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1.  Alternative technique for changing from nasal to oral endotracheal tube for orthognathic and nasal surgery by using an airway exchange catheter: a case report 
A 28-year-old male patient with right maxillar, zygomatic arch, orbital wall, and nasal bone fractures had an orthognathic and nasal surgery. Naso-endotracheal intubation is the first choice during surgical correction of dentofacial deformities in an orthognathic surgery; however, its presence can interfere with concomitant surgical procedures on the nose. Traditionally, the naso-endotracheal tube will be removed and replaced with an oro-endotracheal tube. We changed the endotracheal tube from nasal to oral by using an airway exchange catheter.
PMCID: PMC4121495  PMID: 25097739
Airway exchange catheter; Nasal surgery; Naso-endotracheal intubation; Orthognathic surgery
2.  Submental tracheal intubation in oromaxillofacial surgery 
Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying.
Materials and Methods:
The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only.
The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.
In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.
PMCID: PMC2739561  PMID: 19753195
Avoiding tracheostomy; oromaxillofacial surgery; intubation
3.  Anæsthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane 
Problems in chest surgery: Cases with prolonged toxæmia or amyloid disease require an anæsthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anæsthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung.
The dangers of an open pneumothorax: (1) Paradoxical respiration—the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed.
(2) Vicious circle coughing. During a paroxysm of coughing dyspnœa will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result.
Special duties of the anæsthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate.
(2) To maintain effcient respiration.
Positive pressure anæsthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO2 poisoning without premonitory signs.
Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery.
Controlled respiration means that the anæsthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand.
Active respiration will cease (i) if the patient's CO2 is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anæsthetic drugs, and (iii) by a combination of (i) and (ii) of less degree.
The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cycloprȯpane. The CO2 absorption method is essential for this technique, and this and controlled respiration should be mastered by the anæsthetist with a familiar agent and used at first only in uncomplicated cases.
The significance of cardiac arrhythmias occuring with cyclopropane is discussed.
The place of the other available anæsthetic agents is discussed particularly on the advisability of using local anæsthesia for the drainage of empyema or lung abscess.
Pharyngeal airway or endotracheal tube? Anæsthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway.
A one-lung anæsthesia is ideal for pneumonectomy. This may be obtained by endotracheal anæsthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed “blind”. Before deciding on blind bronchial intubation, the anæsthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c).
Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manœuvre are described.
In lobectomy for bronchiectasis the anæsthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anæsthesia is the best method. During other procedures it is essential to maintain quiet respiration.
In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anæsthetist is essential.
PMCID: PMC1998132  PMID: 19992357
4.  Pediatric cuffed endotracheal tubes 
Endotracheal intubation in children is usually performed utilizing uncuffed endotracheal tubes for conduct of anesthesia as well as for prolonged ventilation in critical care units. However, uncuffed tubes may require multiple changes to avoid excessive air leak, with subsequent environmental pollution making the technique uneconomical. In addition, monitoring of ventilatory parameters, exhaled volumes, and end-expiratory gases may be unreliable. All these problems can be avoided by use of cuffed endotracheal tubes. Besides, cuffed endotracheal tubes may be of advantage in special situations like laparoscopic surgery and in surgical conditions at risk of aspiration. Magnetic resonance imaging (MRI) scans in children have found the narrowest portion of larynx at rima glottides. Cuffed endotracheal tubes, therefore, will form a complete seal with low cuff pressure of <15 cm H2O without any increase in airway complications. Till recently, the use of cuffed endotracheal tubes was limited by variations in the tube design marketed by different manufacturers. The introduction of a new cuffed endotracheal tube in the market with improved tracheal sealing characteristics may encourage increased safe use of these tubes in clinical practice. A literature search using search words "cuffed endotracheal tube" and "children" from 1980 to January 2012 in PUBMED was conducted. Based on the search, the advantages and potential benefits of cuffed ETT are reviewed in this article.
PMCID: PMC3590525  PMID: 23492803
Children; cuffed endotracheal tube; microcuff tube
5.  Submental intubation: An option of airway management for rhinoplasty and rhytidectomy 
For rhinoplasty, full control of facial symmetry will improve the aesthetic results. During rhinoplasty, the nasal intubation is contraindicated while oral intubation may interfere with surgical procedure. Hence an alternative airway option of the submental intubation was planned to study the efficacy of the procedure.
