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1.  Unintended Avulsion of Hypertrophic Adenoids in Posterior Nasopharynx: A Case Report of a Rare Complication Caused by Nasotracheal Intubation 
Case Reports in Anesthesiology  2014;2014:980930.
The enlarged adenoid serves as a mechanical obstacle on the nasopharynx to intricate nasotracheal intubation. No matter what video or direct laryngoscopic techniques are applied, nasotracheal tube navigation from the nasal valve area through the nasal cavity to the nasopharynx is always blind; trauma is not uncommon. Here we report a case of unintended avulsed adenoids that plugged the tube tip while the nasotracheal tube blindly navigated through the nasopharyngeal space. After failing to insert a bent tip of gum elastic bougie passing through the nasopharynx, an alternative method of NTI was performed by mounting the nasotracheal tube on a fiberoptic bronchoscope. The nasotracheal tube was successfully railroaded along the insertion tube of the fiberscope to the trachea.
doi:10.1155/2014/980930
PMCID: PMC4095712  PMID: 25057416
2.  One lung ventilation in a patient with an upper and lower airway abnormality 
Indian Journal of Anaesthesia  2012;56(6):567-569.
One-lung ventilation for a thoracotomy procedure was achieved with the help of a endobronchial blocker in a young girl with limited mouth opening, minimal neck extension, and a distorted tracheo-bronchial anatomy. As the patient would not cooperate for an awake nasotracheal intubation despite adequate preperation, an inhalational anesthetic was used to make the patient unconscious, taking care that spontaneous breathing was maintained. Nasotracheal intubation was done with the help of a fiberoptic bronchoscope. A wire-guided Arndt endobronchial blocker was placed coaxially through the endotracheal tube using a fiberoptic bronchoscope. This case report highlights that in a scenario of both upper and lower airway distortion, a bronchial blocker positioned through a nasotracheal tube under fiberoptic guidance might be the best option when one-lung ventilation is required.
doi:10.4103/0019-5049.104578
PMCID: PMC3546245  PMID: 23325943
Bronchoscopy; fiberoptic; Intratracheal intubation; nasotracheal; thoracic surgical procedures
3.  Tramadol combined with fentanyl in awake endotracheal intubation 
Journal of Thoracic Disease  2013;5(3):270-277.
Objective
To explore the feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation.
Methods
Using Dixon’s up-and-down sequential design, the study enrolled patients from each of the 20-49, 50-60 and 70-and-above age groups scheduled for elective surgery under general anesthesia. The feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation, guided by fiberoptic bronchoscopy, were verified.
Results
After intravenous injection with fentanyl 2.2 μg/kg and tramadol 2.0 mg/kg in the 20-49 age group, fentanyl 1.6 μg/kg and tramadol 1.9 mg/kg in the 50-69 age group and fentanyl 1 μg/kg and tramadol 1.8 mg/kg in those at the age of 70 or above, the patients achieved conscious sedation without obvious respiratory depression. Meanwhile, under these dosages, the patients could easily tolerate the thyrocricocentesis airway surface anesthesia and fiberoptic bronchoscope guided tracheal intubation. Postoperative follow-up showed that most patients had memory of the intubation process but without significant discomfort. No awake endotracheal intubation-related side effect was noted.
Conclusions
Fiberoptic bronchoscope guided nasotracheal intubation can be successfully completed with background administration of fentanyl and tramadol. However, the specific dosages need to be tailored in different age of patients.
doi:10.3978/j.issn.2072-1439.2013.03.10
PMCID: PMC3698251  PMID: 23825758
Awake endotracheal intubation; fiberoptic bronchoscope; nasotracheal intubation; fentanyl; tramadol
4.  Incidence and predictors of difficult nasotracheal intubation with airway scope 
Journal of Anesthesia  2014;28(5):650-654.
Purpose
The airway scope (AWS) improves views of the larynx during orotracheal intubation. However, the role of the AWS in routine nasotracheal intubation has not been studied adequately.
