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1.  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
2.  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.
doi:10.2344/0003-3006-60.3.109
PMCID: PMC3771198  PMID: 24010988
Thermosoftening; Tracheal tubes
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.
doi:10.5681/jcvtr.2013.032
PMCID: PMC3883537  PMID: 24404345
Blind Intubation; Warming; Endotracheal Tube; Oral and Maxillofacial Surgery; Anesthesia
4.  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.
doi:10.3349/ymj.2005.46.4.571
PMCID: PMC2815845  PMID: 16127785
LMA-Fastrach™ETT; maxillofacial trauma; submental intubation
5.  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
6.  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.
Objective
We evaluated a new device designed to clean the endotracheal tube (ETT) in mechanically ventilated patients: the Mucus Shaver.
Design
Prospective, randomized trial.
Setting
University hospital intensive care unit.
Patients
We enrolled 24 patients, expected to remain ventilated for more than 72 hours.
Interventions
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.
Conclusions
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.
doi:10.1097/CCM.0b013e31822e9fe3
PMCID: PMC3405906  PMID: 21926595
Endotracheal tube; secretion removal; endotracheal tube suctioning; endotracheal tube occlusion; Mucus Shaver; mechanical ventilation; bacterial biofilm; ventilator associated pneumonia
7.  A new device for 100 per cent humidification of inspired air 
Critical Care  2000;4(1):54-60.
A new humidifier for use during mechanical ventilation in endotracheally intubated patients is described and tested. The humidifier is based on a heat-moisture exchanger, which absorbs the expired heat and moisture and releases it into the inspired air. External heat and water are then added at the patient side of the heat-moisture exchanger, so that the inspired gas should reach 100% humidity (44 mg/l) at 37°C. In bench tests using constant and decelerating inspiratory flow and minute volumes of 3–25 l the device gave an absolute humidity of 41–44 mg/l, and it reduced the amount of water consumed in eight mechanically ventilated patients compared with a conventional active humidifier. During a 24-h test period there was no water condensation in the ventilator tubing with the new device.
Introduction:
Devices for active humidification of the inspired air in mechanically ventilated patients cause water condensation in the ventilator tubing, which may become contaminated or interfere with the function of the ventilator. The present study describes and tests the performance of a new humidifier, which is designed to eliminate water condensation.
Objectives:
To test the performance of the new humidifier at different ventilator settings in a lung model, and to compare this new humidifier with a conventional active humidifier in ventilator-treated critically ill patients.
Materials and methods:
The humidifier (Humid-Heat; Louis Gibeck AB, Upplands Väsby, Sweden) consists of a supply unit with a microprocessor and a water pump, and a humidification device, which is placed between the Y-piece and the endotracheal tube. The humidification device is based on a hygroscopic heat-moisture exchanger (HME), which absorbs the expired heat and moisture and releases it into the inspired gas. External heat and water are then added to the patient side of the HME, so the inspired gas should reach 100% humidity at 37°C (44 mg H2O/l air). The external water is delivered to the humidification device via a pump onto a wick and then evaporated into the inspired air by an electrical heater. The microprocessor controls the water pump and the heater by an algorithm using the minute ventilation (which is fed into the microprocessor) and the airway temperature measured by a sensor mounted in the flex-tube on the patient side of the humidification device.
The performance characteristics were tested in a lung model ventilated with a constant flow (inspiratory:expiratory ratio 1:2, rate 12–20 breaths/min and a minute ventilation of 3–25 l/min) or with a decelerating flow (inspiratory:expiratory ratio 1:2, rate 12–15 breaths/min and a minute ventilation of 4.7–16.4 l/min). The device was also tested prospectively and in a randomized order compared with a conventional active humidifier (Fisher & Paykel MR730, Auckland, New Zealand) in eight mechanically ventilated, endotracheally intubated patients in the intensive care unit. The test period with each device was 24 h. The amount of fluid consumed and the amount of water in the water traps were measured. The number of times that the water traps were emptied, changes of machine filters, the suctions and quality of secretions, nebulizations, and the amount of saline instillations and endotracheal tube obstruction were recorded. In order to evaluate increased expiratory resistance due to the device, the airway pressure was measured at the end of a prolonged end-expiratory pause at 1 h of use and at the end of the test, and was compared with the corresponding pressure before the experiment. The body temperature of the patient was measured before and after the test of each device.
