Orotracheal Intubation

Intracranial placement of a nasotracheal tube after facial fracture: a rare complication

Extensive facial trauma is often associated with fractures to the skull base, cribriform plate, and sphenoid sinus. Attempted intubation of patients with facial trauma may result in intracranial penetration and placement of nasogastric or nasotracheal tubes into the brain. Such a complication carries significant morbidity and mortality. Intracranial placement of nasogastric tubes has been reported multiple times in the literature. Intracranial placement of a nasotracheal tube, however, has been reported only twice. Such a case is presented, along with a review of the literature and a discussion.

Using interactive videodisc to test advanced airway management skills

PURPOSE

To evaluate the effectiveness of the Actronics Interactive Learning System to teach the psychomotor skills of advanced airway management compared to the traditional method of lecture/demonstration.

METHODS

The study was a nonrandomized, nonequivalent comparison group design of a convenience sample of 86 American Heart Association (AHA), advanced cardiac life support (ACLS) students, who obtained instruction in airway management by the interactive videodisc (IVD) learning system (n = 41), or by the traditional method of demonstration/return demonstration (n = 45). The evaluation criteria for the students were based on the number of attempts required to perform successfully endotracheal (ET) intubation and esophageal obturator airway (EOA) insertion.

RESULTS

No statistically significant differences in the performance of ET insertion between the IVD and the traditional method of instruction could be demonstrated. However, initial certifiers for ACLS learning EOA insertion by the IVD method had a treatment effect (p = 0.004) compared to ACLS students learning by the traditional method. This treatment effect was not noted with ET intubation and EOA insertion for students seeking recertification. In a post-test satisfaction questionnaire, 34 IVD students reported satisfaction with learning airway management using this instructional method, but also expressed a preference to have an ACLS instructor available.

CONCLUSION

This study highlights the role of IVD in teaching the complex skills of advanced airway management.

Intubation of critically ill patients

Respiratory failure is one of the most common causes for admission to an intensive-care unit. Any patient with loss of central nervous system control of breathing, neuromuscular respiratory failure, or impairment of gas exchange may require tracheal intubation and mechanical ventilation. Tracheal intubation provides a conduit for ventilatory support, maintains the patency of an airway that has potential for obstruction, protects the airway from the contents of the stomach, and allows access to the trachea for pulmonary hygiene. Although the mechanics of intubation are easily learned, many factors must be considered in critically ill patients. Herein we summarize the principles of tracheal intubation in acutely ill patients.

Manual translaryngeal jet ventilation and the risk of aspiration in a canine model

STUDY OBJECTIVES

Manual translaryngeal jet ventilation (TLJV) is a safe and effective method of maintaining normal ventilation in apneic subjects. Little data exist on the amount of airway protection afforded with this technique of airway management. We sought to evaluate the risk of aspiration during manual TLJV.

SETTING

Data were collected in a laboratory animal model.

DESIGN

A prospective, nonrandomized, controlled trial was performed.

PARTICIPANTS

Seventeen adult apneic mongrel dogs were enrolled.

INTERVENTIONS

Intratracheal Gastrograffin was instilled and radiographic changes assessed during ventilation using a 0 to 3 scale (none to severe). Thirty-six trials were performed, with equal numbers at both 30 degrees and 45 degrees head elevation. The three groups studied were animals without airway protection (control), animals with a cuffed endotracheal tube (tube), and animals with a percutaneous TLJV cannula and a 50-psi oxygen source ventilated at a rate of 20 breaths per minute (jet).

MEASUREMENTS AND MAIN RESULTS

Significantly less radiographic evidence of aspiration was noted in the jet and tube groups at 30 degrees and 45 degrees compared with control animals (P = .002 each). At 45 degrees head elevation a trend toward increased aspiration scores in the jet group compared with the tube group (P = .065) was observed.

CONCLUSION

In our model, manual TLJV at 20 breaths per minute and an I:E ratio of 1:2 provided protection from aspiration comparable to that observed with a cuffed endotracheal tube at 30 degrees head elevation. At 45 degrees elevation, this protection was diminished.