ABSTRACT
Abstract Background: Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. Case summary: A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. Conclusion: Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans.
Resumo Justificativa: A intubação seletiva neonatal do brônquio principal esquerdo para tratar a doença pulmonar direita é tipicamente feita com elaboradas manobras, instrumentação e dispositivos. Isso é frequentemente atribuído à geometria brônquica que favorece a entrada principal direita de um tubo endotraqueal (TET) deliberadamente avançado para além da carina. Resumo do caso: Recém-nascido com enfisema bolhoso grave que afetava o pulmão direito e precisou com urgência da não ventilação desse pulmão. Para conseguir a intubação brônquica esquerda fizemos uma rotação de 180° do TET, de forma que o olho de Murphy ficasse voltado para a esquerda, e não para a direita, e para simular uma intubação à esquerda orientamos ligeiramente o TET, de modo que sua concavidade virasse para a esquerda em vez de para a direita, como em uma intubação convencional à direita. Conclusão: A intubação urgente do brônquio principal esquerdo com um TET pode ser facilmente obtida se reconhecermos que é a posição da ponta do TET e a direção de sua concavidade que determinam para qual brônquio o TET irá quando avançado. Isso é importante em neonatos criticamente doentes diante da margem de segurança e janela de tempo pequenas e na ausência de tubos de duplo lúmen. O uso de broncofibroscópio e bloqueadores deve ser considerado como planos de segurança.
Subject(s)
Humans , Infant, Newborn , Pulmonary Emphysema/therapy , Intubation, Intratracheal/instrumentation , Intensive Care, Neonatal , BronchoscopesABSTRACT
Objective To explore the application value of videolaryngoscope and Macintosh la ryngoscope in double-lumen endobronchial intubation.Methods Eighty patients (50 males,30 females,aged 18-70 years,ASA grade Ⅰ-Ⅲ) of both sexes,scheduled for thoracic surgery and double lumen endobronchial intubation were randomly divided into two groups using a random number table:videolaryngoscope group and Macintosh laryngoscope group.The intubation time,the success rate of intubation,the views of glottis,the hemodynamics during the first 4 minutes of intubation,the number of positive responses to intubation and the incidence of pharyngalgia at 24 h after the operation were observed and compared between the two groups,the condition of oral hemorrhage and the injury of the tracheal walls were recorded as well.Results Compared with videolaryngoscope group,the C-L grade and the success rate of the first intubation of Macintosh laryngoscope group was significantly higher,the intubation time of Macintosh laryngoscope group was significantly shor ter (P＜0.05).In addition,the positive cases of responses to intubation and the incidence of pharyngalgia at 24 h after the operation of Macintosh laryngoscope group were obviously less than those of videolaryngoscope group (P＜0.05).There was no significant difference between the two groups of oral injury bleeding and the injury of tracheal wall and protuberance.At T2,T3,the two groups of MAP were significantly lower than that of T1,and the MAP of videolaryngoscope group was significantly lower than that of t Macintosh laryngoscope group at T2,T3 (P ＜ 0.05).Conclusion Compared with videolaryngoscope,Macintosh laryngoscope is more suitable for the doublelumen endobronchial intubation in patients predicted without difficulty in intubating.
ABSTRACT
Objective To evaluate the effect of early aerosol inhalation on sore throat of the patients after double lumen endobronchial intubation. Methods 90 patients scheduled for thoracic surgery were randomly assigned to 3 groups,30 cases in each group: control group (Group C), early aerosol inhalation group (group one) and later aerosol inhalation group (group two). All patients were sent to PACU after extubation.The patients in group C were intraveously injected with 6 mL saline , those in group one were treated with aerosol inhalation of 1mg budesonide, while the patients in group two with budesonide at the same dosage 2 h later. Patients were examined with indirect laryngoscopy 6 h after surgery. The cases of vocal cord congestion and glottis edema were recorded. The degree of pharyngolaryneal pain was assessed with the Visual Analogue Scale (VAS) when they were sent to PACU , 6 , 24 and 48 hours after surgery . Results The rates of vocal cord congestion and glottis edema in group one were lower than those in group C and group 2, 6 h after surgery (P < 0.05). The pharyngolaryneal VAS in group one was significantly lower than that in group C and group 2 , 6 and 24 h after operation (P < 0.05), but there was no statistical difference between them 48 h after surgery between 3 groups. Conclusions Aerosol inhalation of budesonide after double lumen endobronchial intubation for the patients scheduled for thoracic surgery during early postoperative stage can reduce the incidences of vocal cord congestion and glottis edema, inhibit airway inflammation, significantly reduce the extent of the POST. The effect is better than that of the lateraerosol inhalation of budesonide.