Methods
One hundred and three patients undergoing dental and maxillofacial surgery that required general anesthesia and nasotracheal intubation were enrolled. The study was approved by our Institution Review Board, and written informed consent was obtained from all patients. We evaluated the success rate of AWS intubation and the incidence of difficult nasotracheal intubation using a modified intubation difficulty scale (IDS) to examine preoperative characteristics and intubation profiles. Categories were difficult intubation (IDS ≥5), mildly difficult (IDS = 1–4), and intubation without difficulty (IDS = 0). We also assessed the incidence of the use of Magill forceps or cuff inflation (the cuff of endotracheal tube is inflated with 10–15 ml air) to guide the endotracheal tube into the glottis.
Results
AWS nasotracheal intubation was 100 % successful. The cuff inflation technique was used in 37 patients. Neither Magill forceps nor other devices were needed for any patient during AWS use. The incidence of difficult nasotracheal intubation was 10 % (n = 10). Of the patients, 61 % (n = 63) had mildly difficult intubation and 29 % (n = 30) had no difficulty. Patients with difficult intubation were more likely to be male and to have a larger tongue and a higher Cormack grade than in the other two groups. Complications, involving minor soft tissue injury, were observed in only 1 patient (1 %).
Conclusion
The AWS achieves a high success rate for nasotracheal intubation with cuff inflation in patients undergoing dental and maxillofacial surgery.
doi:10.1007/s00540-013-1778-2
PMCID: PMC4194022  PMID: 24435879
Airway scope; Video laryngoscope; Difficult nasotracheal intubation
5.  Midline Submental Orotracheal Intubation in Maxillofacial Injuries: A Substitute to Tracheostomy Where Postoperative Mechanical Ventilation is not Required 
Background:
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.
Conclusion:
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
6.  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.
doi:10.5681/jcvtr.2013.032
PMCID: PMC3883537  PMID: 24404345
Blind Intubation; Warming; Endotracheal Tube; Oral and Maxillofacial Surgery; Anesthesia
7.  Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children 
Background:
Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process.
Materials and Methods:
30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place.
Results:
Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15).
Conclusion:
In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.
doi:10.4103/0970-9185.105797
PMCID: PMC3590542  PMID: 23493291
Difficult; equipment; fiberoptic bronchoscope; intubation; laryngeal mask airway; modified oropharyngeal Guedel airway; tracheal
8.  Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel–Feil syndrome 
Saudi Journal of Anaesthesia  2014;8(3):412-414.
The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA.
doi:10.4103/1658-354X.136637
PMCID: PMC4141399  PMID: 25191201
Fiberoptic intubation; Klippel-Feil syndrome; laryngeal mask airway; The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children
9.  Usefulness of a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome -A case report- 
Korean Journal of Anesthesiology  2013;64(2):168-171.
The case of a 33-day-old boy with Pierre Robin syndrome using a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation is presented. After induction with sevoflurane, classical reusable laryngeal mask airway (LMA) #1 was inserted and ultrathin fiberoptic bronchoscope (FOB) was passed through. A Cook® airway exchange catheter (1.6 mm ID, 2.7 mm OD) was passed through the LMA under the guidance of the FOB but failed to enter the trachea despite many trials. Then, an endotracheal tube (3.0 mm ID) was mounted on the FOB and railroaded over the FOB. After successful intubation, the Cook® airway exchange catheter was placed in the midtrachea through the lumen of the endotracheal tube. Even though the tracheal tube was accidentally displaced out of the trachea during LMA removal, the endotracheal tube could be easily railroaded over the airway exchange catheter.
doi:10.4097/kjae.2013.64.2.168
PMCID: PMC3581788  PMID: 23458916
Airway exchange catheter; Fiberoptic intubation; Laryngeal mask airway; Pierre robin syndrome
10.  Parker Flex-Tip and Standard-Tip Endotracheal Tubes: A Comparison During Nasotracheal Intubation 
Anesthesia Progress  2010;57(1):18-24.
Abstract
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.
doi:10.2344/0003-3006-57.1.18
PMCID: PMC2844234  PMID: 20331335
Nasotracheal intubation; Parker Flex-Tip tube; Endotracheal intubation; Endotracheal tube; Fiber-optic intubation
11.  Acute obstruction of an endotracheal tube: a case report. 
Anesthesia Progress  2004;51(2):62-64.
