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Original Article
DOI: 10.4103/2229-5151.128009 Quick Response Code:
Making endotracheal intubation easy and successful, particularly in unexpected difficult airway Susanne Abdulla1,2,3, Sina Abdulla1, Karl‑Peter Schwemm4, Regina Eckhardt1, Walied Abdulla1,4,5
ABSTRACT
Department of Anesthesiology and Intensive Care Medicine, Klinikum Bernburg, Martin Luther‑University Halle‑Wittenberg, Bernburg, 2 Department of Neurology, Otto‑von‑Guericke University, Magdeburg, 3Department of Neurology, Medizinische Hochschule Hannover, Hannover, 4Department of Anesthesiology, Marienkrankenhaus Papenburg, A Teaching Hospital of the University Medical School, Hannover, 5 Johannes Gutenberg University Mainz, Mainz, Germany
1
Background: Difficult intubation, most often due to poor view of the vocal cords on laryngoscopy is an intermittent and often challenging problem for clinically practicing anesthesiologists, maxillofacial surgeons, ear nose, and throat (ENT), emergency, and critical care physicians. Purpose: We present a new approach for facilitating difficult intubation and evaluate its efficacy in a retrospective observational study. Settings and Design: Operating room, emergency department, intensive care unit (ICU), retrospective observational study. Materials and Methods: A semirigid 5.6 Rüsch tracheal tube introducer (bougie) with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the tube was used. After its insertion through the larynx under laryngoscopy, the tube was gently advanced upon rotation at 360° clockwise. Statistical Analysis: Descriptive.
Address for correspondence: Prof. Walied Abdulla, Robert‑Kirchhoff‑Str. 12, D‑06406 Bernburg, Germany. E‑mail: walied.abdulla@t‑online.de
Results: Anesthesia services were analyzed on 10,363 patients over 12 months. In 2453 patients (23.7%) (Group A) intubated in the usual way, difficulties were encountered in 63 patients (2.6%). They were managed either with tube rotation technique (n = 60) or Bonfils endoscope (n = 3). In contrast, 2807 patients (27.1%) (Group B) were intubated using tube rotation technique with introducer. Difficult intubations occurred only in three patients (0.11%) who could be managed with tube rotation by experienced consultant anesthesiologists. Conclusions: The tube rotation technique for intubation was introduced during the Gulf War and has been practiced for the past 19 years without any obvious damage to the trachea in Germany. However, it should be used only by physicians being well familiar with this technique. In addition, well designed controlled studies are needed. Key Words: Airway management, bougie, difficult intubation, tracheal tube introducer
INTRODUCTION Difficult airway management may be a major cause of severe perioperative morbidity and mortality related to anesthesia.[1,2] Preoperatively, a lack of airway assessment, training and teaching seems to be a cause for concern.[3,4] Nevertheless, intubation difficulty arises in 1-4% of patients who have seemingly normal airways.[5] Based on emergent intubations, 10% of the patients are found to 24
have a difficult airway, which is an independent predictor for airway complications.[6] Patients who are difficult to intubate are at higher risk for airway‑related complications; and reported complication rates range from 4.1% to 28% (esophageal intubation, 1.6-9%; aspiration, 2-4%; and oropharyngeal trauma, 0.5-7%).[6] Thus, unexpected difficult intubation is an intermittent and often challenging problem for
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Abdulla, et al.: Making intubation easy and successful
clinically practicing anesthesiologists, maxillofacial surgeons, eye, ear, and nose (ENT), emergency, and critical care physicians. [6,7] An increasing number of airway management devices have been introduced into clinical practice.[3,8] One such device is the tracheal tube introducer (bougie), which has been widely used to facilitate endotracheal intubation. [5‑9] Ideally, it is used when the glottic opening is partially visible, it can also be effective when only the epiglottis is seen. The gum elastic bougie is effective to solve most problems occurring during predicted and unexpected difficult airway management.[10,11] Difficult airway management guidelines advise its use in cases of unexpected difficulty, most often due to a poor view of the vocal cords on laryngoscopy (Cormack‑Lehane grade 3 or 4 view).[12] It ensures a >90% success rate.[5] Clinical manifestations implicated in iatrogenic airway injury are minimal, usually blood on the tip at withdrawal or at later tracheal suction.[5] We present a new approach for making endotracheal intubation easy and successful, particularly in unexpected difficult airway and evaluate its efficacy in a retrospective observational study.
