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Is endotracheal tube displacement during head and neck extension due to ascending movement or tracheal lengthening? An observational ultrasonographic study. J Clin Monit Comput 2023; 37:139-145. [PMID: 35616797 DOI: 10.1007/s10877-022-00870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/21/2022] [Indexed: 01/24/2023]
Abstract
Complications of the endotracheal tube (ETT) displacement during head and neck positional changes are related to not only the tip position but also the cuff pressure against the larynx. Here, we evaluated movement of the ETT cuff relative to laryngeal structures as well as tip displacement from the carina.Sixty-two patients scheduled for thyroidectomy were recruited. The distance from the cricoid cartilage to the upper margin of the cuff (CC) and that from the ETT tip to the carina (TC) were measured using ultrasonography and fiberoptic bronchoscopy, respectively, during flexion and extension. The total tracheal length (TTL) was defined as the combination of CC, TC, and the distance from the upper margin of the cuff to the tip.During flexion, the CC and TC were 1.5 ± 0.6 and 2.9 ± 1.0 cm respectively. Seven patients (11.7%) exhibited excessively deep intubation. After adjusting the cuff position under ultrasonography (CC = 0), the tip position was corrected in 96.7%. While the TC increased by 2.1 ± 1.0 cm after the positional change in extension, the CC decreased by 0.6 ± 0.7 cm because the TTL lengthened (1.4 ± 1.1 cm). Four patients (6.7%) exhibited excessive cuff displacement beyond the cricoid cartilage, which could have been corrected under ultrasonography.In conclusion, the ETT cuff displaced toward the larynx in a less degree than the tip did from the carina due to the tracheal lengthening during head and neck extension. Nevertheless, we suggest that ultrasonographic assessment of cuff position may avoid ETT misplacement. Trial registration https://cris.nih.go.kr/ (approval no. KCT0005319); registered on May 14, 2019.
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Ideal Depth of Endotracheal Intubation at the Vocal Cord Level in Pediatric Patients Considering Racial Differences in Tracheal Length. J Clin Med 2022; 11:jcm11030864. [PMID: 35160315 PMCID: PMC8837153 DOI: 10.3390/jcm11030864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 02/01/2023] Open
Abstract
Numerous formulas that can predict endotracheal intubation depth at the corner of the mouth or the nasal wing of patients have been reported, even though the oral and nasal cavity anatomies differ among patients. Therefore, the purpose of this study was to derive a simple and reliable formula to predict the ideal endotracheal tube insertion depth at the vocal cord level in pediatric patients. The current study was conducted as a retrospective observational study, involving 425 and 335 cardiac pediatric patients in Germany and Japan, respectively, and aimed to determine a formula for predicting tracheal length and ideal depth of endotracheal intubation at the vocal cord level in pediatric patients. The distance between the vocal cords and the carina tracheae was defined as the tracheal length, and was measured on preoperative chest radiographs obtained in the supine position. The tracheal length in cardiac pediatric patients ranged from 6 to 10% of the body height in Germany and from 7 to 11% in Japan. This study revealed racial differences in the tracheal length, that is, in the ideal depth of endotracheal intubation at the vocal cord level. This study suggests that an adequate endotracheal intubation depth can be achieved by inserting endotracheal tubes at the vocal cord level with the minimum tracheal length of each racial group in pediatric patients, for example, 6% and 7% of the body height in Europeans and Asians, respectively. If the endotracheal tube inserted with this method appears to be shallow on chest radiographs, this does not represent an increased risk of accidental extubation, due to an excessively short intubation depth, because the minimum tracheal length for each racial group is considered. That is, it is not due to the endotracheal tube insertion length, but is likely due to the tracheal length of the patient, who has a relatively long tracheal length in the racial group.
