Route For Intubation Research Articles

A modified submental approach for oral endotracheal intubation

Hernandez 5, in 1986, published the first paper on “The submental route for endotracheal intubation”. The technique was developed to avoid tracheostmomy, particularly in maxillofacial trauma cases, where short-term intermaxillary fixation was required. Gordon & Tolstunov4 published 2 cases utilizing the technique. Our initial experience with the technique as presented was less than satisfactory. The technique was modified to utilize a strict midline approach. Fifteen cases utilizing this modified technique are reported, including 14 cases of cranimomaxillofacial trauma and one cmomplex orthognathic surgery case. There have been no operative or postoperative cmomplications. Postoperative submental scarring has been acceptable.

Nasal versus oral intubation for mechanical ventilation of newborn infants.

This section is under preparation and will be included in the next issue. The purpose of the review was to compare the complications associated with intubation by the nasal route with those associated with intubation by the oral route for mechanical ventilation in newborn infants. The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Register of Controlled Trials, MEDLINE and CINAHL. A call was placed on the list servers, NICU-NET and Neonatal Talk for unpublished trials, conference presentations and current trials. All trials using random or quasi-random allocation of patients to either the nasal or oral route of intubation were included. Study quality and eligibility were assessed independently by each author. The standard method of the Cochrane Collaboration and the Neonatal Review Group was used to assess the methodological quality of the included studies. The methodological quality of each study was reviewed by the second author blinded to study authors and institutions. Each reviewer extracted data separately before comparison and resolution of differences. The standard method of the Neonatal Review Group was used to measure the effect of the different routes of intubation, using Relative Risk (RR) and 95% Confidence Intervals (CI). Only two eligible randomized trials were found. Data from these two trials failed to show significant differences between the oral and nasal route of intubation for mechanically ventilated neonates. The rate of failure to intubate using the nasal route was higher in one study. One study found post extubation atelectasis occurred more frequently in nasally intubated infants who weighed less than 1500 grams. The rates of malposition of the tube at the initial intubation, accidental extubation, tube blockage, re-intubation after extubation, septicaemia, clinical infection and local trauma (nasal erosion or palatal groove) were not significantly different for the two groups. Post extubation atelectasis may be more frequent after nasal intubation, particularly in very low birth weight infants. One route of intubation does not seem to be preferable to the other. There is a need for further randomized controlled trials containing larger numbers of infants.

Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Réanimateurs du Centre-Ouest.

The predisposing factors and complications of unplanned extubation (UEX) in mechanically ventilated adult patients are not well recognized. We designed a prospective multicenter observational study to identify risk factors and describe the complications of UEX. We followed 426 ventilated patients over a 2-mo period. Clinical characteristics such as diagnosis on admission and reasons for ventilation were used to classify the patients. The presence or absence of potential risk factors was daily noted, including the types of ventilators, tracheal tubes, tube fixations, ventilatory support modes, route for intubation, and the use of intravenous sedation. Circumstances and complications of UEX were prospectively recorded. Forty-six (10.8%) patients experienced at least one episode of UEX. Ten UEX occurred during nursing procedures. At the moment of UEX, 61% of patients were agitated. The rates of mortality, laryngeal complications, nosocomial pneumonia after extubation, and the length of mechanical ventilation were similar in UEX and non-UEX patients. Patients were more often reintubated after UEX (28 of 46) than after planned extubation (28 of 284). All the non-reintubated UEX patients survived. One death occurred as a direct consequence of UEX. By use of multivariate analysis, we identified four factors contributing to UEX: chronic respiratory failure, endotracheal tube fixation with only thin adhesive tape, orotracheal intubation, and the lack of intravenous sedation. Considering these factors, we hypothesized that simple measures should be adopted to minimize the incidence of UEX and its related complications: more vigilance during procedures at patients' bedsides, adequate sedation of agitated patients, strong fixation of the tracheal tube, particular attention paid to orally intubated patients, and daily reassessment of the possibility of weaning from the ventilator.

