590
18.
19.
20.
21.
22. 23.
24.
25. 26.
Forum
competitive neuromuscular blocking drug. British Journal of Anaesthesia, 45, 837. BLOGG,C.E., SAVEGE, T.M., SIMPSON, J.C., Ross, L.A. & SIMPSON,B.R. (1973) A new muscle relaxant-AH8165. Proceedings of the Royal Society of Medicine, 66, 1023. ARORA,M.V.,CLARKE, R.S.J., DUNDEE,J.W. & MOORE,J . (1973) Initial clinical experience with AH8165 D, a new rapidly acting nondepolarising muscle relaxant. Anaesthesia, 28, 188. COLEMAN,A.J., O'BRIEN,A,, DOWNING,J.W., JEAL,D.E., MOYES,D.G. & LEARY,W.P. (1973) AH8165: a new non-depolarising muscle relaxant. Anaesthesia, 28, 262. HARTLEY,J.M.F. & FIDLER,K. (1977) Rapid intubation with fazadinium. A comparison of fazadinium with suxamethonium and alcuronium. Anaesthesia, 32, 14. YOUNG,H.S.A., CLARKE, R.S.J. & DUNDEE, J.W. (1975) Intubating conditions with AH8165 and suxamethonium. Anaesthesia, 30, 30. CORALL, I.M., WARD,M.E., PAGE,J. & STRUNIN, L. (1977) Conditions for tracheal intubation following fazadinium and pancuronium. British Journal 01 Anaesthesia, 49, 615. BLACKBURN, C.L. & MORGAN,M. (1978) Comparison of speed of onset of action of fazadinium, pancuronium, tubocurarine and suxamethonium. British Journal of Anaesthesia, 50, 361. UNGERER, M.J. & ERASMUS, F.R. (1974) Clinical evaluation of a new non-depolarising muscle relaxant. South African Medical Journal, 48, 2561. BOWEN,D.J., MCGRAND,J.C. & PALMER,R.J.
27. 28.
29.
30. 31.
32.
33.
34.
(I 976) Intraocular pressures after suxamethonium and endotracheal intubation in patients pretreated with pancuronium. British Journal of Anaesthesia, 48, 1201. PERKINS,E.S. (1965) Hand-held applanation tonometer. British Journal of 0ph;halmology. 49, 591. AL-ABRAK,M.H. & SAMUEL, I.R. (1974) Effects of general anaesthesia on the intraocular pressure in man. Comparison of tubocurarine and pancuronium with nitrous oxide and oxygen. British Journal of Ophthalmology, 58, 806. GOLDSMITH, E. (1967) An evaluation of succinylcholine and gallamine as muscle relaxants in relation to intraocular tension. Anaesthesia and Analgesia; Current Researches, 46, 551. SMITH, R.B. & LEASO, N. (1973) Intraocular pressure following pancuronium. Canadian Anaesthetists' Society Journal, 20, 742. SCHREUDER, M. & LINSSEN, G.H. (1972) Intra-ocular pressure and anaesthesia. Anaesthesia, 27, 165. ~ ,(1974) Effect of carbon SAMUEL, J.R. & B E A U G IA. dioxide on the intraocular pressure in man during general anaesthesia. British Journal of Ophthalmology, 58, 62. DUNCALF,D. & WEITZNER,S.W. (1963) The influence of ventilation and hypercapnea on intraocular pressure during anaesthesia. Anesthesia and Analgesia; Current Researches, 42, 232. BEAU&, A. & SAMUEL, J.R. (1973) Some observations on the effect of carbon dioxide on intraocular pressure in man. British Journal of Anaesthesia. 45, 119.