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Zhuang P, Wang W, Cheng M. Effect of head position changes on the depth of tracheal intubation in pediatric patients: A prospective, observational study. Front Pediatr 2022; 10:998294. [PMID: 36160785 PMCID: PMC9498351 DOI: 10.3389/fped.2022.998294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The purpose of this study was to investigate the effect of changing head position on the endotracheal tube (ETT) depth and to assess the risk of inadvertent extubation and bronchial intubation in pediatric patients. METHODS Subjects aged 4-12 years old with orotracheal intubation undergoing elective surgeries were enrolled. After induction, the distances between "the ETT tip and the trachea carina" (T-C) were measured using a Disposcope flexible endoscope in head neutral position, 45° extension and flexion, 60° right and left rotation. The distance of the ETT tip movement relative to the neutral position (ΔT-C) was calculated after changing the head positions. The direction of the ETT tip displacement and the adverse events including endobronchial intubation, accidental tracheal extubation, hoarseness and sore throat were recorded. RESULTS The ETT tip moved toward the carina by 0.5 ± 0.4 cm (P < 0.001) when the head was flexed. After extending the head, the ETT tip moved toward the vocal cord by 0.9 ± 0.4 cm (P < 0.001). Right rotation resulted that the ETT tip moved toward the vocal cord direction by 0.6 ± 0.4 cm (P < 0.001). Moreover, there was no displacement with the head on left rotation (P = 0.126). Subjects with the reinforced ETT had less ETT displacement after changing head position than the taper guard ETT. CONCLUSION The changes of head position can influence the depth of the ETT especially in head extension. We recommend using the reinforced ETT to reduce the ETT displacement in pediatrics to avoid intubation complications. CLINICAL TRIAL REGISTRATION [www.ClinicalTrials.gov], identifier, [ChiCTR2100042648].
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Santos DLS, Andrade PDDO, Gomes ELDFD. Does the endotracheal tube insertion depth predicted by formulas in children have a good concordance with the ideal position observed by X-ray? Rev Bras Ter Intensiva 2020; 32:295-300. [PMID: 32667431 PMCID: PMC7405750 DOI: 10.5935/0103-507x.20200046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate the effectiveness of the different formulas for estimating the insertion depth of an endotracheal tube in children. Methods This was an observational and cross-sectional study that included children between 29 days and 2 years of age who were hospitalized in a pediatric intensive care unit and mechanically ventilated. The formulas based on height [(height/10) + 5], the inner diameter of the tube (endotracheal tube × 3), and weight (weight + 6) were evaluated to determine which of them showed better concordance with the ideal insertion depth of the endotracheal tube as evaluated by X-ray. Results The correlation between the height-based calculation and the ideal depth observed on X-ray was strong, with r = 0.88, p < 0.05, and a concordance correlation coefficient of 0.88; the correlation between the weight-based calculation and depth on X-ray was r = 0.75, p < 0.05, and concordance correlation coefficient 0.43; and the correlation between endotracheal tube diameter-based calculation and depth on X-ray was r = 0.80, p < 0.05, and concordance correlation coefficient 0.78. Lin’s concordance correlation analysis indicated that the measurements showed weak concordance (< 0.90). Conclusion The formulas that estimate the insertion depth of the endotracheal tube in children were not accurate and were discordant with the gold-standard method of X-ray evaluation. There is a need for a new method based on anthropometric variables (weight and height) and age that is effective in guiding health professionals of pediatric intensive care units at the time of intubation.
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Perez FA, Hottinger DG, Evans KN, Giles M, Otto RK, Hunyady A, Gentry KR. Longer upper airway lengths in Robin Sequence: A case-control study using computed tomography. Paediatr Anaesth 2020; 30:683-690. [PMID: 32277728 DOI: 10.1111/pan.13869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/29/2020] [Accepted: 03/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Direct laryngoscopy and intubation are often difficult in children with Robin Sequence. Previous research characterizing anatomic airway differences has focused on parameters influencing airway patency; there is a paucity of data pertaining to intubation trajectories and depth. Such information could impact airway management approaches and decrease the incidence of endotracheal tube malpositioning. AIM The study goal was to examine whether longitudinal airway parameters pertaining to intubation are different in children with Robin Sequence compared with age-matched controls. METHOD This case-control study compared patients with RS <4 years of age who had computed tomography scans of the head and neck to age- and sex-matched controls. Measurements were made of the nasopharynx, oropharynx, hypopharynx, tongue, hyoid, and the front teeth to vocal cord, nares to vocal cord, and nasion-basion distances. Statistical analysis was performed using multiple ANCOVA models with the categorical predictor of Robin Sequence vs control and potential covariates including subject height/length, weight, and age. RESULTS Thirty-three patients with Robin Sequence and 33 control subjects were included. After controlling for subject height/length, mean front teeth to vocal cord distance was 1.2 cm longer (95% CI: 0.9 to 1.6 cm, P < .001) and mean nares to vocal cord distance was 0.8 cm longer (95% CI: 0.4 to 1.2 cm, P < .001) in patients with Robin Sequence than in controls. The tongue was positioned on average 0.5 cm higher (95% CI: 0.3 to 0.8, P < .001) and 0.9 cm more posterior (95% CI: 0.6 to 1.0 cm, P < .001) in cases than in controls. Moreover, in patients with Robin Sequence, the hyoid was positioned on average 0.5 cm more inferiorly (95% CI: 0.2 to 0.8 cm, P < .001) and 0.2 cm more posteriorly (95% CI: 0.1 to 0.4 cm, P < .01) than controls. CONCLUSION In patients with Robin Sequence under 4 years of age, the mean front teeth to vocal cord distance was found to be 1.2 cm longer while the mean nares to vocal cord distance was found to be 0.8 cm longer controlling for subject length. Clinicians should account for these differences when selecting and placing endotracheal tubes, particularly those with a preformed bend.
