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Fulltext [A comparison of ramping position and sniffing position during endotracheal intubation: a systematic review and meta-analysis]

Tsan SEH, Ng KT, Lau J, Viknaswaran NL, Wang CY

Braz J Anesthesiol, 2020 11 09;70(6):667-677.
PMID: 33288219 DOI: 10.1016/j.bjan.2020.08.009

OBJECTIVES: Positioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position.
METHODS: PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack-Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers and complications during ETI.
RESULTS: Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta-analysis was conducted by pooling the effect estimates for all 4 included RCTs (n=632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR=2.05, 95% CI 1.26 to 3.32, p=0.004) and lower likelihood of CLG 3/4 (OR=0.49, 95% CI 0.30 to 0.79, p=0.004), moderate quality of evidence.
CONCLUSION: Our meta-analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large-scale well-designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.

Matched MeSH terms: Intubation, Intratracheal
Vocal Fold Injury Following Intubation

Mohd Umbaik NA, Mohamad I, Nik Hassan NFH

J Craniofac Surg, 2020 10;31(7):2064-2065.
PMID: 32890162 DOI: 10.1097/SCS.0000000000006839
Matched MeSH terms: Intubation, Intratracheal/adverse effects
Fulltext Videolaryngoscope-assisted fibreoptic tracheal intubation in a young adolescent with hunter syndrome for posterior cervical fusion

Zabir, A.F., Frawley, G., Squire, P.

Journal of Surgical Academia, 2013;3(2):92-96.
MyJurnal

We here describe a videolaryngoscope assisted fibreoptic tracheal intubation in a 17-year-old patient with Hunter Syndrome (Mucopolysaccharidosis Type II) and known difficult intubation who required posterior cervical fusion surgery for cervical canal stenosis. The patient had a history of failed nasal and oral fibreoptic intubation. The use of a videolaryngoscope enabled continuous visualization of the tracheal inlet and allowed a straightforward nasal fibreoptic intubation attempt without complications. This report suggests a viable alternative for the management of a known difficult airway in children with mucopolysaccharidosis.

Matched MeSH terms: Intubation, Intratracheal
Velopharyngeal stenosis, a late complication of radiotherapy

Lee SC, Tang IP, Singh A, Kumar SS, Singh S

Auris Nasus Larynx, 2009 Dec;36(6):709-11.
PMID: 19304419 DOI: 10.1016/j.anl.2009.02.002

Choanal stenosis has recently been recognized as a late complication of radiation therapy for nasopharyngeal carcinoma. The management of velopharyngeal stenosis is challenging with high risk of restenosis. We report a case of velopharyngeal stenosis post-radiotherapy and illustrated the use of mitomycin-C to prevent restenosis. Mitomycin-C application has being shown useful adjunct to surgical technique in managing nasopharyngeal stenosis for surgeons.

Matched MeSH terms: Intubation, Intratracheal
Use of capnography delaying the diagnosis of tracheal intubation

Chan YK, Zuraidah S, Tan PS

Anaesthesia, 1998 Dec;53(12):1207-8.
PMID: 10193227

There was a delay in making the correct diagnosis of tracheal intubation in a parturient who developed severe bronchospasm after intubation because we relied on the capnogram.

Matched MeSH terms: Intubation, Intratracheal/adverse effects*
Usage of airway ultrasound as an assessment and prediction tool of a difficult airway management

Adi O, Fong CP, Sum KM, Ahmad AH

Am J Emerg Med, 2021 04;42:263.e1-263.e4.
PMID: 32994082 DOI: 10.1016/j.ajem.2020.09.011

