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1.  Thermosoftening of the Parker Flex-TipTM Tracheal Tube in Preparation for Nasotracheal Intubation 
Anesthesia Progress  2013;60(3):109-110.
The Parker Flex-Tip tracheal tube (PFTT, Parker Medical, Highlands Ranch, Colo) has a soft, flexible, curved tip with double Murphy eyes. Previous studies have shown that the PFTT reduces the incidence of epistaxis during nasotracheal intubation and the incidence of postintubation nasal pain, as compared to conventional tracheal tubes. Although thermosoftening is a well-known and effective technique for reducing epistaxis during nasotracheal intubation with conventional tracheal tubes, we occasionally encounter difficulties with advancing the tube through the nasal passage when the PFTT is thermosoftened prior to nasotracheal intubation. Consequently, when using the PFTT for nasotracheal intubation, the procedure of thermosoftening should be avoided.
PMCID: PMC3771198  PMID: 24010988
Thermosoftening; Tracheal tubes
2.  A Rare Complication of Tracheal Intubation: Tongue Perforation 
Case Reports in Anesthesiology  2012;2012:281791.
Aim. To describe the subsequent treatment of airway trauma sustained during laryngoscopy and endotracheal intubation. Methods. A rare injury occurring during laryngoscopy and endotracheal intubation that resulted in perforation of the tongue by an endotracheal tube and the subsequent management of this unusual complication are discussed. A 65-year-old female with intraparenchymal brain hemorrhage with rapidly progressive neurologic deterioration had the airway secured prior to arrival at the referral institution. The endotracheal tube (ETT) was noted to have pierced through the base of the tongue and entered the trachea, and the patient underwent operative laryngoscopy to inspect the injury and the ETT was replaced by tracheostomy. Results. Laryngoscopy demonstrated the ETT to perforate the base of the tongue. The airway was secured with tracheostomy and the ETT was removed. Conclusions. A wide variety of complications resulting from direct and video-assisted laryngoscopy and tracheal intubation have been reported. Direct perforation of the tongue with an ETT and ability to ventilate and oxygenate subsequently is a rare injury.
PMCID: PMC3465871  PMID: 23056962
3.  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
4.  Unexpected difficulty in ventilating the lungs after tracheal intubation -A case report- 
Korean Journal of Anesthesiology  2011;60(6):437-439.
We experienced difficulty in ventilating the lungs of a patient after tracheal intubation. After intubation, an insufficient amount of tidal volume (VT) was delivered to the patient and the fiberoptic bronchoscopic examination identified partial abutment of the endotracheal tube (ETT) orifice against the tracheal wall. After various attempts to correctly place the ETT, a double-lumen endotracheal tube was placed to achieve a sufficient VT. It is important to notice that even an appropriately placed ETT may get obstructed due to the left sided bevel at its tip.
PMCID: PMC3121092  PMID: 21738848
Airway obstruction; Bronchoscopy; Double lumen tube; Tracheal abutment
5.  Submental Intubation with Reinforced Tube for Intubating Laryngeal Mask Airway 
Yonsei Medical Journal  2005;46(4):571-574.
Submental endotracheal intubation is a simple and secure alternative to either nasoendotracheal intubation or a tracheostomy in the airway management of maxillofacial trauma. However, a submental endotracheal intubation is quite difficult to manage if adverse events such as a tube obstruction, accidental extubation, or a leaking cuff with the endotracheal tube in the submental route occur, which could endanger the patient. This paper describes the use of a LMA-Fastrach™ETT in the submental endotracheal intubation of patients suffering from maxillofacial trauma. One of the patients was a 16-year-old male, and the other was a 19-year-old male. They were scheduled for an open reduction and internal fixation of the maxillofacial fracture including naso-orbital-ethmoidal (NOE) complex, and a zygomaticomaxillary complex fracture. A submental intubation with a LMA-Fastrach™ETT was performed in both cases, and the operation proceeded without any difficulties. These cases show that the use of the LMA-Fastrach™ETT can improve the safety and efficacy of submental endotracheal intubation. This is because the LMA-Fastrach™ETT has a freely detachable connector, and is flexible enough to keep the patency despite the acute angle of airway.
