Tracheal Placement Research Articles

Tracheal stent placement via a tracheostomy for tracheal stenosis after inhalation injury

Tracheal stenosis is one of the late complications of inhalation injury. While tracheal stenosis is usually mild and asymptomatic, it sometimes appears as a severe fixed or dynamic airway obstruction [1]. Although tracheal stenosis in burns can be critical, the treatment remains undefined. We present a case of severe tracheal stenosis complicated by subglottic stenosis after inhalation injury, which we treated successfully with silicone stent placement through a tracheostomy port.

Effect of temperature on success rate for tracheal placement of Frova and BreatheSafe tracheal introducers

Effect of temperature on success rate for tracheal placement of Frova and BreatheSafe tracheal introducers

Extraluminal, C Shaped Polyethylene Prostheses in Two Ponies with Tracheal Collapse

To describe the surgical technique, complications, and outcome after use of extraluminal prostheses in 2 ponies with severe tracheal collapse. Clinical report. Ponies (n=2) with severe tracheal collapse. A ventral median approach was used to expose the trachea from the larynx to the manubrium. Extraluminal, high-density polyethylene, C-shaped prostheses were sutured to the dorsal tracheal membrane and tracheal rings to provide external tracheal support. The surgical approach provided good tracheal access and placement of the rings was uncomplicated. Initial estimates of the tracheal diameter from preoperative radiographs resulted in prostheses that were too small at surgery requiring a 2nd surgical procedure in 1 pony. Postoperative complications were coughing, right laryngeal hemiplegia, seroma formation, and antimicrobial induced colitis. Both ponies had marked resolution of clinical abnormalities after surgery. Recurrent esophageal obstruction resulted in euthanasia of 1 pony 3.5 years after surgery. The other pony was doing well 1 year after surgery. Extraluminal support of the trachea resulted in rapid resolution of clinical signs in 2 ponies with tracheal collapse. Extraluminal tracheal prostheses can resolve clinical abnormalities in ponies with severe tracheal collapse.

Placement of the Univent Tube Without Fiberoptic Bronchoscope Assistance

In this study, we evaluated the feasibility and accuracy of Univent tube (Fuji Systems, Tokyo, Japan) placement with the aid of auscultation (AUS) or as guided by a lighted stylet (LS) compared with placement guided by the fiberoptic bronchoscope (FOB) or the blind intubation technique as recommended by the manufacturer's guidelines. Eighty ASA physical status I-II adult patients requiring single-lung ventilation for elective thoracic surgery were randomly allocated into 4 groups according to the method used for Univent tube positioning: manufacturer-recommended (MR) group (n = 20); FOB group (n = 20); AUS group (n = 20); and LS group (n = 20). Tracheal placement of the Univent tube was accomplished with direct rigid laryngoscopy after anesthetic induction and was positioned by the same anesthesiologist using 1 of the above-described methods. Its position was then checked by another anesthesiologist with an FOB. The number of attempts required for successful tube positioning, the volume of air needed for blocker cuff inflation, and intubation times were recorded, as were the times for single-lung ventilation and the potential for bronchial injury. The intubation time was 182 +/- 42 s in the AUS group and 176 +/- 50 s in the LS group, shorter than that in the FOB (278 +/- 111 s) and MR (266 +/- 127 s) (P < 0.05) groups. The success rate of bronchial blocker insertion into the left bronchus on the first attempt was 100% in the AUS group, 79% in the LS group, and 25% in the MR group. The number of blocker insertion attempts and the volume of air in the blocker cuff in the MR group were significantly higher than those in the AUS and LS (P < 0.05) groups. In the supine position, the number of acceptable bronchial blocker placements was 14 of 20 attempts (70%) in the MR group, significantly fewer than that in the FOB group (18 of 20, 90%) (P < 0.05). In the AUS and LS groups, the number of acceptable bronchial blocker placements was 19 of 20 (95%) and 16 of 20 (80%), respectively. After patients were turned to the lateral decubitus position, the number of acceptable bronchial blocker placements was 10 of 18 (56%) in the MR group, significantly fewer than that in the FOB group (17 of 19, 89.5%) (P < 0.05). In the AUS and LS groups, the number of acceptable bronchial blocker placements was 15 of 20 (75%) and 15 of 19 (79%), respectively. The placement of the Univent tube with the aid of AUS or an LS is feasible, and both techniques require less time than placement aided by an FOB or as recommended by the manufacturer.