ABSTRACT
Objective To evaluate and compare the clinical applications of Disposcope (DS)en-doscope and GlideScope (GS)video laryngoscope in double-lumen endobronchial tube (DLT)intuba-tion of the patients with difficult airway.Methods Forty patients scheduled for elective thoracic sur-gery after failure to place the DLT with modified general laryngoscope 2 attempts were randomly dev-ided into 2 groups,20 cases in each group.Patients underwent DLT with DS (group DS)or GS (group GS)intubation after failure to intubation.The causes of the failure of intubation,the intuba-tion of the video laryngoscope,the time of intubation and the location of left double lumen tube were recorded.And the postoperative injury of oral mucosa,teeth and respiratory tract were observed. Results The causes of the difficulty for DLT intubation included:long,high arched palate,large epi-glottis,reduced jaw opening,protruding or loose incisors,over bite,reduced neck extension.The in-tubating achievement ratio was significantly higher in group DS than in group GS (P < 0.05 ).But there was no obvious difference between the two groups in the location success rate and intubation time.The postoperative incidence of tooth loss and oral mucosal injury was significantly higher in group GS than in group DS (P <0.05).Conclusion Both DS and GS were great helpful to intubation and location of DLT in the patients with difficult airway.But DS was more superior than that of GS in the difficult airway of reduced jaw opening,protruding or loose incisors,over bite and reduced neck extension.
ABSTRACT
Undetected endobronchial intubation during general anesthesia can cause serious complications. However, it is very difficult to determine the exact location of the endotracheal tube when it is positioned in the middle of the trachea. We experienced a patient who showed hypoxia caused by the positioning of the endobronchial tube. We think that the tube might have been advanced from the upper part of the carina into the right main bronchus while the neck was being flexed by the neurosurgeon for achieving better surgical exposure.
Subject(s)
Humans , Anesthesia, General , Hypoxia , Bronchi , Intubation , Neck , TracheaABSTRACT
BACKGROUND: Endotracheal intubation usually causes transient hypertension and tachycardia. The cardiovascular and arousal responses to endotracheal and endobronchial intubation were determined during rapid-sequence induction of anesthesia in normotensive and hypertensive elderly patients. METHODS: Patients requiring endotracheal intubation with (HT, n = 30) or without hypertension (NT, n = 30) and those requiring endobronchial intubation with (HB, n = 30) or without hypertension (NB, n = 30) were included in the study. Anesthesia was induced with intravenous thiopental 5 mg/kg followed by succinylcholine 1.5 mg/kg. After intubation, all subjects received 2% sevoflurane in 50% nitrous oxide and oxygen. Mean arterial pressure (MAP), heart rate (HR), plasma catecholamine concentration, and Bispectral Index (BIS) values, were measured before and after intubation. RESULTS: The intubation significantly increased MAP, HR, BIS values and plasma catecholamine concentrations in all groups, the peak value of increases was comparable between endotracheal and endobronchial intubation. However, pressor response persisted longer in the HB group than in the HT group (5.1 +/- 1.6 vs. 3.2 +/- 0.9 min, P < 0.05). The magnitude of increases in MAP and norepinephrine from pre-intubation values was greater in the hypertensive than in the normotensive group (P < 0.05), while there were no differences in those of HR and BIS between the hypertensive and normotensive groups. CONCLUSIONS: Cardiovascular response and arousal response, as measured by BIS, were similar in endobronchial and endotracheal intubation groups regardless of the presence or absence of hypertension except for prolonged pressor response in the HB group. However, the hypertensive patients showed enhanced cardiovascular responses than the normotensive patients.
