- Email: [email protected]
FAILED INTUBATION—TRANSTRACHEAL VENTILATION
BRITISH JOURNAL OF ANAESTHESIA
1040 System bei Operational im Hals-Nascn-Ohren-Bereich. Anatsthesiol. Reanimat., 5, 139. Spoerel, W. E. (1980). Rebreathing and carbon dioxide rlimination with the Bain circuit. Can. Anaesth. Soc. J., 27, 357. (1983). Rebreathing and end-tidal CO2 during spontaneous breathing with the Bain circuit. Can. Anatsth. Soc. } . , (in press).
FAILED INTUBATION IN OBSTETRIC ANAESTHESIA
L.L. BREADY S . SWARTZMAN D.K. ADCOCK
W.I.CAMPBELL
Belfast
San Antonio
REFERENCES
Boys, J.E. (1983). Failed intubation in obstetric anaesthesia. A case report. Br. J. Anatsth., 55,187. Don Micheal, T.A., and Gordon, A.S. (1980). The oesophageal obturator airway: a new device in emergency cardiopulmonary resuscitation. Br. Mtd. J., 281,1531. Tunstall, M.E. (1976). Failed intubation drill. Anaesthtsia, 31, 850.
FAILED INTUBATION—TRANSTRACHEAL VENTILATION
Sir,—We would like to comment on the case report of Dr Boyi (Boys, 1983). Although the outcome was fovourable in Dr Boys' patients, his approach to the management of an obstetric patient with anticipated difficult intubation, in a non-emergency situation, is not universally acceptable. The leading cause of maternal anaesthetic mortality continues to be pulmonary aspiration of gastric contents (Gutsche, 1979). Despite preoperative «-rnTnin»tion, which suggested "possible difficulty with endotracheal intubation", the author proceeded with a rapid sequence induc-
REFERENCES
Boys, J.E. (1983). Failed intubation in obstetric anaesthesia: A case report. Br. J. Anatsth., 55,187. Gutsche, ?? (1979). ?? deUsser, E.A., and Muravchik, S. (1981). Emergency transtracheal ventilation. Antsthtsiology, 55,606. Marx, G.F., and Finster, M. (1979). Difficulty in endotracheal intubation associated with obstetrical anesthesia. Antsthtsiology, 51, 364. Millar, W.(1980). Management of a difficult airway in obstetrics. Antsthesiology, 52, 523. Scuderi, P.E., McLeskey, C.H., and Comer, P.B. (1982). Emergency percutaneous transtracheal ventilation during anesthesia using readily available equipment. Antsth. Analg., 61, 867. Smith, R.B. (1974). Transtracheal ventilation during anesthesia. Anesth. Analg., 53,225. Schaer, W.B., and Pfaeffle, H. (1975). Percutaneous transtracheal ventilation for anesthesia and resuscitation: a review
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on September 17, 2015
Sir,—I have read with interest Dr Boys' case report (Boys, 1983) of protection of the airway, following failed tracheal intubation by leaving an inflated endotracheal tube in the oesophagus and preceding with a face-mask. There is in fact a piece of equipment available from Eschmann Medical Supplies which can be used for the same purpose, but is safer and more convenient. The device is called the Oesophageal Gastric Tube Airway, a modification of the Oesophageal Obturator Airway used in cardiopulmonary resuscitation by paramedics (Don Michael and Gordon, 1980). This can be used to inflate the lungs whilst the airway is protected from gastric reflux by a large volume cuff on the oesophageal tube. Once the oesophageal tube is inserted, the face-mask is clipped onto it. The airway port of the mask is fitted with a male tapered connector and can be attached to a standard 15 mm angle mount for anaesthesia. The oesophageal tube port permits the passage of a gastric tube for aspiration. I have used this device myself in non-obstetric cases and found it to be quick and simple in use. However, muscle relaxation must exist before attempting passage of the oesophageal rube. Although the airway is protected from gastric reflux, saliva may be aspirated if present in large quantities. Rupture of the oesophagus has occurred very rarely, with the original versions of the Oesophageal Obturator Airway and appeared to be related to the obturator tip rather than the cuff. Since ventilation by this means is as good as by endotracheal intubation (Don Michael and Gordon, 1980) and the device can be passed rapidly or even blindly, I think it is a suitable device to use in conjunction with Tunstall drill (Tunstall, 1976), following failed intubation in obstetrics.