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Affiliation(s)
- Francisco A Perez
- Department of Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | | | - Kelly N Evans
- Department of Pediatrics, Division of Craniofacial Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Marian Giles
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Agnes Hunyady
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Anesthesiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Katherine R Gentry
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Anesthesiology, University of Washington School of Medicine, Seattle, WA, USA
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Yan S, Zhang H. Impact of changes in head position during head and neck surgery on the depth of tracheal tube intubation in anesthetized children. BMC Anesthesiol 2020; 20:124. [PMID: 32448244 PMCID: PMC7245884 DOI: 10.1186/s12871-020-01033-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/06/2020] [Indexed: 01/27/2023] Open
Abstract
Background The classic formula has been used to estimate the depth of tracheal tube intubation in children for decades. However, it is unclear whether this formula is applicable when the head and neck position changes intraoperatively. Methods We prospectively reviewed the data of 172 well-developed children aged 2–12 years (64.0% boys) who underwent head and neck surgery under general anesthesia. The distances from the tracheal carina to the endotracheal tube tip (CT), from the superior margin of the endotracheal tube tip to the vocal cord posterior commissure (CV), and from the tracheal carina to the posterior vocal commissure (TV) were measured in the sniffing position (maximum), neutral head, and maximal head flexion positions. Results Average CT and CV in the neutral head position were 4.33 cm and 10.4 cm, respectively. They increased to 5.43 cm and 11.3 cm, respectively, in the sniffing position, and to 3.39 cm and 9.59 cm, respectively, in the maximal flexion position (all P-values < 0.001). TV remained unchanged and was only dependent on age. After stratifying patients by age, similar results were observed with other distances. CT and CV increased by 1.099 cm and 0.909 cm, respectively, when head position changed from neutral head to sniffing position, and decreased by 0.947 cm and 0.838 cm, respectively, when head position changed from neutral head to maximal flexion. Conclusion Change in head position can influence the depth of tracheal tube intubation. Therefore, the estimated depth should be corrected according to the surgical head position.
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Affiliation(s)
- Siyi Yan
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168, LiTang Road, ChangPing District, Beijing, China
| | - Huan Zhang
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168, LiTang Road, ChangPing District, Beijing, China.
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Yamanaka H, Tsukamoto M, Hitosugi T, Yokoyama T. Changes in nasotracheal tube depth in response to head and neck movement in children. Acta Anaesthesiol Scand 2018; 62:1383-1388. [PMID: 29971764 DOI: 10.1111/aas.13207] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/21/2018] [Accepted: 06/10/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND A tracheal tube is often inserted via the nasal cavity for dental surgery. The position of the tube tip is important, given that the head position sometimes changes during surgery. Head movement induces changes in the length of the trachea (t-length) and/or the distance between the nare and the vocal cords (n-v-distance). In this study, we investigated the changes in t-length and n-v-distance in children undergoing nasotracheal intubation. METHODS Eighty patients aged 2-8 year undergoing dental surgery were enrolled. After nasotracheal intubation with an uncuffed nasotracheal tube (4.5-6.0 mm), the tube was fixed at the patient's nares. The distance between the tube tip and the first carina was measured using a fibrescope with the angle between the Frankfort plane and horizontal plane set at 110°. The location of the tube in relation to the vocal cords was then checked. These measurements were repeated at angles of 80° (flexion) and 130° (extension). The t-length and n-v-distance were then calculated using these measurements. RESULTS On flexion, the t-length shortened significantly from 87.5 ± 10.4 mm to 82.9 ± 10.7 mm (P = 0.017) and the n-v-distance decreased from 128.1 ± 10.7 mm to 125.6 ± 10.4 mm (P = 0.294). On extension, the t-length increased significantly from 87.5 ± 10.4 mm to 92.7 ± 10.1 mm (P = 0.007) and the n-v-distance increased from 128.1 ± 10.7 mm to 129.4 ± 10.7 mm (P = 0.729). The change in t-length was significantly greater than that in the n-v-distance. CONCLUSION A change in the position of the tracheal tube tip in the trachea depends mainly on changes in t-length during paediatric dental surgery.