PMCID: PMC2815845  PMID: 16127785
LMA-Fastrach™ETT; maxillofacial trauma; submental intubation
6.  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
7.  Evaluation of the Truview™ EVO2 laryngoscope for nasotracheal intubation 
Saudi Journal of Anaesthesia  2012;6(4):398-402.
The Truview™ EVO2 laryngoscope, with its unique optical lens system and blade tip angulation, has proved its usefulness in providing adequate laryngeal exposure and intubation via the oral route. However, the same has not been evaluated for nasotracheal intubation.
We evaluated the suitability of the Truview™ EVO2 laryngoscope for nasotracheal intubation.
Fifty ASA grade I and II elective surgical patients were studied. Patients aged below 15 years or having difficult airway were excluded. Under standard anesthesia protocol, nasotracheal intubation was performed using a Truview™ EVO2 laryngoscope and, in cases of inability to complete intubation in three attempts, the Macintosh laryngoscope was used. Time taken for intubation, use of Magill's forceps and need for optimization maneuvers were noted. The primary outcome was percentage of successful intubation, while hemodynamic changes and duration of intubation were taken as secondary outcomes.
Majority (94%) could be intubated successfully with the Truview™ EVO2 laryngoscope. Average time taken for intubation was 50.1 s. The hemodynamic changes were not clinically significant. Regression analysis revealed lack of association between duration of intubation and hemodynamic changes. There were no serious complications.
The Truview™ EVO2 laryngoscope is a useful tool in performing nasotracheal intubation, ensuring a high level of success rate among patients with normal airway anatomy.
PMCID: PMC3591562  PMID: 23492842
Laryngoscope; orthognathic surgery; nasotracheal intubation; Truview™ EVO2
8.  Endotracheal tube intubation with the aid of a laryngeal mask airway, a fiberoptic bronchoscope, and a tube exchanger in a difficult airway patient: a case report 
Korean Journal of Anesthesiology  2014;66(3):237-239.
A 28-year-old male patient with occipito-atlanto-axial instability underwent a cervical fusion with posterior technique. Post-operatively, the endotracheal tube (ETT) was removed, and the patient was transferred to the intensive care unit. After transfer, an upper airway obstruction developed and reintubations with a laryngoscope were attempted but failed. We inserted a #4 proseal laryngeal mask airway (LMA) and passed a 5.0 mm ETT through the LMA with the aid of a fiberoptic bronchoscope. We passed a tube exchanger through the 5.0 mm ETT and exchanged it with a 7.5 mm ETT. This method may be a useful alternative for difficult tracheal intubations.
PMCID: PMC3983421
Airway obstruction; Bronchoscopes; Cervical vertebrae; Laryngeal masks; Spinal fusion; Tube exchanger
9.  A Case of Death Caused by Tracheal Tube Aspiration 
Airway management, especially outside the operating room, needs meticulous observation in order to avoid certain risks, such as; endotracheal tube (ETT) disloca­tion, esophageal intubation, and unwanted extubation. ETT or tracheostomy dislocation is responsible for one-half of death or brain damage cases in the ICU. Despite appropri­ate fixation of an ETT, the previously mentioned compli­cations can still occur . A broken ETT and consequent airway obstruction may lead to lethal complications.
Case Presentation:
We report a case of death caused by tracheal tube aspiration, where it was located distal to the vocal cords, with a part of it entering the right bronchus and the mediastinum, after tearing the right bronchus.
The vigilance and experience of medical personnel in the ICU, appropriate IV sedation, and using a bite block are the best ways to prevent mortality caused by aspiration of an ETT in all intubated patients.
PMCID: PMC3961024  PMID: 24660153
Airway Management; Endotracheal Intubation Complications; Endotracheal Intubation Mortality
10.  A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation 
In emergency settings, verification of endotracheal tube (ETT) location is important for critically ill patients. Ignorance of oesophageal intubation can be disastrous. Many methods are used for verification of the endotracheal tube location; none are ideal. Quantitative waveform capnography is considered the standard of care for this purpose but is not always available and is expensive. Therefore, this feasibility study is conducted to compare a cheaper alternative, bedside upper airway ultrasonography to waveform capnography, for verification of endotracheal tube location after intubation.