tion of general anaesthesia. No mention is made of prior attempt at awake intubation, or of consideration of regional anaesthesia. He recognizes that "difficulties with intubation of the trachea and failure to intubatc are major causes of anaesthetic morbidity and mortality in pregnancy", yet did not report use of usual and customary manoeuvres to reduce this risk. Gutsche strongly recommends "awake blind nasal intubation in any patient in whom a difficult laryngoscopy is anticipated" (Gutsche, 1979). Additionally, Boys' introduction states that, "In obstetrics, time is often limited because of the presence of fetal distress of acute haemorrhage" (Boys, 1983). In this case report, neither fetal distress or haemorrhage was reported to have been present. The author concludes that his technique "requires readily available equipment and no special skills" (Boys, 1983). We agree with Dr Boys' technique of occluding the oesophagus in this case. Our choice of technique following the manoeuvre in a patient who was difficult to ventilate with a mask would be the use of percutaneous transtracheal jet ventilation (PTJV). Since the early 1970's Spoerel and others have used PTJV as a rapid effective means of establishing an airway and ventilating patients who have upper airway problems (Spoerel, Narayaran and Singh, 1971; Smith, 1974). Marx and Finster (1979) have recommended, among other precautionary measures, that a sterile tracheotomy tray and a Stinson device, which is a 12-gauge i.v. ranmiln attached to a resuscitation bag (Stinson, 1977), be available in every delivery room. Millar (1980) recommended use of the jet ventilator as a rapid and effective means to ventilate the paralysed obstetric patient with a difficult airway, and others have suggested having available on every anaesthesia machine a PTJV system (delisser and Muravchik, 1981). A modified PTJV system can be quickly assembled from readily available items in the operating or delivery room using a 14-gauge Angiocath catheter, a three-way plastic stopcock, oxygen tubing, double-ended connector, and the fresh gas hose from the anaesthesia machine (Scuderi, McLeskey and Comer, 1982). It must be remembered there are complications with PTJV associated with the high pressure source of oxygen (Smith, Schaer and Pfaefflc, 1975). In conclusion, we feel that, in an unconscious patient who is difficult to ventilate with a mask, PTJV should be used.
CORRESPONDENCE
1041
and report of complications. Can. Anaath. Soc. J., 22,607. Spoerel, W.E., Narayanan, P.S., and Singh, N.P. (1971). Transtracheal ventilation. Br. J. Anaath., 43,932. Stinson, T.W. (1977). A simple connector for transtracheal ventilation. Anesthesiology, 47,232.
E. BOYS
Bury St Edmonds
WATERTON SYMPOSIUM
Sir,—I read with particular interest Professor Gray's contribution, having been present at the epoch-making meeting at the Royal Society of Medicine to which he refers (Gray and Hal ton, 1946). However, an error has crept in—the meeting was on March 1 1946, not 1945. The account of the discussion following their presentation includes the contributions by Dr Prescott and Dr Organe, as he then was, of work on curare being undertaken simultaneously in London. Regretably, that by the late Dr E. S. Rowbotham, under whom I was then Resident Anaesthetist at Charing Cross Hospital, was ignored by the reporter. This work was later published (Prescott, Organe and Rowbotham, 1946) and Sir Geoffrey Organe referred to these matters in his paper at the second "Lest we forget" Symposium at the Royal Society of Medicine (Organe, 1979). They were indeed "Exciting and dangerous days". H. A. CONDON
London REFERENCES
Gray, T. C , and Hal ton, J. A. (1946). A Milestone in Anaesthesia? PTOC. R. SOC. Mid., 39., 400.