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Affiliation(s)
- Hitoshi Yamanaka
- Department of Dental Anesthesiology Faculty of Dental Science Kyushu University Fukuoka Japan
| | - Masanori Tsukamoto
- Department of Dental Anesthesiology Kyushu University Hospital Fukuoka Japan
| | - Takashi Hitosugi
- Department of Dental Anesthesiology Faculty of Dental Science Kyushu University Fukuoka Japan
| | - Takeshi Yokoyama
- Department of Dental Anesthesiology Faculty of Dental Science Kyushu University Fukuoka Japan
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Dave MH, Schmid K, Weiss M. Airway dimensions from fetal life to adolescence-A literature overview. Pediatr Pulmonol 2018; 53:1140-1146. [PMID: 29806162 DOI: 10.1002/ppul.24046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/04/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Data on airway dimensions in pediatric patients are important for proper selection of pediatric airway equipment such as endotracheal tubes, double-lumen tubes, bronchial blockers, or stents. The aim of the present work was to provide a synopsis of the available data on pediatric airway dimensions. METHODS A systematic literature search was carried out in the PubMed database, Scopus, Embase, Web of Science, Prisma, and Google Scholar and secondarily completed by a reference search. Based on inclusion and exclusion criteria, a final selection of 109 studies with data on pediatric airway dimensions published from 1923 to 2018 were further analyzed. RESULTS Six different airway measurement methods were identified. They included anatomical examinations, chest X-ray, computed tomography, magnetic resonance tomography, bronchoscopy, and ultrasound. Anatomical studies were more abundant compared to other methods. Data provided were very heterogeneously presented and powered. In addition, due to different study conditions, they are hardly comparable. Among all, anatomical and computer tomography studies are thought to provide the most reliable data. Ultrasound is an upcoming technique to estimate airway parameters of fetus and premature infants. There was, in general, a lack of comprehensive studies providing a complete range of airway dimensions in larger groups of patients from birth to adolescence. CONCLUSIONS This work revealed a large heterogeneity of studies providing data on pediatric airway dimensions, making it impossible to compare, or assemble them to normograms for clinical use. Comprehensive studies in large population of children are needed to provide full range nomograms on pediatric airway dimensions.
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Affiliation(s)
- Mital H Dave
- Department of Anesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Kathrin Schmid
- Department of Anesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Markus Weiss
- Department of Anesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
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Miller KA, Kimia A, Monuteaux MC, Nagler J. In Reply to: Discrepancy Between Pediatric and Adult Patients Concerning Misplaced Endotracheal Tubes During Intubation. J Emerg Med 2017; 52:578-579. [PMID: 28126257 DOI: 10.1016/j.jemermed.2016.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 12/16/2016] [Indexed: 06/06/2023]
Affiliation(s)
| | - Amir Kimia
- Boston Children's Hospital, Boston, Massachusetts
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Herway ST, Benumof JL. The Tracheal Accordion and the Position of the Endotracheal Tube. Anaesth Intensive Care 2017; 45:177-188. [DOI: 10.1177/0310057x1704500207] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this review is to, first, determine the static factors that affect the length of the human trachea across different populations and, second, to investigate whether or not there are dynamic factors that cause the length of the human trachea to vary within the same individual. We also investigated whether these changes in tracheal length within the same individual are significant enough to increase the risk of endobronchial intubation or accidental extubation. A PubMed/MEDLINE and a Web of Science database English-language literature search was conducted in May 2016 with relevant keywords and MeSH terms when available. We found that gender, extremes of age, patient height, postsurgical changes and co-existing disease are static patient factors that affect the length of the human trachea. Dynamic clinical changes that occur under anaesthesia, including Trendelenburg position, head and neck flexion and extension, paralysis of the diaphragm and pneumoperitoneum, cause the trachea to act as an accordion, decreasing and increasing its length. The length of the human trachea in both awake and anaesthetised and paralysed patients is a critical consideration in preventing both endobronchial intubation and tracheal extubation. It is clear from the literature that tracheal length varies widely across populations and, additionally, with the dynamic clinical changes that occur under anaesthesia, the trachea acts as an accordion decreasing and increasing its length within the same individual. Knowledge of the magnitude of the change in tracheal dimensions in response to these factors is an important clinical consideration.