Fibreoptic intubation through the laryngeal mask airway: effect of operator experience*

In a randomised crossover study, we compared times and success rates for tracheal placement of a fibrescope and railroading of a tracheal tube through the classic laryngeal mask airway by anaesthetists with limited experience in fibreoptic intubation (trainees) and those who were experts. Thirty-two patients, 32 trainees and three experts took part. The median (IQR [range]) times to fibrescope placement for trainees and experts were 21 (18-30 [12-58]) s and 17 (14-24 [9-55]) s, respectively (95% CI for the difference 2-8 s; p = 0.023). There were no significant differences between trainees and experts in the times to placement of the laryngeal mask airway (41 (33-47 [31-105]) s and 36 (33-43 [30-52]) s, respectively; p = 0.24), railroading times (43 (40-58 [33-87]) s and 44 (38-57 [31-83]) s, respectively; p = 0.96) and total intubation time (114 (97-127 [80-213]) s and 95 (89-116 [74-139]) s, respectively; p = 0.13). There was no significant difference in the number of attempts needed for successful placement of the fibrescope (p = 0.12) and railroading the tracheal tube (p = 0.22). The differences between experts and trainees when using fibrescope assisted intubation via the classic laryngeal mask airway were not clinically important.

A Prospective Comparison of Diaphragmatic Ultrasound and Chest Radiography to Determine Endotracheal Tube Position in a Pediatric Emergency Department

Investigators report endotracheal tube misplacement in up to 40% of emergent intubations. The standard elements of confirmation have significant limitations. Diaphragmatic ultrasound is a potentially viable addition to the confirmatory process. Our primary hypothesis is that ultrasound is equivalent to chest radiography in determining endotracheal tube position within the airway in emergent pediatric intubations. We enrolled a prospective, convenience sample from all intubated patients in our emergency department. The primary outcome was the agreement between diaphragmatic ultrasound and chest radiography for endotracheal tube position. On ultrasound, tracheal placement equaled bilateral diaphragmatic motion, bronchial placement equaled unilateral diaphragmatic motion, and esophageal placement equaled no or paradoxical diaphragmatic motion during delivery of positive pressure. Study sonographers were blind to radiographic results. Our secondary outcome was the timeliness of ultrasound versus chest radiography results. Our institutional review board approved this study with a waiver of informed consent. One hundred twenty-seven patients were enrolled. In 24 (19%) patients, the endotracheal tube was in the mainstem bronchus on chest radiography. There were no esophageal intubations in the sample. Ultrasound and chest radiography agreed on endotracheal tube placement in 106 patients (94 tracheal and 12 mainstem), for an overall agreement of 0.83. The sensitivity of ultrasound for tracheal placement was 0.91. The specificity of ultrasound for mainstem intubation was 0.50. Thirty-four patients had a second ultrasound by a separate, blinded sonographer; 33 of 34 of the results of the second sonographer were in agreement with the initial sonogram, for an interrater agreement of 97%. Clinically useful chest radiography results took a median of 8 minutes longer to achieve than ultrasound results. Diaphragmatic ultrasound was not equivalent to chest radiography for endotracheal tube placement within the airway. However, ultrasound results were timelier, detected more misplacements than standard confirmation alone, and were highly reproducible between sonographers.