In vivo binding of mannose specific lectin from garlic to intestinal epithelium

The present study was undertaken to determine the effect of high molecular weight (110 kDa) garlic ( Allium sativum) lectin (ASA 110) on body weight changes and its fate in the intestine of rats. Purified lectin or native/heat treated crude garlic extracts were administered to male swiss albino rats by intragastric intubation route for 7 days. The biological effects included arrest of gain in body weight, which was associated with decreased food intake. Results show that as lectin passed through the gut, it specifically bound to various cellular components of the intestinal mucosa. Although, jejunum showed the presence of mannose receptors located in the core of the lamina propria, duodenum showed lectin binding in the basal region and brush border membrane. Similar binding pattern between ASA 110 and normal intestinal mucosa was confirmed in vitro on tissue sections using fluorescent technique. Lectin activity was detected in the fecal extract of treated rats and was antigenically similar to the native lectin preparation. It suggests that the garlic lectin could withstand all enzymatic reactions while passing through the gut. However, its binding to the mucosal epithelium of gastrointestinal tract was indicative of deleterious effects.

Analysis of intubations: Before and after establishment of a rapid sequence intubation protocol for air medical use

After finding the success rate of intubations in our air medical program to be less than optimal (with a success rate of only 73%), a protocol for increased doses of sedatives and neuromuscular blocking (NMB) agents was developed for field use by flight nurses and paramedics. A retrospective chart review was performed for 100 intubations before and 100 intubations after establishment of this protocol. Success rate of intubation increased from 73% to 96%, which was statistically significant (p < 0.01). No difference existed between the two groups with regard to age, gender, Glasgow Coma Scale scores, nature of injury, route of intubation, number of attempts or percent intubated. Two patients (2%) became bradycardic using the new protocol. Our results suggest that protocols including sedatives and NMB agents can be used safely and effectively by an appropriately trained air medical team of nurses and paramedics and may improve patient care.

Intubation techniques in the helicopter

The purpose of this study is an analysis of 630 field intubations of trauma patients by flight personnel of the San Diego Life Flight program. We compared nasotracheal intubadon to rapid sequence induction orotracheal intubadon and noninduced orotracheal intubation. We measured success of intubation route, complications, and overall patient outcome. Flight records, quality assurance flight procedure data, and hospitalization data from the San Diego Trauma Registry were reviewed over a 4-year period, from 1988 to 1991. The results of our study show that rapid sequence induction orotracheal intubation has a higher success rate, fewer complications, and a better patient outcome compared to noninduced orotracheal intubation and blind nasotracheal intubation. We recommend that rapid sequence induction oral intubadon be the standard method for prehospital airway management in trauma patients.

Nasal intubation in the presence of frontobasal fractures: A retrospective study

In most cases, surgical management of craniofacial fractures involves correction of occlusion. This requires nasal intubation. In the case of frontobasal fractures with simultaneous cerebrospinal fluid (CSF) fistula, nasal intubation is thought to increase the risk of meningitis. An analysis of the records of 160 patients with frontobasal fractures and CSF fistulae showed that the route of intubation had no influence on the postoperative complication rate. Nasal intubation is therefore not contraindicated in frontobasal fractures with CSF fistulae.

Nosocomial maxillary sinusitis during mechanical ventilation: comparison of orotracheal versus the nasotracheal route for intubation

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n=53) or nasotracheal (n=58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral;p<0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p<0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.

The toxicity of Catha edulis (khat) in mice

A large number of people in East Africa and Southern Arabia chew khat leaves because of its pleasurable and stimulating effects. Due to its habit forming property, the khat has been classified as a "Substance of Abuse" by the World Health Organization. In view of the large number of medical problems reported in khat chewers, the present study was undertaken to investigate the chronic toxicity of khat in mice. Three groups of mice were treated with aqueous solution of khat extract in the dose of 50, 100, and 200 mg/kg. body weight daily by oral intubation route for 6 weeks. The results indicated a dose-dependent decrease in body weight, an increase in the incidence of mortality and induction of site specific body and eye lesions. The histopathological examination of the lesions revealed reactive hyperplasia and necrosis in the lymphoid tissues. The necrotic areas in the subcutaneous tissues showed the presence of numerous polymorphs.