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Affiliation(s)
- S. T. Herway
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - J. L. Benumof
- Department of Anesthesiology, University of California San Diego, CA, USA
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Simons T, Söderlund T, Handolin L. Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study. Eur J Trauma Emerg Surg 2017; 43:797-804. [DOI: 10.1007/s00068-016-0758-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 12/29/2016] [Indexed: 12/15/2022]
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Tewari A, Samy RN, Castle J, Frye TM, Habeych ME, Mohamed M. Intraoperative Neurophysiological Monitoring of the Laryngeal Nerves During Anterior Neck Surgery: A Review. Ann Otol Rhinol Laryngol 2016; 126:67-72. [PMID: 27803238 DOI: 10.1177/0003489416675354] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Contributions to the literature on intraoperative neuro monitoring (IONM) during endocrine and head and neck surgery have increased over recent years. Organizational support for neural monitoring during surgery is becoming evident and is increasingly recognized as an adjunct to visual nerve identification. A comprehensive understanding of the role of IONM for prevention of nerve injuries is critical to maximize safety during surgery of the anterior compartment of the neck. This review will explore the potential advantages of IONM to improve the outcomes among patients undergoing anterior neck surgery.
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Affiliation(s)
- Anurag Tewari
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Ravi N Samy
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | - Miguel E Habeych
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Mahmoud Mohamed
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
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Changes in uncuffed endotracheal tube leak during laparoscopic inguinal herniorrhaphy in children. J Anesth 2016; 30:702-6. [PMID: 27193326 DOI: 10.1007/s00540-016-2190-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/07/2016] [Indexed: 10/21/2022]
Abstract
The present study was conducted to investigate changes in uncuffed endotracheal tube (ETT) leak during laparoscopic surgery. The study included 31 patients aged between 1 and 6 years scheduled for elective laparoscopic inguinal herniorrhaphy. Inspiratory and expiratory tidal volumes (TVi and TVe) were measured during mechanical ventilation, and ETT leak was calculated using the formula-ETT leak = (TVi - TVe)/TVi × 100 (%), assessed at the following time-points-5 min after the start of mechanical ventilation (T1, baseline), just before the start of surgery (T2), 5 min after the induction of pneumoperitoneum with 15° Trendelenburg tilt (T3), and at the end of surgery (T4). Additionally, leak pressure was assessed after successful tracheal intubation (T0, baseline) at T2, T3 and T4. Uncuffed ETT leak significantly decreased at T3 compared with T1 (baseline). Leak pressure significantly increased at T3 and T4 compared with T0 (baseline). Further studies are needed in order to determine whether the results are universal and associated with clinically significant outcomes.
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Schmidt AR, Ulrich L, Seifert B, Albrecht R, Spahn DR, Stein P. Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis. Scand J Trauma Resusc Emerg Med 2016; 24:22. [PMID: 26944389 PMCID: PMC4779199 DOI: 10.1186/s13049-016-0212-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Pre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child. Methods Data from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions. Results In primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae. Conclusion Difficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.
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Affiliation(s)
- Alexander R Schmidt
- Department of Anaesthesiology, University Children's Hospital, Zurich, Switzerland
| | - Lea Ulrich
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Roland Albrecht
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. .,Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland.
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Hunyady AI, Otto RK, Christensen A, Jonmarker C. Nares-to-carina distance in children: does a 'modified Morgan formula' give useful guidance during nasal intubation? Paediatr Anaesth 2015; 25:936-42. [PMID: 26033678 DOI: 10.1111/pan.12693] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Knowledge of the normal nares-to-carina (NC) distance might prevent accidental bronchial intubation and be helpful when designing preformed endotracheal tubes (ETT). OBJECTIVE The aim was to measure NC distance and to examine whether a height/length-based 'modified Morgan formula' would give useful guidance for nasotracheal ETT depth positioning. METHODS Two groups were studied. A younger group consisted of nasally intubated postoperative patients. In these, NC distance was obtained as the sum of ETT length and the distance from the ETT tip to the carina, as measured from an anteroposterior chest X-ray. An older group consisted of children who had undergone computerized tomography (CT) examination including head, neck, and chest. In these, NC was measured directly from the CT image. The modified Morgan formula was derived from the NC vs height/length relationship. RESULTS Nares-to-carina distance was best predicted by a linear equation based on patient height. The equation in the younger group (1 day-8 years, n = 57) was: NC (cm) = 0.14 × height + 5.8, R(2) = 0.90, and in the older group (2.1-20 years, n = 45): NC (cm) = 0.15 × height + 3.4, R(2) = 0.93. The equation for the groups combined (n = 102) was: NC (cm) = 0.14 × height + 6.2, R(2) = 0.97. Based on the latter equation, a modified Morgan formula was identified as: ETT position at nares in cm = 0.12 × height + 5. If the ETT had been placed as calculated by this formula, the ETT tip would have been at 85 + 5% (mean ± sd) of NC distance, and the ETT tip-to-carina distance would have been 3.1 ± 1.1 cm (range 0-6.6). Bronchial intubation would not have occurred in any child, but a comparison to tracheal length measurements indicates that ETT tip position could be too proximal in some children. CONCLUSION The study confirms previous reports: NC distance can be well predicted from height/length. A modified Morgan formula might decrease the risk for accidental endobronchial intubation in infants and children, but ETT position need to be confirmed by auscultation or other verification.
