Severe upper airway obstruction due to delayed retropharyngeal hematoma formation following blunt cervical trauma

Background

We report a case of severe upper airway obstruction due to a retropharyngeal hematoma that presented nearly one day after a precipitating traumatic injury. Retropharyngeal hematomas are rare, but may cause life-threatening airway compromise.

Case presentation

A 50 year-old man developed severe dyspnea with oropharyngeal airway compression due to retropharyngeal hematoma 20 hours after presenting to the emergency department. The patient also had a fractured first cervical vertebra and was diagnosed with a left brachial plexopathy. The patient underwent emergent awake fiberoptic endotracheal intubation to provide a definitive airway.

Conclusion

Retropharyngeal hematoma with life-threatening airway compromise can develop hours or days after a precipitating injury. Clinicians should be alert to the potential for this delayed airway collapse, and should also be prepared to rapidly secure the airway in this patient population likely to have concomitant cervical spinal or head injuries.     

Factors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department

Objectives

Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED). The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication.

Methods

A matched case-control study with a case to control ratio of 1∶3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities.

Results

Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7%) had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%). Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001). Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58–8.55], p = 0.01).

Conclusion

Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation.     

Laryngoscope and a New Tracheal Tube Assist Lightwand Intubation in Difficult Airways due to Unstable Cervical Spine

Purpose

The WEI Jet Endotracheal Tube (WEI JET) is a new tracheal tube that facilitates both oxygenation and ventilation during the process of intubation and assists tracheal intubation in patients with difficult airway. We evaluated the effectiveness and usefulness of the WEI JET in combination with lightwand under direct laryngoscopy in difficult tracheal intubation due to unstable cervical spine.

Methods

Ninety patients with unstable cervical spine disorders (ASA I-III) with general anaesthesia were included and randomly assigned to three groups, based on the device used for intubation: lightwand only, lightwand under direct laryngoscopy, lightwand with WEI JET under direct laryngoscopy.

Results

No statistically significant differences were detected among three groups with respect to demographic characteristics and C/L grade. There were statistically significant differences between three groups for overall intubation success rate (p = 0.015) and first attempt success rate (p = 0.000). The intubation time was significantly longer in the WEI group (110.8±18.3 s) than in the LW group (63.3±27.5 s, p = 0.000) and DL group (66.7±29.4 s, p = 0.000), but the lowest SpO2 in WEI group was significantly higher than other two groups (p<0.01). The WEI JET significantly reduced successful tracheal intubation attempts compared to the LW group (p = 0.043). The severity of sore throat was similar in three groups (p = 0.185).

Conclusions

The combined use of WEI JET under direct laryngoscopy helps to assist tracheal intubation and improves oxygenation during intubation in patients with difficult airway secondary to unstable spine disorders.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-TRC-14005141     

靶控输注系统（TCI）在清醒插管中的应用进展

靶控输注系统(TCI)在清醒插管中的应用越来越多地被麻醉医师所关注。清醒插管是临床上处理困难气道插管的常用措施,其过程要求患者处于可唤醒的镇静状态。临床上应用靶控输注丙泊酚、瑞芬太尼达到镇静作用已较普遍,近年来右美托咪啶的应用日益推广,本文针对三种药物使用靶控输注系统在清醒插管中的应用综述了近几年的研究进展。     

Airway Management in Croup and Epiglottitis

Treatment techniques for airway obstruction in croup and epiglottitis are reviewed in the medical literature. Series totaling 295 nasotracheal intubations, and 591 tracheostomies were reviewed. There were two deaths attributable to airway complications in 126 patients in whom nasotracheal intubation was carried out. In three patients subglottic granulation tissue and subglottic stenoses developed from short-term nasotracheal intubation. There were no subglottic stenoses or tracheal stenoses reported in the 591 tracheostomies. From this review, it would seem feasible to use nasotracheal intubation for short-term airway treatment in croup and epiglottitis. The increasing occurrence of laryngeal and tracheal complications with long-term intubation suggests that tracheostomy be considered in such cases.     