Organe, G. (1979). The introduction of muscle relaxants. Audiocassette of 'Ltst Wt Forgtt-2' meeting; in possession of Association of Anaesthetists. Prescott, F., Organe, G., and Rowbotham, E. S. (1946). Tubocurarine chloride as an adjunct to anaesthesia. Lanctt, 2, 80.
T. CECIL GRAY
Liverpool
ELECTRICAL AND MECHANICAL ACTIVITY OF THE RAT DUODENUM
Sir, —I am writing concerning the publication "Effects of Tnhalntion Anaesthetic Agents on the Electrical and Mechanical Activity of the Rat Duodenum," by Wright and colleagues (1982). It is puzzling to me how this publication proceeded through the editorial process of your Journal with one striking error. Presumably, these surgeons were trying to correlate their observations in rats with the occurrence of ileus in postoperative surgical patients. They conclude, "The results presented in this study suggest that of the anaesthetic agents tested, only enflurane is unlikely to contribute to the reduction in intestinal motility which follows operative procedures". I would like to suggest that this conclusion is totally unwarranted for the following reason. Although there was no documentation of the dose of the anaesthetics administered (blood or end-tidal concentrations), in fact the administered concentration of halothane (4%) was twice that of enflurane (2%), when in fact it is rather well demonstrated that enflurane is approximately half as potent as halothane in all species tested thus far (Quasher, Eger and Tinker, 1980). Consequently it «<*"n« apparent that what these investigators have observed may well be a dose effect. Before such a conclusion can be drawn, it is incumbent upon these investigators to repeat their experiments using equipotent doses of the anaesthetics. R. G. MERIN
Houston REFERENCES
Quasher, Eger and Tinker (1980). Anesthtsiology, 53, 315. Wright, J. W., Heary, T. E. J., Balfour, T. W., and Hardcastle, J. D. (1982). Effects of inhalation anaesthetic agents on the electrical and mechanical activity of the rat duodenum. Br. J. Anaath., 54, 1223.
Sir,—Thank you for granting us the opportunity to reply to Professor Merin's comments concerning our paper (Wright et al., 1982). We are puzzled that Professor Merin uses as the basis of his criticism a paper by Quasher, Eger and Tinker (1980) which contains no data on the potency of enflurane in the rat. We did not measure blood or end-tidal concentrations of the inhalation agents studied because we wished to examine the change in intestinal motor activity at the induction of anaesthesia and, of course, to follow on the recording as anaesthesia deepened. The need for i.v. cannulation or intubation of the rats would have excluded this possibility. We did measure the concentration of anaesthetic drug, in the gas leaving the study chamber, throughout the 30-min study. We considered that this concentration was similar to the inspired concentration. In spite of the different inspired concentrations of the agents used, the
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on September 17, 2015
Sir,—I thank Drs Bready, Swartzman and Adcock, for their comments on my article. I should like to clear up some misunderstandings. By "possible difficulty" I did not imply likely impossibility. Of course I would not have proceeded had I expected to fail to intubate. When I abandoned attempts to intubate, it was the course of greatest safety at the time. I may have succeeded had I persisted. I agree that there was no fetal distress in my case, but I considered my actions to be the safest way out of the predicament. The maintenance of the patient's airway required great effort, using one hand, and there was risk of regurgitation. I dealt with the latter by isolating the oesophagus. Spontaneous respiration was then restored. I could then devote both hands to maintaining the patient's airway. The oropharyngeal airway was only to save effort, not to improve a less than adequate ventilation. I am not familiar with transcutaneous jet ventilation and would be unhappy to use an unknown technique when in difficulty, while still able to use more familiar ones. Next time this patient presents for anaesthesia I shall use awake intubation with a fibreoptic bronchoscope, as I consider myself inexpert at blind nasal intubation.
Sir,—I must thank Dr Condon most sincerely for pointing out the error in respect of the date of the R. S. M. Section meeting. It was, as he writes, held on the March 1 1946. The error was entirely a result of my lapsus menti and not "typographical". The other dates in the published summary of my contribution to the "Waterton" meeting were correct. I am so pleased, too, that he mentioned other workers of the time, especially Stanley Rowbotham—a very significant and largely unsung pioneer in many advances in anaesthesia.
