Successful difficult intubation Tracheal tube placement over a gum‐elastic bougie

Abstract

SummaryA randoniised study was carried out to assess the effect of tracheal tube rotation on the passage of a tube over a gum-elastic bougie into the trachea in 100 patients. Key wordsDififficult tracheal intubation; gum-elastic bougie.Successful management of a difficult intubation using a gum-elastic bougie is completed in two phases. The first involves passage of the bougie through the larynx into the trachea. The methods employed to recognise the position of the bougie in the trachea when the vocal cords are not visible were previously investigated in this centre. ' The tracheal tube is passed over the bougie into the trachea in the second phase. The successful placement of a bougie through the larynx, in our clinical experience, may frequently be followed by difficulty in this second phase. Cossham' has suggested that rotation of the tracheal tube a quarter-turn anticlockwise may improve the success rate in these circumstances, although this has never been quantified. Therefore, a systematic study was conducted to investigate the effect of anticlockwise rotation of the tracheal tube over the bougie. We also assessed whether the presence or absence of a laryngoscope in the mouth influenced the passage of the tracheal tube because some anaesthetists withdraw the laryngoscope before passing the tube over the bougie. MethodsInformed consent was obtained from all patients, after approval from the Ethics Committee. One hundred patients aged 18-70 years, in ASA grades 1 and 2, for whom tracheal intubation was planned as part of the anaesthetic sequence were studied. Patients were excluded from the study if they were to have ocular or neurosurgical procedures; those patients with asthma and in those cases when cricoid pressure was to be used were also excluded.The normal orientation of the tracheal tube with the bevel to the left will be referred to as the 0" (neutral) position; the orientation of the tube with a quarter-turn anticlockwise such that the bevel faces posteriorly will be referred to as the -90" position. The Portex standard cuffed tracheal tubes used were of 9 mm internal diameter for men and 8 mm for women. The ECG, blood pressure and oxygen saturation (by pulse oximeter) were monitored in all patients throughout the period of anaesthesia. Patients were pre-oxygenated for 3 minutes. Anaesthesia was induced with an intravenous agent chosen by the anaesthetist present. Muscle relaxation was achieved by the administration of suxamethonium 1.5 mg/kg intravenously. Laryngoscopy was performed after 60 seconds using a Macintosh blade, size 3.The initial view of the glottic structures was classified according to Cormack and Lehane:' grade I , the glottis can be fully exposed (including anterior and posterior commissures); grade 2, the glottis is partially exposed (posterior commissure only); grade 3, the glottis cannot be exposed (epiglottis visible); grade 4, neither the glottis nor the epiglottis can be exposed.A 15-FG gum-elastic bougie (Eschmann, UK) was passed into the trachea after laryngoscopy. The...

The effect of cricoid pressure on intubation facilitated by the gum elastic bougie*

“…It is not possible to make a direct comparison of the frequency of impingement between the sexes from our data. Dogra et al [4], also used 8.0-and 9.0-mm tubes for women and men and reported a similar 50% rate of glottic impingement, but did not comment on the influence of gender. It is logical to expect a bigger tube to cause more impingement.…”

“…This has become the standard manoeuvre to overcome the obstruction when impingement occurs. Dogra et al [4] in their influential study investigated this phenomenon and found that impingement was common and that the 90CCWR manoeuvre was highly effective in overcoming the obstruction. They reported impingement in 12 ⁄ 25 subjects with the tube in the neutral position and in none of 25 subjects with 90CCWR.…”

Comparison of fibrescope guided intubation via the classic laryngeal mask airway and i‐gel in a manikin*

“…Intubation with tracheal tube railroaded directly over the fibrescope For this method of fibrescope guided intubation, a 6.0 mm reinforced tracheal tube (Mallincrodt, Hazelwood, MO, USA), with the tube bevel facing posteriorly [14,15], was mounted on the fibrescope by the investigator. Total timing of the first intubation consisted of two timed sections: time 1 -from the participant's picking up the fibrescope to obtaining a view of the carina; and time 2 -from the start of railroading the tube into the trachea over the fibrescope, to removal of the fibrescope and delivery of a single breath.…”

Poor performance of the pediatric airway exchange catheter in adults with cervical spine immobilization

“…18,19 This has also been described with the passage of the tube over a gum-elastic bougie. 20 The main cause of this constriction is the creation of a cleft along the tube bevel by the difference in the OD of the fibrescope or bougie and the ID of the tube. In this study, we used a PAEC with an OD of 4 mm and a tracheal tube with ID of 7.5 mm.…”