This report describes a case of sudden ventilatory failure, originally diagnosed as bronchospasm, in a child during general anesthesia. A blood clot impaction in the nasotracheal tube was detected using flexible fiberoptic bronchoscopy. The clot was successfully treated as a result of its passage. We hope this report will stress to dental anesthesiologists the intraoperative importance of fiberoptic bronchoscopy not only as an intubation-aiding device but also as a diagnostic and therapeutic tool.
Images
PMCID: PMC2007470  PMID: 15366320
12.  Nasotracheal Fiberoptic Intubation: Patient Comfort, Intubating Conditions and Hemodynamic Stability During Conscious Sedation with Different Doses of Dexmedetomidine 
The study aims to evaluate the efficacy of two doses of dexmedetomidine for sedation during awake fiberoptic intubation (AFOI). The study was designed in a prospective, randomized, double-blinded manner and carried out in an academic medical university. Forty young co-operative patients aged 15–45 years of either sex belonging to ASA class I-II, planned for elective maxillo-facial surgery formed the study group. All patients received midazolam 0.05 mg/kg, glycopyrrolate 0.2 mg, ondansetron 4 mg, and ranitidine 50 mg IV 15 min before as premedication, oxygen by nasal cannula, and topical local anesthetics to the airway. Patients were randomly assigned to one of the groups; dexmedetomedine 1 μg/kg IV (Group L), or dexmedetomidine 1.5 μg/kg IV (Group H). Observer’s Assessment of Alertness/Sedation (OAA/S) was assessed. Primary outcome measurements were: HR, MAP, SpO2 and EtCO2 and secondary outcome measurements were: intubation scores by vocal cord movement, coughing and limb movement, fiberoptic intubation comfort score, nasotracheal intubation score and airway obstruction score. On the first post-operative day, recall, level of discomfort during fiberoptic intubation, adverse events and satisfaction score were also assessed. There were no significant hemodynamic differences between the two groups. OAA/S was significantly better with dexmedetomidine 1.5 μg/kg (p < 0.05) and patients were significantly calmer, more cooperative and satisfied during awake fiberoptic intubation with dexmedetomidine 1.5 μg/kg with fewer transient adverse effects. Dexmedetomidine 1.5 μg/kg proved to be more effective for sedation for awake fiberoptic intubation.
doi:10.1007/s12663-012-0469-0
PMCID: PMC3955476  PMID: 24644397
Dexmedetomidine; Awake fiberoptic intubation
13.  Nasotracheal Fiberoptic Intubation: Patient Comfort, Intubating Conditions and Hemodynamic Stability During Conscious Sedation with Different Doses of Dexmedetomidine 
The study aims to evaluate the efficacy of two doses of dexmedetomidine for sedation during awake fiberoptic intubation (AFOI). The study was designed in a prospective, randomized, double-blinded manner and carried out in an academic medical university. Forty young co-operative patients aged 15–45 years of either sex belonging to ASA class I-II, planned for elective maxillo-facial surgery formed the study group. All patients received midazolam 0.05 mg/kg, glycopyrrolate 0.2 mg, ondansetron 4 mg, and ranitidine 50 mg IV 15 min before as premedication, oxygen by nasal cannula, and topical local anesthetics to the airway. Patients were randomly assigned to one of the groups; dexmedetomedine 1 μg/kg IV (Group L), or dexmedetomidine 1.5 μg/kg IV (Group H). Observer’s Assessment of Alertness/Sedation (OAA/S) was assessed. Primary outcome measurements were: HR, MAP, SpO2 and EtCO2 and secondary outcome measurements were: intubation scores by vocal cord movement, coughing and limb movement, fiberoptic intubation comfort score, nasotracheal intubation score and airway obstruction score. On the first post-operative day, recall, level of discomfort during fiberoptic intubation, adverse events and satisfaction score were also assessed. There were no significant hemodynamic differences between the two groups. OAA/S was significantly better with dexmedetomidine 1.5 μg/kg (p < 0.05) and patients were significantly calmer, more cooperative and satisfied during awake fiberoptic intubation with dexmedetomidine 1.5 μg/kg with fewer transient adverse effects. Dexmedetomidine 1.5 μg/kg proved to be more effective for sedation for awake fiberoptic intubation.
doi:10.1007/s12663-012-0469-0
PMCID: PMC3955476  PMID: 24644397
Dexmedetomidine; Awake fiberoptic intubation
14.  Foot length, an accurate predictor of nasotracheal tube length in neonates 
BACKGROUND—Existing guidelines for optimal positioning of endotracheal tubes in neonates are based on scanty data and relate to measurements that are either non-linear or poorly reproducible in sick infants. Foot length can be measured simply and rapidly and is related to a number of external body measurements.