Subject(s)
Aged , Humans , Anesthesia , Arousal , Arterial Pressure , Heart Rate , Hypertension , Intubation , Intubation, Intratracheal , Methyl Ethers , Nitrous Oxide , Norepinephrine , Oxygen , Plasma , Succinylcholine , Tachycardia , ThiopentalABSTRACT
BACKGROUND: The purpose of the present study was to determine the optimal dose of bolus remifentanil to attenuate hemodynamic changes to laryngoscopic double-lumen endobronchial intubation. METHODS: A total of 80 ASA I or II patients requiring double-lumen endobronchial intubation were randomly assigned to receive normal saline (NS) or one of the three different doses (0.5microgram/kg (group R0.5), 1.0microgram/kg (group R1.0) or 2.0microgram/kg (group R2.0)) of remifentanil. Study drugs for each group were administered over 30 seconds after induction of anesthesia with thiopental sodium and rocuronium. Laryngoscopic endobronchial intubation was carried out 90 seconds after the administration of study drug. Arterial blood pressure and heart rate were recorded at preanesthetic baseline, preintubation, postintubation, and every one minute during the initial 5 minute period after intubation. RESULTS: Mean arterial pressure at postintubation period increased significantly compared to baseline value in group NS, R0.5, and R1.0, but there were no significant changes in group R2.0. Heart rate showed significant increase in comparison to baseline value at every postintubation period in group NS, R0.5, R1.0, with no significant changes in group R2.0. CONCLUSIONS: We suggest that 2.0microgram/kg of remifentanil attenuate the hemodynamic changes to double-lumen endobronchial intubation without adverse effect.
Subject(s)
Humans , Anesthesia , Arterial Pressure , Heart Rate , Hemodynamics , Intubation , ThiopentalABSTRACT
BACKGROUND: This study examined the cardiovascular responses to double-lumen endobronchial intubation during rapid sequence induction of anesthesia, and compared the effect of remifentanil and alfentanil in a randomized, double-blind, placebo-controlled study in three groups of 20 elderly patients each. METHODS: Anesthesia was induced with intravenous thiopental (4-6 mg/kg) immediately followed by either remifentanil 2 microgram/kg, alfentanil 30microgram/kg, or saline (placebo) given over 30 sec. Succinylcholine 1.5 mg/kg was given for neuromuscular block. The laryngoscopy and intubation were performed 60 sec later. RESULTS: The intubation significantly increased systolic arterial pressure (SAP) and heart rate (HR) in all groups. The maximum pressure changes in the remifentanil and alfentanil groups (36 +/- 26 and 33 +/- 30 mmHg, respectively) were significantly lower than the 83 +/- 35 mmHg in the control group. The maximum HR in the remifentanil (77 +/- 13 bpm) and alfentanil (80 +/- 13 bpm) groups was lower when compared to controls (93 +/- 11 bpm). The norepinephrine and epinephrine concentrations increased after intubation in the control group but remained unaltered in both the alfentanil and remifentanil groups. There were no significant differences between the remifentanil and alfentanil groups in HR, SAP or catecholamines at any time. Five patients in the remifentanil group and three in the alfentanil group received ephedrine for hypotension. CONCLUSIONS: Endobronchial intubation elicited a significant pressor response, and that both remifentanil and alfentanil similarly attenuated the pressor response. However, the incidence of hypotension confirms that both drugs should be used with caution in elderly patients.
Subject(s)
Aged , Humans , Alfentanil , Anesthesia , Arterial Pressure , Catecholamines , Ephedrine , Epinephrine , Heart Rate , Hypertension , Hypotension , Incidence , Intubation , Laryngoscopy , Neuromuscular Blockade , Norepinephrine , Succinylcholine , Tachycardia , ThiopentalABSTRACT
BACKGROUND: In pediatric anesthesia, a method using deliberate endobronchial intubation and auscultation has been used for proper endotracheal tube depth. Tube size, however, may influence on auscultation for air leak between the tube and main bronchus. We attempted to ascertain whether the uncuffed tracheal tube (TT) size affects verifying tube placement by auscultation in children. METHODS: In 23 children, we measured the distance from the carina to the tip of a tube when the first auscultatory sound could be detected on the left chest and when the breathing sound of both chests equalized during withdrawal from right main bronchus. Then, we compared them with those of either a one-size larger or a one-size smaller tube. RESULTS: The distance from the carina to the tip at the first sound was significantly longer in the smaller tracheal tube (1.8 cm vs 1.5 cm, P = 0.01). The tube tip at the equalized breath sounds was 0.6 cm below the carina in both tubes. CONCLUSIONS: These results suggest that detecting endobronchial intubation may be more difficult when using uncuffed tracheal tubes with one-size smaller tube and that auscultation with deliberate bronchial intubation can place the uncuffed TT deeper than an intended depth.
Subject(s)
Child , Humans , Anesthesia , Auscultation , Bronchi , Intubation , Respiratory Sounds , ThoraxABSTRACT
A tracheoesophageal fistula (TEF) was detected in a woman who received chemotherapy for acute lymphoblastic leukemia. The fistula biopsy confirmed the aspergillus infection. A large fistula was located at the lateral wall of the carina involving the proximal left main bronchus, and the orifice of left main bronchus was almost completely obstructed by white mass-like plaque. Primary repair was planned using the right thoracotomy approach. We originally planned to selectively intubate the left lung with the aid of fiberoptic bronchoscope without success. Therefore, we selectively intubated the right lung. Hypoxemia developed during surgery and the level of oxygenation was improved by selectively intubating the left bronchus from the surgical field once the defect had been exposed. We review the ventilation technique and anesthetic problems encountered in patients with a large distal TEF.
