with the intubating laryngeal mask. In the group of patients where the laryngeal mask was not employed, no attempts were made to extend the head on the neck, but the jaw was pulled forward by an assistant. In those patients where the intubating laryngeal mask was employed, a size 5 was used in men and a 4 in women. A tracheal tube was inserted into the laryngeal mask and the fibrescope was passed through the tube into the trachea. The tracheal tube was then advanced further over the fibrescope. For study purposes, only one attempt with 2 minutes for insertion of the fibrescope and 2 minutes for tracheal intubation over the fibrescope was allowed. The ease of the tracheal intubation was then assessed. In the second set of 40 patients, tracheal intubation with manual in-line stabilization was attempted. Patients were randomized to receive intubation using the fibreoptic bronchoscope only or fibreoptic intubation through the intubating laryngeal mask. In those patients in whom the head and neck were placed in the neutral position (head on a 7 cm pad) it was possible to insert the fibrescope into the trachea in 37 of 42 patients (88%). In those patients in whom the intubating laryngeal mask was used, the laryngeal mask was successfully inserted on the first attempt in all patients, and fibroscopy through the LMA succeeded in 38 of 42 patients (90%). Ease of intubation was also classified as better when the intubating laryngeal mask was employed. When the patient's head and neck were stabilized by the manual in-line method, the fibrescope was inserted into the trachea within 2 minutes in only 8 of 20 patients (40%). The intubating laryngeal mask could be inserted on the first attempt in 19 of 20 patients, and fibroscopy through the laryngeal mask was successful in 19 of 20 patients (95%). Again, tracheal intubation was judged to be easier where the laryngeal mask was used. Overall, when the intubating laryngeal mask was used, there were no marked differences in the success rate of fibroscopy and tracheal intubation between the “neutral” position and the one using manual in-line stabilization. This report is consistent with several in the literature, which mention successful intubation through an intubating laryngeal airway after failed or previously difficult fibreoptic tracheal intubation. Additionally, the authors have provided support for the use of an intubating laryngeal mask, when it is necessary to provide manual in-line stabilization for the cervical spine. (PHP)

Cricoid pressure applied after placement of laryngeal mask impedes subsequent fibreoptic tracheal intubation through mask†

We studied 70 patients to see if cricoid pressure applied after insertion of the laryngeal mask altered the success rate of tracheal intubation through the mask. After induction of anaesthesia and neuromuscular blockade, patients were randomly allocated to have either cricoid pressure (Group C) or sham pressure (Group S). The view of the glottis through the laryngeal mask was assessed before and after the test pressure, and tracheal intubation through the mask was attempted using a fibreoptic bronchoscope. The test pressure did not alter the view of the glottis in any patient in group S, whereas it narrowed the glottic aperture in 16 out of 35 patients in group C. The fibrescope was inserted into the trachea in all patients in group S and in 25 patients in group C. The success rate of tracheal intubation in group S (31 patients) was significantly higher than in group C (21 patients, P << 0.001; 95% CI for difference: 9-48%). The time for insertion of the fibrescope in group S (median (95% CI): 12 (11-12) s) was significantly faster than in group C (16 (14-17) s, P << 0.001; 95% CI for difference: 3-6 s), and the time for tracheal intubation in group S (16 (15-18) s) was significantly faster than in group C (22 (19-24) s, P < 0.0005; 95% CI for difference: 3-7 s). Cricoid pressure after insertion of the laryngeal mask makes tracheal intubation through the mask significantly more difficult.

Cervical Spine Instability and Dwarfism

Department of Anesthesiology; Orthopedic Hospital Vienna-Speising; Vienna, AustriaIn Reply:-I thank Dr. Auden for his interest in my case report. I really wanted to stress three points by reporting this tragic event.1. Every anesthesiologist should be aware of a possible upper cervical instability in this specific patient population.2. I recommend an accurate diagnostic procedure concerning the cervical region, including exploration, flexion-extension series, and computed tomography. If a patient has signs of cervical instability, a discussion with the neurosurgeon is warranted.3. In addition, in the case of negative radiologic findings, intraoperative management must be done with extreme care and should include the use of a cervical collar, flexible fiberoptic tracheal intubation, and accurate postoperative monitoring.Gerhard Redl, M.D.Department of Anesthesiology; Orthopedic Hospital Vienna-Speising; Vienna, Austria(Accepted for publication March 12, 1999.)

Cuffed oropharyngeal airway (COPA) as an adjunct to fibreoptic tracheal intubation

The cuffed oropharyngeal airway (COPA) was evaluated as an adjunct to oral and nasal fibreoptic tracheal intubation in 40 adult patients during general anaesthesia. Time from start to completion of intubation decreased rapidly with experience (median time 138 s). We conclude that the COPA may be a useful adjunct to fibreoptic tracheal intubation, allowing control and support of the airway during the procedure, using various anaesthetic techniques, in an acceptable amount of time. The ability to perform fibreoptic tracheal intubation while effectively supporting the airway using the COPA may be advantageous in managing the difficult airway and in trainee education.