OBJECTIVES—To evaluate the relation of foot length to nasotracheal length in direct measurements at post mortem examinations, and then compare its clinical relevance with traditional weight based estimates in a randomised controlled trial.
METHODS—The dimensions of the upper airway were measured at autopsy in 39 infants with median (range) postmenstrual age and birth weight of 32 (24-43) weeks and 1630 (640-3530) g. The regression equations with 95% prediction intervals were calculated to estimate the optimal nasotracheal length from foot length. In a randomised trial, 59 neonates were nasally intubated according to foot length and body weight based estimates to assess the achievement of "optimal" and "satisfactory" tube placements.
RESULTS—In the direct measurements of the airway at autopsy, foot length was a better predictor of nasotracheal distances (r2 = 0.79) than body weight, gestational age, and head circumference (r2 = 0.67, 0.58, and 0.60 respectively). Measurement of foot length was easy and highly reproducible. In the randomised controlled trial, there were no significant differences between the foot length and body weight based estimates in the rates of optimal (44% v 56%) and satisfactory (83% v 72%) endotracheal tube placements.
CONCLUSIONS—Foot length is a reliable and reproducible predictor of nasotracheal tube length and is at least as accurate as the conventional weight based estimation. This method may be particularly valuable in sick unstable infants.


doi:10.1136/fn.85.1.F60
PMCID: PMC1721291  PMID: 11420326
15.  Airway Management in Maxillofacial Trauma: Do We Really Need Tracheostomy/Submental Intubation 
Background: There are various techniques available for airway management in patients with maxillofacial trauma. Patients with panfacial injuries may need surgical airway access like submental intubation or tracheostomy, which have their associated problems. We have been managing these types of cases by a novel technique, i.e, intraoperative change of nasotracheal to orotracheal intubation.
Aim: To review our experience about various techniques for the airway management in patient with maxillofacial trauma. To analyse the possibility of using nasotracheal intubation and intraoperative change of nasotracheal to orotracheal intubation in panfacial fractures.
Materials and Methods: In a tertiary care centre four hundred eighty seven patients of maxillofacial injuries, operated over a period of 2 years were reviewed in relation to age, sex, mode of injury, type of facial fractures, methods of airway management and their associated complications.
Results: Young patients with male predominance is the most common affected population. Panfacial fracture is the most common type of injury (39.83%) among facial fractures. Airway was managed with intraoperative change of nasotracheal to orotracheal intubation in 33.05% of the patients whereas submental intubation or tracheostomy was done in 8.62% of the patients.
Conclusion: Nasal route for endotracheal intubation is not a contraindication in the presence of nasal fractures, base of skull fractures and CSF leak. By changing the nasotracheal intubation to orotracheal intubation intraoperatively in cases panfacial fractures, most of the tracheostomies and submental intubations can be avoided.
doi:10.7860/JCDR/2014/7861.4112
PMCID: PMC4003693  PMID: 24783087
Maxillofacial trauma; Airway management; Naso-tracheal intubation; Oro-tracheal intubation
16.  Facilitation of fiberoptic nasotracheal intubation with magnesium sulfate: A double-blind randomized study 
Background:
A double-blinded, prospective, and randomized study was designed to determine the efficacy and tolerability of intravenous (IV) magnesium sulfate (MgSO4) to facilitate fiberoptic bronchoscopic (FOB) nasotracheal intubations.