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Affiliation(s)
- Agnes I Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Alexis Christensen
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA, USA
| | - Christer Jonmarker
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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García Araque HF, Valencia Orgaz O, López Vicente R, Gutiérrez Vidal SE. Airway anatomy for the bronchoscopist: An anesthesia approach. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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García Araque HF, Valencia Orgaz O, López Vicente R, Gutiérrez Vidal SE. Anatomía de la vía aérea para el broncoscopista. Una aproximación a la anestesia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2014.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Airway anatomy for the bronchoscopist: An anesthesia approach☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1097/01819236-201442030-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Dralle H, Sitges-Serra A, Angelos P, Poveda MCD, Dionigi G, Barczynski M, Phelan E, Randolph G. Intraoperative Monitoring of the Recurrent Laryngeal Nerve during Thyroidectomy: A Standardized Approach Part 2. ACTA ACUST UNITED AC 2012. [DOI: 10.5005/jp-journals-10002-1091] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ABSTRACT
This is the second of two articles on intraoperative neural monitoring. The aim of part one was to provide a concise overview of intraoperative nerve monitoring in thyroid surgery and its effectiveness. Part 1 included a brief review of the surgical anatomy of the recurrent laryngeal nerve and described the surgical landmarks which can be used to identify the nerve during surgery. Part 2 will describe in detail a standardized approach to intraoperative nerve monitoring during thyroid surgery. A brief review of the nerve monitoring procedure and all its requirements will be discussed. The article concludes with the description of a troubleshooting algorithm for intraoperative loss of signal.
How to cite this article
Poveda MCD, Dionigi G, Sitges- Serra A, Barczynski M, Angelos P, Dralle H, Phelan E, Randolph G. Intraoperative Monitoring of the Recurrent Laryngeal Nerve during Thyroidectomy: A Standardized Approach Part 2. World J Endocr Surg 2012;4(1):33-40.
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Electromyographic endotracheal tube placement during thyroid surgery in neuromonitoring of recurrent laryngeal nerve. Kaohsiung J Med Sci 2011; 27:96-101. [DOI: 10.1016/j.kjms.2010.08.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 08/25/2010] [Indexed: 11/21/2022] Open
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Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccolli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Sloan T, Van Slycke S, Snyder S, Takami H, Volpi E, Woodson G. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 2011; 121 Suppl 1:S1-16. [PMID: 21181860 DOI: 10.1002/lary.21119] [Citation(s) in RCA: 619] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem-solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options.
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Affiliation(s)
- Gregory W Randolph
- Department of Otology and Laryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Fennessy BG, O'Connor R, Cronin M, Fenton JE, Hughes JP. Safety implications of the Boyle-Davis mouth gag and tracheal tube position in tonsillectomy. Br J Anaesth 2010; 105:863-6. [PMID: 20926477 DOI: 10.1093/bja/aeq264] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The risk of death after tonsillectomy is extremely small, and is mostly caused by the direct or indirect effects of haemorrhage or anaesthetic complications. These complications include aspiration, accidental dislodgement of the tracheal tube (TT), and pneumothorax or pneumomediastinum. The Boyle-Davis mouth gag (BDG) is a device used to visualize the oropharynx and stabilize the TT during tonsillectomy. We postulate that a deployed BDG may influence the position of the TT, and potentially result in silent aspiration, accidental extubation, and unilateral pulmonary ventilation. This has not, to our knowledge, been evaluated before. The aim of this prospective, pilot study was to evaluate the displacement of the TT upon opening and closing the BDG, in an objective manner. METHODS Patients undergoing tonsillectomy with/without adenoidectomy at a regional department underwent flexible bronchoscopy to evaluate the changes in position of the TT tip with the BDG in an open and closed position, relative to the position of the carina. RESULTS Twenty-three patients were enrolled into the study. Deploying the BDG resulted in TT displacement in 96% of patients. The mean displacement was 9.5 mm (range -10 to +27 mm). CONCLUSIONS We believe that this study raises concerns not previously highlighted, on how manipulating a BDG may influence the TT position. It may serve to explain additional mechanisms of potentially fatal anaesthetic complications such as TT dislodgement, unilateral ventilation, and pneumothorax, particularly in paediatric patients, after tonsillectomy.