The submental intubation may improve the aesthetic results of rhinoplasty and facial symmetry.
Setting and Design:
This is a prospective cohort observational study.
Materials and Methods:
Fifteen adult consented patients of ASA grade I and II of either gender aged 20 to 38 years who met the inclusion criteria were enrolled. After induction, orotracheal intubation was done with flexometallic tube, followed by a 1.5-cm skin incision in the submental region, adjacent to lower border of mandible;then endotracheal tube was taken out through this incision. At the end of surgery, the procedure was reversed and submental wound was stitched. Patients were extubated after proper suctioning of oral cavity. No intraoperative and postoperative complications have occurred.
The submental intubation was performed in 15 patients by medial approach without any difficulty. The average time taken to perform the procedure was 7.27±0.63 min. No anesthetic and surgical complications were encountered in any patients. The submental scar was almost invisible after 2 months.
Submental intubation offers a secure airway, efficient ventilation, and uninterrupted operating field to the plastic surgeon. Lack of anesthesia and surgical complications encouraged us to present the advantages of submental intubation on the basis of our own experience.
PMCID: PMC4173372
Aesthetic scar; flexometallic endotracheal tube; rhinoplasty; submental intubation
6.  Assessment of the subglottic region by ultrasonography for estimation of appropriate size endotracheal tube: A clinical prospective study 
Endotracheal intubation is important to carry out various surgical procedures. The estimation of endotracheal tube size is governed by narrowest diameter of the upper airway. The objective of the study was to assess the narrowest tracheal diameter by ultrasound for selection of the appropriate size endotracheal tube.
Materials and Methods:
After the approval of institution ethical committee and written informed consent, 112 patients aged 3 to 18 years of both genders with normal airways, scheduled for surgery under general anesthesia and intubation, were enrolled for this prospective clinical observational study. Preanesthetic ultrasonography of the subglottic region was performed by experienced ultrasonologist with a high-resolution linear array transducer in sniffing position for every patient and the subglottic tracheal diameter was estimated to select the appropriate-size endotracheal tube. The endotracheal tube, calculated on the basis of physical indices and by ultrasound, was statistically correlated with the appropriate size endotracheal tube used clinically for intubation.
The ultrasound guided selection criterion has estimated the appropriate-sized endotracheal tube better than physical indices (age or height)-based formulas. The estimated endotracheal tube size by ultrasound was significantly correlated with the clinically used endotracheal tube.
Ultrasonography may be used for the assessment of the subglottic diameter of trachea in children to estimate the appropriate size endotracheal tube for intubation.
PMCID: PMC4173447
Endotracheal tube; subglottic diameter; ultrasound; upper airway
7.  Submental/Transmylohyoid Route for Endotracheal Intubation in Maxillofacial Surgical Procedures: A Review 
Patients with severe panfacial injuries usually require long-term airway management. Nasal intubation may be contraindicated in case of nasoorbitoethmoidal fractures and also there may be a need for intraoperative and short-term postoperative intermaxillary fixation to achieve optimum reduction of fractures. The need for unobstructed access to the perinasal area during bimaxillary orthognathic procedures is felt many a time and to avoid a tracheostomy with its attending morbidity, many techniques have evolved that involve a submandibular/transmylohyoid or submental approach for temporary oroendotracheal intubation. In this article, we present our experience of patients by using submental/transmylohyoid route for endotracheal intubation. technique gives the surgeon and the anesthetist comfortable control over their respective domains, is easy to learn and implement in the operating protocol with no added costs. How to cite the article: Prakash VJ, Chakravarthy C, Attar AH. Submental/transmylohyoid route for endotracheal intubation in maxillofacial surgical procedures: A review. J Int Oral Health 2014;6(3):125-8.