Nosocomial maxillary sinusitis during mechanical ventilation: A prospective comparison of orotracheal versus the nasotracheal route for intubation

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n = 53) or nasotracheal (n = 58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48 h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral; p less than 0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p less than 0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.

Work practices relating to intubation and associated procedures in intensive care units in Sweden.

A survey into the current usage of tracheal tubes and associated procedures, such as various sedation regimes and antacid therapy, in intensive care units was carried out in Sweden by sending a questionnaire to physicians in charge of intensive care units in 70 acute hospitals which included seven main teaching hospitals. The purpose of the survey was to see how far the recent advances in tube and cuff design and awareness of the problems caused by prolonged therapeutic paralysis in intensive care units have influenced the attitudes and work practices of physicians in Sweden. Forty-nine replies were received (a 70% response rate). All hospitals used polyvinyl chloride tubes of Magill design, with high residual volume, low pressure cuffs. Intensive care units in 85.7% of teaching hospitals and 47.6% of non-teaching hospitals preferred the nasal route for intubation. Most non-teaching hospitals used a size 7 tube in both adult male and female patients for nasal intubation. The majority of units changed from tracheal tubes to tracheostomy after a period of 1-2 weeks. 85% of all hospitals monitored intracuff pressure as a routine, and in most intensive care units the cuff was inflated to no-leak ventilation. The majority of units rarely used muscle relaxants. Phenoperidine and diazepam were the most popular drugs used for the sedation technique. 71.4% of teaching hospitals and 40.9% of non-teaching hospitals used antacids routinely in patients on intermittent positive pressure respiration. The results are discussed.

Acute Complications of Endotracheal Intubation: Relationship to Reintubation, Route, Urgency, and Duration

Sixty-one consecutive medical intensive care unit patients who were intubated for more than three days were prospectively studied for complications. Patients who were reintubated had a higher incidence of all complications (chi square = 5.4; p less than .025), as did those with prolonged intubation (chi square = 16.1; p less than .005). Neither route nor urgency had an adverse clinical effect. In contrast there was a 13 percent incidence of acute tracheolaryngeal complications, but no association was found with reintubation, route, urgency, or total duration of endotracheal intubation.

Prevention of subglottic stenosis in neonatal ventilation

Mechanical ventilation of the newborn is now widely used in neonatal intensive care. The oro-tracheal route of intubation is simpler, but for long-term ventilation has been considered unstable. A method of fixation of oro-tracheal tubes is described which overcomes this instability. Five hundred consecutive ventilated infants were intubated by the oro-tracheal route and the tube was fixed by the method described. Of the 500 ventilated infants, 213 died without being extubated. Of the 287 survivors, 44 developed a degree of post-extubation stridor. No surviving infant developed clinical evidence of subglottic stenosis and in almost 200 postmortem examinations laryngeal narrowing was not identified. The method of oro-tracheal fixation described is stable and may reduce the incidence of subglottic stenosis.

The submental route for endotracheal intubation: A new technique

A technique of intubation is presented, which can be a valuable alternative to tracheostomy. The tube is passed through a submental incision into the oral cavity.

Rapid long tube intubation of the jejunum--an improved technique.

This study details improvements in the intubation of a long intestinal decompression tube by use of a new flexible tip guide wire and a new intestinal decompression tube. The intubation route of the endoscope was changed from the oral to the nasal cavity. Although the guide wire formerly used (TGBD-65-345) could be inserted into the descending part of the duodenum by passing it through the biopsy channel of the endoscope, with this new method, the guide wire (TGBD-65-450) could be inserted into the upper jejunum. The endoscope could also be left in the stomach, when this method was used. The long tube was introduced along this guide wire into the upper jejunum. As a result of these improvements, the intubation rate for long intestinal decompression tubes was significantly more rapid and the time reduced. Intubation rate to the jejunum was 96 percent successful, as compared with a former success rate of 75 percent. The intubation time was decreased to 11.3 +/- 5.6 min. to the duodenum and 18.6 +/- 8.6 min. to the upper jejunum. This differs markedly from the former method which required 16.0 +/- 5.3 min. and 39.6 +/- 22.7 min, respectively.