MATERIALS AND METHODS Only consultant anesthesiologists running the operating rooms at the time of the study were invited to participate. They were informed what the study entailed. None of them declined to take part. The choice and use of intubating introducers were left to them, depending on their own experience of using them. Generally, the tracheal tube introducer is indicated for expected or confirmed difficult intubations, crash intubation in emergency situations and in patients with full stomach, and intubation using spiral tubes in surgical procedures with field avoidance or in prone position.
was easily formed and well adapted to the anatomical airway structures of the patient. All the introducers used in this trial were brand‑new. For evaluating the visibility of the glottic opening and thus assuming the intubation difficulty, the conventional Cormack and Lehane classification of grades of laryngeal view was used on the base of the Cook’s modification (grade 1 – most of cords visible; grade 2a – posterior cords visible, grade 2b – only arytenoids visible; grade 3a – epiglottis visible and liftable, grade 3b – epiglottis visible but closely applied to posterior pharyngeal wall; grade 4 – no part of larynx visible).[13] During laryngoscopy, once identifying the epiglottis clearly (Cormack and Lehane 2a and 2b, easy or restricted view), the laryngoscope blade (Macintosh size 3 or 4) was first placed with its tip in the plica glossoepiglottica and raised in the direction of the handle vigorously while the nurse retracting the skin at the right corner of the mouth and moving the larynx to the proper position as required by the anesthesiologist to facilitate a better view for insertion of the tracheal tube introducer. After insertion of the introducer through the larynx into the trachea under laryngoscopic control, the endotracheal tube should then be gently advanced upon rotation around 360° clockwise into the trachea [Figures 2 and 3]. If the posterior commissure remained covered by the epiglottis during laryngoscopy (Cormack and Lehane 3a and 3b, restricted or difficult view), the insertion of the introducer might succeed under the epiglottis when lifted carefully by the cranially directed tip of the introducer. Advancing the tube gently followed blindly over the introducer into the trachea by good lubrication of the introducer and the tube itself. It should never be advanced against resistance, and only by tube rotation
A 5.6 Rüsch tracheal tube introducer with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the tube was used for facilitating endotracheal intubation in adult patients with or without difficult intubation. Using a lubricant (Xylocain ® Gel 2%, AstraZeneca Germany, Wedel), the gum elastic bougie was introduced as an internal splint in the tube to give it the necessary form for an unexpected difficult intubation [Figure 1]. It
Figure 1: The tracheal introducer protrudes at least 6 cm (=4 digits) beyond the distal end of the Magill tube
Figure 2: Laryngoscopy in a patient with stiff neck and limited mouth opening, gently advancing the Magill tube upon rotation around 360° clockwise into the trachea
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Abdulla, et al.: Making intubation easy and successful
360°. Important is also the observable backward push of the introducer by good lubrication while advancing the tube endotracheally [Figures 2 and 3].
RESULTS Anesthesia services at the “Marienkrankenhaus” in Papenburg, a teaching hospital of the Hannover Medical School, Germany were analyzed on a total number of 10,363 patients over a period of 12 months from 20 October 2010 to 19 October 2011 [Figure 4]. Approval from the institutional review board was obtained in advance. Of these, 5103 (49%) patients were excluded from the study because services were offered using local/ regional anesthesia (n = 2020, 19.5%) or laryngeal mask
(n = 1172, 11.3%), and most ophthalmological patients (n = 1911, 18.4%) were operated on using either a retrobulbar or a peribulbar block with standby and a small dosage of propofol while performing the block. Only 5260 of the 10,363 patients (50.8%) were intubated for different surgical procedures as outlined in Table 1. A total of 2453 patients (23.7%) (Group A) were intubated with an introducer keeping its tip inside the tube in the usual way, but without using tube rotation technique. In this group, intubation difficulties were encountered in 63 patients (2.6%). All of them were managed either with the tube rotation technique (n = 60) (Cormack and Lehane 3a und 3b) or Bonfils endoscope (n = 3) (Cormack and Lehane 3b/4). However, 2807 patients (27.1%) (Group B) were initially intubated with tracheal tube introducer and tube rotation technique as described earlier. Most of them were successfully intubated; difficult intubations occurred only in three patients (0.11%) who could finally be managed with tube introducer rotation technique by experienced consultant anesthesiologists (Cormack and Lehane 3b).
