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Ivan Magill: Forceps for intratracheal anesthesia
The Journal
ofEmergency Medicine,
Vol. 1,
pp.543-545,
1984
Printed in the USA
IVAN MAGILL: FORCEPS FOR INTRATRACHEAL George Sternbach, Department
of Emergency
for Facial and Jaw Injuries at Sidcup, described a method for the administration of intratracheal anesthesia via the nasal route.* The following is a brief description of a method of anesthesia which I have found very useful in plastic operations, and which is recommended for all operative procedures in the region of the mouth. . . . It consists essentially of three maneuvers: 1. Passing the catheter through the nose and nasopharynx. 2. Catching it up in the oropharynx by means of a special guiding rod. 3. Directing it into the trachea.
History Each day brings a new class of cases to which it [intratracheal insufflation anesthesia] is adapted, so that soon we will all be wondering how we got along without it.
=
MD, FACEP
Writing in The British Medical Journal of October 16, 1920, Stanley Rowbotham, anesthesiologist at The Queen’s Hospital
0 Keywords-airway; intubation; nasal tracheal intubation; Magill forceps
Jackson,
ANESTHESIA
Services, Standford Unwersity Medical Center, Stanford, CA 94305
0 Abstract-Nasal tracheal intubation is a standard airway management technique in emergency medicine. Although possessing a number of advantages, this procedure, when performed under laryngoscopic visualization, possesses all the complications of oral endotracheal intubation. In addition, a number of complications are specific to this airway technique, including epistaxis, perforation of the posterior pharyngeal wall, trauma to the adenoids, rupture of the endotracheal tube balloon, and transient bacteremia. The procedure was first described in 1920 by two anesthesiologists, Stanley Rowbotham and Ivan Magill. Each developed a device to aid the insertion of the tip of the endotracheal tube into the glottis. Magill’s forceps are still the instrument of choice for nasal tracheal intubation carried out under laryngoscopic visualization.
-Chevalier
Copyright 0 1984 Pergamon Press Ltd
??
1913l
Details of the procedure for each of the maneuvers:
were provided
1. The passage of the catheter through the nose is usually easy. It should be curved with the eye facing inwards, and, after lubrication with sterile Vaseline, passed through the nares with its concavity towards the floor of the nose . . . 2. A view of the catheter is obtained by means of the laryngoscope passed to the back of the mouth. The guiding rod is passed down the speculum and its extremity pushed into the notch in the end of the catheter . . . 3. The laryngoscope is now manipulated so that
Medical Classics is an ongoing feature of JEM, focusing on “classic” contributions to emergency medicine. The section is routinely authored by George Sternbach, MD, Stanford University Medical Center.
RECEIVED:22
August 1983; ACCEPTED:15 September 1983 543
0736-4679184 $3.00 + .OO
544
a view of the glottis is obtained, and the end of the catheter directed between the cords by the guiding rod. The paper concluded with a description of efforts made to refine the technique. Attempts were made to judge the curve on the catheter required to direct its end towards the mid point of the thyroid cartilage after passage through the nose; but so far experiments have shown this to be a very uncertain method of tracheal catheterization, the correct curve for each case being very difficult to estimate. The guiding rod, nasal tubes, and metal angle piece were made for me by Messrs. Meyer and Phelps. A fortnight later, a letter appeared in the same journal from Ivan W. Magill, anesthestist and colleague of Rowbotham’s at Sidcup. It was a brief description of an appliance - also crafted by the omnipresent Messrs. Meyer and Phelps - formulated by the author to facilitate intratracheal placement of a nasal anesthetic catheter.3 The forceps are constructed with a bend to clear the field of vision . . . the ends which grasp the catheter representing a cylinder split longitudinally and serrated on the inner surface. Introduction of the catheter into the trachea is carried out with the aid of an electrically illuminated speculum, as in Dr. Rowbotham’s method, but I find in the forceps the following advantages over Dr. Rowbotham’s guiding rod: 1. There is no injury to the end of the catheter, and therefore no liability of small pieces of the friable material being left in the trachea. 2. The catheter is more easily picked up in the oral pharynx, and once grasped the hold is secure, without the necessity of holding the free end which protrudes from the nose, as is the case with the guiding rod. 3. The forceps can be used at the side of, as well as inside, the speculum. 4. The field of vision is always clear.