发光管芯引导插管在感染手术气道处理中的应用

目的:观察和评估发光管芯在感染手术患者麻醉常规气管内插管和预测困难气管内插管的适用性与安全性,并比较改变光棒前端弯曲角度的临床实用效果。方法:选择136例ASA I~Ⅲ级全麻下行择期手术的肝炎后肝硬化患者,其中正常气道120例,可顺利气管插管,120例患者按照插管时弯曲光棒角度不同随机分为A组(60°)和B组(90°);困难气道插管患者分为C组(90°)。分别记录各组插管时间、插管次数、插管的成功率、插管期间血流动力学变化以及术后并发症情况,同时测量医生与患者呼吸道之间的距离。结果:A、B和C组的一次插管成功率分别为100%、96.6%和81.2%,时间分别为(12.3±3.8)s、(13.2±4.1)s和(18.2±5.5)s,三组各自的插管总成功率均为100%。而且改变光棒前端角度的A组插管时间均较B、C组短,发现光棒插管对循环功能的影响小,术后并发症少,医生与患者呼吸道之间的距离为(34±4)cm。结论:在感染手术患者气管插管过程中使用发光管芯引导插管成功率高、对患者的循环影响低且术后并发症少,更为重要的是降低了医务人员与传染性患者近距离接触的机率。     

The optimum sevoflurane concentration for supraglottic airway device Blockbuster™ insertion with spontaneous breathing in obese patients: a prospective observational study

Background

Airway management of the obese patient presenting for surgery is more likely to be a challenging problem. Supraglottic airway device has been adopted as a bridge to connect ventilation and tracheal intubation in obese patients who would be suffered with difficult intubation. The optimum sevoflurane concentration for supraglottic airway device insertion allowing spontaneous breathing in 50% of obese patients (ED₅₀) is not known. The purpose of this study was to determine the ED₅₀ of sevoflurane for supraglottic airway device Blockbuster? insertion with spontaneous breathing in obese patients requiring general anesthesia.

Methods

Thirty elective obese patients (body mass index 30-50 kg/m²) undergoing bariatric surgery were recruited in this study. The predetermined target sevoflurane concentration (initiating at 2.5% with 0.5% as a step size) was sustained for >5 min using a modified Dixon’s up-and-down method, and then the supraglottic airway device Blockbuster? was inserted. The patient’s response to supraglottic airway device insertion was classified as either ‘movement’ or ‘no-movement’. The ED₅₀ of sevoflurane were determined by calculating the midpoint concentration of crossover point from ‘movement’ or ‘no-movement’ response.

Results

The ED₅₀ of sevoflurane for supraglottic airway device Blockbuster? insertion in obese patients calculated using up-and-down method were 2.50?±?0.60%. The ED₅₀ and ED₉₅ (95% confidence interval) obtained by probit regression analysis were 2.35 (1.28–3.42) % and 4.03 (3.16–17.83) % for supraglottic airway device Blockbuster? insertion, respectively.

Conclusion

We conclude that the optimum end-tidal sevoflurane concentration required for the supraglottic airway device Blockbuster? insertion allowing spontaneous breathing in 50% of obese patients (ED₅₀) is 2.5?±?0.6%.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IPR-16009071, Registered on 24 August 2016.

     

可视喉镜气管插管对心跳骤停抢救患者血流动力学及心肺复苏质量的影响

摘要 目的：探讨可视喉镜气管插管对心跳骤停抢救患者血流动力学及心肺复苏质量的影响。方法：选取联勤保障部队第九四〇医院于2020年4月~2022年5月期间收治的98例心跳骤停抢救患者为研究对象,根据插管方式将患者分为B组（可视喉镜气管插管,n=50）、A组（传统直接喉镜气管插管,n=48）。对比两组插管次数、声门暴露时间、插管时间、气道与牙齿损伤、心肺复苏质量及血流动力学指标变化情况,观察两组不良反应发生情况。结果：B组的插管次数少于A组,声门暴露时间、插管时间短于A组,气道与牙齿损伤比例少于A组（P<0.05）。B组的插管成功率、心肺复苏（CPR）成功率、存活率均高于A组（P<0.05）。B组插管后15 min的收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）及心率（HR）均低于A组同期（P<0.05）。B组的不良反应发生率低于A组（P<0.05）。结论：相比于传统直接喉镜气管插管用于心跳骤停抢救患者,可视喉镜气管插管可维持血流动力学稳定,提高插管成功率和心肺复苏质量,安全性较好。     