PMCID: PMC4109242  PMID: 25083048
Intubation; orthognathic surgery; panfacial trauma; submental; tracheostomy; transmylohyoid
8.  Full Endoscopic Transsphenoidal Surgery for Pituitary Adenoma-emphasized on Surgical Skill of Otolaryngologist 
The purpose is to summarize the experience in full endoscopic transsphenoidal resection of pituitary adenoma in 28 patients by rhinologist, and introduce the surgical skill of otolaryngologist, especially skills and cautions when operating inside nose. We removed pituitary adenoma in 28 patients via entirely endoscopic transsphenoidal approach with the help of special-designed instruments; we performed the procedure bloodlessly within limited time. The skill emphasized bilateral nostrils and four hands technique which was as delicate as possible not to scratch nasal mucosa or injure nasal frame. The special instruments included curette with suction, monopolar electrotome and bipolar coagulation forceps with suction, powered surgical equipments (Diamond Bur, Irrigation Tubing for Blades and Burs for nasal endoscopic surgery). Among 28 patients, there were 16 total resections, 8 subtotal resections, 3 partial resections, and 1 only biopsy due to excessive bleeding and hard nature. Of 19 patients with preoperative visual impairment, 12 patients had postoperative improvement in visual acuity and visual field. All the procedures were finished within 60 to 90 min. Complications seldom occurred except transient diabetes insipidus, especially no nasal-related signs or complications but 1 had epistaxis. The full endoscopic transsphenoidal surgery is a promising approach for pituitary adenoma resection. Multidisciplinary collaboration will lead to optimal cure for the patients. New technique and special-designed instruments can facilitate greatly this procedure.
PMCID: PMC3918297  PMID: 24533411
Nasal endoscopy; Pituitary adenoma; Complication; Surgical skill
9.  Warming Endotracheal Tube in Blind Nasotracheal Intubation throughout Maxillofacial Surgeries 
Introduction: Blind nasotracheal intubation is an intubation method without observation of glottis that is used when the orotracheal intubation is difficult or impossible. One of the methods to minimize trauma to the nasal cavity is to soften the endotracheal tube through warming. Our aim in this study was to evaluate endotracheal intubation using endotracheal tubes softened by hot water at 50 °C and to compare the patients in terms of success rate and complications.
Methods: 60 patients with ASA Class I and II scheduled to undergo elective jaw and mouth surgeries under general anesthesia were recruited.
Results: success rate for Blind nasotracheal intubation in the control group was 70% vs. 83.3% in the study group. Although the success rate in the study group was higher than the control group, this difference was not statistically significant. The most frequent position of nasotracheal intubation tube was tracheal followed by esophageal and anterior positions, respectively.
Conclusion:In conclusion, our study showed that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during blind nasotracheal intubation; however it could not facilitate blind nasotracheal intubation.
PMCID: PMC3883537  PMID: 24404345
Blind Intubation; Warming; Endotracheal Tube; Oral and Maxillofacial Surgery; Anesthesia
10.  Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial 
Objective To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity.
Design Prospective randomised blinded study.
Setting Department of anaesthesia in tertiary academic hospital.
Participants 160 consecutive patients (American Society of Anesthesiologists category I or II) aged 19-75 scheduled for elective gynaecological or urological surgery.
Interventions Patients were randomly assigned to eight study groups. In four groups, an endotracheal tube was fibreoptically positioned 2.5-4.0 cm above the carina, whereas in the other four groups the tube was positioned in the right mainstem bronchus. The four groups differed in the bedside test used to verify the position of the endotracheal tube. To determine whether the tube was properly positioned in the trachea, in each patient first year residents and experienced anaesthetists were randomly assigned to independently perform bilateral auscultation of the chest (auscultation); observation and palpation of symmetrical chest movements (observation); estimation of the position of the tube by the insertion depth (tube depth); or a combination of all three (all three).
Main outcome measures Correct and incorrect judgments of endotracheal tube position.
Results 160 patients underwent 320 observations by experienced and inexperienced anaesthetists. First year residents missed endobronchial intubation by auscultation in 55% of cases and performed significantly worse than experienced anaesthetists with this bedside test (odds ratio 10.0, 95% confidence interval 1.4 to 434). With a sensitivity of 88% (95% confidence interval 75% to 100%) and 100%, respectively, tube depth and the three tests combined were significantly more sensitive for detecting endobronchial intubation than auscultation (65%, 49% to 81%) or observation(43%, 25% to 60%) (P<0.001). The four tested methods had the same specificity for ruling out endobronchial intubation (that is, confirming correct tracheal intubation). The average correct tube insertion depth was 21 cm in women and 23 cm in men. By inserting the tube to these distances, however, the distal tip of the tube was less than 2.5 cm away from the carina (the recommended safety distance, to prevent inadvertent endobronchial intubation with changes in the position of the head in intubated patients) in 20% (24/118) of women and 18% (7/42) of men. Therefore optimal tube insertion depth was considered to be 20 cm in women and 22 cm in men.