Lighted stylet-guided intubation via the intubating laryngeal airway in a patient with Hallermann-Streiff syndrome

Hallermann-Streiff syndrome is a congenital syndrome associated with oculomandibulofacial abnormalities and potentially difficult airways. This case report describes the novel use of a lighted stylet-guided tracheal tube insertion through a new supraglottic airway, the intubating laryngeal airway (ILA), in a patient with Hallermann-Streiff syndrome who had anticipated difficult airway. A 26-year-old male with Hallermann-Streiff syndrome was scheduled for a vitrectomy. The patient had mandibulofacial dystocia with a bird-like appearance, a mouth opening of 4 cm, a receding chin, and a Mallampati class 3 examination. The surgeon requested muscle paralysis and no movement during surgery. After receiving midazolam, fentanyl and propofol, a size 3.5 ILA was inserted and lung ventilation was easy to perform. A 7.5-mm internal diameter tracheal tube was mounted on a lighted stylet with its inner rigid stylet removed. After succinylcholine administration, the lighted stylet-tracheal tube assembly was inserted via the ILA until the transillumination just vanished below the sternal notch. The lighted stylet was removed, the circuit was connected, and capnography confirmed tracheal placement of tube. The ILA was deflated and left in situ. Upon emergence from anesthesia, the tracheal tube, and subsequently the ILA, were removed without complications. This case presents a novel use of a lighted stylet-guided tracheal tube insertion through the ILA in a patient with Hallermann-Streiff syndrome. This intubation technique can be considered in patients with difficult airways as a primary route of intubation, or as a secondary rescue strategy.

MDCT Detection of Airway Stent Complications: Comparison with Bronchoscopy

The objective of our study was to evaluate the detection rate of central airway stent complications using MDCT as compared with bronchoscopy. A review was performed of all consecutive patients undergoing MDCT and bronchoscopy for suspected complications of airway stents during an 18-month period. MDCT images were interpreted in a blinded fashion by an experienced thoracic radiologist before bronchoscopy was performed, and the accuracy of MDCT was determined using bronchoscopy as the gold standard. MDCT images were specifically assessed for the presence of the following complications: narrowing of stent lumen due to granulation tissue or secretions (or both), stent fracture, stent invasion by adjacent neoplasm, stent migration, and perforation of adjacent airways. The study population was composed of 21 patients, with mean age of 48 years (range, 16-79 years), who underwent tracheal (n = 3), tracheobronchial (n = 7), or bronchial (n = 11) stent placement for benign (n = 13) or malignant (n = 8) airway disorders. Eleven of 21 stents were metallic and the remaining 10 were silicone. Thirty complications were detected in 21 patients, including stent luminal narrowing due to granulation tissue or secretions (or both) (n = 13), stent migration (n = 9), stent fracture (n = 4), stent invasion by adjacent neoplasm (n = 3), and tracheal perforation (n = 1). MDCT accurately detected 29 (97%) of the 30 complications diagnosed by bronchoscopy. There was one false-negative case in which MDCT failed to detect a stent fracture. There were no false-positive diagnoses of stent complications. MDCT is highly accurate for detecting airway stent complications.

A simple aspiration test to determine the accuracy of oesophageal placement of fine-bore feeding tubes

To evaluate whether a simple aspiration test can be used to accurately confirm the correct placement of fine-bore feeding tubes in the oesophagus and prevent their inadvertent placement in the bronchial tree. We conducted an ethically approved, randomised, blinded trial to assess the accuracy of a simple aspiration test to differentiate between oesophageal and tracheal placement. A tertiary referral cardiothoracic surgical unit. Twenty patients under-going elective cardiac surgery. Once anesthetised, a fine-bore feeding tube was inserted into the oesophagus or trachea and a researcher, blinded to the position, then performed the test. This involved attempted aspiration of > or =10 ml of air before and after insufflation of 10 ml of air and comparison with capnography, a test that has been shown to be highly sensitive and specific. With this small number of patients, the test accurately differentiated between ten oesophageal and ten tracheal placements. A simple aspiration test could be a useful adjunct to prevent inadvertent bronchial placement of fine-bore feeding tubes. Careful attention must be paid to the technique to ensure that no false positives occur.