Anaesthesia, 1979, Volume 34. pages 590-592
Complications of guided blind endotracheal intubation Dr 0.0.Akinyemi, MB, BS, FFARCS, Senior Lecturer and Consultant, Department of Anaesthesia, University College Hospital, Ibadan, Nigeria The technique of guided blind tracheal intubation was first described by Waters in 1963.' It was devised mainly to solve the problem of difficulty in airway maintenance in patients who have deformities of the upper jaw, but it can also be used in other problem cases. Briefly, the technique is that a widebore needle (such as the Tuohy needle) is passed percutaneously through the cricothyroid membrane into the larynx, its tip pointing cephalad. A thin polythene catheter is next passed through it and advanced between the vocal cords into the pharynx where it coils up. The cannula is next hooked out of the nostril (or mouth) a n d finally a tracheal tube is threaded over it into the trachea. This technique had t o be used in twelve patients by the author between April 1974 and April 1978. The complica-
tions observed in this series are presented in this paper. Materials and method
There were eight male and four female patients aged between 9 a n d 25 years in this series. They were all undergoing surgery o n the mandible for the repair of ankylosis of both jaws. In one male, the ankylosis resulted from primary osteomyelitis of the mandible. I n all the other patients, the bony ankylosis was a result of cancrum oris. Anaesthesia was induced with a sleep dose of thiopentone followed by spontaneous inhalation of nitrous oxide, oxygen a n d ether, after a few breaths of halothane t o smoothen the induction. T h e gas
59 1
Forum mixture was administered via the circle absorber system and face mask. When each patient was deep enough, blind nasotracheal intubation was attempted. If after four attempts this failed, guided blind nasotracheal intubation was performed. The technique described originally by Waters was followed as much as possible, but with experience it was modified in the following ways. The tracheal tube was rotated slightly as it is advanced through the vocal cords. Care was taken that the epidural cannula (which was the guide used in all cases) was not pulled too taut during the advance of the tube. The tracheal tubes used were not too soft and were 0.5 to 1 mm narrower in diameter than the standard size tube for each patient. The head was tilted sideways during the manoeuvre.
Results The complications observed are shown in Table 1. In three cases, bleeding occurred externally from the puncture site. This would have arisen either from the skin or the isthmus of the thyroid gland. It however caused no concern as it invariably ceased on direct pressure. In two others, bleeding resulted from trauma to the nasal mucosa by the blunt hook. This stopped spontaneously after a few minutes. Breathholding occurred in one patient when the epidural cannula was being advanced through the larynx into the pharynx. This, however, stopped when the advance of the cannula was ended. It was apparently a reflex response to a light plane of anaesthesia. The inspiratory obstruction seen in one case is noteworthy. After the tracheal tube had been passed a s described, expired air passed out through it unobstructed but the flow of inspired air was impeded and inspiration was accompanied by signs of respiratory obstruction. The tracheal tube was withdrawn into the pharynx and re-passed. The same signs occurred again. It was thought that the epiglottis was in the way, probably partly folded downwards by the tip of the tube. The tube was therefore withdrawn into the pharynx the second time, and the lower part of the larynx was pressed backwards before the tube was advanced into the trachea. The inspiratory obstruction disappeared after this manoeuvre. Hooking the cannula out of the pharynx through the nostril was difficult in three cases. In the author’s limited experience, this procedure can take a much longer time than described by other workers.2 In one patient, it was impossible to hook the cannula out in spite of obvious evidence that the hook had caught on the cannula. The cannula had to be withdrawn by a pull on its distal end and reintroduced before successful ‘fishing’ out ensued. The probable causes of difficulty were macroglossia
Table 1. Complications of guided blind nasotracheal intubation in twelve patients Complication
Number
Bleeding: Puncture site Nostril Breath-holding Respiratory (inspiratory) obstruction Difficulty in hooking out cannula
3 2 1
Loss of hook
1
1
3
in the second patient, and knotting of the cannula in the third. In yet another case, published elsewhere,’ the hook was lost in the pharynx. This was apparently due t o the poor design of that particular hook. Since then, the all-metal hook has been used more frequently.