Results:
Both with constant flow and decelerating flow, the Humid-Heat gave an absolute humidity of 41–44 mgH2O/l at 37°C, with the lower level at the highest ventilation. In the patients, both Humid-Heat and the conventional active humidifier (MR730) maintained temperatures, indicating that they provided the intended heat and moisture to the inspired air. With both devices, the body temperature was maintained during the test period. There was no difference in the amount of secretions, the quality of the secretions and the frequency of suctions, saline instillations or nebulizations between the test periods with the two devices. There was no endotracheal tube obstruction, and after 1 h of use and at the end of the test no increased airway resistance was found with either device. When the MR730 was used, however, the water traps needed to be emptied six to 14 (mean eight) times (total amount of fluid in the traps was 100–300 ml) and the machine filters were changed two to six (mean four) times due to an excessive amount of condensed water with flow obstruction. No condensation of water was found in the tubing with the Humid-Heat. The water consumption was 23–65 ml/h (mean 30 ml/h) with the MR730 and 4–8 ml/h (mean 6 ml/h) with the Humid-Heat (P < 0.0008). The same relations were found when the water consumption was corrected for differences in minute ventilation.
Discussion:
The new humidifier, the Humid-Heat, gave an absolute humidity of 41–44 mg/l at 37°C in the bench tests. The tests in ventilated patients showed that the device was well tolerated and that condensation in the tubing was eliminated. There was no need to empty water traps. The test period was too short to evaluate whether the new device had any other advantages or disadvantages compared with conventional humidifiers.
PMCID: PMC29037  PMID: 11056746
airway humidification; heated humidifier; intensive care; mechanical ventilation
8.  The Endotracheal Tube Air Leak Test Does Not Predict Extubation Outcome in Critically Ill Pediatric Patients 
Objective:
Endotracheal tube air leak pressures (ALT) are used to predict post-extubation upper airway compromise such as stridor, upper airway obstruction, or risk of reintubation. To determine if the absence of an endotracheal tube air leak (ALT ≥ 30 cm H2O) measured during the course of mechanical ventilation predicts extubation failure in infants and children.
Design:
Prospective, blinded cohort.
Setting:
Multidisciplinary pediatric intensive care unit of a university hospital.
Patients:
Patients age ≤ 18 years and intubated ≥ 24 hours
Interventions
The pressure required to produce an audible endotracheal tube air leak was measured within 12 hours of intubation and extubation. Unless prescribed by the medical care team, patients did not receive neuromuscular blocking agents during ALT measurements.
Measurements and Main Results:
The need for reintubation (i.e., extubation failure) was recorded during the 24 hour post-extubation period. Seventy-four patients were enrolled resulting in 59 observed extubation trials. The extubation failure rate was 15.3% (9/59). Seven patients were treated for post-extubation stridor. Extubation failure was associated with a longer median length of ventilation, 177 vs. 78 hours, p=0.03. Extubation success was associated with the use of post-extubation non-invasive ventilation (p = 0.04).
The air leak was absent for the duration of mechanical ventilation (i.e., ≥ 30 cm H2O at intubation and extubation) in ten patients. Absence of the air leak did not predict extubation failure (negative predictive value, NPV 27%, 95% CI 6% to 60%). The ALT was ≥ 30 cm H2O prior to extubation in 47% (28/59) of patients yet 23 patients extubated successfully (NPV 18%).
