Management of laryngeal foreign bodies in children.
Foreign body aspiration is one of the leading causes of accidental death in children. Food items are the most common items aspirated in infants and toddlers, whereas older children are more likely to aspirate non-food items. Laryngeal impaction of a foreign body is very rare as most aspirated foreign bodies pass through the laryngeal inlet and get lodged lower down in the airway. Two rare cases of foreign body aspiration with subglottic impaction in very young children (under 2 years of age) are described. In both the cases subglottic impaction occurred consequent to attempted removal of foreign body by blind finger sweeping. The clinical presentation, investigations, and management of these rare cases are discussed. (+info)
Correlating fibreoptic nasotracheal endoscopy performance and psychomotor aptitude.
We have investigated the correlation between the scores attained on computerized psychometric tests, measuring psychomotor and information processing aptitudes, and learning fibreoptic endoscopy with the videoendoscope. Sixteen anaesthetic trainees performed two adaptive tracking tasks (ADTRACK 2 and ADTRACK 3) and one information management task (MAZE) from the MICROPAT testing system. They then embarked on a standardized fibreoptic training programme during which they performed 15 supervised fibreoptic nasotracheal intubations on anaesthetized oral surgery patients. There was a significant correlation between the means of the 15 endoscopy times and both ADTRACK 2 (r = -0.599, P = 0.014) and ADTRACK 3 (r = -0.589, P = 0.016) scores. The correlation between the means of the 15 endoscopy times and MAZE scores was not significant. The ratios of the mean endoscopy time for the last seven endoscopies to the mean endoscopy time for the first seven endoscopies were not significantly correlated with ADTRACK 2, ADTRACK 3 or MAZE scores. Psychomotor abilities appeared to be determinants of trainees' initial proficiency in endoscopy, but did not appear to be determinants of trainees' rates of progress during early fibreoptic training. (+info)
Perianesthetic dental injuries: frequency, outcomes, and risk factors.
BACKGROUND: Dental injury is well-recognized as a potential complication of laryngoscopy and tracheal intubation. However, the frequency, outcomes, and risk factors for this problem have not been documented in a well-defined patient population. METHODS: The authors analyzed the dental injuries of 598,904 consecutive cases performed on patients who required anesthetic services from 1987 through 1997. Dental injuries were defined as perianesthetic events (those occurring within 7 days) that required dental interventions to repair, stabilize, or extract involved dentition or support structures. A 1:3 case-control study of 16 patient and procedural characteristics was performed for cases that occurred during the first 5 yr of the study. Conditional logistic regression was used for data analysis. RESULTS: There were 132 cases (1:4,537 patients) of dental injury. One half of these injuries occurred during laryngoscopy and tracheal intubation. The upper incisors were the most commonly involved teeth, and most injuries were crown fractures and partial dislocations and dislodgements. Multivariate risk factors for dental injury in the case control study included general anesthesia with tracheal intubation (odds ratio [OR] = 89), preexisting poor dentition (OR = 50), and increased difficulty of laryngoscopy and intubation (OR = 11). CONCLUSIONS: Based on these data from a large surgical population at a single training institution, approximately 1:4,500 patients who receive anesthesia services sustain a dental injury that requires repair or extraction. Patients most at risk for perianesthetic dental injury include those with preexisting poor dentition who have one or more risk factors for difficult laryngoscopy and tracheal intubation. (+info)
Bolus dose remifentanil for control of haemodynamic response to tracheal intubation during rapid sequence induction of anaesthesia.
The effect of three bolus doses of remifentanil on the pressor response to laryngoscopy and tracheal intubation during rapid sequence induction of anaesthesia was assessed in a randomized, double-blind, placebo-controlled study in four groups of 20 patients each. After preoxygenation, anaesthesia was induced with thiopental 5-7 mg kg-1 followed immediately by saline (placebo) or remifentanil 0.5, 1.0 or 1.25 micrograms kg-1 given as a bolus over 30 s. Cricoid pressure was applied just after loss of consciousness. Succinylcholine 1 mg kg-1 was given for neuromuscular block. Laryngoscopy and tracheal intubation were performed 1 min later. Arterial pressure and heart rate were recorded at intervals until 5 min after intubation. Remifentanil 0.5 microgram kg-1 was ineffective in controlling the increase in heart rate and arterial pressure after intubation but the 1.0 and 1.25 micrograms kg-1 doses were effective in controlling the response. The use of the 1.25 micrograms kg-1 dose was however, associated with a decrease in systolic arterial pressure to less than 90 mm Hg in seven of 20 patients. (+info)
Laryngeal movements during the respiratory cycle measured with an endoscopic imaging technique in the conscious horse at rest.
A video-laryngoscopic method, implemented with an algorithm for the correction of the deformation inherent in the endoscope optical system, has been used to measure the dorsoventral diameter (Drg) and the cross-sectional area (CSArg) of the rima glottidis in five healthy workhorses during conscious breathing at rest. Simultaneous recording of the respiratory airflow was also obtained in two horses. Drg measured 82.7 +/- 4.5 mm (mean +/- S.D.) independently of the respiratory phase, and did not differ from the measurement in post-mortem anatomical specimens of the same horses. CSArg ranged from 1130 +/- 117 mm2 (mean +/- S.D.) during the inspiratory phase to 640 +/- 242 mm2 during the expiratory phase; being always narrower than tracheal cross-sectional area, which was 1616 +/- 224 mm2, as determined from anatomical specimens. Both inspiratory and expiratory airflow waves displayed a biphasic pattern. Maximal laryngeal opening occurred in phase with the second inspiratory peak, while during expiration CSArg attained a minimum value during the first expiratory peak which was significantly smaller (P < 0.01) than the area subsequently maintained during the rest of the expiratiory phase. These quantitative measurements of equine laryngeal movements substantiate the important role played by the larynx in regulating upper airway respiratory resistance and the expiratory airflow pattern at rest. (+info)
Intramuscular rocuronium in infants and children: a multicenter study to evaluate tracheal intubating conditions, onset, and duration of action.