急救中光棒法与直接喉镜法气管插管引发心血管反应的比较

目的:比较光棒法与直接喉镜法气管插管对心血管系统的影响,探讨光棒在临床急救领域的适用性。方法:选取我院急诊科室进行抢救的80名患者,随机分为两组,分别采用光棒法和直接喉镜法进行气管插管。记录插管所需时间、一次插管成功次数,以及插管前、插管时、插管后1分钟、插管后3分钟患者的收缩压、舒张压、平均动脉压、心率和血氧饱和度的变化情况。数据分析使用使用检验、t检验秩和检验、重复测量方差分析。结果:两组间性别、年龄、身高、体重、ASA、Mallampati评分差异无统计学意义,具备可比性。光棒组平均插管时间少于喉镜组(光棒:31.23 9.94秒,喉镜:48.15 8.67秒),一次插管成功率(97.5%)也高于喉镜组(80.0%)。经重复测量方差分析结果显示,光棒组各时点的收缩压(F=38.312,P=0.000)、舒张压(F=219.692,P=0.000)、平均动脉压(F=54.739,P=0.000)、心率(F=195.161,P=0.000)的整体趋势要低于与喉镜组。血氧饱和度(F=0.020,P=0.889)在两组间差异无统计学意义。结论:在气管插管过程中,光棒法比直接喉镜法引发的心血管系统变化更小,而且插管所需时间更短、一次成功率更高,是一种值得在急诊科室推广的气管插管技术。     

Endotracheal intubation with Airtraq versus Storz videolaryngoscope in children younger than two years - a randomized pilot-study

ABSTRACT: BACKGROUND: New laryngoscopes have become available for use in small children. The aim of the study was to compare the Storz videolaryngoscope (SVL) to the Airtraq Optical laryngoscope (AOL) for tracheal intubation in children younger than two years of age who had a normal airway assessment. Our hypothesis was that the SVL would have a better success rate than the AOL. METHODS: Ten children aged 2 years or younger scheduled for elective cleft lip/palate surgery were included. The anesthesia was standardized and a Cormack-Lehane (CL)-score was obtained using a Macintosh laryngoscope. After randomization CL-score and endotracheal tube positioning in front of the glottis was performed with one device, followed by the same procedure and intubation with the other device. The video-feed was recorded along with real-time audio. The primary endpoint was the success rate, defined as intubation in first attempt. Secondary endpoints were the time from start of laryngoscopy to CL-score, tube positioning in front of the glottis, and intubation. RESULTS: Two intubation attempts were needed in two of five patients randomized to the SVL. The difference in time (SVL vs. AOL) to CL-score was 4.5 sec (p = 0.0449). The difference in time (SVL vs. AOL) to tube positioning was 11.6 sec (p = 0.0015). Time to intubation was 29.0 sec for SVL and 15.8 sec for AOL. CONCLUSION: No difference in the success rate of endotracheal intubation could be established in this ten patient sample of children younger than two years with a normal airway assessment scheduled for elective cleft lip/palate surgery. However, the Airtraq Optical videolaryngoscope showed a number of time related advantages over the Storz videolaryngoscope. Because of the small sample size a larger trial is needed to confirm these findings. Both devices were considered safe in all intubations.     

The usefulness of the McGrath MAC laryngoscope in comparison with Airwayscope and Macintosh laryngoscope during routine nasotracheal intubation: a randomaized controlled trial

Background

McGrath MAC video laryngoscope offers excellent laryngosopic views and increases the success rate of orotracheal intubation in some cases. The aim of this study was to determine the usefulness of McGrath MAC for routine nasotracheal intubation by comparing McGrath MAC with Airway scope and Macintosh laryngoscope.

Methods

A total of 60 adult patients with ASA physical status class 1 or 2, aged 20–70 years were enrolled in this study. Patients were scheduled for elective oral surgery under general anesthesia with nasotracheal intubation. Exclusion criteria included lack of consent and expected difficult airway. Patients were randomly allocated to three groups: McGrath MAC (n?=?20), Airway scope (n?=?20), and Macintosh laryngoscope (n?=?20). After induction, nasotracheal intubation was performed by six expert anesthesiologists with more than 6 years of experience.

Results

There were no significant differences in preoperative airway assessment among the three groups. Successful tracheal intubation time was 26.8?±?5.7 (mean?±?standard deviation) s for McGrath MAC, 36.4?±?11.0 s for Airway scope, and 36.5?±?8.9 s for Macintosh laryngoscope groups. The time for successful tracheal intubation for McGrath MAC group was significantly shorter than that for Airway scope and Macintosh laryngoscope (p?<?0.01). McGrath MAC significantly improved the Cormack Lehane grade for nasotracheal intubation compared with Macintosh laryngoscope (p?<?0.05).

Conclusion

McGrath MAC significantly facilitates routine nasotracheal intubation compared with Airwayscope and Macintosh laryngoscope by shortening the tracheal intubation time and improving the Cormack Lehane grade.