Conclusions:
An endotracheal tube air leak pressure ≥ 30 cm H2O measured in the non-paralyzed patient prior to extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube.
doi:10.1097/PCC.0b013e3181849901
PMCID: PMC2782931  PMID: 18679147
air leak test; cuff leak test; predictor variables; extubation; mechanical ventilation; endotracheal tube leak; respiratory failure; pediatric; neonate; stridor; non-invasive ventilation
9.  A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/2036-7902-5-7
PMCID: PMC3772703  PMID: 23826756
Bedside upper airway ultrasonography; Endotracheal intubation; Verification; Waveform capnography
10.  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.
Context:
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.
Aim:
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.
Methods:
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.
Results:
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)).
Conclusion:
Conventional PVC tube can be safely used for tracheal intubation through the ILMA.
doi:10.4103/0019-5049.108555
PMCID: PMC3658329  PMID: 23716761
Fastrach; intubating laryngeal mask airway; polyvinyl chloride; tracheal intubation
11.  Submental tracheal intubation in oromaxillofacial surgery 
Background:
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.
Results:
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.
Conclusion:
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.
doi:10.4103/0970-0358.41105
PMCID: PMC2739561  PMID: 19753195
Avoiding tracheostomy; oromaxillofacial surgery; intubation
12.  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
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.
Context:
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.
Aims:
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.
Methods:
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.
Results:
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.
Conclusions:
The TruView blade is a useful option for tracheal intubation in patients with suspected cervical spine injury.
doi:10.4103/1658-354X.101216
PMCID: PMC3498663  PMID: 23162398
Cervical spine injury; manual in-line axial stabilization; McCoy laryngoscopes; tracheal intubation; TruView EVO2
14.  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.
doi:10.1136/bmj.c5943
PMCID: PMC2977961  PMID: 21062875
15.  Laryngeal Injury From Prolonged Intubation: A Prospective Analysis of Contributing Factors 
The Laryngoscope  2010;121(3):596-600.
Objectives/Hypothesis
The factors leading to laryngeal injury due to intubation are not fully understood. This study sought to determine if duration of intubation, size of endotracheal tube, and/or type of endotracheal tube impact the degree of vocal fold immobility and other laryngeal injury upon extubation.
Study Design
Prospective study.
Methods
Sixty-one adult patients intubated for more than 48 hours were examined by recorded flexible nasolaryngoscopy shortly after extubation.
Results
Forty-one percent of patients had some degree of vocal fold immobility. However, neither the duration of intubation (range, 2–28 days; mean, 9.1 days), the size of endotracheal tube (range, 6 to 8), nor the type of endotracheal tube significantly affected the degree of laryngeal injury including vocal fold immobility. Additionally, none of the collected demographic information (age, gender, height, weight) significantly affected the degree of laryngeal injury.
Conclusions
In this cohort, duration of intubation, type of endotracheal tube, and size of endotracheal tube do not significantly correlate to the incidence of vocal fold mobility and degree of laryngeal injury noted after prolonged intubation.
doi:10.1002/lary.21403
PMCID: PMC3084628  PMID: 21344442
Laryngeal injury; prolonged intubation; vocal cord paralysis; hi-lo endotracheal tube; vocal cord immobility
16.  Evaluation of the Truview™ EVO2 laryngoscope for nasotracheal intubation 
Saudi Journal of Anaesthesia  2012;6(4):398-402.
Background:
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.
Aim:
We evaluated the suitability of the Truview™ EVO2 laryngoscope for nasotracheal intubation.
Methods:
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.
Results:
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.
Conclusion:
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.
doi:10.4103/1658-354X.105882
PMCID: PMC3591562  PMID: 23492842
Laryngoscope; orthognathic surgery; nasotracheal intubation; Truview™ EVO2
17.  A prolonged observational study of tracheal tube displacements: Benchmarking an incidence <0.5-1% in a medical-surgical adult intensive care unit 
Background and Aims:
Tracheal tubes are commonly used in intensive care unit (ICU) and lead to complications like displacements. The primary aim of the study was to evaluate if the rate of tracheal tube displacement benchmarked at <1% per patient and <0.5% per tracheal tube day, could be sustained over a prolonged period. The secondary aim was to document the patterns of all forms airway accident and to evaluate their consequences.