1040 System bei Operational im Hals-Nascn-Ohren-Bereich. Anatsthesiol. Reanimat., 5, 139. Spoerel, W. E. (1980). Rebreathing and carbon dioxide rlimination with the Bain circuit. Can. Anaesth. Soc. J., 27, 357. (1983). Rebreathing and end-tidal CO2 during spontaneous breathing with the Bain circuit. Can. Anatsth. Soc. } . , (in press).
FAILED INTUBATION IN OBSTETRIC ANAESTHESIA
L.L. BREADY S . SWARTZMAN D.K. ADCOCK
W.I.CAMPBELL
Belfast
San Antonio
REFERENCES
Boys, J.E. (1983). Failed intubation in obstetric anaesthesia. A case report. Br. J. Anatsth., 55,187. Don Micheal, T.A., and Gordon, A.S. (1980). The oesophageal obturator airway: a new device in emergency cardiopulmonary resuscitation. Br. Mtd. J., 281,1531. Tunstall, M.E. (1976). Failed intubation drill. Anaesthtsia, 31, 850.
FAILED INTUBATION—TRANSTRACHEAL VENTILATION
Sir,—We would like to comment on the case report of Dr Boyi (Boys, 1983). Although the outcome was fovourable in Dr Boys' patients, his approach to the management of an obstetric patient with anticipated difficult intubation, in a non-emergency situation, is not universally acceptable. The leading cause of maternal anaesthetic mortality continues to be pulmonary aspiration of gastric contents (Gutsche, 1979). Despite preoperative «-rnTnin»tion, which suggested "possible difficulty with endotracheal intubation", the author proceeded with a rapid sequence induc-
REFERENCES
Boys, J.E. (1983). Failed intubation in obstetric anaesthesia: A case report. Br. J. Anatsth., 55,187. Gutsche, ?? (1979). ?? deUsser, E.A., and Muravchik, S. (1981). Emergency transtracheal ventilation. Antsthtsiology, 55,606. Marx, G.F., and Finster, M. (1979). Difficulty in endotracheal intubation associated with obstetrical anesthesia. Antsthtsiology, 51, 364. Millar, W.(1980). Management of a difficult airway in obstetrics. Antsthesiology, 52, 523. Scuderi, P.E., McLeskey, C.H., and Comer, P.B. (1982). Emergency percutaneous transtracheal ventilation during anesthesia using readily available equipment. Antsth. Analg., 61, 867. Smith, R.B. (1974). Transtracheal ventilation during anesthesia. Anesth. Analg., 53,225. Schaer, W.B., and Pfaeffle, H. (1975). Percutaneous transtracheal ventilation for anesthesia and resuscitation: a review
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on September 17, 2015
Sir,—I have read with interest Dr Boys' case report (Boys, 1983) of protection of the airway, following failed tracheal intubation by leaving an inflated endotracheal tube in the oesophagus and preceding with a face-mask. There is in fact a piece of equipment available from Eschmann Medical Supplies which can be used for the same purpose, but is safer and more convenient. The device is called the Oesophageal Gastric Tube Airway, a modification of the Oesophageal Obturator Airway used in cardiopulmonary resuscitation by paramedics (Don Michael and Gordon, 1980). This can be used to inflate the lungs whilst the airway is protected from gastric reflux by a large volume cuff on the oesophageal tube. Once the oesophageal tube is inserted, the face-mask is clipped onto it. The airway port of the mask is fitted with a male tapered connector and can be attached to a standard 15 mm angle mount for anaesthesia. The oesophageal tube port permits the passage of a gastric tube for aspiration. I have used this device myself in non-obstetric cases and found it to be quick and simple in use. However, muscle relaxation must exist before attempting passage of the oesophageal rube. Although the airway is protected from gastric reflux, saliva may be aspirated if present in large quantities. Rupture of the oesophagus has occurred very rarely, with the original versions of the Oesophageal Obturator Airway and appeared to be related to the obturator tip rather than the cuff. Since ventilation by this means is as good as by endotracheal intubation (Don Michael and Gordon, 1980) and the device can be passed rapidly or even blindly, I think it is a suitable device to use in conjunction with Tunstall drill (Tunstall, 1976), following failed intubation in obstetrics.