DISCUSSION
Figure 3: Final assessment of the tube being placed endotracheally
Basrah University Medical Center in Iraq had been caring for patients with the most devastating facial injuries during the first and second Gulf Wars. Under such difficult circumstances, the most senior author of this article started to use the above described technique of tube rotation during endotracheal intubation in life‑threatening airway emergencies. Under his supervision, we also have practiced the tube rotation technique using the malleable introducer with its soft tip
Figure 4: Flow diagram of anesthesia services over 12 months
26
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Abdulla, et al.: Making intubation easy and successful
Table 1: Analysis of anesthesia services over 12 months Total services (n=10,363)
Intubations Group A (n=2453) Group B (n=2807) (n=5260) without rotation with rotation (success rate) (success rate)
Surgery (1813) Trauma (1841) Orthopedics (2086) Gynecology (1057) Obstetrics (650) Neurosurgery (150) Urology (410) ENT (131) Eye surgery (1937) Hand surgery (288)
1421 1202 1243 824 24 150 208 131 26 31
799 (781) 416 (392) 656 (645) 419 (413) 11 (9) 130 (128) 22 (22)
622 (622) 786 (784) 587 (586) 405 (405) 13 (13) 150 (150) 78 (78) 131 (131) 26 (26) 9 (9)
ENT: Ear nose, and throat
protruding at least 6 cm beyond the distal end of the tube at two German teaching hospitals for 19 years without any obvious damage to the trachea. From 1992 to 2010, retrospective observations at the “Klinikum Bernburg,” a teaching hospital of Martin Luther‑University in Halle, Germany showed that the tube rotation technique was applied easily and successfully in 7200 patients. Only 4 out of 7200 patients (0.056%) could not be intubated with the presented technique. In two patients scheduled for gynecologic surgery and surgical reintervention after carotid endarteriectomy (Cormack and Lehane 3b/4), intubation was accomplished with the tube rotation technique under jet ventilation using a jet cannula inserted intratracheally through the cricothyroid membrane. The other two patients were managed by fiberoptic intubation or laryngeal mask (Cormack and Lehane 3b/4). Based upon the high success rate, a retrospective observational study was conducted at the “Marienkrankenhaus” in Papenburg, a teaching hospital of the Hannover Medical School in Germany over one year. The results were comparable to those of the retrospective observations obtained at the “Klinikum Bernburg.” They also showed that the rotation technique has proven useful in all intubations, particularly in patients with suggested or confirmed difficult intubations or crash intubation with or without full stomach. Baum et al. described a similar technique without tube rotation for the Oxford nonkinking tube (ONK tube) in detail and recommended its use for controlling unexpected difficult intubation.[14] The main objective of any technique securing the airway in unexpected difficult intubations, particularly in patients with full stomach is to minimize the time interval between loss of protective airway reflexes and tracheal intubation with a cuffed endotracheal tube[15] and to intubate safely under controlled circumstances with the least possible trauma to the pharyngeal structures and upper airways, while maintaining the vital signs. Using the tube rotation technique after sufficient training, the objective can easily be achieved even by intubators without strong muscle
power for visualization of the glottic opening during laryngoscopy. However, the intubator must be well familiar with the tube rotation technique at 360° clockwise. For the safety of the patient, the manufacturers’ recommendation that lubrication be used when bougies are employed to assist endotracheal intubation should be followed. The 5.6 tracheal tube introducer as an internal malleable splint with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the endotracheal tube for adults must be easily formed and well adapted to the anatomical airway structures of the patient; on the other hand, it must also be stable enough to stay in a desired shape during intubation. The tube should be gently advanced upon rotation 360° clockwise with the introducer into the trachea to allow for smooth passage through the glottis and to avoid the introducer tip catching on laryngeal structures. Important is also the observable backward push of the introducer by good lubrication while gently advancing the tube upon rotation endotracheally. However, mounting the tube onto the introducer and introducing them as a unit is not advised, and it is more likely to cause airway trauma. Therefore, a carefully passed introducer that advances into the trachea by rotation without resistance is added assurance that an endotracheal tube will be able to be placed without causing further damage. Potential signs of correct placement of the introducer seen to pass through the vocal cords, such as “clicks” as it passes along the tracheal rings, and “distal hold up” as it reaches the tracheal bifurcation, could not be detected in our study. Thus, any endotracheal damage will be prevented by good lubrication and rotation of both endotracheal tube and its introducer. However, advancing the tube without rotation, while inserting the introducer endotracheally, may harm the trachea either by perforation or laceration of tracheal wall. It seems likely that the risk of tissue trauma is much greater with “distal hold up” than with “clicks,” especially with introducers that can exert large forces. [16] The final position of the tube is then established with capnography during manual ventilation. Nevertheless, it must be emphasized that this technique particularly in difficult airway should only be performed when adequate skills and experience have been acquired. During our experience for the past 24 years on more than 10007 patients, we are not aware of any cases of tissue trauma. In the literature, however, there have been only a few reports of severe complications, such as pharyngeal perforation, mainstem bronchus bleeding, perforation of the tracheal mucosa, and tracheal abrasion associated with hemopneumothorax. Most bougie placement complications are related to perforation caused by aggressive placement or from railroading, pushing the endotracheal tube over the bougie against resistance.[17]
