Emergency videoendoscopic endonasal tracheal intubation for severe upper airway stenosis.
ABSTRACT: PURPOSE:Upper airway stenosis is one of the most formidable situations in medicine and is frequently encountered in the ENT clinic. We introduce here our method of emergency endonasal endotracheal intubation under videoendoscopic observation. METHODS:Transnasal endoscopic observation was done, and the region of airway stenosis was detected. Then, the endotracheal tube was prepared and the endoscope was inserted into the tube. The endoscope with tube was inserted up to the larynx. Immediately after the administration of lidocaine to the larynx, the endoscope with tube was inserted to the endolarynx and then to the trachea. The endotracheal tube was tightly held in the nostril, and the endoscope was removed. RESULTS:We have encountered four cases this year. The primary disease developing airway stenosis was acute epiglottitis due to pharyngeal and deep neck abscesses in three cases and laryngeal edema due to Ludwig's angina. All patients underwent uneventful intubation, and dyspnea was immediately ceased. CONCLUSION:In cases showing severe suffocation, the clinician should perform airway maintenance even in an outpatient setting apart from a more monitored setting like the operation room. This technique resembles the usual nasal endoscopic laryngeal observation and is done even in the usual ENT office and/or emergency room. The supine position tends to worsen airway stenosis in patients with upper airway stenosis; however, this technique can be performed in a sitting or semi-sitting position. This method is less invasive for patients and also reduces the risk to the medical staff, especially in this COVID-19 era.
Project description:Air-Q intubating laryngeal mask airway (ILA) is used as a supraglottic airway device and as a conduit for endotracheal intubation. This study aims to assess the efficacy of the Air-Q ILA regarding ease of insertion, adequacy of ventilation, rate of successful intubation, haemodynamic response and airway morbidity.Sixty patients presenting for elective surgery at our Medical College Hospital were selected. Following adequate premedication, baseline vital parameters, pulse rate and blood pressure were recorded. Air-Q size 3.5 for patients 50-70 kg and size 4.5 for 70-100 kg was selected. After achieving adequate intubating conditions, Air-Q ILA was introduced. Confirming adequate ventilation, appropriate sized endotracheal tube was advanced through the Air-Q blindly to intubate the trachea. Placement of the endotracheal tube in trachea was confirmed.Air-Q ILA was successfully inserted in 88.3% of patients in first attempt and 11.7% patients in second attempt. Ventilation was adequate in 100% of patients. Intubation was successful in 76.7% of patients with Air-Q ILA. 23.3% of patients were intubated by direct laryngoscopy following failure with two attempts using Air-Q ILA. Post-intubation the change in heart rate was statistically significant (P < 0.0001). 10% of patients were noted to have a sore throat and 5% of patients had mild airway trauma.Air-Q ILA is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation. It benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway.
Project description:BACKGROUND:Tracheal intubation with the patient in the lateral position is difficult because the laryngeal view is compromised during direct laryngoscopy. Flexible video endoscopes may facilitate intubation even when laryngeal views are poor on direct laryngoscopy because the patients are positioned laterally. Thus, this trial aims to compare the efficacy of flexible video endoscopes to Macintosh laryngoscopes for orotracheal intubation in the lateral position and to investigate their feasibility, i.e., whether the use of the two devices in combination can secure the airway when endotracheal intubation in the lateral position has failed using one device. METHODS:This will be a prospective, randomized, single-center, clinical trial. One hundred and seventy-four patients aged 18-65 years, who have been scheduled to undergo tracheal intubation under uniform general anesthetic techniques for elective kidney surgery in the lateral decubitus position will be randomly divided into the flexible video endoscope and the Macintosh laryngoscope groups. Primary outcomes include intubation time and intubation success rate. Secondary outcomes include overall user satisfaction (graded from 1 to 10 (1 = very poor, 10 = excellent)) and perioperative side effects and complications, such as frequency of esophageal intubation, lip or dental injury, sore throat, and hoarseness. DISCUSSION:The trial will clarify the efficacy of intubation with a Macintosh laryngoscope and a flexible video endoscope in the lateral position, and whether the two devices could be used in combination to secure the airway in cases where endotracheal intubation in the lateral position has failed with one device. TRIAL REGISTRATION:Chinese Clinical Trial Register, ChiCTR- IOR-15007175 . Registered on 6 October 2015.
Project description:Background:The rigid tube for laryngoscopy is an instrument used in ENT, for inspecting the larynx and its vicinity. We used it to facilitate intubation, in ENT patients. Methods:Twenty patients attending for surgery were included for study. Group 1 (n=10) had no airway pathology but at least two predictors of an anatomically difficult airway. Group 2 (n=10) had an obstructing airway pathology. After anesthesia induction, classical laryngoscopy was performed, and intubation grade registered. Using the retromolar approach the rigid tube advanced slowly, the epiglottis was lifted, and the vocal cords were visualized. The bougie was introduced through the rigid tube into the trachea, the rigid tube was extracted, and the intubating tube was placed in the trachea, over the bougie. Results:The mean (SD) maneuver duration was 59.4 (18.2) sec. The Cormack-Lehane view of the glottis at classical laryngoscopy was poor in four patients in Group 1 and six patients in Group 2. The lowest desaturation was 82%. No complications other than sore throat were noted. Conclusion:The rigid tube for laryngoscopy is a useful tool for intubation in ENT patients. We noticed an advantage against classical intubation in patients with base of tongue carcinoma, reduced mouth opening and protruding upper incisors with this instrument.