tion of general anaesthesia. No mention is made of prior attempt at awake intubation, or of consideration of regional anaesthesia. He recognizes that "difficulties with intubation of the trachea and failure to intubatc are major causes of anaesthetic morbidity and mortality in pregnancy", yet did not report use of usual and customary manoeuvres to reduce this risk. Gutsche strongly recommends "awake blind nasal intubation in any patient in whom a difficult laryngoscopy is anticipated" (Gutsche, 1979). Additionally, Boys' introduction states that, "In obstetrics, time is often limited because of the presence of fetal distress of acute haemorrhage" (Boys, 1983). In this case report, neither fetal distress or haemorrhage was reported to have been present. The author concludes that his technique "requires readily available equipment and no special skills" (Boys, 1983). We agree with Dr Boys' technique of occluding the oesophagus in this case. Our choice of technique following the manoeuvre in a patient who was difficult to ventilate with a mask would be the use of percutaneous transtracheal jet ventilation (PTJV). Since the early 1970's Spoerel and others have used PTJV as a rapid effective means of establishing an airway and ventilating patients who have upper airway problems (Spoerel, Narayaran and Singh, 1971; Smith, 1974). Marx and Finster (1979) have recommended, among other precautionary measures, that a sterile tracheotomy tray and a Stinson device, which is a 12-gauge i.v. ranmiln attached to a resuscitation bag (Stinson, 1977), be available in every delivery room. Millar (1980) recommended use of the jet ventilator as a rapid and effective means to ventilate the paralysed obstetric patient with a difficult airway, and others have suggested having available on every anaesthesia machine a PTJV system (delisser and Muravchik, 1981). A modified PTJV system can be quickly assembled from readily available items in the operating or delivery room using a 14-gauge Angiocath catheter, a three-way plastic stopcock, oxygen tubing, double-ended connector, and the fresh gas hose from the anaesthesia machine (Scuderi, McLeskey and Comer, 1982). It must be remembered there are complications with PTJV associated with the high pressure source of oxygen (Smith, Schaer and Pfaefflc, 1975). In conclusion, we feel that, in an unconscious patient who is difficult to ventilate with a mask, PTJV should be used.
CORRESPONDENCE
1041
and report of complications. Can. Anaath. Soc. J., 22,607. Spoerel, W.E., Narayanan, P.S., and Singh, N.P. (1971). Transtracheal ventilation. Br. J. Anaath., 43,932. Stinson, T.W. (1977). A simple connector for transtracheal ventilation. Anesthesiology, 47,232.
E. BOYS
Bury St Edmonds
WATERTON SYMPOSIUM
Sir,—I read with particular interest Professor Gray's contribution, having been present at the epoch-making meeting at the Royal Society of Medicine to which he refers (Gray and Hal ton, 1946). However, an error has crept in—the meeting was on March 1 1946, not 1945. The account of the discussion following their presentation includes the contributions by Dr Prescott and Dr Organe, as he then was, of work on curare being undertaken simultaneously in London. Regretably, that by the late Dr E. S. Rowbotham, under whom I was then Resident Anaesthetist at Charing Cross Hospital, was ignored by the reporter. This work was later published (Prescott, Organe and Rowbotham, 1946) and Sir Geoffrey Organe referred to these matters in his paper at the second "Lest we forget" Symposium at the Royal Society of Medicine (Organe, 1979). They were indeed "Exciting and dangerous days". H. A. CONDON
London REFERENCES
Gray, T. C , and Hal ton, J. A. (1946). A Milestone in Anaesthesia? PTOC. R. SOC. Mid., 39., 400.
Organe, G. (1979). The introduction of muscle relaxants. Audiocassette of 'Ltst Wt Forgtt-2' meeting; in possession of Association of Anaesthetists. Prescott, F., Organe, G., and Rowbotham, E. S. (1946). Tubocurarine chloride as an adjunct to anaesthesia. Lanctt, 2, 80.