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Abdulla, et al.: Making intubation easy and successful
Using the ‘‘distal hold‑up sign’’ may favor lung trauma since railroading the endotracheal tube is sometimes difficult and necessitates placing force on the introducer, which already abuts against the bronchial wall. [18] If an injury is suspected after the intubation process and imaging is not a contributory factor, a diagnosis can be made with a chest computed tomography (CT) scan or bronchoscopy.[18]
LIMITATIONS This article has certain limitations due to the retrospective design of the study. The detection of complications in this design is always difficult and makes the interpretation of the presented results problematic. In addition, there is no comparison group to truly compare outcome and efficacy of intubation with or without tube rotation technique. Even then, the value of results is pertinent, due to the fact that complications are most commonly evaluated in observational or small sample studies. However, additional randomized, prospective, controlled studies are required to clearly establish the benefits and value of the tube rotation technique. Finally, we were unable to analyze long‑term follow‑up after intubation.
2. 3. 4. 5. 6. 7. 8.
9. 10. 11. 12.
CONCLUSIONS The tube rotation technique has greatly facilitated the management of an unexpected difficult airway and also provided an additional technique to safely perform endotracheal intubation in patients with unexpected difficult airway. However, it should be used only by physicians being well familiar with this technique. Based on our experience and observations inside and outside the operating room we should not be reluctant to use it. We also suggest that well designed controlled studies should be performed to evaluate its use, efficacy, and safety in securing the airway by placement of an endotracheal tube in both emergency patients and those under general anesthesia.
REFERENCES 1.
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Hove LD, Steinmetz J, Christoffersen JK, Moller A, Nielsen J, Schmidt H. Analysis of deaths related to anesthesia in the period 1996-2004 from
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closed claims registered by the Danish Patient Insurance Association. Anesthesiology 2007;106:675‑80. Cooper GM, McClure JH. Anaesthesia chapter from saving mothers lives: Reviewing maternal deaths to make pregnancy safer. Br J Anaesth 2008;100:17‑22. Crosby ET, Cooper RM, Douglas MJ, Doyle DJ, Hung OR, Labrecque P, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth 1998;45:757‑76. McPherson D, Vaughan RS, Wilkes AR, Mapleson WW, Hodzovic I. A survey of anaesthetic practice in predicting difficult intubation in UK and Europe. Eur J Anaesthesiol 2012;29:218‑22. Hodzovic I, Wilkes AR, Stacey M, Latto IP. Evaluation of clinical effectiveness of the Frova single‑use tracheal tube introducer. Anaesthesia 2008;63:189‑94. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital‑Airway outcomes and complications. Anesthesiology 2011;114:42‑8. Drolet P. Management of the anticipated difficult airway‑A systematic approach: Continuing Professional Development. Can J Anesth 2009;56:683‑701. Pandit JJ, Popat MT, Cook TM, Wilkes AR, Groom P, Cooke H, et al. The Difficult Airway Society “ADEPT” Guidance on selecting airway devices: The basis of a strategy for equipment evaluation. Anaesthesia 2011;66:726‑37. Janakiraman C, Hodzovic I, Reddy S, Desai N, Wilkes AR, Latto IP. Evaluation of tracheal tube introducers in simulated difficult intubation. Anaesthesia 2009;64:309‑14. Combes X, Le Roux B, Suen P, Dumerat M, Motamed C, Sauvat S, et al. Unanticipated difficult airway in anesthetized Patients. Anesthesiology 2004;100:1146‑50. Latto IP, Stacey M, Mecklenburgh J, Vaughan RS. Survey of the use of the gum elastic bougie in clinical practice. Anaesthesia 2002;57:379‑84. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269‑77. Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000;55:274‑9. Baum JA, Sachs G, Stanke HG. The unexpectedly difficult airway‑A plea for the Oxford‑Non‑Kinking‑Tube. Anästhesiol Intensivmed Notfallmed Schmerzther 2004;39:610‑5. El‑Orbany M, Connolly LA. Rapid sequence induction and intubation: Current Controversy. Anesth Analg 2010;110:1318‑25. Hodzovic I, Latto IP, Wilkes AR, Hall JE, Mapleson WW. Evaluation of Frova, single‑use intubation introducer, in a manikin. Comparison with Eschmann multiple‑use introducer and Portex single‑use introducer. Anaesthesia 2004;59:811‑6. Phelan MP. Use of the endotracheal bougie introducer for difficult intubations. Am J Emerg Med 2004;22:479‑82. Sahin M, Anglade D, Buchberger M, Jankowski A, Albaladejo P, Ferretti GR. Case reports: Iatrogenic bronchial rupture following the use of endotracheal tube introducers. Can J Anesth 2012;59:963‑7.