Subjects and Methods:
This was a prospective observational study of Intubated and ventilated patients in a General Medical-Surgical Adult ICU. The incidence of accidental extubation, self extubation, partial displacement and blockages of tracheal tubes were recorded.
Results:
The overall tracheal tube displacement rate was 61/10,112 (0.6%) per patient and 61/28,464 (0.22%) per tracheal tube day. There were 30 additional incidents of blockage, kinking or biting of the tracheal tube. Physiological consequences-69 were mild, 10 moderate, 12 major and one death. Of the 91 accidents, 30 were partly and 30 were completely preventable. 76 incidents involved an endotracheal tube (54 displaced, 12 blocked and 10 bitten-kinked) and 15 a tracheostomy tube (seven displaced and eight blocked). Accidents were more common in medical than surgical patients (medical = 48, cardiac surgical = 17 and other surgical/trauma = 26).
Conclusion:
Tracheal tube displacement rate in a mixed medical-surgical adult ICU was maintained below the pre-set benchmark of <1% per patient and <0.5% per intubated day over nearly a decade.
doi:10.4103/0972-5229.132466
PMCID: PMC4047687  PMID: 24914254
Airway accidents; endotracheal tube; tracheostomy tube; unplanned extubation
18.  ProSeal laryngeal mask airway: An alternative to endotracheal intubation in paediatric patients for short duration surgical procedures 
Indian Journal of Anaesthesia  2010;54(6):541-545.
The laryngeal mask airway (LMA) is a supraglottic airway management device. The LMA is preferred for airway management in paediatric patients for short duration surgical procedures. The recently introduced ProSeal (PLMA), a modification of Classic LMA, has a gastric drainage tube placed lateral to main airway tube which allows the regurgitated gastric contents to bypass the glottis and prevents the pulmonary aspiration. This study was done to compare the efficacy of ProSeal LMA with an endotracheal tube in paediatric patients with respect to number of attempts for placement of devices, haemodynamic responses and perioperative respiratory complications. Sixty children, ASA I and II, weighing 10-20 kg between 2 and 8 years of age group of either sex undergoing elective ophthalmological and lower abdominal surgeries of 30-60 min duration, randomly divided into two groups of 30 patients each were studied. The number of attempts for endotracheal intubation was less than the placement of PLMA. Haemodynamic responses were significantly higher (P<0.05) after endotracheal intubation as compared to the placement of PLMA. There were no significant differences in mean SpO2 (%) and EtCO2 levels recorded at different time intervals between the two groups. The incidence of post-operative respiratory complications cough and bronchospasm was higher after extubation than after removal of PLMA. The incidence of soft tissue trauma was noted to be higher for PLMA after its removal. There were no incidences of aspiration and hoarseness/sore throat in either group. It is concluded that ProSeal LMA can be safely considered as a suitable and effective alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.
doi:10.4103/0019-5049.72644
PMCID: PMC3016575  PMID: 21224972
ET tube; haemodynamic response; PLMA
19.  Evaluation of the new supraglottic airway S.A.L.T to aid blind orotracheal intubation: A pilot study 
Background and Objective:
Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T) is a new airway gadget conceived as an effective device to facilitate blind oro-tracheal intubation. Literature review showed no available clinical study on human subjects. The aim of our study was to evaluate S.A.L.T as an adjunct to blind oro-tracheal intubation.
Methods:
Study design: Single centre, Single group, Open label, Prospective, Interventional pilot study. Study Group: 30 adult patients of either sex belonging to ASA I and II, scheduled for elective surgery under General anaesthesia. Patients were pre-medicated with inj. Glycopyrrolate 0.2 mg and inj. Midazolam 2 mg and induced with Inj. Propofol 2 mg/kg IV. After inj. Suxamethonium 1.5 mg/kg IV, S.A.L.T was inserted and a size 7.0 ID cuffed ETT was inserted through it immediately. The time period, from insertion of the S.A.L.T to the insertion of the ETT was noted. A successful intubation was defined as to insert SALT and intubate through it within 2 minutes irrespective of the number of attempts. Airway trauma, if any was recorded.