Airway assessment is important in emergency airway management. A difficult airway can lead to life-threatening complications. A perfect airway assessment tool does not exist and unanticipated difficulty will remain unforeseen. Current bedside clinical predictors of the difficult airway are unreliable but airway ultrasound can be used as an adjunct to predict difficult laryngoscopy. We report a case of a 60-year-old man presenting to the emergency department with shortness of breath, hoarseness of voice and stridor. Airway ultrasound revealed a large laryngeal mass narrowing the upper airway, extending to bilateral vocal cords with heterogenous echogenicity. In view of impending complete upper airway obstruction, acute respiratory distress and airway ultrasound findings, urgent emergency tracheostomy was chosen as definitive airway over endotracheal intubation or surgical cricothyroidotomy. Point of care ultrasound (POCUS) was used to evaluate this patient with severe upper airway obstruction. A laryngeal mass was detected by ultrasound and this pointed towards the presence of a difficult airway. POCUS was a good non-invasive tool used for airway assessment in this uncooperative and unstable patient. Ultrasound predictors of the difficult airway include the inability to visualize the hyoid bone, short hyomental distance ratio, high pretracheal anterior neck thickness and large tongue size. Besides airway assessment, ultrasound can also help to predict endotracheal tube size, confirm intubation and guide emergency airway procedures such as cricothyroidotomy and tracheostomy. Point of care ultrasound of the upper airway can be used in airway assessment to identify distorted airway anatomy, pathological lesions and guide treatment decisions.

Matched MeSH terms: Intubation, Intratracheal
Type IV laryngotracheo-oesophageal cleft--management of a difficult airway

Lim SK, Fadhilah T, Ibtisan I

Paediatr Anaesth, 1998;8(4):337-40.
PMID: 9672933

Congenital laryngotracheo-oesophageal cleft is a rare anomaly which presents a challenge to the anaesthetists because of the potential problems of establishing and maintaining an airway. We report the anaesthetic management of a one-month old baby with complete or type IV laryngotracheo-oesophageal presenting for the repair of the defect. The management of the precarious airway is presented and the various techniques of managing the airway are reviewed.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Transient unilateral parotid gland swelling following upper endoscopy

Chieng Jin Yu, Then Ru Fah, Sharifah Intan Safura Shahabudin, Pan Yan

Journal of Clinical and Health Sciences, 2021;6(1):50-52.
MyJurnal

Transient parotid gland swelling could happen as complication after per oral endoscopy or
intubation. We reported a 53-year-old man who developed transient unilateral parotid gland
swelling following esophagogastroduodenoscopy (OGDS) with dilatation of achalasia cardia.
The swelling of the parotid gland was transient and resolved completely without any
intervention.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Tracheoesophageal fistula (TOF)-blind pouch intubation: a case report

Arshad R

Med J Malaysia, 1984 Jun;39(2):159-62.
PMID: 6513857

A case of Tracheoesophageal Fistula (TOF) was presented where the blind upper esophageal pouch was mistakenly intubated; in spite of this, adequate lung ventilation was possible for more than one hour. This was only noticed by the surgeon upon incision of the lower end of the pouch.

Matched MeSH terms: Intubation, Intratracheal*
Fulltext Tracheal agenesis: a rare cause of unsuccessful tracheal intubation during resuscitation

Iszuari M, Mazita A, Tan GC, Hayati AR, Shareena I, Cheah FC

Med J Malaysia, 2010 Dec;65(4):317-8.
PMID: 21901957

Tracheal agenesis is a rare congenital airway anomaly that usually results in a fatal outcome. The diagnosis is usually made through post-mortem examination. In the current literature, there has been no reported long-term survival although a few reports claimed prolongation of life of several hours to days. This condition is commonly associated with premature birth, polyhydramnios and a male predominance. In 90% of the cases, it is associated with multiple cardiovascular, gastrointestinal and genitourinary tract anomalies which are incompatible with life. We report a case of a premature newborn with severe respiratory distress, absent cry and cyanosis soon after birth. Attempts at endotracheal intubation failed as it was no possible to negotiate the tube beyond the vocal cords. Needle cricothyrotomy and attempted tracheostomy also failed to secure the airway. The diagnosis was confirmed at post-mortem examination.

Matched MeSH terms: Intubation, Intratracheal*
Tracheal T-tube: a novel endoscopic insertion technique

Rahimah AN, Shahfi FI, Masaany M, Gazali N, Siti SH

J Laryngol Otol, 2016 Oct;130(10):967-968.
PMID: 27774924

Laryngotracheal stenosis is a complex condition of airway compromise involving either the larynx or trachea, or both.