Cite this article as: Abdulla S, Abdulla S, Schwemm K, Eckhardt R, Abdulla W. Making endotracheal intubation easy and successful, particularly in unexpected difficult airway. Int J Crit Illn Inj Sci 2014;4:24-8. Source of Support: Nil, Conflict of Interest: None declared.
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
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Original Article
DOI: 10.4103/2229-5151.128009 Quick Response Code:
Making endotracheal intubation easy and successful, particularly in unexpected difficult airway Susanne Abdulla1,2,3, Sina Abdulla1, Karl‑Peter Schwemm4, Regina Eckhardt1, Walied Abdulla1,4,5
ABSTRACT
Department of Anesthesiology and Intensive Care Medicine, Klinikum Bernburg, Martin Luther‑University Halle‑Wittenberg, Bernburg, 2 Department of Neurology, Otto‑von‑Guericke University, Magdeburg, 3Department of Neurology, Medizinische Hochschule Hannover, Hannover, 4Department of Anesthesiology, Marienkrankenhaus Papenburg, A Teaching Hospital of the University Medical School, Hannover, 5 Johannes Gutenberg University Mainz, Mainz, Germany
1
Background: Difficult intubation, most often due to poor view of the vocal cords on laryngoscopy is an intermittent and often challenging problem for clinically practicing anesthesiologists, maxillofacial surgeons, ear nose, and throat (ENT), emergency, and critical care physicians. Purpose: We present a new approach for facilitating difficult intubation and evaluate its efficacy in a retrospective observational study. Settings and Design: Operating room, emergency department, intensive care unit (ICU), retrospective observational study. Materials and Methods: A semirigid 5.6 Rüsch tracheal tube introducer (bougie) with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the tube was used. After its insertion through the larynx under laryngoscopy, the tube was gently advanced upon rotation at 360° clockwise. Statistical Analysis: Descriptive.
