Bilateral vocal cord paralysis following endotracheal intubation

The flexible bronchoscope. A tool for anesthesiologists

Fiberoptic intubation is the technique of choice in management of a difficult intubation. It should be a first choice, not a last resort after attempts with conventional techniques have failed. It should be mastered by all physicians involved in airway management. The technique is cost-effective because it avoids airway trauma and cancellation of surgical cases because of failed intubation. The flexible bronchoscope for airway management as a diagnostic, therapeutic, and problem-solving tool is not used to the degree that it deserves. Anesthesiologists and other critical care physicians should master the technique and use it on a daily basis. The widespread use of the instrument for airway management deserves encouragement.

Tracheostomy management in the chronically ventilated patient

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

Unilateral vocal cord paralysis following endotracheal intubation

The present report describes a case of postoperative paralysis of the left recurrent laryngeal nerve in a patient undergoing surgery at a site far from the anatomic course of the nerve. Possible aetiological factors, symptoms, management and prophylaxis are discussed.

Intubation of critically ill patients

Airway management of critically ill patients has been enhanced by the recent introduction of several new types of artificial airways and laryngoscopes. New drugs for sedation and neuromuscular blockade have been developed to facilitate care of the intubated patient. Guidelines for management of the difficult airway have been introduced. Several new prospective studies have improved our understanding of complications of intubation and how to avoid these sometimes tragic events. A consensus is evolving that TLI and tracheotomy each have clear advantages and disadvantages in prolonged airway maintenance and that multiple factors, not simply the duration of TLI, must be considered in the optimal timing of tracheotomy for each patient. Complex medicolegal and ethical issues directly impact intubation, perhaps more so than any other practice in critical care medicine. Physicians who care for critically ill patients should be familiar with these recent developments and concepts in airway management.

Right vocal fold paralysis as a result of central venous catheterization

Invasive peri- and post-operative monitoring is being increasingly utilized, and a corresponding increase of concomitant complications are becoming apparent. Two cases of complete right vocal fold paralysis are reported as a possible complication of right central venous catheterization. The underlying aetiology of this complication is presumed to be either direct trauma at the time of introduction of the central venous catheter, or by thrombosis and fibrosis around the recurrent laryngeal or vagus nerve. It is suggested that multiple attempts at cannulation and leaving the central line in situ for long periods increases the risk of this complication. When the integrity of the left recurrent laryngeal nerve or vagus is jeopardized or must be sacrificed during surgery, it is suggested that ipsilateral central lines are inserted to minimize the risk of bilateral vocal fold paralysis. Cases of vocal fold paralysis secondary to central line insertion should be followed expectantly and surgical intervention only be considered after 12 months review.