Colorimetric capnography to ensure correct nasogastric tube position

PurposeWe evaluate a procedure, combining colorimetric capnography with epigastric auscultation, to ensure nasogastric (NG) feeding tube correct position without any radiograph. MethodsWe first evaluated the accuracy of colorimetric capnography in detecting tracheal positioning in a control group of 100 mechanically ventilated patients. The procedure was thereafter evaluated in a study group including patients requiring an NG tube. The NG tube was first inserted 30 cm and connected to a colorimetric capnograph (first step). If the capnograph did not detect carbon dioxide, insertion was completed to a total distance of 50 cm. An epigastric auscultation after air insufflation and a second capnography (second step) were performed. A radiograph evaluated correct tube position. ResultsIn the control group, colorimetric capnograph sensitivity to detect tracheal placement was 100%. In the study group, negative predictive value of first-step capnography to rule out tracheobronchial insertion was 100%. The association of a first-step negative capnography with a positive epigastric auscultation correctly identified all but one gastric insertions, yielding a sensitivity of 98.5% (95% confidence interval, 95.7-100). The positive predictive value of this association to detect gastric placement was 100%. ConclusionColorimetric capnography combined with epigastric auscultation is safe and accurate in ensuring correct gastric tube insertion.

Nasotracheal intubation in patients with an unanticipated difficult airway — I

To the Editor: We read, with interest, the recent case report written by Drs. Uria et al.1, and we agree with their assessment that it is important to perform a preliminary laryngoscopy prior to inserting a nasal tube. However, their recommendation to insert a bougie through the RAE® nasal tube, with its distal acute curve, can result in inappropriate bending of the distal portion which is unfavourable to insertion of the bougie into the laryngeal aperture. Also, the gritty feel in contact with the tracheal rings2 has the potential to interfere with the operator’s judgment of correct tracheal placement of the bougie, particularly when a 7.5-mm oral tube is inserted between the vocal cords. Moreover, we have found that digital displacement of the oral tube, posteriorly and rostrally, in patients with an unanticipated difficult airway, cannot always bring the vocal cords into view. Therefore, we consider the airway management plan outlined by Uria et al. to be suitable for those patients where facemask ventilation can be easily achieved or for situations where fibreoptic equipment is unavailable. When the laryngeal views obtained by preliminary laryngoscopy are Cormack-Lehane grades 3 or 4, we prefer a modified Piepho’s algorithm to perform nasal intubation.3 If facemask ventilation is not difficult, we use fibreoptic nasal intubation as our primary option. To avoid the potential danger of causing bleeding by insertion of a nasal tube, we usually select the nasal tubes made from soft flexible materials such as the Portex® Ivory PVC cuffed tube (Sims Portex Ltd., Kent, UK), because this tube can be passed through the nasal passage with a minimum of mucosal damage.4 We do not encourage use of the RAE® nasal tube during fibreoptic intubation, because its preformed curve can interfere with fibrescopy, and there may be difficulty in advancing the tube over the fibreoptic bronchoscope (FOB) into the trachea. If facemask ventilation is difficult, an intubating laryngeal mask airway is inserted to maintain a patent airway and to provide a channel for orotracheal intubation using the FOB or the lightwand. To ensure convenience for subsequent tube exchange, we advocate inserting an oral endotracheal tube with an internal diameter 1–1.5 mm smaller than the intended endotracheal tube. After the nasal tube, obturated with an inflated Foley catheter, is guided through the nostril into the hypopharynx, according to the methods described by Russell,5 the FOB is inserted via the nasal tube into the trachea alongside the oral tube. Next, the oral to nasal tube exchange is completed. In our experience, due to the ability to maintain adequate lung ventilation while minimizing the risk of epistaxis, this modified Piepho’s algorithm can provide additional safety during nasotracheal intubation.