Address for correspondence: Prof. Walied Abdulla, Robert‑Kirchhoff‑Str. 12, D‑06406 Bernburg, Germany. E‑mail: walied.abdulla@t‑online.de
Results: Anesthesia services were analyzed on 10,363 patients over 12 months. In 2453 patients (23.7%) (Group A) intubated in the usual way, difficulties were encountered in 63 patients (2.6%). They were managed either with tube rotation technique (n = 60) or Bonfils endoscope (n = 3). In contrast, 2807 patients (27.1%) (Group B) were intubated using tube rotation technique with introducer. Difficult intubations occurred only in three patients (0.11%) who could be managed with tube rotation by experienced consultant anesthesiologists. Conclusions: The tube rotation technique for intubation was introduced during the Gulf War and has been practiced for the past 19 years without any obvious damage to the trachea in Germany. However, it should be used only by physicians being well familiar with this technique. In addition, well designed controlled studies are needed. Key Words: Airway management, bougie, difficult intubation, tracheal tube introducer
INTRODUCTION Difficult airway management may be a major cause of severe perioperative morbidity and mortality related to anesthesia.[1,2] Preoperatively, a lack of airway assessment, training and teaching seems to be a cause for concern.[3,4] Nevertheless, intubation difficulty arises in 1-4% of patients who have seemingly normal airways.[5] Based on emergent intubations, 10% of the patients are found to 24
have a difficult airway, which is an independent predictor for airway complications.[6] Patients who are difficult to intubate are at higher risk for airway‑related complications; and reported complication rates range from 4.1% to 28% (esophageal intubation, 1.6-9%; aspiration, 2-4%; and oropharyngeal trauma, 0.5-7%).[6] Thus, unexpected difficult intubation is an intermittent and often challenging problem for
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Abdulla, et al.: Making intubation easy and successful
clinically practicing anesthesiologists, maxillofacial surgeons, eye, ear, and nose (ENT), emergency, and critical care physicians. [6,7] An increasing number of airway management devices have been introduced into clinical practice.[3,8] One such device is the tracheal tube introducer (bougie), which has been widely used to facilitate endotracheal intubation. [5‑9] Ideally, it is used when the glottic opening is partially visible, it can also be effective when only the epiglottis is seen. The gum elastic bougie is effective to solve most problems occurring during predicted and unexpected difficult airway management.[10,11] Difficult airway management guidelines advise its use in cases of unexpected difficulty, most often due to a poor view of the vocal cords on laryngoscopy (Cormack‑Lehane grade 3 or 4 view).[12] It ensures a >90% success rate.[5] Clinical manifestations implicated in iatrogenic airway injury are minimal, usually blood on the tip at withdrawal or at later tracheal suction.[5] We present a new approach for making endotracheal intubation easy and successful, particularly in unexpected difficult airway and evaluate its efficacy in a retrospective observational study.
MATERIALS AND METHODS Only consultant anesthesiologists running the operating rooms at the time of the study were invited to participate. They were informed what the study entailed. None of them declined to take part. The choice and use of intubating introducers were left to them, depending on their own experience of using them. Generally, the tracheal tube introducer is indicated for expected or confirmed difficult intubations, crash intubation in emergency situations and in patients with full stomach, and intubation using spiral tubes in surgical procedures with field avoidance or in prone position.
was easily formed and well adapted to the anatomical airway structures of the patient. All the introducers used in this trial were brand‑new. For evaluating the visibility of the glottic opening and thus assuming the intubation difficulty, the conventional Cormack and Lehane classification of grades of laryngeal view was used on the base of the Cook’s modification (grade 1 – most of cords visible; grade 2a – posterior cords visible, grade 2b – only arytenoids visible; grade 3a – epiglottis visible and liftable, grade 3b – epiglottis visible but closely applied to posterior pharyngeal wall; grade 4 – no part of larynx visible).[13] During laryngoscopy, once identifying the epiglottis clearly (Cormack and Lehane 2a and 2b, easy or restricted view), the laryngoscope blade (Macintosh size 3 or 4) was first placed with its tip in the plica glossoepiglottica and raised in the direction of the handle vigorously while the nurse retracting the skin at the right corner of the mouth and moving the larynx to the proper position as required by the anesthesiologist to facilitate a better view for insertion of the tracheal tube introducer. After insertion of the introducer through the larynx into the trachea under laryngoscopic control, the endotracheal tube should then be gently advanced upon rotation around 360° clockwise into the trachea [Figures 2 and 3]. If the posterior commissure remained covered by the epiglottis during laryngoscopy (Cormack and Lehane 3a and 3b, restricted or difficult view), the insertion of the introducer might succeed under the epiglottis when lifted carefully by the cranially directed tip of the introducer. Advancing the tube gently followed blindly over the introducer into the trachea by good lubrication of the introducer and the tube itself. It should never be advanced against resistance, and only by tube rotation
A 5.6 Rüsch tracheal tube introducer with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the tube was used for facilitating endotracheal intubation in adult patients with or without difficult intubation. Using a lubricant (Xylocain ® Gel 2%, AstraZeneca Germany, Wedel), the gum elastic bougie was introduced as an internal splint in the tube to give it the necessary form for an unexpected difficult intubation [Figure 1]. It
Figure 1: The tracheal introducer protrudes at least 6 cm (=4 digits) beyond the distal end of the Magill tube
Figure 2: Laryngoscopy in a patient with stiff neck and limited mouth opening, gently advancing the Magill tube upon rotation around 360° clockwise into the trachea
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
25
Abdulla, et al.: Making intubation easy and successful
360°. Important is also the observable backward push of the introducer by good lubrication while advancing the tube endotracheally [Figures 2 and 3].