Results:
Only 40% of the patients were successfully intubated [(20.4% to 59.6% with 95% confidence interval (CI)]. The mean number of attempts required for intubation was 1.4 ± 0.67 (CI - 0.99 to 1.8) and the mean time for intubation was 26.3 ± 19.0 seconds (CI - 14.3 to 38.4 sec). Mallampati class I had more success rate than class III (P < 0.05). No airway trauma was recorded.
Conclusion:
S.A.L.T shows limited usefulness as an adjunct for aided blind oro-tracheal intubation.
doi:10.4103/2229-5151.124112
PMCID: PMC3891189  PMID: 24459620
Airway management; emergencies; intubation; laryngoscopy
20.  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
21.  Measurement of endotracheal tube secretions volume by micro computed tomography (MicroCT) scan: an experimental and clinical study 
BMC Anesthesiology  2014;14:22.
Background
Biofilm accumulates within the endotracheal tube (ETT) early after intubation. Contaminated secretions in the ETT are associated with increased risk for microbial dissemination in the distal airways and increased resistance to airflow. We evaluated the effectiveness of micro computed tomography (MicroCT) for the quantification of ETT inner volume reduction in critically ill patients.
Methods
We injected a known amount of gel into unused ETT to simulate secretions. We calculated the volume of gel analyzing MicroCT scans for a length of 20 cm. We then collected eleven ETTs after extubation of critically ill patients, recording clinical and demographical data. We assessed the amount of secretions by MicroCT and obtained ETT microbiological cultures.
Results
Gel volumes assessed by MicroCT strongly correlated with injected gel volumes (p < 0.001, r2 = 0.999).
MicroCT revealed the accumulation of secretions on all the ETTs (median 0.154, IQR:0.02-0.837 mL), corresponding to an average cross-sectional area reduction of 1.7%. The amount of secretions inversely correlated with patients’ age (p = 0.011, rho = −0.727) but not with days of intubation, SAPS2, PaO2/FiO2 assessed on admission. Accumulation of secretions was higher in the cuff region (p = 0.003). Microbial growth occurred in cultures from 9/11 ETTs, and did not correlate with secretions amount. In 7/11 cases the same microbes were identified also in tracheal aspirates.
Conclusions
MicroCT appears as a feasible and precise technique to measure volume of secretions within ETTs after extubation. In patients, secretions tend to accumulate in the cuff region, with high variability among patients.
doi:10.1186/1471-2253-14-22
PMCID: PMC3986655  PMID: 24678963
Endotracheal tube; Micro computed tomography; Secretions; Volume; Cross-sectional area
22.  The use of VivaSight™ single lumen endotracheal tube in morbidly obese patients undergoing laparoscopic sleeve gastrectomy 
BMC Anesthesiology  2014;14:31.
Background
The population of obese patients is progressively growing and bariatric operations are becoming increasingly common. Morbidly obese patients require special anesthetic care and are often considered to be difficult to ventilate and intubate. The VivaSight™ Single Lumen tube is an endotracheal tube with a camera embedded in its tip. The view from the tip appears continuously on a monitor in the anesthesiologist's vicinity. The aim of this study was to assess the VivaSight™ in comparison with conventional endotracheal tube as an aid in the intubation and surveillance of tube position during surgery of obese patients.
Methods
This is a prospective study of 72 adult obese patients who underwent laparoscopic sleeve gastrectomy. The patients were randomly assigned to be intubated by either the VivaSight™ (40 patients, test group) or a conventional endotracheal tube (32 patients, control group). Data on the patients, the pre-operative airway evaluation, the endotracheal intubation and the post-operative outcome were collected and compared.
Results
The Mallampati scores were significantly higher in the test group than in the control group. Endotracheal intubation took 29 ± 10 and 24 ± 8 seconds using the VivaSight™ and a conventional tube respectively (p = 0.02). Three of the patients in the control group, while none of those in the test group, had soft tissue injury (p < 0.05).