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Affiliation(s)
- B G Fennessy
- Department of ENT, University of Limerick Medical School and the Midwestern Regional Hospital, Dooradoyle, Limerick, Ireland.
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Gwak MJ, Park JY, Suk EH, Kim DH. Effects of head rotation on the right internal jugular vein in infants and young children. Anaesthesia 2010; 65:272-6. [DOI: 10.1111/j.1365-2044.2009.06209.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Effect of head posture on pediatric oropharyngeal structures: implications for airway management in infants and children. Curr Opin Anaesthesiol 2009; 22:396-9. [PMID: 19434789 DOI: 10.1097/aco.0b013e3283294cc7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although head and neck posture has direct effects on the upper airway in infants and children, many of these effects remain unclear or not well established. As airway patency and airway access are critical in sedated and/or unconscious children, recent developments in this area should be made known to pediatric anesthesiologists, intensive care physicians and other emergency caregivers. RECENT FINDINGS All recent studies observed large interindividual variability in anatomical measurements, especially in trachea length. More evidence has been gained that lateral position improves upper airway patency in sedated children. Several studies brought indirect information on head posture for laryngoscopy and intubation. SUMMARY The site of obstruction of the airway in sedated children in different postures is now more clear. Implications of head flexion and extension in intubated children have been extensively studied, and clinical consequences have been detailed. Due to large interindividual anatomic variability, depth marks set on the tubes by their manufacturers and guidelines regarding calculations of insertion depth should be made with caution in infants and neonates. Despite several studies, there is still little scientific evidence regarding proper head posture for laryngoscopy and intubation.
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Wong DT, Ip HYV. Usage of a fibreoptic scope to verify tracheal tube placement in the pediatric population. Can J Anaesth 2009; 56:385-6; author reply 386. [PMID: 19343463 DOI: 10.1007/s12630-009-9074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 02/12/2009] [Indexed: 11/26/2022] Open
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Rapid estimation of distance from the tip of the tracheal tube to carina using fibreoptic bronchoscopy. Can J Anaesth 2008; 55:787-8. [DOI: 10.1007/bf03016355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Wong DT, Weng H, Lam E, Song HB, Liu J. Lengthening of the Trachea During Neck Extension: Which Part of the Trachea Is Stretched? Anesth Analg 2008; 107:989-93. [DOI: 10.1213/ane.0b013e31817ef177] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jordi Ritz EM, Von Ungern-Sternberg BS, Keller K, Frei FJ, Erb TO. The impact of head position on the cuff and tube tip position of preformed oral tracheal tubes in young children. Anaesthesia 2008; 63:604-9. [PMID: 18477271 DOI: 10.1111/j.1365-2044.2008.05440.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Head and neck movements affect both the length of the trachea and the position of tracheal tubes. This is of relevance when using cuffed tubes because changes in the position of the tube tip may not be equal to changes in the position of the cuff. The aim of the study was to assess the impact of head and neck movement on the position of the tube tip and the cuff of newly designed, oral preformed tracheal tubes in children. The tracheas of 128 children aged 1-8 years were intubated with preformed oral tubes. The distances 'carina-to-tracheal tube tip' and 'vocal cords-to-tube tip' were measured endoscopically. These measurements were performed with the head and neck in a functional neutral position (110 degrees ), during neck flexion (80 degrees ) and neck extension (130 degrees ). Tracheal length was dependent on head and neck position: neck extension elongated the trachea (p < 0.0001), and neck flexion shortened the trachea (p < 0.0001). Neck flexion moved the tube inward and resulted in endobronchial displacement in two patients. Neck extension moved the tube outwards. While no cuff was positioned between the vocal cords, cuff movement to the cricoid area occurred frequently. Complex interactions during head and neck movement along with the fixed insertion depth of preformed tubes often cause inadvertent malpositioning of the tube tip and cuff. Further changes to tube and cuff lengths might improve the safety of oral preformed tubes in children.