Commentary The Queen’s Hospital at Sidcup had been established to provide facial and plastic surgery for British soldiers injured in
George Sternbach
World War I. Rowbotham and Magi11 utilized the nasal route for tracheal intubation to keep the endotracheal tube out of the facial operative field. However, the tube was used exclusively for the administration of anesthesia, and not for ventilation. Ventilation was not controlled, but entirely spontaneous.4 The insertion of “intratracheal insufflation tubes” for the delivery of anesthesia was begun in 1878 and was in sufficiently widespread use by 1913 to draw from Chevalier Jackson the opinion on its utility as just quoted. Jackson, developer of an early laryngoscope, first described the “sniffing” position, and his commentary on the technique of endotracheal intubation is as timely today as when it was written: Only one thing seems to deter anyone from using the method . . . of inspecting the larynx and passing the catheter or tube by sight. This is the lack of confidence in the ability promptly and skillfully to expose the larynx with the laryngeal speculum. No one , . . should hesitate for one moment about this procedure, if he will take the trouble to pay attention to a few points . . . The patient’s head must be in full extension . . . The epiglottis must be identified before it is passed. The speculum must pass sufficiently far below the tip of the epiglottis so that the latter does not slip . . . The most important thing of all is the position of the patient, and next to that comes recognition of the epiglottis . . . It has been customary to draw the head over the table to gain the full extension . . . but for the insertion of the insufflation tube, it is quite unnecessary to have the head extend beyond the table, and in fact it is undesirable.’ The use of the nasal route for tracheal intubation, initiated by Rowbotham and Magill, is an important element in the airway management armamentarium of the emergency physician. Magi11 forceps, virtually unchanged since their inception, are still the instrument of choice when the procedure is carried out under laryngoscopic visualization. Nasal tracheal intubation can often be accomplished with less manipulation of the neck than oral intubation. The endotra-
Ivan
545
Magill
cheal tube is, in general, better tolerated for prolonged periods when placed by the nasal route. In addition, the tube is not vulnerable to being bitten by the patient5 In selecting the nostril to be intubated, the nose should be examined to determine whether septal deviation, mucosal hypertrophy, or other factors render one side more patent than the other. The right nostril has been recommended in most circumstances, because difficulty is sometimes encountered in attempting to advance the catheter under direct vision with the left hand holding the laryngoscope.6 Occasionally the tube, when advanced from the nasal end, happens to possess the correct curvature to pass directly through the glottic opening. This obviates the need for utilizing the forceps. This is especially likely when the epiglottis is elevated with a straight-blade laryngoscope. Rowbotham and Magi11 both noted, that “definite attempts to judge this curve and so simplify the procedure have not, however, met with much success.“7 All complications of oral endotracheal intubation apply to this procedure. In addition, there are a number of complications specific to nasal tracheal intubation. The most commonly encountered one is nasal hemorrhage. Epistaxis may result from the avulsion of nasal mucosa covering the septum or turbinates. Hemorrhage thus in-
duced may be minor or profuse. Bleeding may be avoided or diminished through the use of a relatively small-caliber endotracheal tube, proper constriction of the nasal mucosa with cocaine or other topical agents, and through copious lubrication of the tube. Perforation of the posterior pharyngeal wall may be caused, with subsequent submucosal passage of the endotracheal tube. Trauma to the adenoids may also occur. These complications may be avoided by gentle advancement of the tube. Excessive force should not be applied to the tube in an effort to facilitate its passage. The tube should not be grasped directly at the cuff with the Magi11 forceps. This may weaken the balloon and cause its subsequent rupture. Bacteremia has been demonstrated to occur following nasal tracheal intubation.8,9 This is thought to relate either to tissue trauma during the intubation, with entry of nasal organisms into the circulation, or to the transfer of normal nasopharyngeal flora into the trachea.* The bacteremia is transient and would be expected to do little harm to an otherwise healthy individual. However, adverse effects may be produced in certain vulnerable patients, including those who are in shock, suffer from chronic illness, are immunocompromised, or have cardiac valvular abnormalities.
REFERENCES 1. Jackson C: The technique of insertion of intratracheal insufflation tubes. Surg Gynecol Obstet 1913; 17507-509. 2. Rowbotham S: Intratracheal anesthesia by the nasal route for operation on the mouth and lips. Br Med J 1920; 2:590-591. 3. Magi11 IW: Forceps for intratracheal anesthesia. Br Med J 1920; 2:670. 4. Davis DA: Historical Vignettes of Modern Anesthesia. Philadelphia, FA Davis Co, 1968, pp 47-66. 5. Rosen P, Sternbach CL: Atlas of Emergency Medicine. ed 2. Baltimore, Williams and Wilkins, 1983, pp 16-17.
6. Stoelting
RK: Endotracheal intubation. In Miller RD (ed): Anesthesia. New York, Churchill Livingstone, 1981, p 244. 7. Rowbotham ES, Magi11 I: Anesthetics in the plastic surgery of the face and jaws. Proc Roy Soi Med (Sect Anesth) 1921: 14:17-27. 8. Berry FA, Yarbrough S, Yarbrough N, et al: Transient bacteremia during dental manipulation in children. Pediatrics 1973; 51:476-479. 9. Berry FA, Blankenbaker WL, Ball CG: A comparison of bacteremia occurring with nasotracheal and orotracheal intubation. Anesth Analg 1973;52:873-
876.
ofEmergency Medicine,
Vol. 1,
pp.543-545,
1984
Printed in the USA
IVAN MAGILL: FORCEPS FOR INTRATRACHEAL George Sternbach, Department
of Emergency
for Facial and Jaw Injuries at Sidcup, described a method for the administration of intratracheal anesthesia via the nasal route.* The following is a brief description of a method of anesthesia which I have found very useful in plastic operations, and which is recommended for all operative procedures in the region of the mouth. . . . It consists essentially of three maneuvers: 1. Passing the catheter through the nose and nasopharynx. 2. Catching it up in the oropharynx by means of a special guiding rod. 3. Directing it into the trachea.