T. CECIL GRAY
Liverpool
ELECTRICAL AND MECHANICAL ACTIVITY OF THE RAT DUODENUM
Sir, —I am writing concerning the publication "Effects of Tnhalntion Anaesthetic Agents on the Electrical and Mechanical Activity of the Rat Duodenum," by Wright and colleagues (1982). It is puzzling to me how this publication proceeded through the editorial process of your Journal with one striking error. Presumably, these surgeons were trying to correlate their observations in rats with the occurrence of ileus in postoperative surgical patients. They conclude, "The results presented in this study suggest that of the anaesthetic agents tested, only enflurane is unlikely to contribute to the reduction in intestinal motility which follows operative procedures". I would like to suggest that this conclusion is totally unwarranted for the following reason. Although there was no documentation of the dose of the anaesthetics administered (blood or end-tidal concentrations), in fact the administered concentration of halothane (4%) was twice that of enflurane (2%), when in fact it is rather well demonstrated that enflurane is approximately half as potent as halothane in all species tested thus far (Quasher, Eger and Tinker, 1980). Consequently it «<*"n« apparent that what these investigators have observed may well be a dose effect. Before such a conclusion can be drawn, it is incumbent upon these investigators to repeat their experiments using equipotent doses of the anaesthetics. R. G. MERIN
Houston REFERENCES
Quasher, Eger and Tinker (1980). Anesthtsiology, 53, 315. Wright, J. W., Heary, T. E. J., Balfour, T. W., and Hardcastle, J. D. (1982). Effects of inhalation anaesthetic agents on the electrical and mechanical activity of the rat duodenum. Br. J. Anaath., 54, 1223.
Sir,—Thank you for granting us the opportunity to reply to Professor Merin's comments concerning our paper (Wright et al., 1982). We are puzzled that Professor Merin uses as the basis of his criticism a paper by Quasher, Eger and Tinker (1980) which contains no data on the potency of enflurane in the rat. We did not measure blood or end-tidal concentrations of the inhalation agents studied because we wished to examine the change in intestinal motor activity at the induction of anaesthesia and, of course, to follow on the recording as anaesthesia deepened. The need for i.v. cannulation or intubation of the rats would have excluded this possibility. We did measure the concentration of anaesthetic drug, in the gas leaving the study chamber, throughout the 30-min study. We considered that this concentration was similar to the inspired concentration. In spite of the different inspired concentrations of the agents used, the
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on September 17, 2015
Sir,—I thank Drs Bready, Swartzman and Adcock, for their comments on my article. I should like to clear up some misunderstandings. By "possible difficulty" I did not imply likely impossibility. Of course I would not have proceeded had I expected to fail to intubate. When I abandoned attempts to intubate, it was the course of greatest safety at the time. I may have succeeded had I persisted. I agree that there was no fetal distress in my case, but I considered my actions to be the safest way out of the predicament. The maintenance of the patient's airway required great effort, using one hand, and there was risk of regurgitation. I dealt with the latter by isolating the oesophagus. Spontaneous respiration was then restored. I could then devote both hands to maintaining the patient's airway. The oropharyngeal airway was only to save effort, not to improve a less than adequate ventilation. I am not familiar with transcutaneous jet ventilation and would be unhappy to use an unknown technique when in difficulty, while still able to use more familiar ones. Next time this patient presents for anaesthesia I shall use awake intubation with a fibreoptic bronchoscope, as I consider myself inexpert at blind nasal intubation.
Sir,—I must thank Dr Condon most sincerely for pointing out the error in respect of the date of the R. S. M. Section meeting. It was, as he writes, held on the March 1 1946. The error was entirely a result of my lapsus menti and not "typographical". The other dates in the published summary of my contribution to the "Waterton" meeting were correct. I am so pleased, too, that he mentioned other workers of the time, especially Stanley Rowbotham—a very significant and largely unsung pioneer in many advances in anaesthesia.