RESULTS Anesthesia services at the “Marienkrankenhaus” in Papenburg, a teaching hospital of the Hannover Medical School, Germany were analyzed on a total number of 10,363 patients over a period of 12 months from 20 October 2010 to 19 October 2011 [Figure 4]. Approval from the institutional review board was obtained in advance. Of these, 5103 (49%) patients were excluded from the study because services were offered using local/ regional anesthesia (n = 2020, 19.5%) or laryngeal mask
(n = 1172, 11.3%), and most ophthalmological patients (n = 1911, 18.4%) were operated on using either a retrobulbar or a peribulbar block with standby and a small dosage of propofol while performing the block. Only 5260 of the 10,363 patients (50.8%) were intubated for different surgical procedures as outlined in Table 1. A total of 2453 patients (23.7%) (Group A) were intubated with an introducer keeping its tip inside the tube in the usual way, but without using tube rotation technique. In this group, intubation difficulties were encountered in 63 patients (2.6%). All of them were managed either with the tube rotation technique (n = 60) (Cormack and Lehane 3a und 3b) or Bonfils endoscope (n = 3) (Cormack and Lehane 3b/4). However, 2807 patients (27.1%) (Group B) were initially intubated with tracheal tube introducer and tube rotation technique as described earlier. Most of them were successfully intubated; difficult intubations occurred only in three patients (0.11%) who could finally be managed with tube introducer rotation technique by experienced consultant anesthesiologists (Cormack and Lehane 3b).
DISCUSSION
Figure 3: Final assessment of the tube being placed endotracheally
Basrah University Medical Center in Iraq had been caring for patients with the most devastating facial injuries during the first and second Gulf Wars. Under such difficult circumstances, the most senior author of this article started to use the above described technique of tube rotation during endotracheal intubation in life‑threatening airway emergencies. Under his supervision, we also have practiced the tube rotation technique using the malleable introducer with its soft tip
Figure 4: Flow diagram of anesthesia services over 12 months
26
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Abdulla, et al.: Making intubation easy and successful
Table 1: Analysis of anesthesia services over 12 months Total services (n=10,363)
Intubations Group A (n=2453) Group B (n=2807) (n=5260) without rotation with rotation (success rate) (success rate)
Surgery (1813) Trauma (1841) Orthopedics (2086) Gynecology (1057) Obstetrics (650) Neurosurgery (150) Urology (410) ENT (131) Eye surgery (1937) Hand surgery (288)
1421 1202 1243 824 24 150 208 131 26 31
799 (781) 416 (392) 656 (645) 419 (413) 11 (9) 130 (128) 22 (22)
622 (622) 786 (784) 587 (586) 405 (405) 13 (13) 150 (150) 78 (78) 131 (131) 26 (26) 9 (9)
ENT: Ear nose, and throat
protruding at least 6 cm beyond the distal end of the tube at two German teaching hospitals for 19 years without any obvious damage to the trachea. From 1992 to 2010, retrospective observations at the “Klinikum Bernburg,” a teaching hospital of Martin Luther‑University in Halle, Germany showed that the tube rotation technique was applied easily and successfully in 7200 patients. Only 4 out of 7200 patients (0.056%) could not be intubated with the presented technique. In two patients scheduled for gynecologic surgery and surgical reintervention after carotid endarteriectomy (Cormack and Lehane 3b/4), intubation was accomplished with the tube rotation technique under jet ventilation using a jet cannula inserted intratracheally through the cricothyroid membrane. The other two patients were managed by fiberoptic intubation or laryngeal mask (Cormack and Lehane 3b/4). Based upon the high success rate, a retrospective observational study was conducted at the “Marienkrankenhaus” in Papenburg, a teaching hospital of the Hannover Medical School in Germany over one year. The results were comparable to those of the retrospective observations obtained at the “Klinikum Bernburg.” They also showed that the rotation technique has proven useful in all intubations, particularly in patients with suggested or confirmed difficult intubations or crash intubation with or without full stomach. Baum et al. described a similar technique without tube rotation for the Oxford nonkinking tube (ONK tube) in detail and recommended its use for controlling unexpected difficult intubation.[14] The main objective of any technique securing the airway in unexpected difficult intubations, particularly in patients with full stomach is to minimize the time interval between loss of protective airway reflexes and tracheal intubation with a cuffed endotracheal tube[15] and to intubate safely under controlled circumstances with the least possible trauma to the pharyngeal structures and upper airways, while maintaining the vital signs. Using the tube rotation technique after sufficient training, the objective can easily be achieved even by intubators without strong muscle