Conclusion Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements.
Trial registration NCT01232166.
PMCID: PMC2977961  PMID: 21062875
11.  Anesthetic considerations for orthognathic surgery with evaluation of difficult intubation and technique for hypotensive anesthesia. 
Anesthesia Progress  2000;47(4):151-156.
Orthognathic surgery is carried out to improve facial appearance and/or to improve malocclusion. Usually, patients are young and healthy. However, they may have airway problems. Reinforced silicone low-pressure, high-volume endotracheal tubes and p-xylometazoline (Otrivin) for nasal vasoconstriction reduces problems due to the endotracheal tubes. A head-up position with ventilator and monitoring equipment at the foot end helps the surgeons as well as the surgery. Surgeons may be the cause of endotracheal tube problems. Bleeding is a major problem that may be encountered and is reduced by induced hypotension. During osteotomies, severe bradycardia may occur and may even lead to cardiac arrest. In the early postoperative period, bleeding may be a problem. Later ulceration at the tip of the nose and on the buttocks may be seen if preventive measures are not carried out.
PMCID: PMC2149032  PMID: 11432182
12.  Submental intubation in patients with panfacial fractures: A prospective study 
Indian Journal of Anaesthesia  2011;55(3):299-304.
Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.
PMCID: PMC3141161  PMID: 21808409
Airway management; panfacial fractures; submental intubation
13.  Results of nonendoscopic endonasal dacryocystorhinostomy 
Surgical scarring on the face and disrupted anatomy in the medial canthal area following external dacryocystorhinostomy (DCR) can be avoided by an endonasal approach. This study examined the outcome of direct visualization endonasal DCR, performed by young surgeons and residents.
A retrospective case series of 75 consecutive endonasal DCRs performed under direct visualization from July 2002 to July 2004 were reviewed. Surgery was performed by surgeons and residents who had received no special training in the procedure. Full success was defined as no symptoms of tearing after surgery and anatomical patency with fluorescein flow on nasal endoscopy or patency to lacrimal syringing. Partial success was defined as a tearing decrease compared with prior to surgery and with anatomical patency, and failure was defined as no significant improvement in persistent tearing. The average follow-up duration was 26.83 ± 16.26 (range 6–55) months.
Seventy-five DCRs were performed on 63 patients (four male, 59 female) of mean age 49.44 ± 16.63 (range 21–85) years. The surgery was successful in 54/75 eyes (72%), 37/54 eyes (68.5%), and 30/42 eyes (71.4%) at 6, 12, and 24 months, respectively. Partial success was achieved in 13/75 (17.3%), 9/54 (16.7%), and 9/42 (21.4%), and the failure rates were 10.7%, 14.8%, and 7.1% at 6, 12, and 24 months, respectively. The overall functional success with this technique was 74.7% and the overall anatomical patency was 92.0%. There were no serious complications arising from the surgery; three minor complications were documented, ie, an incorrectly placed silicone tube in the lower canaliculus, tube prolapse, and postoperative bleeding which needed nasal packing and eventually a developed retention cyst in the nasal cavity.
Endonasal DCR under direct visualization is a simple technique with minimal complications and a low learning curve, without the necessity for expensive instruments.
PMCID: PMC3422139  PMID: 22927743
endonasal DCR; dacryocystorhinostomy; lacrimal surgery; nasolacrimal duct obstruction
14.  Midline Submental Orotracheal Intubation in Maxillofacial Injuries: A Substitute to Tracheostomy Where Postoperative Mechanical Ventilation is not Required 
Maxillofacial fractures present unique airway problems to the anaesthesiologist. Nasotracheal intubation is contraindicated due to associated Lefort I, II or III fractures. The requirement for intraoperative maxillomandibular fixation (MMF) to re-establish dental occlusion in such cases precludes orotracheal intubation. Tracheostomy has a high complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. Hernandez1 in 1986 first described “The submental route for endotracheal intubation”. Later some workers faced difficult tube passage, bleeding, and sublingual gland involvement with this approach. They modified this to strict midline submental intubation and there were no operative or postoperative complications in their cases.67&8. Therefore we used mid line approach for submental orotracheal intubation in this study to demonstrate its feasibility and reliability and that it can be used as an excellent substitute to short term tracheostomy.