This was a prospective, single-centre, observational study, conducted at the HRPB, Ipoh. It included patients who were intubated in the emergency department from 28 March 2012 to 17 August 2012. A waiver of consent had been obtained from the Medical Research Ethics Committee. Bedside upper airway ultrasonography was performed after intubation and compared to waveform capnography. Specificity, sensitivity, positive and negative predictive value and likelihood ratio are calculated.
A sample of 107 patients were analysed, and 6 (5.6%) had oesophageal intubations. The overall accuracy of bedside upper airway ultrasonography was 98.1% (95% confidence interval (CI) 93.0% to 100.0%). The kappa value (Κ) was 0.85, indicating a very good agreement between the bedside upper airway ultrasonography and waveform capnography. Thus, bedside upper airway ultrasonography is in concordance with waveform capnography. The sensitivity, specificity, positive predictive value and negative predictive value of bedside upper airway ultrasonography were 98.0% (95% CI 93.0% to 99.8%), 100% (95% CI 54.1% to 100.0%), 100% (95% CI 96.3% to 100.0%) and 75.0% (95% CI 34.9% to 96.8%). The likelihood ratio of a positive test is infinite and the likelihood ratio of a negative test is 0.0198 (95% CI 0.005 to 0.0781). The mean confirmation time by ultrasound is 16.4 s. No adverse effects were recorded.
Our study shows that ultrasonography can replace waveform capnography in confirming ETT placement in centres without capnography. This can reduce incidence of unrecognised oesophageal intubation and prevent morbidity and mortality.
Trial registration
National Medical Research Register NMRR11100810230.
PMCID: PMC3772703  PMID: 23826756
Bedside upper airway ultrasonography; Endotracheal intubation; Verification; Waveform capnography
11.  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
12.  Increased success of blind nasotracheal intubation through the use of nasogastric tubes as a guide. 
Anesthesia Progress  1996;43(2):58-60.
We were able to improve the success rate of blind nasotracheal intubation by using nasogastric tubes as a guide during intubation, first, for passing the endotracheal tube through the nasal cavity, and second, passing it from the pharynx to the larynx. By adding both sedation by modified neuroleptanalgesia (NLA) and topical and transtracheal administration of lidocaine, our technique became safer and smoother. We have completed 36 cases without accident, with an average time for intubation of 8.25 min. The Rüsh spiral tube was thought to be the most suited to this form of intubation because of the 90 degrees cut of its tip, its high-volume cuff, and its flexibility in all directions. These features are useful for hearing breath sounds, raising the tip of the tube by inflation of the cuff, and advancing the tube in a turning motion.
PMCID: PMC2148780  PMID: 10323127
13.  Comparison of the use of McCoy and TruView EVO2 laryngoscopes in patients with cervical spine immobilization 
Saudi Journal of Anaesthesia  2012;6(3):248-253.
The cervical spine has to be stabilized in patients with suspected cervical spine injury during laryngoscopy and intubation by manual in-line axial stabilization. This has the propensity to increase the difficulty of intubation. An attempt has been made to compare TruView EVO2 and McCoy with cervical spine immobilization, which will aid the clinician in choosing an appropriate device for securing the airway with an endotracheal tube (ETT) in the clinical scenario of trauma.
To compare the effectiveness of TruView EVO2 and McCoy laryngoscopes when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization.
Settings and design:
K. M. C. Hospital, Mangalore, This was a randomized control clinical trial.
Sixty adult patients of either sex of ASA physical status 1 and 2 who were scheduled to undergo general anesthesia with endotracheal intubation were studied. Comparison of intubation difficulty score (IDS), hemodynamic response, Cormack and Lehane grade, duration of the tracheal intubation and rate of successful placement of the ETT in the trachea between TruView EVO2 and McCoy laryngoscopes was performed.
The results demonstrated that TruView has a statistically significant less IDS of 0.33 compared with an IDS of 1.2 for McCoy. TruView also had a better Cormack and Lehane glottic view (CL 1 of 77% versus 40%) and less hemodynamic response.
The TruView blade is a useful option for tracheal intubation in patients with suspected cervical spine injury.