1437 POST-EXTUBATION ATELECTASIS – THE ROLE OF NASAL VERSUS ORAL ENDOTRACHEAL INTUBATION

To determine whether a particular type of endotracheal (ET) tube plays a role in post-extubation atelectasis, 86 consecutive admissions to the IICU of The Children's Hospital of Philadelphia were prospectively studied. All required >48 hrs. intubation. The infants were admitted for the following conditions: 70(81.4%)-respiratory distress syndrome; 5(5.8%)-apnea; 4(4.6%)-birth asphyxia; 3(3.5%)-persistent pulmonary hypertension; 3 (3.5%)-sepsis; 1(1.2%)-congenital anomalies (non-respiratory). Infants were assigned randomly to either an oral (OT) or nasal (NT) endotracheal tube for their entire hospitalization. Mean birthweights were: OT 1895±112 SEM gms.; NT 1903±143 SEM gms. (NS). Mean gestational ages were: OT 32.1±.6 SEM wks.; NT 32.9±.5 SEM wks. (NS). Fifteen of 43 (34.9%) of infants in the NT group developed post-extubation segmental or lobar atelectasis, whereas 5/43 (11.6%) of infants in the OT group had post-extubation atelectasis (p<.025). Eleven of the NT babies (25.6%) and five (11.6%) of the OT babies required reintubation (NS). This study suggests that nasal ET tubes result in a significantly increased incidence of post-extubation atelectasis in the neonate as compared to oral ET tubes. Since the human newborn is an obligate nose breather, nasal intubation for greater than 48 hrs may lead to significant edema and increased upper airway resistance after extubation. Oral ET tubes, especially for the premature baby with RDS, may therefore be the preferred route of intubation.

Alteration of endotracheal tube position. Flexion and extension of the neck.

Malposition of the endotracheal tube is a frequent complication in patients being treated for ventilatory failure. It was suspected that motion of the head might alter the position of the tube and result in malposition. Twenty adult patients with ventilatory failure, in tubated with an 8.0-mm endotracheal tube (5 oral and 15 nasal) were studied. The cuff was deflated in 10 of the 20 patients. With the patient in a semierect sitting position, standardized portable anterior-posterior chest roentgenograms were obtained with the neck in flexion, neutral, and hypertension and in 5 of the patients after right lateral head rotation. Movement of the endotracheal tube tip relative to the carina was measured from each roentgenogram. The endotracheal tube moved a similar distance regardless of the route of intubation or the inflation status of the cuff. Therefore, all groups were combined for analysis. The tube moved an average of 1.9 cm toward the carina with flexion from a neutral position, 1.9 cm away from the carina with extension, and 0.7 cm away with lateral head rotation. Malposition of the endotracheal tube may result from changes in head position. To minimize the possible injurious effects of that malposition, we recommend that the tip of the endotracheal tube be placed in the middle third of the trachea with the neck in a neutral position. Finally, knowledge of the head position is crucial to the proper radiographic interpretation of endotracheal tube position.

Tracheostomy or Endotracheal Intubation

Current management of many critically ill and injured patients demands ventilatory support. The option of support through an endotracheal or tracheostomy tube is governed by eight factors: Shape of the tube, area of the cuff, material, illness or injury prompting respiratory support, size of the patient and airway, humidity, activity of the larynx and time involved in support. Review of our own experience and that of others prompts the conclusion that endotracheal intubation is relatively safe, should be used almost exclusively in infants, and is tolerated well by adults for periods to six days. Secondary tracheostomy will be required for adults requiring longer periods of support and those patients in whom secretions are too thick or copious to be managed by suctioning through the endotracheal tube. Obviously, there are some patients whose illness or injury will leave no option as to the route of intubation.