Trial registration

UMINCTR Registration number UMIN000023506. Registered 5 Aug 2016.

     

右美托咪定复合丙泊酚在清醒气管插管中的麻醉效果及对呼吸和循环的影响

目的:探讨右美托咪定复合丙泊酚应用于清醒气管插管的麻醉效果及对呼吸和循环的影响。方法:选择我院2015年1月~2016年12行清醒气管插管患者80例,按麻醉方式分组,每组40例,对照组采用丙泊酚麻醉诱导,研究组麻醉诱导予以右美托咪定复合丙泊酚。比较两组麻醉效果、呼吸和循环的变化及并发症的发生情况。结果:研究组插管时间、Ramsay评分、耐受良好、插管成功率、呼吸次数、分钟通气量、心率、平均动脉压均显著高于对照组(P0.05),潮气量、去甲肾上腺素、皮质醇、并发症总发生率均明显低于对照组(P0.05)。结论:右美托咪定复合丙泊酚用于清醒气管插管的麻醉效果确切,可使有效减轻对呼吸和循环的影响。     

Bacterial tracheitis in children.

We examined the records of 14 patients aged 7 months to 10 1/4 years who were treated for bacterial tracheitis from May 1982 to December 1987; the management protocol for 13 of the patients included the use of nasotracheal intubation. The infection was caused by Staphylococcus aureus in seven, Haemophilus influenzae in three, Branhamella catarrhalis in one and Streptococcus pneumoniae in one. Both H. influenzae and B. catarrhalis were isolated in another patient, and no organism was found in the remaining patient. In addition to the bacteria, viruses were cultured from the tracheal secretions of two patients. The mean duration of intubation was 7.6 days and of hospital stay 9.2 days. Twelve of the cases occurred during the cold months of the year (October to March). Of the three deaths only one occurred in the pediatric intensive care unit and was due to severe bronchospasm and an air leak that caused bilateral pneumothorax and pneumomediastinum. In one patient subglottic stenosis developed that necessitated tracheostomy. Healing began 5 to 9 days after the onset of symptoms, as demonstrated with the use of repeated fibreoptic bronchoscopy. We found that the airway could be safely managed with the use of a nasotracheal tube. Bronchoscopy helped to confirm the diagnosis, to remove adherent secretions and to monitor the course of the disease. The ventilation tube can be removed after the patient''s temperature returns to normal, if there is an air leak around the tube, if the quantity and viscosity of the secretions decrease and if healing is observed at bronchoscopy.     

Direct airway injury results in elevated levels of sulfidopeptide leukotrienes, detectable in airway secretions.

Sulfidopeptide leukotrienes (LTC4/D4/E4) are suspected to be important lipid mediators in inflammatory responses in the lung. Previous investigations have provided evidence to support enhanced synthesis and secretion of these eicosanoids into bronchoalveolar lavage fluid in patients with Adult Respiratory Distress Syndrome (ARDS). We have prospectively examined the relationship between sulfidopeptide leukotriene levels in tracheal aspirates of 14 intubated and mechanically ventilated patients. When compared with the aspirate from one patient who required ventilation because of respiratory muscle weakness, the tracheal aspirates from eight ARDS patients had elevated leukotriene levels (range 2020-2052 pg/aspirate). However, the aspirates from four of the five patients with direct airway injury [inhalational burn (n = 3) and massive aspiration of gastric contents (n = 2)] contained significantly higher amounts of sulfidopeptide leukotrienes (range 10309-52244 pg/aspirate). Three of the five patients with direct airway injury did not develop ARDS. We conclude that simple aspiration of tracheal secretions can be used to monitor airway leukotriene biosynthesis in patients with lung injury and that elevated airway leukotriene levels may reflect airway epithelial damage, but may not predict the development of ARDS.     

LARYNGOSPASM FROM THE ANESTHESIOLOGIST'S VIEWPOINT

Laryngeal spasm is a problem constantly confronting the anesthetist. It can be serious and may produce fatal cerebral or cardiac complications. Etiologic agents include primary vagal hypertonicity, anoxemia, and painful stimulation of whatever source.Laryngeal spasm must be differentiated from simple obstruction by the tongue or foreign bodies, epiglottic impaction, laryngeal edema, tracheal spasm and collapse, and bronchial spasm.Proper checking of the patient before anesthesia and adequate premedication with atropine or scopolamine are preventive measures of great value. Once spasm has developed the etiologic agent should be removed if possible. Other measures include intravenous administration of atropine or curare, tracheal intubation, and tracheotomy.     

