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EMERGENCY CAESAREAN SECTION—TRACHEAL INTUBATION OR OESOPHAGEAL GASTRIC TUBE AIRWAY?
Br. J. Anaesth. (1988), 60, 476-181
CORRESPONDENCE
R. WILLIAMSON Durban
REFERENCES 1. Tunstall ME. Tactile orotracheal intubation British Journal of Anaesthesia 1985; 57: 356. 2. Tunstall ME. "Esophageal gastric tube airway"—a potential hazard. British Journal of Anaesthesia 1985 ; 57: 931r932. 3. Tunstall ME, Geddes C. "Failed intubation " in obstetric anaesthesia. An indication for the use of the "Esophageal Gastric Tube Airway". British Journal of Anaesthesia 1984; 56: 659-661.
Sir,—Dr Williamson has rightly questioned the introduction of the head-down posture in the case report of an obese patient whose trachea could not be intubated and who had become cyanosed. An updated "failed intubation drill" indicates that, where positioning in the full left lateral posture is not possible, the next instruction in the sequence, to tilt the table headdown, is not implemented [1]. In this article [1] the various disadvantages of the head-down tilt are outlined. However, in the circumstances of the case report under discussion the anxiety caused by the possibility of stomach contents appearing in the pharynx, and being aspirated, produced a conditioned reflex response: the table was tilted head-down. When cyanosis develops during a continuous but unsuccessful attempt to intubate the trachea, one cannot wait for a more experienced anaesthetist to appear. Patients without intubation difficulties in general present no problems for ventilation by bag and mask. On the other hand, where there is difficulty in intubating the trachea it is sometimes also difficult to ventilate the lungs by bag and mask. Why do mothers continue to die, either from failure to intubate or from aspiration associated with difficult or failed intubation [2]? If, simultaneously with effective cricoid pressure, ventilation by bag and face-mask is always easy, in theory there should not be any deaths from hypoxia or aspiration associated with failed or difficult intubation. In our case of failed intubation and similarly in the patient described by Boys [3], the airway was clearly improved when the tongue and epiglottis were displaced forwards by the oesophageal tube. In the absence of a correctly placed tracheal tube cricoid pressure should not be released completely unless the mother either is in a complete left lateral position (with head-down tilt) or has her oesophagus intubated with a cuffed tube. If the anaesthetist is uncertain if he has intubated the oesophagus, the tube should be pushed to the angle of the mouth, outside the face-mask, and bag-and-mask ventilation attempted. If the patient's colour improves, it confirms that the tube is in the oesophagus, where it had probably better be left in situ. It is then used as an oesophageal gastric tube airway. M. E. TUNSTALL C. GEDDES
Aberdeen REFERENCES 1. Tunstall ME, Sheikh A. Failed intubation protocol: oxygenation without aspiration. Clinics in Anaesthesiology 1986; 4: 171-187. 2. Department of Health and Social Security. Report on Health and Social Subjects, No. 29. London: HMSO, 1986. 3. Boys JE. Failed intubation in obstetric anaesthesia. A case report. British Journal of Anaesthesia 1983; 55: 187-188.
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on July 3, 2015
EMERGENCY CAESAREAN SECTION—TRACHEAL INTUBATION OR OESOPHAGEAL GASTRIC TUBE AIRWAY? Sir—The correspondence from Tunstall [1, 2] on tracheal intubation in a 116-kg patient for emergency Caesarean section, for which an oesophageal gastric tube airway was used, prompts some comment on the original case report [3]. First the authors described "a larynx where the arytenoids and epiglottis could only just be seen" at laryngoscopy. In my experience this is neither an unusual nor an uncommon situation. Colleagues agree that they would expect to be able to introduce a tube in such circumstances and that they would have made a second attempt, particulary if the first attempt had been made by a trainee of lesser or little experience. This could have provided oxygenation most quickly with least delay, although an attempt to oxygenate with mask and oral airway (with the patient still supine) might be tried first. Second, one must question the introduction of the headdown posture when, for a number of reasons, the patient could not be turned to the full lateral position. The management of the mask and jaw would be made more difficult, the greater weight applied to the diaphragm could have been responsible for the difficulty in ventilation, the increased venous pressure and associated venous congestion could have given the appearance of continuing cyanosis, and the risk of regurgitation from the stomach would be greater. At the same time, the relaxation of cricoid pressure, whether for the purpose of ventilation or intubation or for insertion of the oesophageal gastric tube airway, is surely unacceptable, since it exposes the airway to aspiration and soiling. However, cricoid (and laryngeal) pressure can hinder, in addition to assist intubation, and the utmost care and supervision must be exercised in its correct application. Also, in obese patients with a very short neck, it is worth trying more flexion or more extension of the neck to see if laryngeal visualization is improved. It may be easier to insert the laryngoscope with the head down and the neck extended, and I often use this manoeuvre in such patients when required to perform blind nasal intubation.