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Affiliation(s)
- E-M Jordi Ritz
- Division of Anaesthesia, University Children's Hospital, Roemergasse 8, 4058 Basel, Switzerland.
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Optimal Depth of NIM EMG Endotracheal Tube for Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerve During Thyroidectomy. World J Surg 2008; 32:1935-9. [DOI: 10.1007/s00268-008-9549-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yoo SY, Kim JH, Han SH, Oh AY. A comparative study of endotracheal tube positioning methods in children: safety from neck movement. Anesth Analg 2007; 105:620-5. [PMID: 17717214 DOI: 10.1213/01.ane.0000278149.66027.0b] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The unexpected displacement of the endotracheal tube (ETT) as a result of neck movements can cause endobronchial intubation and accidental extubation. The ETT is subject to movement even after its proper placement has been confirmed either clinically or radiographically. METHODS One-hundred-seven children (2-8 yr) were divided randomly into three groups. In Group I, the ETT was entered into the main bronchus and withdrawn until equal sounds in both lung were heard, and then withdrawn 2 cm. In Group II, the ETT position was determined by placing the prescribed marks on the ETT at the level of the vocal cords, and in Group III, by palpating the ETT tip at the suprasternal notch. In all groups, the distance between the ETT tip and the carina was measured using a fiberoptic bronchoscope. The relative ETT tip position along the trachea (carina; 0%, vocal cords; 100%) was assessed in each position during neck movement. RESULTS The relative position of the ETT with the patient in the neutral position in Groups I, II, and III was 21.4% +/- 6.7%, 46.5% +/- 13.0%, and 43.4% +/- 11.1%, respectively. In Group I, the relative ETT position after flexion was 9.5% +/- 10.3%, and endobronchial intubation was observed in five children (14.3%). There was no extubation or endobronchial intubation in the other two groups. CONCLUSIONS Positioning the ETT by auscultation places the ETT more deeply than the midtrachea, which can increase the risk of endobronchial intubation during neck flexion.
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Affiliation(s)
- Seung-Yeon Yoo
- Department of Anesthesiology, Seoul National University Bundang Hospital, Seongnam City, Korea.
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Abstract
BACKGROUND During laparoscopic gynecologic surgery, pneumoperitoneum combined with the Trendelenburg position moves the carina towards the tip of the endotracheal tube (ETT), decreasing the margin of safety for the ETT position and increasing accidental endobronchial intubation. However, it remains to be established whether the tracheal length itself is actually changed. We conducted a prospective observational study to measure the change in the length of the trachea and the distance between the ETT tip and the carina in patients undergoing gynecologic laparoscopic surgery. METHODS Twenty-three patients scheduled for laparoscopic gynecologic surgery were enrolled. In the neutral position, the tracheal length was measured using a fiberoptic bronchoscope. The distance between the ETT tip and the carina was also measured. The tracheal length and the distance between the ETT tip and the carina were measured again 10 min after carbon dioxide (CO(2)) pneumoperitoneum (12-14 mmHg) combined with the Trendelenburg position (15 degrees ). RESULTS In the neutral position, the tracheal length was 11.09 +/- 0.90 cm and the distance between the ETT tip and the carina was 3.36 +/- 1.04 cm. After pneumoperitoneum combined with the Trendelenburg position, the distance between the ETT tip and the carina had decreased by 0.85 +/- 0.28 cm. The tracheal length had also decreased by 0.42 +/- 0.19 cm, which was equivalent to 49.7% of the decrease in the distance between the ETT tip and the carina. CONCLUSIONS These results suggest that tracheal shortening may contribute to a decrease in the distance between the ETT tip and the carina, increasing the risk of accidental endobronchial intubation during laparoscopic gynecologic surgery.
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Affiliation(s)
- J-H Kim
- Department of Anesthesiology, Seoul National University Bundang Hospital, Seoul, South Korea
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Current World Literature. Curr Opin Anaesthesiol 2006; 19:660-5. [PMID: 17093372 DOI: 10.1097/aco.0b013e3280122f5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Choudhry DK, Mackenzie WG. Anesthetic Issues with a Hyperextended Cervical Spine in a Child with Emery-Dreifuss Syndrome. Anesth Analg 2006; 103:1611-3. [PMID: 17122279 DOI: 10.1213/01.ane.0000246588.32148.0a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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