Patients and Methods:
A total of 120 patients scheduled to undergo elective awake fiberoptic nasotracheal intubation, while they were anesthetized for elective surgery were randomly allocated to one of three groups: The control Group S (n = 40) received 100 ml (50 ml 0.9% saline + 50 ml paracetamol) was infused in 10 min and direct IV 5 ml 0.9% normal saline, Group MD (n = 40): Received midazolam IV in a dose of 0.07 mg/kg in 5 ml 0.9% normal saline and 100 ml 0.9% was infused in 10 min and Group MS (n = 40): IV 45 mg/kg MgSO4 10 min in 100 ml of 0.9% normal saline through 10 min and direct IV 5 ml 0.9% normal saline.
Results:
Time required for nasotracheal intubation was significantly less in group Groups MD and MS, as compared with the control group, but not significant between the two groups. (Group MD: 9.05 + 1.95 min, Group MS 3.75 + 0.75 min and Group S 16.85 + 1.7 min). However, the number of fiberoptic intubation was significantly more in the MD and MS groups, as compared with the control group. Easy intubation (control group: 0, Group MD: 25 and Group MS: 35), moderate difficulty (control group: 5, Group MD: 12 and Group MS: 4) and difficult (control group: 35, Group MD: 3 and Group MS: 1). Procedure adverse events were significantly lower in Group MS. None of the patients in Group MS had procedure hypoxia, but it occurred in 10 patients of Group MD and 20 patients in Group S. Six patients in Group S and two in Group MD had procedure apnea whereas, none of the patients in the MS group experienced this. After medication and just before intubation heart rate and mean arterial pressure were significantly less in Groups MD and MS, as compared to the control group (Group MD: 77 + 7.7 beat/min, Group MS: 70 + 5.6 beat/min and Group S: 80 + 7.8 beat/min) (Group MD: 90 + 8.5 mmHg, Group MS: 80 + 8.1 mmHg and Group S: 105 + 10.5 mmHg). This difference however, significant between Group MD and Group MS.
Conclusion:
Intravenous MgSO4 improved awaken FOB intubation without adverse hemodynamic or respiratory effects.
doi:10.4103/0259-1162.143111
PMCID: PMC4258977
Fiberoptic; magnesium sulfate; nasotracheal intubation
17.  Tracheal compression during shoulder arthroscopy in the beach-chair position 
Background: Respiratory distress is a rare complication of outpatient shoulder arthroscopy and mostly associated with general anesthesia, pneumothorax, anaphylaxis, or phrenic nerve paralysis.
Objective: We report on a shoulder arthroscopy complicated by tracheal compression caused by extravasation of irrigation fluid into soft tissues of the upper airway while the patient was in the beach-chair position under general anesthesia.
Case Summary: A 33-year-old male was scheduled for shoulder arthroscopy for impingement syndrome of the right shoulder under general anesthesia combined with interscalene brachial plexus block. During the operation, the patient's neck, right chest, and shoulder were observed to be swollen and tense on palpation. A fiberoptic bronchoscopic evaluation through the endotracheal tube revealed that the trachea was compressed to the left, but not completely obstructed. It was determined that the irrigation fluid had leaked subcutaneously from the shoulder joint to the neck. Vital signs were stable and the patient could be adequately ventilated despite the airway obstruction. The patient was transferred to the ward 16 hours after the operation with stable vital signs and discharged from the hospital on the second day.
Conclusions: We report a case of airway obstruction due to tracheal compression from extravasation of irrigation fluid during shoulder arthroscopy under general anesthesia combined with peripheral nerve block in the beach-chair position. General anesthesia with endotracheal intubation protected the patient from a possibly fatal complication.
doi:10.1016/S0011-393X(10)80006-2
PMCID: PMC3969593  PMID: 24688159
shoulder arthroscopy; general anesthesia; tracheal compression; beach-chair position
18.  Variables Associated with Successful Intubation Attempts Using Video Laryngoscopy: A Preliminary Report in a Helicopter Emergency Medical Service 
Background
Multiple studies have demonstrated varying rates of successful endotracheal intubation (ETI). Until the application of video laryngoscopy, little information regarding prehospital intubation could be analyzed objectively by individuals other than the provider performing the ETI.
Objective
To evaluate the association of variables recorded during video laryngoscopy and successful ETI attempts, defined as placing the endotracheal tube in the trachea.