Discussion
Guided blind tracheal intubation is one of the available methods of solving the problem of difficult laryngoscopy and intubation. In practice, it is usually resorted to only after other methods have failed. This is because it is technically more involved. The small number of patients in this series reflects this fact. The other alternative steps that can be used include blind nasal intubation, the use of a fibreoptic endoscope (i.e. modified endoscope4), the use of a wire hook in the oropharynx t o guide the tube backwards or forward^,^ the use of a suction catheter to lift the lower end of the tube away from an obstacle into the oropharynx6 or the avoidance of tracheal intubation as by the use of ketamina. Cases in which blind nasotracheal intubation was successful were excluded from this series. The fibreoptic endoscope is not freely available to anaesthetists in our hospital. The use of a wirehook or suction catheter is possible only if the mouth can be opened. In none of these cases could the mouth be opened. Ketamine has been used successfully in similar cases, but there is evidence that laryngeal reflexes may be very active in children under the influence of ketamine.’ Just as with other methods of endotracheal intubation, expertise with this technique comes with practice. Moreover, the more frequently this technique is used, the more readily one appreciates the possible complications and the steps needed t o prevent or treat them. The hazards so far, in this small series, are rather minor. Perhaps the one that has been anticipated but has not been observed is laryngeal spasm. It was initially surprising to observe that there could still be difficulty in intubating the trachea in spite of the guiding catheter. A little reflection,
592
Forum
however, reveals the following causes; the use of too large a tube, causing a hold-up at the larynx, kinking of the tube or eosophageal intubation; too much tension on the guiding catheter leading to the tracheal tube impinging on the epiglottis; too light a plane of anaesthesia before the manoeuvre, causing breathholding or even possibly laryngeal spasm and hence preventing the advance of the endotracheal tube. Another disturbing problem is that of packing the pharynx. A way of solving this is to use a streamlined cuffed tube. Another way is to request the surgeon to pack the pharynx as soon as he is able to open the mouth sufficiently. In one patient, it was possible to pack the pharynx by gently inserting, with a blunt thin stilette, a thin roll of wet bandage through the other nostril. As bleeding constitutes most of the complications seen in this series, it is suggested that the technique be avoided in patients with a pre-existing history of haemorrhagic diathesis. A definite advantage of this technique is that it curtails the necessity for tracheostomy which was frequently resorted to in the past. Tracheostomy, especially in children, has its own inherent complications which in this environment may be magnified by shortage of medical and nursing staff and nebulisers. As the complications of guided blind tracheal intubation are minor, it should be considered as an alternative to tracheostomy wherever possible. In conclusion, the complications of gutded blind tracheal intubation seen so far are minor enough to justify its more frequent use in patients presenting intubation problems.
undergoing guided blind nasotracheal intubation are presented. The commonest was minor bleeding, followed by difficulty in hooking the cannula out of the nostril. These complications are minor enough to justify the more frequent use of the technique in patients with intubation problems. K e y words
INTUBATION, ENDOTRACHEAL; complications, technique. Acknowledgments
The author is indebted to Mr G.O. Adedokun for secretarial assistance and to surgical colleagues in the Dental and Faciomaxillary Unit of the Department of Surgery, University College Hospital, Ibadan, for their patience and co-operation during this study. References 1. WATERS, D.J. (1963) Guided blind endotracheal
2. 3. 4. 5. 6.
intubation for patients with deformities of the upper airway. Anaesthesia, 18, 158-162. SCURR,C. (1975) A complication of guided blind intubation. Anaesthesia, 30, 41 1 4 1 2 . AKINYEMI, O.O., JOHN,A. (1974) A complication of guided blind intubation. Anaesthesia, 29, 733-735. MURPHY, P.(1967) A fibre-optic endoscope used for nasal intubation. Anaesthesia, 22, 489491. BEARMAN, A.J. (1962) Device for nasotracheal intubation. Anesthesiology, 23, 130-131. TAHIR, A.H. (1970) A simple manoeuvre to aid the passage of a nasotracheal tube into the oropharynx.
British Journal of Anaesthesia, 42, 631-632. 7. YEUNG,M.L.,LIN,R.S.H.(1972) Laryngeal reflexes
in children under ketamine anaesthesia. British Summary
The complications observed in twelve patients
Journal of Anaesthesia, 44, 1089-1092.