Project description:Importance:The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. Objective:To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. Design, Setting, and Patients:The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Interventions:Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). Main Outcomes and Measures:The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Results:Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. Conclusions and Relevance:In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. Trial Registration:clinicaltrials.gov Identifier: NCT02902146.
Project description:The most important action in the resuscitation of a newborn in the delivery room is to establish effective assisted ventilation. The face mask and endotracheal tube are the devices used to achieve this goal. Laryngeal mask airways that fit over the laryngeal inlet have been shown to be effective for ventilating newborns at birth and should be considered as an alternative to facemask ventilation or endotracheal intubation among newborns weighing >2,000 g or delivered ?34 weeks' gestation. A recent systematic review and meta-analysis of supraglottic airways in neonatal resuscitation reported the results of four randomized controlled trials (RCTs) stating that fewer infants in the group using laryngeal mask airways required endotracheal intubation (1.5%) compared to the group using face masks (12.0%). However, there were methodological concerns over all the RCTs including the fact that the majority of the operators in the trials were anesthesiologists.Our hypothesis is based on the assumption that ventilating newborns needing positive pressure ventilation with a laryngeal mask airway will be more effective than ventilating with a face mask in a setting where neonatal resuscitation is performed by midwives, nurses, and pediatricians. The primary aim of this study will be to assess the effectiveness of the laryngeal mask airway over the face mask in preventing the need for endotracheal intubation.This will be an open, prospective, randomized, single center, clinical trial. In this study, 142 newborns weighing >1,500 g or delivered ?34 weeks gestation needing positive pressure ventilation at birth will be randomized to be ventilated with a laryngeal mask airway (LMA SupremeTM, LMA Company, UK - intervention group) or with a face mask (control group).Proportion of newborns needing endotracheal intubation.Apgar score at 5 minutes, time to first breath, onset of the first cry, duration of resuscitation, death or moderate to severe hypoxic-ischemic encephalopathy within 7 days of life.ClinicalTrials.gov identifier: NCT01963936 (October 11, 2013).
Project description:Background and Aims:Supraglottic airways (SGAs) are generally used for airway management; but can also be used as a conduit for tracheal intubation. Our primary aim was to evaluate i-Gel and laryngeal mask airway (LMA) classic as conduits for tracheal intubation using ventilating bougie by assessing number of attempts and time for insertion of SGAs, ventilating bougie and endotracheal tube (ETT), and total intubation time. Material and Methods:A randomized clinical trial was carried out in 58 patients requiring general anesthesia and endotracheal intubation for planned surgery. They were randomly divided into Group I and Group C. After induction of anesthesia, i-Gel was inserted in Group I and LMA Classic in Group C; ventilating bougie was passed through SGA followed by the removal of SGA and railroading of ETT over ventilating bougie. Parameters observed were number of attempts and time taken for device insertion, total intubation time, and hemodynamic variables. Results:Twenty-nine patients were included in each group. First attempt success rate for SGA insertion (86.2% in Group I and 75.9% in Group C (P = 0.5)), ventilating bougie insertion (79.32% in Group I and 82.8% in Group C (P = 0.99)) and ETT insertion (100% in Group I and 96.5% in Group C) was not different in the two groups. Total intubation time was 93.3 ± 9.0 s in Group I and 108. 96 ± 16.5 s in Group C (P < 0.0001). Conclusions:i-Gel and LMA Classic both can be used as a conduit for tracheal intubation using ventilating bougie with stable hemodynamic parameters.
Project description:A 56-year-old man presented with a 6-month history of progressively increasing neck swelling, dysphagia and hoarseness of voice. CT scan revealed multi-nodular goitre and also showed a lesion in the supraglottis. It also showed another lesion in the supraglottis. Fine-needle aspiration cytology of thyroid revealed follicular cells. Routine flexible laryngoscopy was performed to evaluate vocal cord function; however, we found a smooth well-defined lesion just above the glottis, obstructing the direct view of the vocal cords, and an endangered airway. A provisional diagnosis of a laryngeal cyst was made. With all necessary precautions intubation was performed with a bougie and a reinforced endotracheal tube was inserted. Total thyroidectomy was performed first. With direct suspension laryngoscopy an attempt was made to deliver the laryngeal lesion, however, the lesion could not be removed. A suprahyoid lateral pharyngotomy was performed to deliver the lesion. Histopathology of the lesion revealed hibernoma.