Methods
We retrospectively reviewed intubations performed by a single helicopter emergency medical service (HEMS) using a video larygoscope from March 1, 2010, to October 1, 2010. All videos were de-identified and analyzed by a single researcher. Time intervals (e.g., attempt time) and intubation process variables (e.g., Cormack-Lehane [C-L] view) were abstracted from all videos. Time intervals were begun when the laryngoscope blade passed the lips and entered the oral cavity (entry). We describe variables using means and standard deviations (continuous), medians with interquartile ranges (ordinal), and percentages with 95% confidence intervals (categorical). We then looked at univariate associations between these variables and ETI success using logistic regression.
Results
We recorded 116 intubations during the study period. Twenty-nine recordings were either incomplete (n = 26) or of insufficient quality for analysis (n = 3). The remaining 87 videos represented 87 different patients with a total of 102 attempts at laryngoscopy. Thirty-six providers performed 64 cases, with the majority of providers (n = 21) performing only one intubation. The first-pass success rate in this series was 76% (n = 66), with 98% success within three attempts. Successful ETI attempts had lower entry–to–percentage of glottic opening (POGO) times (16.6 sec vs. 32.1 sec, p = 0.013), entry–to–first view of the endotracheal tube or entry-to-tube times (17.6 sec vs. 27.4 sec, p = 0.04), higher POGO scores (76 vs. 39, p < 0.001), and a lower C-L view (one vs. three, p < 0.001). Recognized esophageal intubation was more likely to occur during unsuccessful ETI attempts (43% vs. 8%, p < 0.001).
Conclusion
Video laryngoscopy can measure multiple components of ETI performance. Successful ETI attempts have significantly shorter entry-to-POGO times and entry-to-tube times, obtain better views of the glottic opening (POGO and C-L view), and have a lower incidence of recognized esophageal intubation.
doi:10.3109/10903127.2011.640764
PMCID: PMC3603855  PMID: 22191806
airway; intubation; video laryngoscopy; helicopter emergency medical service (HEMS)
19.  Appropriate Head Position for Nasotracheal Intubation by Using Lightwand Device (Trachlight) 
Anesthesia Progress  2014;61(2):47-52.
The purpose of this study was to determine the relationship between the head position and the subsequent ease of nasotracheal intubation by using the lightwand device Trachlight (TL). Patients requiring nasotracheal intubation were subdivided into 3 groups according to the intubated head position (group S: sniffing position; group E: extension position; and group N: neutral position). The number of attempts, the total intubation time, and the failures of the TL intubation were recorded. Intubation difficulty by means of TL was assessed by the ordinal 6-point scale. Of the 300 patients enrolled in the study, TL intubation was successful in 91.3% of them. There was no significant difference in the success rate of the first attempt between the groups. No correlation between the ordinal scale and the head position was observed. The total intubation time and the ratio of “unsuccessful” cases were not significantly different among the 3 groups. TL is an effective alternative for patients who require nasotracheal intubation. Our study did not determine the most favorable head position for nasotracheal intubation with the TL, so we recommend that nasotracheal intubation with TL be started with the head in the neutral position and then changed to a more appropriate position, if necessary, on an individual basis.
doi:10.2344/0003-3006-61.2.47
PMCID: PMC4068087  PMID: 24932977
Nasotracheal intubation; Lightwand device (Trachlight); Appropriate head position.
20.  Innovative use of the fiberoptic bronchoscope 
Tracheostomy can be challenging, especially in the presence of edema or infiltrative malignancy. We present a case in which a fiberoptic bronchoscope that is routinely used for difficult intubation helped to locate the trachea in an emergency situation. A 50 year-old male, a diagnosed case of anaplastic carcinoma of thyroid, presented with respiratory distress and was immediately taken to the operating theater for an emergency tracheostomy. Following an inhalational induction, the patient was intubated with an endotracheal tube. Surgical tracheostomy was extremely difficult as, on neck exploration, there was a plaque of disease infiltrating various tissue planes. When even after considerable dissection the trachea could not be located, we passed a fiberoptic bronchoscope through the endotracheal tube. This helped as it was seen as a trans- illumination and the tracheal position could be confirmed. The rest of the tracheostomy was uneventful.
doi:10.4103/0971-5851.107090
PMCID: PMC3618647  PMID: 23580826
Anaplastic carcinoma of thyroid; difficult tracheostomy; fiberoptic bronchoscope
21.  Emergency thyroidectomy: Due to acute respiratory failure 
Highlights
•CT scan has a great value for retrosternally extended giant goiter cases.•If the general status of the patient prevents CT scan, bedside ultrasound can be used instead.•Nasal awake intubiation is an appropriate choice for the patients with destructed trachea.•Emergency thyroidectomy is a common option for the treatment of giant goiter causing airway obstruction.