18.
19.
20.
21.
22. 23.
24.
25. 26.
Forum
competitive neuromuscular blocking drug. British Journal of Anaesthesia, 45, 837. BLOGG,C.E., SAVEGE, T.M., SIMPSON, J.C., Ross, L.A. & SIMPSON,B.R. (1973) A new muscle relaxant-AH8165. Proceedings of the Royal Society of Medicine, 66, 1023. ARORA,M.V.,CLARKE, R.S.J., DUNDEE,J.W. & MOORE,J . (1973) Initial clinical experience with AH8165 D, a new rapidly acting nondepolarising muscle relaxant. Anaesthesia, 28, 188. COLEMAN,A.J., O'BRIEN,A,, DOWNING,J.W., JEAL,D.E., MOYES,D.G. & LEARY,W.P. (1973) AH8165: a new non-depolarising muscle relaxant. Anaesthesia, 28, 262. HARTLEY,J.M.F. & FIDLER,K. (1977) Rapid intubation with fazadinium. A comparison of fazadinium with suxamethonium and alcuronium. Anaesthesia, 32, 14. YOUNG,H.S.A., CLARKE, R.S.J. & DUNDEE, J.W. (1975) Intubating conditions with AH8165 and suxamethonium. Anaesthesia, 30, 30. CORALL, I.M., WARD,M.E., PAGE,J. & STRUNIN, L. (1977) Conditions for tracheal intubation following fazadinium and pancuronium. British Journal 01 Anaesthesia, 49, 615. BLACKBURN, C.L. & MORGAN,M. (1978) Comparison of speed of onset of action of fazadinium, pancuronium, tubocurarine and suxamethonium. British Journal of Anaesthesia, 50, 361. UNGERER, M.J. & ERASMUS, F.R. (1974) Clinical evaluation of a new non-depolarising muscle relaxant. South African Medical Journal, 48, 2561. BOWEN,D.J., MCGRAND,J.C. & PALMER,R.J.
27. 28.
29.
30. 31.
32.
33.
34.
(I 976) Intraocular pressures after suxamethonium and endotracheal intubation in patients pretreated with pancuronium. British Journal of Anaesthesia, 48, 1201. PERKINS,E.S. (1965) Hand-held applanation tonometer. British Journal of 0ph;halmology. 49, 591. AL-ABRAK,M.H. & SAMUEL, I.R. (1974) Effects of general anaesthesia on the intraocular pressure in man. Comparison of tubocurarine and pancuronium with nitrous oxide and oxygen. British Journal of Ophthalmology, 58, 806. GOLDSMITH, E. (1967) An evaluation of succinylcholine and gallamine as muscle relaxants in relation to intraocular tension. Anaesthesia and Analgesia; Current Researches, 46, 551. SMITH, R.B. & LEASO, N. (1973) Intraocular pressure following pancuronium. Canadian Anaesthetists' Society Journal, 20, 742. SCHREUDER, M. & LINSSEN, G.H. (1972) Intra-ocular pressure and anaesthesia. Anaesthesia, 27, 165. ~ ,(1974) Effect of carbon SAMUEL, J.R. & B E A U G IA. dioxide on the intraocular pressure in man during general anaesthesia. British Journal of Ophthalmology, 58, 62. DUNCALF,D. & WEITZNER,S.W. (1963) The influence of ventilation and hypercapnea on intraocular pressure during anaesthesia. Anesthesia and Analgesia; Current Researches, 42, 232. BEAU&, A. & SAMUEL, J.R. (1973) Some observations on the effect of carbon dioxide on intraocular pressure in man. British Journal of Anaesthesia. 45, 119.