PMCID: PMC3498663  PMID: 23162398
Cervical spine injury; manual in-line axial stabilization; McCoy laryngoscopes; tracheal intubation; TruView EVO2
14.  A Randomized Controlled Trial of Capnography in the Correction of Simulated Endotracheal Tube Dislodgement 
Unrecognized dislodgement of an endotracheal tube (ETT) during the transport of an intubated patient can have life-threatening consequences. Standard methods to monitor these patients, such as pulse oximetry and physical examination, are both subject to inaccuracies with patient movement and ambient noise. Capnography provides a continuous and objective measure of ventilation that can alert a provider immediately to an airway problem. The objective of this study was to determine through simulation if capnography decreases time to correction of dislodged ETTs during the transport of intubated patients, in comparison to standard monitoring.
Paramedics and paramedic students were randomized as to whether or not they had capnography available to them in addition to standard monitoring during a simulated scenario. In the scenario, subjects monitored an intubated baby who subsequently experiences a dislodgement of the ETT during interfacility transport. Time to correction of the ETT dislodgement was the primary outcome. The secondary outcome was correction of dislodgement prior to decline in pulse oximetry.
Fifty-three subjects were enrolled in the study, with complete data on 50 subjects. Median time to correction of ETT dislodgement was 2.02 minutes (95% CI = 1.22 to 4.12 minutes) for the capnography group versus 4.00 minutes (95% CI = 3.35 to 5.50 minutes) in the standard monitoring group (p = 0.05). Forty-eight percent of subjects using capnography corrected the ETT dislodgement prior to decline in pulse oximetry compared with 12% of controls (p = 0.01). There were no differences in time to correction of dislodgement based on years of experience, perceived comfort, reported adequacy of teaching, or past use of capnography.
The addition of capnography to standard monitoring significantly improves recognition of ETT dislodgement and reduces the time to correction of dislodged ETTs by prehospital providers in a simulated pediatric transport setting.
PMCID: PMC3117244  PMID: 21676056
15.  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.
PMCID: PMC3546245  PMID: 23325943
Bronchoscopy; fiberoptic; Intratracheal intubation; nasotracheal; thoracic surgical procedures
16.  Endotracheal tube defects: Hidden causes of airway obstruction 
Saudi Journal of Anaesthesia  2010;4(2):108-110.
Manufacturing defects of endotracheal tube (ETT) are still encountered in anesthesia practice. Many such defects go unnoticed during routine inspection prior to their use. Such defects in ETT may lead to partial or complete airway obstruction in an intubated patient. We report a case of partial airway obstruction with a prepacked, single use, uncuffed ETT due to a manufacturing defect in the form of a plastic meniscus at the distal end of the tube. This case report highlights the significance of standard monitoring of ventilation and the role of a vigilant clinician in detecting such defects in avoiding critical events as can arise from the use of such defective ETTs. It also emphasizes the need for double checking ETTs prior to their use.
PMCID: PMC2945507  PMID: 20927272
Endotracheal tube; ventilation; monitoring; intubation
17.  Video Laryngoscopy for Tracheal Intubation 
Executive Summary
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of video-assisted laryngoscopy for tracheal intubation.
The Technology
Video-assisted, rigid laryngoscopes have been recently introduced that allow for the illumination of the airway and the accurate placement of the endotracheal tube. Two such devices are available in Canada: the Bullard® Laryngoscope that relies on fibre optics for illumination and the GlideScope® that uses a video camera and a light source to illuminate the airway. Both are connected to an external monitor so health professionals other than the operator can visualize the insertion of the tube. These devices therefore may be very useful as teaching aids for tracheal intubation.
Review Strategy
The objective of this review was to examine the effectiveness of the most commonly used video-assisted rigid laryngoscopes used in Canada for tracheal intubation. According to the Medical Advisory Secretariat standard search strategy, a literature search for current health technology assessments and peer-reviewed literature from Medline (full citations, in-process and non-indexed citations) and Embase for was conducted for citations from January 1994 to January 2004. Key words used in the search were as follows: Video-assisted; video; emergency; airway management; tracheal intubation and laryngoscopy.
Summary of Findings
Two video-assisted systems are available for use in Canada. The Bullard® video laryngscope has a large body of literature associated with it and has been used for the last 10 years, although most of the studies are small and not well conducted. The literature on the GlideScope® is limited. In general, these devices provide better views of the airway but are much more expensive than conventional direct laryngoscopes. As with most medical procedures, video-assisted laryngoscopy requires training and skill maintenance for successful use.