Project description:INTRODUCTION:Respiratory failure requiring endotracheal intubation accounts for a significant proportion of intensive care unit (ICU) admissions. Little attention has been paid to the laryngeal consequences of endotracheal intubation. Acute laryngeal injury (ALgI) after intubation occurs at the mucosal interface of the endotracheal tube and posterior larynx and although not immediately manifest at extubation, can progress to mature fibrosis, restricted glottic mobility and clinically significant ventilatory impairment. A recent prospective observational study has shown that >50% of patients intubated >24 hours in an ICU develop ALgI. Strikingly, patients with AlgI manifest significantly worse subjective breathing at 12 weeks. Current ALgI treatments are largely surgical yet offer a marginal improvement in symptoms. In this study, we will examine the ability of a postextubation medical regime (azithromycin and inhaled budesonide) to improve breathing 12 weeks after ALgI. METHODS AND ANALYSIS: A prospective, single-centre, double-blinded, randomised, control trial will be conducted at Vanderbilt Medical Center. Participants will be recruited from adult patients in ICUs. Participants will undergo a bedside flexible nasolaryngoscopy for the identification of ALgI within 72 hours postextubation. In addition, participants will be asked to complete peak expiratory flow measurements immediately postintubation. Patients found to have ALgI will be randomised to the placebo control or medical therapy group (azithromycin 250 mg and budesonide 0.5 mg for 14 days). Repeat peak expiratory flow, examination of the larynx and patient-reported Clinical COPD (chronic obstructive pulmonary disease) Questionnaire, Voice Handicap Index and 12-Item Short Form Health Survey questionnaires will be conducted at 12 weeks postextubation. Consented patients will also have patient-specific, disease-specific and procedure-specific covariates abstracted from their medical record. ETHICS AND DISSEMINATION:The Institutional Review Board (IRB) Committee of the Vanderbilt University Medical Center has approved this protocol (IRB #171066). The findings of the trial will be disseminated through peer-reviewed journals, national and international conferences. TRIAL REGISTRATION NUMBER:NCT03250975.
Project description:INTRODUCTION:Tracheal intubation is one of the most daily practiced procedures performed in intensive care unit (ICU). It is associated with severe life-threatening complications, which can lead to intubation-related cardiac arrest. Using a preshaped endotracheal tube plus stylet may have potential advantages over endotracheal tube without stylet. The stylet is a rigid but malleable introducer which fits inside the endotracheal tube and allows for manipulation of the tube shape; to facilitate passage of the tube through the laryngeal inlet. However, some complications from stylets have been reported including mucosal bleeding, perforation of the trachea or oesophagus and sore throat. The use of a stylet for first-attempt intubation has never been assessed in ICU and benefit remains to be established. METHODS AND ANALYSIS:The endotracheal tube plus stylet to increase first-attempt success during orotracheal intubation compared with endotracheal tube alone in ICU patients (STYLETO) trial is an investigator-initiated, multicentre, stratified, parallel-group unblinded trial with an electronic system-based randomisation. Patients will be randomly assigned to undergo the initial intubation attempt with endotracheal tube alone (ie,without stylet, control group) or endotracheal tube + stylet (experimental group). The primary outcome is the proportion of patients with successful first-attempt orotracheal intubation. The single, prespecified, secondary outcome is the incidence of complications related to intubation, in the hour following intubation. Other outcomes analysed will include safety, exploratory procedural and clinical outcomes. ETHICS AND DISSEMINATION:The study project has been approved by the appropriate ethics committee 'Comité-de-Protection-des-Personnes Nord-Ouest3-19.04.26.65808 Cat2 RECHMPL19_0216/STYLETO2019-A01180-57'". Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If combined use of endotracheal tube plus stylet facilitates tracheal intubation of ICU patients compared with endotracheal tube alone, its use will become standard practice, thereby decreasing first-attempt intubation failure rates and, potentially, the frequency of intubation-related complications. TRIAL REGISTRATION DETAILS:ClinicalTrials.gov Identifier: NCT04079387; Pre-results.
Project description:To evaluate a comprehensive scoring system which combines clinical manifestations of Pierre Robin Sequence (PRS) including severity of breathing difficulties, body weight and preoperative Cormack-Lehane grade, for its correlation with perioperative PRS airway management decision.Forty PRS children were retrospectively recruited after surgery. Specialists examined all subjects and scored for clinical manifestations (1´ - 4´), weight gain (1´- 4´), dyspnea scores (1´- 4´), and Cormack-Lehane grade (1´- 4´). The correlation of the integrated scores and the necessity of endotracheal intubation or laryngeal mask application were analyzed. In addition, the score correlation with postoperative dyspnea and/or low pulse oxygen saturation (SPO2) levels after extubation was determined.In our study every individual patient had a score from 0´ to 16´, while the higher in the numbers represented higher risk of breathing difficulty. All patients with comprehensive scores <10 points underwent endotracheal intubation successfully. Patients scoring 10-12 points had an intubation success rate of 47%, whereas all patients scored >13 points required a laryngeal mask assisted airway management and were considered to have difficult airways. Dyspnea after extubation and postoperative low SPO2 occurred among patients who scored over 10 points.In PRS patients, preoperative weight gaining status and severity of dyspnea in combination with Cormack-Lehane classification provide a scoring system that could help to optimize airway management decisions such as endotracheal intubation or laryngeal mask airway placement and has the potential to predict postoperative dyspnea or low SPO2 levels.