Remifentanil for conscious sedation and analgesia during awake fiberoptic tracheal intubation: a case report with pharmacokinetic simulations

We report a case of awake, fiberoptic tracheal intubation of a difficult airway (Ludwig’s angina) using remifentanil as part of the sedation-analgesia regimen. Remifentanil’s rapid onset-rapid offset pharmacokinetic profile enabled precise control of the level of opioid effect. In combination with other drugs, remifentanil may offer some clinical advantages compared to the other fentanyl congeners in providing the opioid component of conscious sedation-analgesia for awake tracheal intubation in patients with difficult airways.

Fiberoptic Tracheal Intubation (&lt;Special Issue&gt; The Consideration for The Intubation)

Fiberoptic Tracheal Intubation (&lt;Special Issue&gt; The Consideration for The Intubation)

Continuous Ventilation During Transnasal Fiberoptic Bronchoscope-Aided Tracheal Intubation

Continuous Ventilation During Transnasal Fiberoptic Bronchoscope-Aided Tracheal Intubation

Laryngeal mask airway and the ASA difficult airway algorithm.

Laryngeal mask airway and the ASA difficult airway algorithm.

Learning fibreoptic skills in ear, nose and throat clinics

We have compared the progress of anaesthetists taught fibreoptic techniques on awake patients in ear, nose and throat clinics with that of anaesthetists taught by traditional methods. Twelve anaesthetists participated in the study and were randomly allocated to the ear, nose and throat group or to the traditional training group. Each individual in the ear, nose and throat group attended the outpatient clinic and performed ten nasendoscopies on awake patient, whose upper airway had been anaesthetised with cocaine, under the supervision of an ear, nose and throat surgeon. Each individual in the traditional roup performed ten nasendoscopies on anaesthetised oral surgery inpatients under the supervision of an anaesthetist. To assess the effectiveness of the two training methods, each anaesthetist in each group then attempted ten fibreoptic nasotracheal intubations on anaesthetised oral surgery patients. There was no significant difference between either the success rates or mean successful tracheoscopy times between the two groups. Nasendoscopy training in the ear, nose and throat clinic appears to be good way of learning fibreoptic skills, which can then be readily applied to fibreoptic tracheal intubation in anaesthetic practice.

Arterial Carbon Dioxide Tensions During Fiberoptic Tracheal Intubation

Arterial Carbon Dioxide Tensions During Fiberoptic Tracheal Intubation

Intubation difficile : aide apportée par le gonflement du ballonnet de la sonde d'intubation nasotrachéale

A case is reported of an unexpected difficult nasotracheal intubation for respiratory distress syndrome in a 72-yr-old obese woman with chronic obstructive pulmonary disease. After positioning the tip of the tracheal tube in the oropharynx, direct laryngoscopy did not allow exposure neither of the glottis nor of the corniculate cartilages. Fibreoptic tracheal intubation was decided. While preparing fibreoptic instruments, an attempt at blind intubation was performed. The tracheal tube cuff was inflated with 15 mL of air and then advanced gently until slight resistance was felt as the inflated cuff made contact with the vocal cords. At that time it was deflated and the tracheal tube advanced into the trachea. In the presence of normal pharyngeal anatomy, inflation of the tracheal tube cuff in the oropharynx is assumed to centre the tip of the tube and to direct it anteriorely towards the larynx. A recent prospective and randomized study has shown that tracheal tube cuff inflation in the oropharynx is effective in improving the success rate of blind nasotracheal intubation in paralysed patients with normal pharyngeal anatomy. Only case reports have shown the efficacy of tracheal tube cuff inflation in the pharynx as an aid to difficult blind nasotracheal intubation in emergency. Further controlled studies in this area would be valuable.

Diprivan ® : sédation pour intubation difficile

No study has compared anaesthetic protocols appropriate for the sedation for fiberoptic tracheal intubation. Extrapolation of results of randomised studies comparing sedation techniques for diagnostic bronchoscopy under local anaesthesia enables the following conclusions: 1. Possible hypnotic agents for this procedure are benzodiazepines, barbiturates and propofol. Fentanyl improves the conditions for bronchoscopy. 2. Sedation using propofol is a well established technique. The induction dose, given as a bolus injection is 1 mg.kg-1, followed by continuous maintenance infusion of 1 mg.kg.h-1. 3. Irrespective of the sedation protocol used, there is always respiratory depression which justifies the need for preoxygenation, continuous oxygenation and Spo2 monitoring. Reversal of benzodiazepine and opioid effects may temporarily protect against respiratory depression.