Subject(s)
Female , Humans , Hypoxia , Aspergillus , Biopsy , Bronchi , Bronchoscopes , Drug Therapy , Fistula , Lung , Oxygen , Precursor Cell Lymphoblastic Leukemia-Lymphoma , Thoracotomy , Tracheoesophageal Fistula , VentilationABSTRACT
BACKGROUND: Endobronchial intubation should elicit significant circulatory responses. We examined the effects of alfentanil on hemodynamic and catecholamine responses to endobronchial intubation in elderly patients. METHODS: A total of 60 patients aged over 60 years requiring endobronchial intubation were randomized into three groups of 20 patients each. Anesthesia was induced with thiopental 4~6 mg/kg followed by saline (placebo) or alfentanil 10 or 30microgram/kg given as a bolus over 30 s. Succinylcholine 1 mg/kg was given for neuromuscular block. Laryngoscopy and intubation were performed 1 min later. RESULTS: The intubation significantly increased systolic arterial pressure and heart rate. The maximum pressure changes from pre-intubation values in both alfentanil groups (58+/-27 and 33+/-30 mm Hg in 10 and 30microgram/kg, respectively) were significantly lower compared with that of 83+/-35 mm Hg in the control group. The tachycardiac response was not significantly affected by alfentanil 10microgram/kg, but attenuated by alfentanil 30microgram/kg. The plasma norepinephrine concentrations were increased, which was not affected by alfentanil 10microgram/kg, but was significantly attenuated by alfentanil 30microgram/kg. Both doses of alfentanil abolished the increase of plasma epinephrine concentrations. Three patients in the 30microgram/kg group received ephedrine for hypotension. CONCLUSIONS: This study showed that endobronchial intubation elicited significant pressor response, and that alfentanil 30microgram/kg is more efficacious in attenuating the hemodynamic and catecholamine responses, although potential hypotension warrants a caution of its use, in elderly patients.
Subject(s)
Aged , Humans , Alfentanil , Anesthesia , Arterial Pressure , Catecholamines , Ephedrine , Epinephrine , Heart Rate , Hemodynamics , Hypertension , Hypotension , Intubation , Laryngoscopy , Neuromuscular Blockade , Norepinephrine , Plasma , Succinylcholine , Tachycardia , ThiopentalABSTRACT
General anesthesia for the removal of a large mediastnal tumor has been troublesome job for anesthesiologists due to life- threatening complications such as airway obstruction, cardiovascular collapse etc. during induction and maintenance of anesthesia. Anticipation and prevention of possible complications are important aspects of the safe anesthesia for mediastinal tumor removal. We experienced a general anesthesia for the 60 years old patient with a large right superior and posterior mediastnal mass that has compressed and deformed the main trachea towards the left side. Instead of routine double lumen or Univent tube intubation, we performed left endobronchial intubation with ordinary single lumen endotracheal tube by fiberoptic bronchoscope for rapid and accurate intubation. One-lung ventilation was uneventful during surgery. This case demonstrates that endobronchial intubation with 5.1 mm fiberoptic bronchoscope can be one of the options for rapid and secure airway for the removal of large mediastinal mass.
Subject(s)
Humans , Middle Aged , Airway Obstruction , Anesthesia , Anesthesia, General , Bronchoscopes , Intubation , One-Lung Ventilation , TracheaABSTRACT
General anesthesia for the removal of a large mediastnal tumor has been troublesome job for anesthesiologists due to life- threatening complications such as airway obstruction, cardiovascular collapse etc. during induction and maintenance of anesthesia. Anticipation and prevention of possible complications are important aspects of the safe anesthesia for mediastinal tumor removal. We experienced a general anesthesia for the 60 years old patient with a large right superior and posterior mediastnal mass that has compressed and deformed the main trachea towards the left side. Instead of routine double lumen or Univent tube intubation, we performed left endobronchial intubation with ordinary single lumen endotracheal tube by fiberoptic bronchoscope for rapid and accurate intubation. One-lung ventilation was uneventful during surgery. This case demonstrates that endobronchial intubation with 5.1 mm fiberoptic bronchoscope can be one of the options for rapid and secure airway for the removal of large mediastinal mass.