气管插管患者行经皮扩张气管切开术的安全性研究

目的研究气管插管患者行经皮扩张气管切开术的安全性。方法将121例经口气管插管患者随机分成对照组59例,观察组62例。两组患者均行经皮扩张气管切开术,对照组按常规方法于局麻前将气管插管拔出至门齿18～20cm处,观察组在经皮扩张完气管前壁后将气管插管全部拔出。结果两组患者手术操作时间、出血量比较差异均无统计学意义（P〉0.05）;气管插管意外脱出发生率比较,对照组高于观察组,差异有统计学意义（P〈0.05）。结论在扩张气管前壁后拔出气管插管更有利于患者安全。     

机械通气患者人工气道管理技术进展

机械通气技术在严重急慢性呼吸衰竭的患者抢救治疗中广泛应用,人工气道管理技术方法在机械通气过程中显示十分重要作用,有效的气道管理技术方法可减少机械通气过程中一些并发症如呼吸机相关性肺炎等。结合临床应用机械通气技术体会,本文主要对人工气道管理技术方法总结分析。     

Tracheal blood flow during spontaneous and mechanical ventilation of dry gases in sheep

Tracheal blood flow increases greater than twofold in response to eucapnic hyperventilation of dry gas in anesthetized sheep. To determine whether this occurs at normal minute ventilation, we studied sheep in which tracheal blood flow was measured in response to humid and dry gas ventilation while 1) awake and spontaneously breathing and 2) anesthetized and intubated during isocapnic mechanical ventilation. In additional sheep, three tracheal mucosal temperatures were measured during humid and dry gas mechanical ventilation to measure airway tissue cooling. Tracheal blood flow was determined by use of a left atrial injection of 15-microns-diam radiolabeled microspheres. Previously implanted flow probes on the pulmonary artery and the common bronchial artery allowed continuous recording of cardiac output and bronchial blood flow. Tracheal blood flow in awake spontaneously breathing sheep was 10.8 +/- 5.6 (SD) ml.min-1.100 g wet wt-1 while humid gas was breathed, and it was unchanged with dry gas. In contrast, isocapnic ventilation of intubated animals with dry gas resulted in a 10-fold increase in blood flow to the most proximal two-ring tracheal segment compared with that seen while humid gases were spontaneously ventilated [101 +/- 75 vs. 11 +/- 6 (SD) ml.min-1.100 g-1, P less than 0.05]. Despite a 10-fold increase in proximal tracheal blood flow, there was no response in distal tracheal and bronchial blood flow, as indicated by no change in the common bronchial artery blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)     

经支气管镜气管插管与常规气管插管救治呼吸衰竭对比分析

目的：回顾性分析呼吸机辅助呼吸救治危重呼吸衰竭患者气管插管方式对于救治成功率的影响。方法：我科收治的各种呼吸衰竭患者94例,回顾分析插管方式对于救治成功率、引发心跳骤停及其对心肺复苏效果的影响。结果：经纤维支气管镜经口气管插管（35例）与经直接喉镜经口（59例）引发心跳骤停有明显统计学差异（X^2=11．5,v=1,t〈0．001）。经直接喉镜经口气管插管在术前用药与否对引发心跳骤停并无统计学意义,但是对于引发心跳骤停后心肺复苏成功率确有明显统计学意义。结论：经纤维支气管镜气管插管具有较高的安全性,在经直接喉镜气管插管是选择镇静药或浅麻醉药物应慎重,尽力避免心跳骤停和心肺复苏失败。     

Simplification of rat intubation on inclined metal plate

Small-animal intubation is often necessary during inhalation anesthesia to allow steady-state conditions for large operations and in vivo experiments in all fields of experimental surgery. In rats, placing an orotracheal tube is technically difficult primarily because of the small size of the subject and the lack of equipment specifically designed for this task. We describe a simple rat intubation technique in which the animal is suspended in dorsal recumbency on an inclined metal plate. The animal, anesthetized with ether, is fixed to a 70 degrees-inclined metal plate in a dorsal position by means of a Mersilene ribbon hooked around the upper incisors. This method of positioning the animal is the most important step in the intubation process and further facilitates the technique already described by other authors. A human otoscope was used as a laryngoscope, intubation was performed using the Seldinger technique, and a 14-gauge intravenous catheter served as an endotracheal tube. This inexpensive technique is quickly learned and can be used in any laboratory. Safe and reliable airway management can thus be achieved, permitting in vivo examinations and operations.