Anaesthesia, 1979, Volume 34. pages 590-592
Complications of guided blind endotracheal intubation Dr 0.0.Akinyemi, MB, BS, FFARCS, Senior Lecturer and Consultant, Department of Anaesthesia, University College Hospital, Ibadan, Nigeria The technique of guided blind tracheal intubation was first described by Waters in 1963.' It was devised mainly to solve the problem of difficulty in airway maintenance in patients who have deformities of the upper jaw, but it can also be used in other problem cases. Briefly, the technique is that a widebore needle (such as the Tuohy needle) is passed percutaneously through the cricothyroid membrane into the larynx, its tip pointing cephalad. A thin polythene catheter is next passed through it and advanced between the vocal cords into the pharynx where it coils up. The cannula is next hooked out of the nostril (or mouth) a n d finally a tracheal tube is threaded over it into the trachea. This technique had t o be used in twelve patients by the author between April 1974 and April 1978. The complica-
tions observed in this series are presented in this paper. Materials and method
There were eight male and four female patients aged between 9 a n d 25 years in this series. They were all undergoing surgery o n the mandible for the repair of ankylosis of both jaws. In one male, the ankylosis resulted from primary osteomyelitis of the mandible. I n all the other patients, the bony ankylosis was a result of cancrum oris. Anaesthesia was induced with a sleep dose of thiopentone followed by spontaneous inhalation of nitrous oxide, oxygen a n d ether, after a few breaths of halothane t o smoothen the induction. T h e gas
59 1
Forum mixture was administered via the circle absorber system and face mask. When each patient was deep enough, blind nasotracheal intubation was attempted. If after four attempts this failed, guided blind nasotracheal intubation was performed. The technique described originally by Waters was followed as much as possible, but with experience it was modified in the following ways. The tracheal tube was rotated slightly as it is advanced through the vocal cords. Care was taken that the epidural cannula (which was the guide used in all cases) was not pulled too taut during the advance of the tube. The tracheal tubes used were not too soft and were 0.5 to 1 mm narrower in diameter than the standard size tube for each patient. The head was tilted sideways during the manoeuvre.
Results The complications observed are shown in Table 1. In three cases, bleeding occurred externally from the puncture site. This would have arisen either from the skin or the isthmus of the thyroid gland. It however caused no concern as it invariably ceased on direct pressure. In two others, bleeding resulted from trauma to the nasal mucosa by the blunt hook. This stopped spontaneously after a few minutes. Breathholding occurred in one patient when the epidural cannula was being advanced through the larynx into the pharynx. This, however, stopped when the advance of the cannula was ended. It was apparently a reflex response to a light plane of anaesthesia. The inspiratory obstruction seen in one case is noteworthy. After the tracheal tube had been passed a s described, expired air passed out through it unobstructed but the flow of inspired air was impeded and inspiration was accompanied by signs of respiratory obstruction. The tracheal tube was withdrawn into the pharynx and re-passed. The same signs occurred again. It was thought that the epiglottis was in the way, probably partly folded downwards by the tip of the tube. The tube was therefore withdrawn into the pharynx the second time, and the lower part of the larynx was pressed backwards before the tube was advanced into the trachea. The inspiratory obstruction disappeared after this manoeuvre. Hooking the cannula out of the pharynx through the nostril was difficult in three cases. In the author’s limited experience, this procedure can take a much longer time than described by other workers.2 In one patient, it was impossible to hook the cannula out in spite of obvious evidence that the hook had caught on the cannula. The cannula had to be withdrawn by a pull on its distal end and reintroduced before successful ‘fishing’ out ensued. The probable causes of difficulty were macroglossia
Table 1. Complications of guided blind nasotracheal intubation in twelve patients Complication
Number
Bleeding: Puncture site Nostril Breath-holding Respiratory (inspiratory) obstruction Difficulty in hooking out cannula
3 2 1
Loss of hook
1
1
3
in the second patient, and knotting of the cannula in the third. In yet another case, published elsewhere,’ the hook was lost in the pharynx. This was apparently due t o the poor design of that particular hook. Since then, the all-metal hook has been used more frequently.