Endotracheal Stent Granulation Stenosis Resolution after Colchicine Therapy in a Dog

Endotracheal Stent Granulation Stenosis Resolution after Colchicine Therapy in a Dog

191: The Ability of Emergency Physicians to Differentiate Tracheal Versus Esophageal Placement of an Eschmann Stylet by Tactile Sensation

The Eschmann stylet (bougie) is a commonly used intubation rescue device, which may be used to guide placement of an endotracheal tube into the trachea where visualization of the glottis is difficult. The general method of use for blind insertion includes feeling the stylet’s deflections off the tracheal cartilage rings in a successful placement. Although previously published success rates for Eschmann stylet-assisted intubation are generally greater than 90%, no data have been published on physicians’ abilities to determine esophageal versus tracheal placement through tactile stimuli only.

Detection of inadvertent tracheal placement of nasogastric tubes

Acta Anaesthesiologica ScandinavicaVolume 52, Issue 4 p. 574-575 Letters to the Editor Detection of inadvertent tracheal placement of nasogastric tubes M. El-Orbany, M. El-OrbanySearch for more papers by this author M. El-Orbany, M. El-OrbanySearch for more papers by this author First published: 13 March 2008 https://doi.org/10.1111/j.1399-6576.2008.01613.xCitations: 1 Address:Mohammad El-OrbanyDepartment of AnesthesiologyMedical College of WisconsinMilwaukee, WI USAe-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume52, Issue4April 2008Pages 574-575 RelatedInformation

An investigation into the length of standard tracheostomy tubes in critical care patients*

A number of problems have been reported with the use of standard length tracheostomy tubes in adult critical care patients. We measured the depth from the skin surface to the tracheal wall and the angle of the tracheal stoma during percutaneous tracheostomy. In vitro measurements were also performed on standard tracheostomy tubes. Comparison of in vivo and in vitro dimensions demonstrated that standard length tracheostomy tubes are too short for the average critical care patient. We recommend that both the stomal and intratracheal lengths should be made longer by approximately 1 cm and tubes should be redesigned to an angle of 110-120 degrees to allow optimal tracheal placement.

Evaluation of clinical effectiveness of the Frova single‐use tracheal tube introducer

A prospective observational study design was used to evaluate the clinical effectiveness of the Frova single-use tracheal tube introducer. Data were collected from 203 patients. Consultants and trainee anaesthetists completed 61 (30%) and 142 (70%) forms respectively, when the Frova introducer was used. It was successfully placed in the trachea in 194/203 (96%) of patients with two attempts at placement by the first clinician. The first clinician failed to either pass the Frova introducer or railroad the tube in six (3%) and 10 (5%) of the 203 patients respectively. The success rate by the first clinician was significantly influenced by the laryngeal view obtained (p < 0.0001). There was only one failure to place the Frova introducer in the trachea by either the first or second clinician. Airway trauma was detected in 11/203 (5%) patients. In six of these 11 patients blood was detected on tracheal suction; 'distal hold up' was elicited in five of these six. The Frova introducer has a high success rate for tracheal placement but has noteworthy potential to produce airway trauma.

The inhibitory effects, according to infusion rate of remifentanil, on the hemodynamic responses during laryngeal microscopic surgery