There seems to be a discrepancy between the seeming advantages of these devices in the management of difficult airway and their availability and uptake outside the operating room. The uptake of these devices by non-anesthetists in Ontario at this time may be limited because:
Difficult intubation is relatively infrequent outside the operating room
Many alternative and inexpensive devices are available
There are no professional supports in place for the training and maintenance of skills for the use of these devices outside anesthesia.
Video laryngoscopy has no obvious utility in preventing airborne viral transmission from patient to provider but may be useful for teaching purposes.
PMCID: PMC3387773  PMID: 23074455
18.  Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children 
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.
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).
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.
PMCID: PMC3590542  PMID: 23493291
Difficult; equipment; fiberoptic bronchoscope; intubation; laryngeal mask airway; modified oropharyngeal Guedel airway; tracheal
19.  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.
PMCID: PMC3581788  PMID: 23458916
Airway exchange catheter; Fiberoptic intubation; Laryngeal mask airway; Pierre robin syndrome
20.  A clinical assessment of the Mucus Shaver, a device to keep the endotracheal tube free from secretions 
Critical Care Medicine  2012;40(1):119-124.
We evaluated a new device designed to clean the endotracheal tube (ETT) in mechanically ventilated patients: the Mucus Shaver.
Prospective, randomized trial.
University hospital intensive care unit.
We enrolled 24 patients, expected to remain ventilated for more than 72 hours.
The Mucus Shaver is a concentric, inflatable catheter for the removal of mucus and secretions from the interior surface of the ETT. The Mucus Shaver is advanced to the distal ETT tip, inflated and subsequently withdrawn over a period of 3–5 seconds. Patients were prospectively randomized, within 2 hours of intubation, to receive standard ETT suctioning treatment or standard suctioning plus Mucus Shaver use, until extubation.
Measurements and Main Results
During the study period, demographic data, recent medical history, adverse events and staff evaluation of the Mucus Shaver were recorded. At extubation, each ETT was removed, cultured and analyzed by Scanning Electron Microscopy (SEM). 12 patients were assigned to the study group and 12 to the control group. No adverse events related to the use of the Mucus Shaver were observed. At extubation, only 1 ETT from the Mucus Shaver group was colonized, while in the control group, 10 ETTs were colonized (8% vs. 83%; p<0.001). SEM showed little secretions on the ETTs from the study group, while thick bacterial deposits were present on all the ETTs from the control group (p<0.001 by Fisher’s exact test, using a maximum biofilm thickness of 30 µm as cut-off). The nursing staff was satisfied by the overall safety, feasibility, and efficacy of the Mucus Shaver.
The Mucus Shaver is a safe, feasible and efficient device for ETT cleaning in the clinical setting. The Mucus Shaver is helpful in preventing ETT colonization by potentially harmful microorganisms.
PMCID: PMC3405906  PMID: 21926595
Endotracheal tube; secretion removal; endotracheal tube suctioning; endotracheal tube occlusion; Mucus Shaver; mechanical ventilation; bacterial biofilm; ventilator associated pneumonia
21.  A novel method using Seldinger's technique for submental intubation in major craniomaxillofacial fractures: A case series 
Indian Journal of Anaesthesia  2014;58(1):48-50.
Airway management is a challenge to anesthesiologists particularly in maxillofacial surgeries. The oral tracheal tube is unsuitable because it interferes with the surgical field and prevents dental occlusion. Nasotracheal intubation may not always be possible due to structural deformity or trauma to the nasal bones. Tracheostomy and submental intubation have their drawbacks. To overcome these shortcomings we used Percutaneous Dilatational Tracheostomy Kit (PDTK) to modify the technique of submental intubation. Serial dilatations were performed over the guide wire before passing the tracheal tube by submental route, using the PDT kit in four patients. Submental intubation could be achieved in all the four cases with this technique and there were no associated complications. Seldinger's technique is a simple and easy technique with minimal bleeding, imperceptible scar, and more importantly anesthesiologists feel more comfortable because of their familiarity with the Seldinger technique.
PMCID: PMC3968651
Maxillofacial surgeries; percutaneous dilatational tracheostomy kit; seldinger's technique
22.  Ventilation via Cut Nasotracheal Tube During General Anesthesia 
Anesthesia Progress  2013;60(1):11-14.