BACKGROUND: This multicenter, assessor-blinded, randomized study was done to confirm and extend a pilot study showing that intramuscular rocuronium can provide adequate tracheal intubating conditions in infants (2.5 min) and children (3 min) during halothane anesthesia. METHODS: Thirty-eight infants (age range, 3-12 months) and 38 children (age range, 1 to 5 yr) classified as American Society of Anesthesiologists physical status 1 and 2 were evaluated at four investigational sites. Anesthesia was maintained with halothane and oxygen (1% end-tidal concentration if <2.5 yr; 0.80% end-tidal concentration if >2.5 yr) for 5 min. One half of the patients received 0.45 mg/kg intravenous rocuronium. The others received 1 mg/kg (infants) or 1.8 mg/kg (children) of intramuscular rocuronium into the deltoid muscle. Intubating conditions and mechanomyographic responses to ulnar nerve stimulation were assessed. RESULTS: The conditions for tracheal intubation at 2.5 and 3 min in infants and children, respectively, were inadequate in a high percentage of patients in the intramuscular group. Nine of 16 infants and 10 of 17 children had adequate or better intubating conditions at 3.5 and 4 min, respectively, after intramuscular rocuronium. Better-than-adequate intubating conditions were achieved in 14 of 15 infants and 16 of 17 children given intravenous rocuronium. Intramuscular rocuronium provided > or =98% blockade in 7.4+/-3.4 min (in infants) and 8+/-6.3 min (in children). Twenty-five percent recovery occurred in 79+/-26 min (in infants) and in 86+/-22 min (in children). CONCLUSIONS: Intramuscular rocuronium, in the doses and conditions tested, does not consistently provide satisfactory tracheal intubating conditions in infants and children and is not an adequate alternative to intramuscular succinylcholine when rapid intubation is necessary. (+info)
Clinical assessment of a plastic optical fiber stylet for human tracheal intubation.
BACKGROUND: The authors compared the performance of a prototype intubation aid that incorporated plastic illumination and image guides into a stylet with fiberoptic bronchoscopy and direct laryngoscopy for tracheal intubation by novice users. METHODS: In a randomized, nonblinded design, patients were assigned to direct laryngoscopy, fiberoptic bronchoscopy, or imaging stylet intubation groups. The quality of laryngeal view and ease with which it was attained for each intubation was graded by the laryngoscopist. Time to intubation was measured in 1-min increments. A sore-throat severity grade was obtained after operation. RESULTS: There were no differences in demographic, physical examination, or surgical course characteristics among the groups. The laryngoscope produced an adequate laryngeal view more easily than did the imaging stylet or bronchoscope (P = 0.001) but caused the highest incidence of postoperative sore throat (P<0.05). Although the time to intubation for direct laryngoscopy was shorter than for imaging stylet, which was shorter than fiberoptic bronchoscopy (P<0.05), the quality of laryngeal view with the imaging stylet was inferior to both direct laryngoscopy and fiberoptic bronchoscopy techniques (P<0.05). CONCLUSIONS: Novices using the imaging stylet produce fewer cases of sore throat (compared with direct laryngoscopy) and can intubate faster than when using a bronchoscope in anesthetized adult patients. The imaging stylet may be a useful aid for tracheal intubation, especially for those unable to maintain skills with a bronchoscope. (+info)
Laryngeal mask airway size selection in males and females: ease of insertion, oropharyngeal leak pressure, pharyngeal mucosal pressures and anatomical position.
We have compared ease of insertion, oropharyngeal leak pressure, directly measured pharyngeal mucosal pressure and anatomical position (assessed fibreoptically) for the size 4 and size 5 laryngeal mask airway (LMA) in 20 male and 20 female patients. Microchip pressure sensors were attached to the LMA at locations corresponding to the piriform fossa, hypopharynx, base of the tongue, lateral and posterior pharynx, and the oropharynx. Oropharyngeal leak pressure, mucosal pressure and fibreoptic position were recorded during inflation of the cuff from 0 to 30 ml in 10-ml increments. In males, oropharyngeal leak pressure over the inflation range was higher for size 5 (21 vs 17 cm H2O; P = 0.01); mucosal pressure over the inflation range was higher in the posterior pharynx for size 4 (7 vs 2 cm H2O; P = 0.007), and higher in the piriform fossa (8 vs 5 cm H2O; P = 0.003) and hypopharynx (9 vs 5 cm H2O; P = 0.003) for size 5. In females, oropharyngeal leak pressure over the inflation range was the same (21 vs 21 cm H2O), but mucosal pressure over the inflation range was higher in the piriform fossa (21 vs 8 cm H2O; P = 0.003) and posterior pharynx (4 vs 2 cm H2O; P = 0.004) for size 4, and higher in the lateral pharynx (5 vs 1 cm H2O; P = 0.01) and oropharynx (11 vs 5 cm H2O; P = 0.009) for size 5. The distribution of mucosal pressure was different for size 4 between males and females, but not for size 5. For both males and females, fibreoptic position was similar. We conclude that the size 5 LMA is optimal in males, but either size is suitable for females. The shape of the pharynx may be different between males and females. (+info)