power for visualization of the glottic opening during laryngoscopy. However, the intubator must be well familiar with the tube rotation technique at 360° clockwise. For the safety of the patient, the manufacturers’ recommendation that lubrication be used when bougies are employed to assist endotracheal intubation should be followed. The 5.6 tracheal tube introducer as an internal malleable splint with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the endotracheal tube for adults must be easily formed and well adapted to the anatomical airway structures of the patient; on the other hand, it must also be stable enough to stay in a desired shape during intubation. The tube should be gently advanced upon rotation 360° clockwise with the introducer into the trachea to allow for smooth passage through the glottis and to avoid the introducer tip catching on laryngeal structures. Important is also the observable backward push of the introducer by good lubrication while gently advancing the tube upon rotation endotracheally. However, mounting the tube onto the introducer and introducing them as a unit is not advised, and it is more likely to cause airway trauma. Therefore, a carefully passed introducer that advances into the trachea by rotation without resistance is added assurance that an endotracheal tube will be able to be placed without causing further damage. Potential signs of correct placement of the introducer seen to pass through the vocal cords, such as “clicks” as it passes along the tracheal rings, and “distal hold up” as it reaches the tracheal bifurcation, could not be detected in our study. Thus, any endotracheal damage will be prevented by good lubrication and rotation of both endotracheal tube and its introducer. However, advancing the tube without rotation, while inserting the introducer endotracheally, may harm the trachea either by perforation or laceration of tracheal wall. It seems likely that the risk of tissue trauma is much greater with “distal hold up” than with “clicks,” especially with introducers that can exert large forces. [16] The final position of the tube is then established with capnography during manual ventilation. Nevertheless, it must be emphasized that this technique particularly in difficult airway should only be performed when adequate skills and experience have been acquired. During our experience for the past 24 years on more than 10007 patients, we are not aware of any cases of tissue trauma. In the literature, however, there have been only a few reports of severe complications, such as pharyngeal perforation, mainstem bronchus bleeding, perforation of the tracheal mucosa, and tracheal abrasion associated with hemopneumothorax. Most bougie placement complications are related to perforation caused by aggressive placement or from railroading, pushing the endotracheal tube over the bougie against resistance.[17]
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Abdulla, et al.: Making intubation easy and successful
Using the ‘‘distal hold‑up sign’’ may favor lung trauma since railroading the endotracheal tube is sometimes difficult and necessitates placing force on the introducer, which already abuts against the bronchial wall. [18] If an injury is suspected after the intubation process and imaging is not a contributory factor, a diagnosis can be made with a chest computed tomography (CT) scan or bronchoscopy.[18]
LIMITATIONS This article has certain limitations due to the retrospective design of the study. The detection of complications in this design is always difficult and makes the interpretation of the presented results problematic. In addition, there is no comparison group to truly compare outcome and efficacy of intubation with or without tube rotation technique. Even then, the value of results is pertinent, due to the fact that complications are most commonly evaluated in observational or small sample studies. However, additional randomized, prospective, controlled studies are required to clearly establish the benefits and value of the tube rotation technique. Finally, we were unable to analyze long‑term follow‑up after intubation.
2. 3. 4. 5. 6. 7. 8.
9. 10. 11. 12.
CONCLUSIONS The tube rotation technique has greatly facilitated the management of an unexpected difficult airway and also provided an additional technique to safely perform endotracheal intubation in patients with unexpected difficult airway. However, it should be used only by physicians being well familiar with this technique. Based on our experience and observations inside and outside the operating room we should not be reluctant to use it. We also suggest that well designed controlled studies should be performed to evaluate its use, efficacy, and safety in securing the airway by placement of an endotracheal tube in both emergency patients and those under general anesthesia.
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Cite this article as: Abdulla S, Abdulla S, Schwemm K, Eckhardt R, Abdulla W. Making endotracheal intubation easy and successful, particularly in unexpected difficult airway. Int J Crit Illn Inj Sci 2014;4:24-8. Source of Support: Nil, Conflict of Interest: None declared.
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
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