Many patients with disabilities need recurrent dental treatment under general anesthesia because of high caries prevalence and the nature of dental treatment. We evaluated the use of a nasal device as a possible substitute for flexible laryngeal mask airway to reduce the risk of unexpected failure accompanying intubation; we succeeded in ventilating the lungs with a cut nasotracheal tube (CNT) with its tip placed in the pharynx. We hypothesized that this technique would be useful during dental treatment under general anesthesia and investigated its usefulness as part of a minimally invasive technique. A prospective study was designed using general anesthesia in 37 dental patients with disabilities such as intellectual impairment, autism, and cerebral palsy. CNT ventilation was compared with mask ventilation with the patient in 3 positions: the neck in flexion, horizontal position, and in extension. The effect of mouth gags was also recorded during CNT ventilation. The percentages of cases with effective ventilation were similar for the 2 techniques in the neck extension and horizontal positions (89.2–97.3%). However, CNT ventilation was significantly more effective than mask ventilation in the neck flexion position (94.6 vs 45.9%; P < .0001). Mouth gags slightly reduced the rate of effective ventilation in the neck flexion position. Most dental treatments involving minor oral surgeries were performed using mouth gags during CNT ventilation. CNT ventilation was shown to be superior to mask ventilation and is useful during dental treatment under general anesthesia.
PMCID: PMC3601724  PMID: 23506278
General anesthesia; Cut nasotracheal tube.
23.  Cuff Inflation to Aid Nasotracheal Intubation Using the C-MAC Videolaryngoscope 
Ghana Medical Journal  2011;45(2):84-86.
A preliminary report is presented of a technique for using the C-MAC videolaryngoscope to carry out nasopharyngeal intubations. The main thrust of the technique is that cuff inflation of the endotracheal tube is used to lift the endotracheal tube off the posterior pharyngeal wall and thus direct it towards the glottis. The technique was used successfully in 5 consecutive patients needing nasotracheal intubation. Indeed a couple of these patients might have been difficult to intubate using conventional laryngoscopy. The full technique is described together with pictures at the various stages of intubation.
PMCID: PMC3158534  PMID: 21857727
Cuff inflation; C-MAC videolaryngoscope; nasotracheal intubation; difficult intubation
24.  Airway Management in Croup and Epiglottitis 
Western Journal of Medicine  1977;126(3):184-189.
Treatment techniques for airway obstruction in croup and epiglottitis are reviewed in the medical literature. Series totaling 295 nasotracheal intubations, and 591 tracheostomies were reviewed. There were two deaths attributable to airway complications in 126 patients in whom nasotracheal intubation was carried out. In three patients subglottic granulation tissue and subglottic stenoses developed from short-term nasotracheal intubation. There were no subglottic stenoses or tracheal stenoses reported in the 591 tracheostomies. From this review, it would seem feasible to use nasotracheal intubation for short-term airway treatment in croup and epiglottitis. The increasing occurrence of laryngeal and tracheal complications with long-term intubation suggests that tracheostomy be considered in such cases.
PMCID: PMC1237501  PMID: 349884
25.  Damage to the cuff of EMG tube at endotracheal intubation by using a lightwand -A case report- 
Korean Journal of Anesthesiology  2010;59(Suppl):S17-S20.
Electromyogpraphic endotracheal tube (EMG tube) is a new device used to monitor recurrent laryngeal nerve integrity during thyroid surgery. The EMG tube has 2 pairs of electrodes on the surface of silicon-based tube reached to inner space of tube cuff. We experienced an unusual endotracheal tube-related problem from the distinct structural feature of the EMG tube. In this case, we intubated a patient who had difficult airway with the EMG tube using a lightwand. After successful endotracheal intubation, we could not expand the pilot balloon and ventilate the patient effectively. We removed the EMG tube and found that one of electrodes of the EMG tube is bended and made a right angle with the long axis of the tube, and perforated the tube cuff. So we report this case to make anesthesia providers aware that much more attention is needed to use EMG tube during endotracheal intubation.
PMCID: PMC3030028  PMID: 21286432
Complication; Electromyographic endotracheal tube; Intubation; Lightwand; Recurrent laryngeal nerve monitoring; Thyroid surgery

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