Matched MeSH terms: Intubation, Intratracheal/instrumentation*; Intubation, Intratracheal/methods
Thirty years of submental intubation: a review

Lim D, Ma BC, Parumo R, Shanmuhasuntharam P

Int J Oral Maxillofac Surg, 2018 Sep;47(9):1161-1165.
PMID: 29731193 DOI: 10.1016/j.ijom.2018.04.015

Submental intubation has been used as an alternative to conventional intubation in the field of oral and maxillofacial surgery since its introduction by Francisco Hernández Altemir in 1986. A review of submental intubation was performed using data from all case reports, case-series, and prospective and retrospective studies published between 1986 and 2016. The indications, variations in incision length, incision sites, types of endotracheal tube used, methods of exteriorization, and complications were recorded and analyzed. A total of 70 articles reporting 1021 patients were included. The main indication was maxillofacial trauma (86.9%, n=887), followed by orthognathic surgery (5.8%, n=59), skull base surgery (2.8%, n=29), and rhinoplasty and rhytidectomy (1.5%, n=15). The complication rate was relatively low: 91.0% of patients (n=929) were complication-free. The most common complication was infection, occurring in 3.5% (n=36) of the total number of patients, followed by scarring (1.2%, n=12) and formation of an orocutaneous or salivary fistula (1.1%, n=11). In summary, submental intubation is a good alternative airway with minimal complications.

Matched MeSH terms: Intubation, Intratracheal/adverse effects; Intubation, Intratracheal/methods*
The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children

Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG

Paediatr Anaesth, 2005 Dec;15(12):1094-7.
PMID: 16324030 DOI: 10.1111/j.1460-9592.2005.01633.x

BACKGROUND: Laryngospasm is a well-known problem typically occurring immediately following tracheal extubation. Propofol is known to inhibit airway reflexes. In this study, we sought to assess whether the empiric use of a subhypnotic dose of propofol prior to emergence will decrease the occurrence of laryngospasm following extubation in children.
METHODS: After approval from the Institutional Ethics Committee and informed parental consent, we enrolled 120 children ASA physical status I and II, aged 3-14 years who were scheduled to undergo elective tonsillectomy with or without adenoidectomy under standard general anesthesia. Before extubation, the patients were randomized and received in a blinded fashion either propofol 0.5 mg.kg(-1) or saline (control) intravenously. Tracheal extubation was performed 60 s after administration of study drug, when the child was breathing regularly and reacting to the tracheal tube.
RESULTS: Laryngospasm was seen in 20% (n = 12) of the 60 children in the control group and in only 6.6% (n = 4) of 60 children in the propofol group (P < 0.05).
CONCLUSIONS: During emergence from inhalational anesthesia, propofol in a subhypnotic dose (0.5 mg.kg(-1)) decreases the likelihood of laryngospasm upon tracheal extubation in children undergoing tonsillectomy with or without adenoidectomy.

Matched MeSH terms: Intubation, Intratracheal
The effect of mivacurium pretreatment on intra-ocular pressure changes induced by suxamethonium

Chiu CL, Lang CC, Wong PK, Delilkan AE, Wang CY

Anaesthesia, 1998 May;53(5):501-5.
PMID: 9659028

Forty patients without eye disease, undergoing elective nonophthalmic surgery, were studied in a double-blind, randomised, placebo-controlled study evaluating the efficacy of mivacurium pretreatment in attenuating the rise in intra-ocular pressure in response to suxamethonium administration, laryngoscopy and intubation. The patients were randomly allocated to receive either mivacurium 0.02 mg.kg-1 or normal saline as pretreatment 3 min before a rapid sequence induction technique using alfentanil, propofol and suxamethonium. Suxamethonium induced a significant increase in intra-ocular pressure in the control group but not in the mivacurium pretreatment group (mean (SEM) increase = 3.5 (1.2) mmHg vs. 0.4 (0.8) mmHg, p < 0.05). There was a decrease in intra-ocular pressure in both groups after laryngoscopy and intubation with no significant difference between the two groups. These results show that mivacurium pretreatment is effective in preventing the increase in intra-ocular pressure after suxamethonium administration.