Background: The hemodynamic responses to tracheal intubation and placement of a suspension rigid laryngoscope are increases of the heart rate and blood pressure during laryngeal microscopic surgery (LMS). Therefore, several methods have been used to attenuate these responses. The aim of the present study was to compare the effects of three different infusion rate of remifentanil on the hemodynamic responses and recovery characteristics of patients who are under going LMS. Methods: Forty-five patients (ASA class 1 and 2) who were scheduled for LMS were randomly allocated to three groups. The patients received propofol 3μg/ml (the effective target concentration) with remifentanil 0.2μg/kg/min (Group R0.2), 0.3μg/ kg/min (Group R0.3), or 0.4μg/kg/min (Group R0.4), respectively. The patients` systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and heart rate (HR) were measured at baseline, 1 minute before and after tracheal intubation and 1 minute after placement of a suspension rigid laryngoscope. The patients` recovery characteristics (spontaneous respiration and eye opening) were assessed at 15 to 30 seconds intervals after discontinuation of the anesthetics. Results: The blood pressure and heart rate at the time of tracheal intubation and placement of the suspension rigid laryngoscope were unchanged in Group R0.3, yet they were increased in Group R0.2 and they were decreased in Group R0.4. The emergence time was significantly shorter for the R0.2 and R0.3 Groups than that for Group R0.4. Conclusions: We concluded that TIVA with using propofol and remifentanil (0.3μg/kg/min) can provide a stable hemodynamic status during LMS.

Airway obstruction after extubation following use of transesophageal echocardiography for posterior fossa surgery in the sitting position

We report respiratory obstruction following surgery in the sitting position with tracheal intubation and placement of a transesophageal echocardiography probe. Obstruction was due to pharyngeal oedema, which resolved with 24 hours. The mechanisms of this complication are discussed.

Continuous Monitoring of Dynamic Pulmonary Compliance Enables Detection of Endobronchial Intubation in Infants and Children

Auscultation of breath sounds is used routinely to confirm tracheal placement of endotracheal tubes (ETT). In infants and children, this method is limited by the conduction of breath sounds bilaterally, despite endobronchial intubation. Although several methods of detecting endobronchial intubation have been described, none is both simple and reliable. In this investigation, we determined whether changes in pulmonary compliance and airway pressures, measured using continuous side stream spirometry, can reliably detect endobronchial intubation in pediatric patients. Forty patients aged 1 month to 6 years were included. After endotracheal intubation the ETT was incrementally advanced as two observers monitored breath sounds and spirometry (Pressure-Volume Loops). Changes in pulmonary compliance, peak inspiratory pressure, or auscultation were reported, at which point ETT position was confirmed by fiberoptic bronchoscopy. Endobronchial intubation decreased measured pulmonary compliance by 45 +/- 11% (mean +/- sd; P < 0.001, Range 26%-66%) and increased peak airway pressures by 26 +/- 17% (mean +/- sd; P < 0.001, Range 0-87). Changes in peak airway pressures were smaller and more variable when compared to changes in compliance. Breath-sound auscultation failed to detect endobronchial intubation in 7.5% of cases. Pulmonary compliance changes are a sensitive and an accurate indicator of endobronchial intubation in infants and children. Both increased peak airway pressures and changes in breath sounds are less sensitive indicators of endobronchial intubation.

Frova intubating catheter position can be determined with aspirating oesophageal detection device

Intubating catheters (e.g. gum-elastic bougie) are an invaluable adjunct in the management of a difficult airway. Traditional tactile 'click' (from tracheal rings) and 'hold up' (from carina or bronchus) techniques for confirming tracheal placement are, however, fallible, and definitive placement can only be confirmed following passage of the endotracheal tube. Ensuing delays might contribute to the development of arterial hypoxaemia. Our aim was to determine whether an aspirating oesophageal detector device might be useful for confirming placement of the Frova intubating catheter (a hollow-bore intubating catheter). Eighteen adult patients (American Society of Anaesthiology category 1-2) undergoing elective surgery had the Frova intubating catheter alternately placed in the trachea, or oesophagus, following induction of anaesthesia. Catheter position was assessed using an aspirating oesophageal detector device prior to tracheal intubation. The oesophageal detector device correctly predicted tracheal (n = 18) and oesophageal (n = 18) placement in all patients. All procedures were completed in less than 15 s. In the operating theatre setting the aspirating oesophageal detector device reliably predicts tracheal and oesophageal placement of the Frova intubating catheter.