INTRODUCTION
Giant cervical and mediastinal goiter may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Here, we present a case admitted to the emergency service with a giant goiter along with respiratory failure and poor general health status, which required urgent surgical intervention.
PRESENTATION OF CASE
A 71-year-old female admitted to the emergency room with shortness of breath and poor general health status resulting from a giant cervical swelling progressively increased during the last 7 years and constituted severe respiratory failure which has become severe in the last one month. A giant nodular goiter of the left thyroid lobe extending retrosternally, causing tracheal compression, limiting the neck movements was detected with clinical examination and bedside ultrasound. Emergency thyroidectomy was planned. Fiberoptic-assisted awake nasal intubation was performed in the operating room. Emergency total thyroidectomy was performed for the life-threatening respiratory failure. Postoperative period was uneventful. She was transferred from intensive care unit to the ward on postoperative day 3 and was discharged from the hospital on the postoperative 7th day. Benign multinodular hyperplasia was reported on the histopathological report. Patient was included in routine follow-up.
DISCUSSION
In the present case tracheal destruction due to compression of the giant goiter was found in agreement with previous reports. Emergency thyroidectomy was performed after awake intubation since it is a common surgical option for the treatment of giant goiter causing severe airway obstruction.
CONCLUSION
Respiratory failure due to giant nodular goiter is a life-threatening situation and should be treated immediately by performing awake endotracheal intubation following emergency total thyroidectomy.
doi:10.1016/j.ijscr.2014.11.012
PMCID: PMC4276272  PMID: 25437688
Retrosternal; Giant goiter; Thyroidectomy; Awake intubation; Laryngotracheal compression; Respiratory failure
22.  Assessment of Truflex™ articulating stylet versus conventional rigid Portex™ stylet as an intubation guide with the D-blade of C-Mac™ videolaryngoscope during elective tracheal intubation: study protocol for a randomized controlled trial 
Trials  2013;14:298.
Background
A variety of videolaryngoscopes with angulated blade have been recently introduced into clinical practice. They provide an indirect view of the glottic structures in normal and challenging clinical settings. Despite the very good visualization of the laryngeal structures by these devices, the insertion and advancement of the endotracheal tube may be prolonged and occasionally fail as it does not conform to the enhanced angulation of the blade. To overcome this handicap, it is recommended to use a pre-shaped, styleted tracheal tube during intubation. Unfortunately, these malleable rigid stylets permit only a fixed shape to the advancing endotracheal tube. This may necessitate withdrawal of endotracheal tube-stylet assembly for reshaping, before undertaking a new attempt. This may cause soft tissue injury and hemodynamic disturbance.
This single-blinded randomized clinical trial aims to overcome these handicaps using a novel method of dynamically changing the shape of the advancing endotracheal tube by Truflex™ articulating stylet as per need during D-blade C-Mac™ videolaryngoscopy.
Methods
One hundred and fifty four patients between 18 and 60 years of age belonging to either sex undergoing tracheal intubation under uniform general anesthetic technique will be randomly divided into Portex™ malleable stylet group and Truflex™ articulating stylet group. The primary efficacy variable of success/failure between the two groups will be analyzed using the chi square test. For comparison of intubation times and the Intubation Difficulty Score, ANOVA will be used. Primary efficacy endpoint results will be successful or failed tracheal intubation in the first attempt, total intubation time and the intubation difficulty score. Secondary efficacy endpoints will be overall user satisfaction graded from 1 to 10 (1 = very poor, 10 = excellent), Cormack and Lehane’s grading, glotticoscopy time and ETT negotiation time and total number of intubation attempts. Result of safety endpoints will include dental and airway trauma, hemodynamic disturbances, arrhythmias or cardiac arrest.