Patients & Methods:
We used midline submental intubation in 25 cases selected out of 310 consecutively treated patients with maxillofacial trauma over a 3 year period. After induction orotracheal intubation was done with spiral re-inforced tube. A 1.5-2.0 cm skin incision was made in the submental region in the midline 2.0 cm behind the symphysis and endotracheal tube was taken out through this incision in all the cases. At the end of the surgery the procedure was reversed, the submental wound was stitched; all the patients could be extubated & none of them required post-operative mechanical ventilation.
There were no significant operative or postoperative complications. Postoperative submental scarring was acceptable[6]. We conclude that midline submental intubation is a simple and useful technique with low morbidity. It can be chosen in selected cases of maxillofacial trauma and is an excellent substitute to tracheostomy where postoperative mechanical ventilation is not required.
PMCID: PMC3087271  PMID: 21547178
Submental orotracheal intubation; Maxillofacial injury; Tracheostomy
15.  Management of traumatic pneumothorax with massive air leakage: role of a bronchial blocker: a case report 
Korean Journal of Anesthesiology  2014;67(5):354-357.
Massive air leakage through a lacerated lung produces inadequate ventilation and hypoxemia. Tube exchange from a single to double lumen endotracheal tube (DLT), and lung separation to maintain oxygenation, are challenging for seriously injured patients. In this case report, we aim to describe how a bronchial blocker (BB) makes it easier to perform a lung separation in this situation; it also increases the overall safety of the procedure. A 35-year-old female (163 cm, 47 kg) suffered from blunt chest trauma due to a traffic accident; the accident caused right-sided lung laceration with massive air leakage. Paradoxically, positive ventilation worsened SaO2 and leakage increased through a chest tube. We introduced BB while the patient was still awake: Left-side one-lung ventilation (OLV) was established and anesthesia was induced. After PaO2 was maximized with OLV, we changed the endotracheal tube to DLT without a hypoxic event. By BB placement, we maintained PaO2 at a secure level, conducted mechanical ventilation and exchanged the tube without deterioration.
PMCID: PMC4252350  PMID: 25473467
Bronchial blocker; One-lung ventilation; Pneumothorax
16.  Eschmann Introducer Through Laryngeal Mask Airway: A Cadaveric Trial of An Alternate Means of Rescue Intubation 
Study Objective:
Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation.
Nineteen emergency medicine residents and attending physicians, who were participants in a cadaveric airway course, placed and inflated a size 4 LMA (The Laryngeal Mask Company Ltd., San Diego, CA) on each of six unembalmed human cadavers in the usual fashion. They then attempted to pass a lubricated, 15 Fr, reusable, coude-tipped ETTI (Portex, Smiths Medical, Keene, NH)) through the airspace/handle of the inflated LMA. The LMA was then deflated and removed while the ETTI was held in place. Investigators then determined the location of the ETTI by laryngoscopy.
Of 114 attempts at the rescue procedure, 59 resulted in placement of the bougie into the trachea, yielding an overall success rate of 52% (95% CI 48%–56%). There were no significant differences in performance based on level of training of residents or years of experience of attending physicians.
While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.
PMCID: PMC2850846  PMID: 20411068
17.  Novel use of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient with a predicted difficult airway: a case report 
The Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) has been shown to successfully facilitate difficult intubations when other methods have failed. The Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) has a fixed length of 56 cm, and it has been suggested in the literature that it may be too short for safe use in patients who are tall.
Case presentation
We present the case of a 32-year-old, 180 cm tall Caucasian woman with a predicted difficult airway who presented to our facility for an emergency cesarean section. After several failed intubation attempts via direct laryngoscopy, an airway was established with a laryngeal mask airway. After delivery of a healthy baby, our patient's condition necessitated tracheal intubation. A fiber-optic bronchoscope loaded with an Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) was passed through the laryngeal mask airway into the trachea until just above the carina, but was too short to safely allow for the passage of an endotracheal tube.
We present a novel technique in which the Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) was replaced with a longer (100 cm) exchange catheter, over which an endotracheal tube was passed successfully into the trachea.
PMCID: PMC3353199  PMID: 22502764
18.  Parker Flex-Tip and Standard-Tip Endotracheal Tubes: A Comparison During Nasotracheal Intubation 
Anesthesia Progress  2010;57(1):18-24.