Matched MeSH terms: Intubation, Intratracheal
Fulltext The Use of Stents in Children with Nasolacrimal Duct Obstruction Requiring Surgical Intervention: A Systematic Review

Tai ELM, Kueh YC, Abdullah B

Int J Environ Res Public Health, 2020 02 07;17(3).
PMID: 32046207 DOI: 10.3390/ijerph17031067

Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora. It is managed conservatively in the first year of life, after which surgical treatment is classically based on a stepwise paradigm of probing, intubation, and dacryocystorhinostomy. This systematic review aims to present the current role of intubation in the management of children with NLDO requiring surgical intervention. A search for English-language articles from the electronic databases PubMed, SCOPUS, and the COCHRANE library was conducted over a period of five months in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. The following keywords were used to aid retrieval: stents, children, lacrimal intubation, endoscopic dacryocystorhinostomy, external dacryocystorhinostomy, NLDO, dacryocystitis, congenital, acquired. The primary outcome was defined as the success of the intervention, determined by resolution of symptoms and patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test or syringing. Secondary outcomes included the presence of complications. A total of 144 articles were identified; of these, 35 fulfilled the study criteria. The majority of the included studies involved lacrimal intubation alone, followed by intubation as an adjunctive procedure to balloon dacryoplasty and dacryocystorhinostomy. The overall success rate of these procedures ranged from 41.1% to 100%. Post-operative complications were reported in 65.7% of the included studies. Lacrimal intubation was most commonly performed as a primary procedure in children with NLDO, with high success rates. The main complication was stent dislodgement. There is lack of evidence regarding the benefit of intubation over probing as primary treatment of congenital NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other low-level evidence, such as observational non-randomised trials.

Matched MeSH terms: Intubation, Intratracheal
Fulltext The Performance of Flexible Tip Bougie™ in Intubating Simulated Difficult Airway Model

Mahli N, Md Zain J, Mahdi SNM, Chih Nie Y, Chian Yong L, Shokri AFA, et al.

Front Med (Lausanne), 2021;8:677626.
PMID: 34026801 DOI: 10.3389/fmed.2021.677626

This prospective, randomized, cross-over study compared the performance of the novel Flexible Tip Bougie™ (FTB) with a conventional bougie as an intubation aid in a simulated difficult airway manikin model among anaesthesiology trainees with regards of first pass success rate, time to intubation, number of attempts and ease of use. Sixty-two anesthesiology trainees, novice to the usage of FTB, participated in this study. Following a video demonstration, each participant performed endotracheal intubation on a manikin standardized to a difficult airway view. Each participant performed direct laryngoscopy and intubated the manikin using a conventional bougie and FTB, at least 1 day in between devices, in a randomized order. The first pass success rate was significantly higher with FTB (98.4%) compared to conventional bougie (85.5%), p = 0.008. The median time to intubation was significantly faster when using FTB, median = 32.0 s [Interquartile range (IQR): 23.8-41.3 s] compared to when using conventional bougie, median = 41.5 s (IQR: 31.8-69.5 s), p < 0.001. The FTB required significantly less intubation attempts compared to conventional bougie, p = 0.024. The overall ease of use, scored on a Likert scale from 1 to 5, was significantly higher in the FTB (4.26 ± 0.53) compared to the conventional bougie (3.19 ± 0.83), p < 0.001. This simulated difficult airway manikin study finding suggested that FTB is a useful adjunct for difficult airway intubation. The FTB offered a higher first pass success rate with a faster time to intubation and less required attempts.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Surgical outcomes of absent pulmonary valve syndrome: An institutional experience

Nair AK, Haranal M, Elkhatim IM, Dillon J, Hew CC, Sivalingam S

Ann Pediatr Cardiol, 2020 06 23;13(3):212-219.
PMID: 32863656 DOI: 10.4103/apc.APC_111_19