Trial registration
Current Controlled Trials ISRCTN57679531; Date of registration 12/02/2013
doi:10.1186/1745-6215-14-298
PMCID: PMC3848553  PMID: 24041300
Videolaryngoscope; Tracheal intubation; Truflex stylet
23.  Endotracheal intubation with a video-assisted semi-rigid fiberoptic stylet by prehospital providers 
Background
Emergency medical technicians intubate patients in unfamiliar surroundings and with less than ideal positioning. This study was designed to evaluate advanced life support (ALS) emergency medical technicians' (EMTs) ability to successfully intubate a simulated airway using a video-assisted semi-rigid fiberoptic stylet, the Clarus Video System (CVS).
Methods
ALS EMTs were first shown a brief slideshow and three example videos and then given 20 min to practice intubating a mannequin using both the CVS and standard direct laryngoscopy (DL). The mannequin was then placed on the floor to simulate field intubation at the scene. Each participant was given up to three timed attempts with each technique. Endotracheal tube position was confirmed with visualization by one of the study authors. Comparisons and statistical analysis were conducted using SPSS® Statistics 21 (IBM®). Demographics and survey results were also collected and analyzed.
Results
The median total time for intubation was 15.00 s for DL and 15.50 s for CVS revealing no significant difference between the two techniques (p = 0.425), and there was no significant difference in the number of attempts required to successfully place the endotracheal tube (ETT) (p = 0.997). Demographic factors including handedness and eye dominance did not seem to affect outcomes. Participants reported a relatively high level of satisfaction with the CVS.
Conclusions
ALS EMTs were able to obtain intubation results similar to those of their usual direct laryngoscopy technique when utilizing a video-assisted semi-rigid fiberoptic stylet with very limited instruction and experience with the device. The CVS technique warrants further study for use as an alternative to DL and video laryngoscopy in the prehospital difficult airway scenario.
doi:10.1186/s12245-014-0045-0
PMCID: PMC4269860  PMID: 25593618
Airway; Clarus Video System; Emergency; EMS; EMT; Fiber optic; Fiberoptic; Laryngoscopy; Levitan; Optical; Prehospital; Shikani; Stylet; Video
24.  Failed nasal intubation after successful flexible bronchoscopy: Guide wire to the rescue 
Flexible fiberoptic bronchoscope-guided awake intubation is the most trusted technique for managing an anticipated difficult airway. Even after successfully negotiating the bronchoscope into the trachea, the possibility remains that the preloaded tracheal tube might prove to be inappropriately large, and may not negotiate the nasal structures. In such a situation, the most obvious solution is to take out the bronchoscope, replace the tracheal tube with a smaller one, and repeat the procedure. Unfortunately, sometimes the second attempt is not as easy as the first, as minor trauma during the earlier attempt causes tissue edema and bleeding, which makes the subsequent bronchoscopic view hazy and difficult. We present the anesthetic management of five cases with temporomandibular joint ankylosis where, after successful, though slightly traumatic, bronchoscope insertion into the trachea, the tube could not be threaded in. We avoided a repeat bronchoscopy by making an innovative change in the plan.
doi:10.4103/0970-9185.83692
PMCID: PMC3161472  PMID: 21897518
Flexible fiberoptic bronchoscope; guide wire; intubation; nasal
25.  GlideScope and Frova Introducer for Difficult Airway Management 
Case Reports in Anesthesiology  2013;2013:717928.
The introduction into clinical practice of new tools for intubation as videolaringoscopia has dramatically improved the success rate of intubation and the work of anesthesiologists in what is considered the most delicate maneuver. Nevertheless intubation difficulties may also be encountered with good anatomical visualization of glottic structures in videolaringoscopia. To overcome the obstacles that may occur both in a difficult provided intubation such as those unexpected, associated endotracheal introducer able to facilitate the passage of the endotracheal tube through the vocal cords into the trachea may be useful. We report 4 cases of difficult intubation planned and unplanned and completed successfully using the GlideScope videolaryngoscope associated with endotracheal Frova introducer.
doi:10.1155/2013/717928
PMCID: PMC3749531  PMID: 23991339

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