Discussion
Guided blind tracheal intubation is one of the available methods of solving the problem of difficult laryngoscopy and intubation. In practice, it is usually resorted to only after other methods have failed. This is because it is technically more involved. The small number of patients in this series reflects this fact. The other alternative steps that can be used include blind nasal intubation, the use of a fibreoptic endoscope (i.e. modified endoscope4), the use of a wire hook in the oropharynx t o guide the tube backwards or forward^,^ the use of a suction catheter to lift the lower end of the tube away from an obstacle into the oropharynx6 or the avoidance of tracheal intubation as by the use of ketamina. Cases in which blind nasotracheal intubation was successful were excluded from this series. The fibreoptic endoscope is not freely available to anaesthetists in our hospital. The use of a wirehook or suction catheter is possible only if the mouth can be opened. In none of these cases could the mouth be opened. Ketamine has been used successfully in similar cases, but there is evidence that laryngeal reflexes may be very active in children under the influence of ketamine.’ Just as with other methods of endotracheal intubation, expertise with this technique comes with practice. Moreover, the more frequently this technique is used, the more readily one appreciates the possible complications and the steps needed t o prevent or treat them. The hazards so far, in this small series, are rather minor. Perhaps the one that has been anticipated but has not been observed is laryngeal spasm. It was initially surprising to observe that there could still be difficulty in intubating the trachea in spite of the guiding catheter. A little reflection,
592
Forum
however, reveals the following causes; the use of too large a tube, causing a hold-up at the larynx, kinking of the tube or eosophageal intubation; too much tension on the guiding catheter leading to the tracheal tube impinging on the epiglottis; too light a plane of anaesthesia before the manoeuvre, causing breathholding or even possibly laryngeal spasm and hence preventing the advance of the endotracheal tube. Another disturbing problem is that of packing the pharynx. A way of solving this is to use a streamlined cuffed tube. Another way is to request the surgeon to pack the pharynx as soon as he is able to open the mouth sufficiently. In one patient, it was possible to pack the pharynx by gently inserting, with a blunt thin stilette, a thin roll of wet bandage through the other nostril. As bleeding constitutes most of the complications seen in this series, it is suggested that the technique be avoided in patients with a pre-existing history of haemorrhagic diathesis. A definite advantage of this technique is that it curtails the necessity for tracheostomy which was frequently resorted to in the past. Tracheostomy, especially in children, has its own inherent complications which in this environment may be magnified by shortage of medical and nursing staff and nebulisers. As the complications of guided blind tracheal intubation are minor, it should be considered as an alternative to tracheostomy wherever possible. In conclusion, the complications of gutded blind tracheal intubation seen so far are minor enough to justify its more frequent use in patients presenting intubation problems.
undergoing guided blind nasotracheal intubation are presented. The commonest was minor bleeding, followed by difficulty in hooking the cannula out of the nostril. These complications are minor enough to justify the more frequent use of the technique in patients with intubation problems. K e y words
INTUBATION, ENDOTRACHEAL; complications, technique. Acknowledgments
The author is indebted to Mr G.O. Adedokun for secretarial assistance and to surgical colleagues in the Dental and Faciomaxillary Unit of the Department of Surgery, University College Hospital, Ibadan, for their patience and co-operation during this study. References 1. WATERS, D.J. (1963) Guided blind endotracheal
2. 3. 4. 5. 6.
intubation for patients with deformities of the upper airway. Anaesthesia, 18, 158-162. SCURR,C. (1975) A complication of guided blind intubation. Anaesthesia, 30, 41 1 4 1 2 . AKINYEMI, O.O., JOHN,A. (1974) A complication of guided blind intubation. Anaesthesia, 29, 733-735. MURPHY, P.(1967) A fibre-optic endoscope used for nasal intubation. Anaesthesia, 22, 489491. BEARMAN, A.J. (1962) Device for nasotracheal intubation. Anesthesiology, 23, 130-131. TAHIR, A.H. (1970) A simple manoeuvre to aid the passage of a nasotracheal tube into the oropharynx.
British Journal of Anaesthesia, 42, 631-632. 7. YEUNG,M.L.,LIN,R.S.H.(1972) Laryngeal reflexes
in children under ketamine anaesthesia. British Summary
The complications observed in twelve patients
Journal of Anaesthesia, 44, 1089-1092.