Background: Absent pulmonary valve syndrome (APVS) is a variant of tetralogy of Fallot characterized by aneurysmal pulmonary arteries, which compresses the tracheobronchial tree, leading to respiratory symptoms. We report the mid-term outcomes of surgical correction of patients with APVS.
Subject and Methods: A total of 27 patients underwent surgery between 2001 and 2015, and they were followed up for a mean period of 6.4 ± 4.1 years. Out of the 27 patients, 14 (51.9%) were infants. The median age at repair was 9.8 months. Preoperative intubation was required in six patients (22.2%), and 11 patients (40.7%) had symptoms of respiratory distress. The pulmonary valve was replaced with a valved conduit in 15 patients (55.6%), monocusp valve in 6 patients (22.2%), and a transannular patch in 6 patients (22.2%). Reduction pulmonary arterioplasty was done in all patients.
Results: The overall 10-year survival was 82.1%. There was 81.1% overall freedom from re-intervention at 10 years. No statistically significant difference was found in 10-year survival (P = 0.464) and reoperation rates (P = 0.129) between valved conduit, monocusp, or transannular patch techniques. Older children had statistically significantly longer survival (P = 0.039) and freedom from re-intervention (P = 0.016) compared to infants. Patients without respiratory complications had 100% 10-year survival and 93.3% freedom from reoperation at 10 years compared to 55.6% and 60.1%, respectively, for patients with respiratory complications.
Conclusion: There has been improvement in surgical results for APVS over the years. However, it still remains a challenge to manage infants and patients with persistent respiratory problems.

Matched MeSH terms: Intubation, Intratracheal
Submental intubation - Practical alternative airway in maxillofacial surgeries

Lim D, Parumo R, Ma CB, Palasuntharam S

J Clin Anesth, 2017 09;41:97-98.
PMID: 28802621 DOI: 10.1016/j.jclinane.2017.07.001
Matched MeSH terms: Intubation, Intratracheal/adverse effects; Intubation, Intratracheal/economics; Intubation, Intratracheal/instrumentation; Intubation, Intratracheal/methods*
Subcutaneous emphysema and pneumomediastinum after endotracheal anaesthesia

Chiu CL, Ong GS

Ann Acad Med Singap, 2000 Mar;29(2):256-8.
PMID: 10895351

INTRODUCTION: We report a case of subcutaneous emphysema and pneumomediastinum that presented postoperatively after tracheal extubation.
CLINICAL PICTURE: A 51-year-old man had an uneventful anaesthesia lasting about 6.5 hours. Intubation was performed by a very junior medical officer and was considered difficult. He developed sore throat, chest pain, numbness of both hands and palpable crepitus around the neck postoperatively. Chest X-ray revealed diffuse subcutaneous emphysema, pneumomediastinum and possible pneumopericardium.
TREATMENT: He was treated conservatively with bed rest, oxygen, analgesia, antibiotic prophylaxis, reassurance and close monitoring.
OUTCOME: The patient made an uneventful recovery.
CONCLUSIONS: We discussed the possible causes.

Matched MeSH terms: Intubation, Intratracheal/adverse effects*; Intubation, Intratracheal/methods
Fulltext Sturge-Weber-Syndrome with extreme ocular manifestation and rare association of upper airway angioma with anticipated difficult airway

Wong HS, Abdul Rahman R, Choo SY, Yahya N

Med J Malaysia, 2012 Aug;67(4):435-7.
PMID: 23082461 MyJurnal

We report a rare case of an 18 year old girl with Sturge-Weber syndrome, she had extensive facial port wine stains, right bupthalmos and advanced glaucoma involving both eyes. She underwent right eye glaucoma drainage device surgery under general anaesthesia, and had a difficult intubation due to extensive angiomatous like soft tissue swelling at her upper airway. This report highlights the importance of being aware of the need for continuous follow-up in Sturge-Weber syndrome patients as this syndrome can lead to blindness due to advance glaucoma and the awareness of possible difficult intubation for this group of patients.

Matched MeSH terms: Intubation, Intratracheal*

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