The placement of endotracheal tubes in the airway, particularly through the nose, can cause trauma. Their design might be an important etiologic factor, but they have changed little since their introduction. Recently Parker Medical (Bridgewater, Conn ) introduced the Parker Flex-Tip (PFT) tube, suggesting that it causes less trauma. This study aimed to compare the PFT endotracheal tube to a side-beveled, standard-tip endotracheal tube (ETT) for nasotracheal intubation (Figures 1 and 2). Forty consecutive oral surgery patients requiring nasotracheal intubation were randomized to receive either a standard ETT or the PFT tube. Intubations were recorded using a fiber-optic camera positioned proximal to the Murphy eye of the tube. This allowed visualization of the path and action of the tube tip as it traversed the nasal, pharyngeal, laryngeal, and tracheal airway regions. Video recordings made during intubation and extubation were evaluated for bleeding, trauma, and intubation time. Both bleeding and trauma were recorded using a visual analogue scale (VAS) and by 3 different evaluators. The PFT received significantly better VAS values than the standard tubes from all 3 raters (P < 0.05) in both the extent of trauma and bleeding. Since the intubations were purposefully conducted slowly for photographic reasons, neither tube displayed a time advantage. This study suggests that the PFT tube design may be safer by causing less trauma and bleeding than standard tube designs for nasotracheal intubation.
PMCID: PMC2844234  PMID: 20331335
Nasotracheal intubation; Parker Flex-Tip tube; Endotracheal intubation; Endotracheal tube; Fiber-optic intubation
19.  Endotracheal intubation through the intubating laryngeal mask airway (LMA-Fastrach™): A randomized study of LMA- Fastrach™ wire-reinforced silicone endotracheal tube versus conventional polyvinyl chloride tracheal tube 
Indian Journal of Anaesthesia  2013;57(1):19-24.
A wire-reinforced silicone tube (LMA-Fastrach™ endotracheal tube) is specially designed for tracheal intubation using intubating laryngeal mask airway (ILMA). However, conventional polyvinyl chloride (PVC) tracheal tubes have also been used with ILMA to achieve tracheal intubation successfully.
To evaluate the success of tracheal intubation using the LMA-Fastrach™ tracheal tube versus conventional PVC tracheal tube through ILMA.
Settings and Design:
Two hundred adult ASA physical status I/II patients, scheduled to undergo elective surgery under general anaesthesia requiring intubation, were randomly allocated into two groups.
The number of attempts, time taken, and manoeuvres employed to accomplish tracheal intubation were compared using conventional PVC tubes (group I) and LMA-Fastrach™ wire-reinforced silicone tubes (group II). Intraoperative haemodynamic changes and evidence of trauma and postoperative incidence of sore throat and hoarseness, were compared between the groups.
Statistical Analysis:
The data was analyzed using two Student's t test and Chi-square test for demographics and haemodynamic parameters. Mann Whitney U test was used for comparison of time taken for endotracheal tube insertion. Fisher's exact test was used to compare postoperative complications.
Rate of successful tracheal intubation and haemodynamic variables were comparable between the groups. Time taken for tracheal intubation and manoeuvres required to accomplish successful endotracheal intubation, however, were significantly greater in group I than group II (14.71±6.21 s and 10.04±4.49 s, respectively (P<0.001), and 28% in group I and 3% in group II, respectively (P<0.05)).
Conventional PVC tube can be safely used for tracheal intubation through the ILMA.
PMCID: PMC3658329  PMID: 23716761
Fastrach; intubating laryngeal mask airway; polyvinyl chloride; tracheal intubation
20.  Submandibular Approach for Tracheal Intubation – A Case Report 
Indian Journal of Anaesthesia  2009;53(1):84-87.
Intubating a patient with panfacial fractures is always a challenge to the anaesthesiologist. In a 40-yr-old male patient with left Le Fort's III fracture with nasal bone and symphysis menti fracture, we successfully carried out oral endotracheal intubation which was then modified to submandibular approach to provide adequate surgical field. Initially oral endotracheal intubation was performed, then an incision was made in the submandibular region through which the endotracheal tube was brought out and maintained as submandibular approach throughout the surgery.