CORRESPONDENCE
R. WILLIAMSON Durban
REFERENCES 1. Tunstall ME. Tactile orotracheal intubation British Journal of Anaesthesia 1985; 57: 356. 2. Tunstall ME. "Esophageal gastric tube airway"—a potential hazard. British Journal of Anaesthesia 1985 ; 57: 931r932. 3. Tunstall ME, Geddes C. "Failed intubation " in obstetric anaesthesia. An indication for the use of the "Esophageal Gastric Tube Airway". British Journal of Anaesthesia 1984; 56: 659-661.
Sir,—Dr Williamson has rightly questioned the introduction of the head-down posture in the case report of an obese patient whose trachea could not be intubated and who had become cyanosed. An updated "failed intubation drill" indicates that, where positioning in the full left lateral posture is not possible, the next instruction in the sequence, to tilt the table headdown, is not implemented [1]. In this article [1] the various disadvantages of the head-down tilt are outlined. However, in the circumstances of the case report under discussion the anxiety caused by the possibility of stomach contents appearing in the pharynx, and being aspirated, produced a conditioned reflex response: the table was tilted head-down. When cyanosis develops during a continuous but unsuccessful attempt to intubate the trachea, one cannot wait for a more experienced anaesthetist to appear. Patients without intubation difficulties in general present no problems for ventilation by bag and mask. On the other hand, where there is difficulty in intubating the trachea it is sometimes also difficult to ventilate the lungs by bag and mask. Why do mothers continue to die, either from failure to intubate or from aspiration associated with difficult or failed intubation [2]? If, simultaneously with effective cricoid pressure, ventilation by bag and face-mask is always easy, in theory there should not be any deaths from hypoxia or aspiration associated with failed or difficult intubation. In our case of failed intubation and similarly in the patient described by Boys [3], the airway was clearly improved when the tongue and epiglottis were displaced forwards by the oesophageal tube. In the absence of a correctly placed tracheal tube cricoid pressure should not be released completely unless the mother either is in a complete left lateral position (with head-down tilt) or has her oesophagus intubated with a cuffed tube. If the anaesthetist is uncertain if he has intubated the oesophagus, the tube should be pushed to the angle of the mouth, outside the face-mask, and bag-and-mask ventilation attempted. If the patient's colour improves, it confirms that the tube is in the oesophagus, where it had probably better be left in situ. It is then used as an oesophageal gastric tube airway. M. E. TUNSTALL C. GEDDES
Aberdeen REFERENCES 1. Tunstall ME, Sheikh A. Failed intubation protocol: oxygenation without aspiration. Clinics in Anaesthesiology 1986; 4: 171-187. 2. Department of Health and Social Security. Report on Health and Social Subjects, No. 29. London: HMSO, 1986. 3. Boys JE. Failed intubation in obstetric anaesthesia. A case report. British Journal of Anaesthesia 1983; 55: 187-188.
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on July 3, 2015
EMERGENCY CAESAREAN SECTION—TRACHEAL INTUBATION OR OESOPHAGEAL GASTRIC TUBE AIRWAY? Sir—The correspondence from Tunstall [1, 2] on tracheal intubation in a 116-kg patient for emergency Caesarean section, for which an oesophageal gastric tube airway was used, prompts some comment on the original case report [3]. First the authors described "a larynx where the arytenoids and epiglottis could only just be seen" at laryngoscopy. In my experience this is neither an unusual nor an uncommon situation. Colleagues agree that they would expect to be able to introduce a tube in such circumstances and that they would have made a second attempt, particulary if the first attempt had been made by a trainee of lesser or little experience. This could have provided oxygenation most quickly with least delay, although an attempt to oxygenate with mask and oral airway (with the patient still supine) might be tried first. Second, one must question the introduction of the headdown posture when, for a number of reasons, the patient could not be turned to the full lateral position. The management of the mask and jaw would be made more difficult, the greater weight applied to the diaphragm could have been responsible for the difficulty in ventilation, the increased venous pressure and associated venous congestion could have given the appearance of continuing cyanosis, and the risk of regurgitation from the stomach would be greater. At the same time, the relaxation of cricoid pressure, whether for the purpose of ventilation or intubation or for insertion of the oesophageal gastric tube airway, is surely unacceptable, since it exposes the airway to aspiration and soiling. However, cricoid (and laryngeal) pressure can hinder, in addition to assist intubation, and the utmost care and supervision must be exercised in its correct application. Also, in obese patients with a very short neck, it is worth trying more flexion or more extension of the neck to see if laryngeal visualization is improved. It may be easier to insert the laryngoscope with the head down and the neck extended, and I often use this manoeuvre in such patients when required to perform blind nasal intubation.