Conclusion
We found the VivaSight™ SL to be helpful in the endotracheal intubation and continuous surveillance of tube position in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.
doi:10.1186/1471-2253-14-31
PMCID: PMC4016667  PMID: 24817827
Equipment; Airway; Anesthetic techniques; Fiber-optic; Ventilation; Mechanical; Morbid obesity; Surgery; Bariatric complications
23.  Randomised controlled trial of thiopental for intubation in neonates 
AIMS—To determine the effects of premedication with thiopental on heart rate, blood pressure, and oxygen saturation during semi-elective nasotracheal intubation in neonates.
METHODS—A randomised, placebo controlled, non-blinded study design was used to study 30 neonates (mean birthweight 3.27 kg) requiring semi-elective nasotracheal intubation. The babies were randomly allocated to receive either 6 mg/kg of thiopental (study group) or an equivalent volume of physiological saline (control group) one minute before the start of the procedure. Six infants were intubated primarily and 24 were changed from orotracheal to a nasotracheal tube. The electrocardiogram, arterial pressure wave, and transcutaneous oxygen saturation were recorded continuously 10 minutes before, during, and 20 minutes after intubation. Minute by minute measurements of heart rate, heart rate variability, mean blood pressure (MBP) and transcutaneous oxygen saturation (SpO2) were computed. The differences for all of these between the baseline measurements and those made during and after intubation were determined. Differences in the measurements made in the study and the control groups were compared using Student's t test.
RESULTS—During intubation, heart rate increased to a greater degree (12.0 vs−0.5 beats per minute, p < 0.03) and MBP increased to a lesser degree (−2.9 vs 4.4 mm Hg; p < 0.002) in the infants who were premedicated with thiopental. After intubation only the changes in MBP differed significantly between the two groups (−3.8 vs 4.6 mm Hg; p < 0.001). There were no significant changes in the oxygen saturation between the two groups during or after intubation. The time taken for intubation was significantly shorter in the study group (p < 0.04).
CONCLUSIONS—The heart rate and blood pressure of infants who are premedicated with thiopental are maintained nearer to baseline values than those of similar infants who receive no premedication. Whether this lessening of the acute drop in the heart rate and increase in blood pressure typically seen during intubation of unmedicated infants is associated with long term advantages to the infants remains to be determined.


doi:10.1136/fn.82.1.F34
PMCID: PMC1721021  PMID: 10634839
24.  Comparison of two topographical airway length measurements in adults 
Korean Journal of Anesthesiology  2012;63(5):409-412.
Background
A correct estimate of the tracheal tube insertion depth can prevent complications, including endobronchial intubation and vocal cord trauma. We evaluated a new topographical method for endotracheal tube positioning relative to the carina, using a well-known prior topographical method for comparison.
Methods
One hundred adult (male 50, female 50) patients were studied. The comparison topographic length (in cm) was measured by adding the distance between the right mouth corner and the right mandibular angle to the distance between the right mandibular angle and the center of the sternal manubrium. The new endotracheal tube insertion depth (in cm) was determined by adding the distance between the right mouth corner and the vocal cords, measured with the endotracheal tube itself, to the distance between the thyroid prominence and the manubriosternal joint, and then subtracting 4 cm. After intubation, the endotracheal tube was positioned properly at the right mouth corner and the endotracheal tube tip was evaluated using a fiberoptic bronchoscope at the carina.
Results
The distances from the tip of the endotracheal tube to the carina were not significantly different between the methods in the same gender. However, our method allowed endotracheal tube tip placement between 3 cm and 5 cm, above the carina more frequently than the prior method in males.
Conclusions
The new topographical method can be used as a guide to positioning the endotracheal tubes.
doi:10.4097/kjae.2012.63.5.409
PMCID: PMC3506849  PMID: 23198033
Airway; Carina; Intubation; Manubriosternal joint; Topographical
25.  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

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