PMCID: PMC2900041  PMID: 20640085
Submandibular intubation; Maxillofacial surgeries; Panfacial fractures; Le Fort's fracture
21.  Prosthognathic Rehabilitation of A Patient with Underlying Skeletal Discrepancy- A Case Report 
Vertical and anterioposterior maxillary excesses can be treated with a combination of orthopaedic functional appliances, orthodontics and surgery. Treatment varies according to the age, patient reports for treatment. In patients who are treated with either of the above mentioned treatment modalities, if they require prosthetic replacement on a later date, especially of anterior teeth, prosthetic treatment alone does not give an aesthetic outcome. A partially edentulous, elderly patient with underlying skeletal discrepancy (Class II Skeletal deformity) in relation to 12,11,21,22 was treated with a combination of orthognathic surgery and prosthetic rehabilltation. An orthognathic surgery (leforte I osteotomy) was performed to manage vertical maxillary excess, class II skeletal pattern of maxilla and increased lower third facial height. Dental compensations in the mandibular arch were decompensated surgically with lower subapical osteotomy. Prosthetic restorations of missing anterior teeth were done later, such that facial and dental aesthetics. The records showed that the results were stable 12 months after prosthognathic (prosthodontic and orthognathic) treatment. A team approach enabled the female patient in her fifth decade of life, to receive better function, aesthetics and increased quality of life. Doing prosthetic restorations in patients with underlying skeletal discrepancies may become a challenge , which should be achieved without compromising on final outcome, with a calculated risk benefit ratio.
PMCID: PMC4003664  PMID: 24783156
Prosthognathic; Orthognathic surgery; Fixed prosthesis
22.  Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia 
Critical Care  2014;18(2):R77.
The use of a system for continuous control of endotracheal tube cuff pressure reduced the incidence of ventilator-associated pneumonia (VAP) in one randomized controlled trial (RCT) with 112 patients but not in another RCT with 142 patients. In several guidelines on the prevention of VAP, the use of a system for continuous or intermittent control of endotracheal cuff pressure is not reviewed. The objective of this study was to compare the incidence of VAP in a large sample of patients (n = 284) treated with either continuous or intermittent control of endotracheal tube cuff pressure.
We performed a prospective observational study of patients undergoing mechanical ventilation during more than 48 hours in an intensive care unit (ICU) using either continuous or intermittent endotracheal tube cuff pressure control. Multivariate logistic regression analysis (MLRA) and Cox proportional hazard regression analysis were used to predict VAP. The magnitude of the effect was expressed as odds ratio (OR) or hazard ratio (HR), respectively, and 95% confidence interval (CI).
We found a lower incidence of VAP with the continuous (n = 150) than with the intermittent (n = 134) pressure control system (22.0% versus 11.2%; p = 0.02). MLRA showed that the continuous pressure control system (OR = 0.45; 95% CI = 0.22-0.89; p = 0.02) and the use of an endotracheal tube incorporating a lumen for subglottic secretion drainage (SSD) (OR = 0.39; 95% CI = 0.19-0.84; p = 0.02) were protective factors against VAP. Cox regression analysis showed that the continuous pressure control system (HR = 0.45; 95% CI = 0.24-0.84; p = 0.01) and the use of an endotracheal tube incorporating a lumen for SSD (HR = 0.29; 95% CI = 0.15-0.56; p < 0.001) were protective factors against VAP. However, the interaction between type of endotracheal cuff pressure control system (continuous or intermittent) and endotracheal tube (with or without SSD) was not statistically significant in MLRA (OR = 0.41; 95% CI = 0.07-2.37; p = 0.32) or in Cox analysis (HR = 0.35; 95% CI = 0.06-1.84; p = 0.21).
The use of a continuous endotracheal cuff pressure control system and/or an endotracheal tube with a lumen for SSD could help to prevent VAP in patients requiring more than 48 hours of mechanical ventilation.
PMCID: PMC4057071  PMID: 24751286
23.  A comparison of conventional tube and EndoFlex tube for tracheal intubation in patients with a cervical spine immobilisation 
The EndoFlex is a new type of tracheal tube with an adjustable distal tip that can be bent without the use of a stylet. The aim of this study was to compare a standard endotracheal tube with the EndoFlex tracheal tube for intubation in patients with simulated cervical spine injury.
A group of 60 patients without any kind of the cervical spine injury, classified as the ASA physiological scale I or II and qualified for elective surgery procedures were intubated with the use of classical Macintosh laryngoscope, and either a standard endotracheal tube with the intubation stylet in it or EndoFlex tube without stylet. The subjects were randomized into two subgroups. All patients have had the cervical collar placed on their neck for the simulation of intubation procedure in case of the spinal injury.
The intubation procedure was performed by 16 anesthetists with different experience (5-19 yrs). Time of intubation with the use of EndoFlex tube was similar to that with a the use of standard endotracheal tube and intubation stylet: Me (median) 19.5 s [IQR (interquatile range) 18-50] vs. Me 20 s [IQR 17-60] respectively (p = 0.9705). No significant additional maneuvers were necessary during intubation with the use of EndoFlex tube in comparison with standard endotracheal tube (70% vs. 56.6%) (p = 0.4220). Subjective assessment of the usability of both tubes revealed that more anesthesiologists found intubations with the use of EndoFlex more demanding than intubation with conventional tracheal tube and intubation stylet. The assessment of usability: very easy 3.3% vs. 20%, easy 83.4% vs. 56.7%, difficult 10% vs. 20% and very difficult 3.3% vs. 3.3% for standard endotracheal tube with stylet and EndoFlex, respectively.
In conclusion we asses, that the EndoFlex tube does not improve intubation success rate, in fact it requires more maneuvers facilitating intubation and was found to be more difficult to use.
PMCID: PMC4222123  PMID: 24267640
Intubation; Cervical collar; EndoFlex
24.  Endonasal endoscopic dacryocystorhinostomy: our experience 
To study the outcome of endonasal endoscopic dacryocystorhinostomy (DCR) with or without mucosal flap preservation, without mitomycin local application, silicon tube stenting or laser assistance. To determine the duration of the surgical procedure of DCR, influence of simultaneously performed endonasal endoscopic procedures for concomitant sinonasal diseases.
Combined retrospective and prospective study in our tertiary referral center. 24 patients with chronic dacryocystitis underwent 25 standard endonasal endoscopic DCR procedures, 10 with and 15 without mucosal flap preservation. 6 of these had concomitant sinonasal diseases for which they underwent septoplasty or functional endoscopic sinus surgery (FESS) or both, simultaneously or as staged procedures. Relief from epiphora and patency of the nasolacrimal fistula was assessed by nasal endoscopy and syringing of the lacrimal apparatus at 1 week, 3 weeks and 3 months postoperatively.
Out of 18 patients who underwent only DCR, 17 patients (94.44%) had complete relief from epiphora. Out of 6 patients who underwent 7 DCRs with concomitant sinonasal surgery, 5 patients (85.71%) had complete relief from epiphora. Overall 23 out of 25 DCRs (92%) had complete relief. In 15 of the 25 procedures, mucosal flap was excised completely. In remaining 10 procedures, flap was trimmed, repositioned to cover exposed bone around the newly created nasolacrimal fistula. In either situation, only one patient each had partial block of the nasolacrimal fistula. Average duration of the surgical procedure of DCR was 18 min.
Endonasal endoscopic DCR is a viable alternative to external DCR, co-existing sinonasal diseases can be managed simultaneously, as may be required in 25% of cases. It can be performed under 20 min without mucosal flap preservation, mitomycin local application, silicon tube stenting or laser assistance and can still provide a good success rate (92%) with less complications.
PMCID: PMC3449975  PMID: 23120640
Epiphora; Endoscopic dacryocystorhinostomy; DCR; Mucosal flap
25.  Vocal cord paralysis following orthognathic surgery intubation 
Annals of Maxillofacial Surgery  2011;1(2):166-168.
The incidence of recurrent laryngeal nerve paralysis following short-term oro-endotracheal intubation for any surgical procedure is very rare. The diagnosis becomes very difficult if the surgical procedure may alter the vocal characteristics following surgery. We report a case of a 24 year-old healthy male patient who developed prolonged hoarseness which developed after having undergone a bimaxillary orthognathic surgical procedure. Following surgery, the patient's complaints of hoarseness and mild coughing on taking thin liquids were investigated with the assistance of the otolarynology voice department. A flexible fiberoptic laryngoscopy and videostroboscopy showed a partial paralysis of the left vocal cord suggesting damage to the left recurrent laryngeal nerve. The recovery was gradual and resolved without any intervention in approximately 6 weeks. Prolonged change or loss of voice quality following an orthognathic surgical procedure, as discussed in this case, when associated with difficulty in swallowing thin or thick liquids warrants a thorough investigation and can be managed at times with observation alone.
PMCID: PMC3591023  PMID: 23483672
Oro-endotracheal intubation; orthognathic surgery; prolonged hoarseness; recurrent laryngeal nerve paralysis

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