History Each day brings a new class of cases to which it [intratracheal insufflation anesthesia] is adapted, so that soon we will all be wondering how we got along without it.
=
MD, FACEP
Writing in The British Medical Journal of October 16, 1920, Stanley Rowbotham, anesthesiologist at The Queen’s Hospital
0 Keywords-airway; intubation; nasal tracheal intubation; Magill forceps
Jackson,
ANESTHESIA
Services, Standford Unwersity Medical Center, Stanford, CA 94305
0 Abstract-Nasal tracheal intubation is a standard airway management technique in emergency medicine. Although possessing a number of advantages, this procedure, when performed under laryngoscopic visualization, possesses all the complications of oral endotracheal intubation. In addition, a number of complications are specific to this airway technique, including epistaxis, perforation of the posterior pharyngeal wall, trauma to the adenoids, rupture of the endotracheal tube balloon, and transient bacteremia. The procedure was first described in 1920 by two anesthesiologists, Stanley Rowbotham and Ivan Magill. Each developed a device to aid the insertion of the tip of the endotracheal tube into the glottis. Magill’s forceps are still the instrument of choice for nasal tracheal intubation carried out under laryngoscopic visualization.
-Chevalier
Copyright 0 1984 Pergamon Press Ltd
??
1913l
Details of the procedure for each of the maneuvers:
were provided
1. The passage of the catheter through the nose is usually easy. It should be curved with the eye facing inwards, and, after lubrication with sterile Vaseline, passed through the nares with its concavity towards the floor of the nose . . . 2. A view of the catheter is obtained by means of the laryngoscope passed to the back of the mouth. The guiding rod is passed down the speculum and its extremity pushed into the notch in the end of the catheter . . . 3. The laryngoscope is now manipulated so that
Medical Classics is an ongoing feature of JEM, focusing on “classic” contributions to emergency medicine. The section is routinely authored by George Sternbach, MD, Stanford University Medical Center.
RECEIVED:22
August 1983; ACCEPTED:15 September 1983 543
0736-4679184 $3.00 + .OO
544
a view of the glottis is obtained, and the end of the catheter directed between the cords by the guiding rod. The paper concluded with a description of efforts made to refine the technique. Attempts were made to judge the curve on the catheter required to direct its end towards the mid point of the thyroid cartilage after passage through the nose; but so far experiments have shown this to be a very uncertain method of tracheal catheterization, the correct curve for each case being very difficult to estimate. The guiding rod, nasal tubes, and metal angle piece were made for me by Messrs. Meyer and Phelps. A fortnight later, a letter appeared in the same journal from Ivan W. Magill, anesthestist and colleague of Rowbotham’s at Sidcup. It was a brief description of an appliance - also crafted by the omnipresent Messrs. Meyer and Phelps - formulated by the author to facilitate intratracheal placement of a nasal anesthetic catheter.3 The forceps are constructed with a bend to clear the field of vision . . . the ends which grasp the catheter representing a cylinder split longitudinally and serrated on the inner surface. Introduction of the catheter into the trachea is carried out with the aid of an electrically illuminated speculum, as in Dr. Rowbotham’s method, but I find in the forceps the following advantages over Dr. Rowbotham’s guiding rod: 1. There is no injury to the end of the catheter, and therefore no liability of small pieces of the friable material being left in the trachea. 2. The catheter is more easily picked up in the oral pharynx, and once grasped the hold is secure, without the necessity of holding the free end which protrudes from the nose, as is the case with the guiding rod. 3. The forceps can be used at the side of, as well as inside, the speculum. 4. The field of vision is always clear.
Commentary The Queen’s Hospital at Sidcup had been established to provide facial and plastic surgery for British soldiers injured in
George Sternbach
World War I. Rowbotham and Magi11 utilized the nasal route for tracheal intubation to keep the endotracheal tube out of the facial operative field. However, the tube was used exclusively for the administration of anesthesia, and not for ventilation. Ventilation was not controlled, but entirely spontaneous.4 The insertion of “intratracheal insufflation tubes” for the delivery of anesthesia was begun in 1878 and was in sufficiently widespread use by 1913 to draw from Chevalier Jackson the opinion on its utility as just quoted. Jackson, developer of an early laryngoscope, first described the “sniffing” position, and his commentary on the technique of endotracheal intubation is as timely today as when it was written: Only one thing seems to deter anyone from using the method . . . of inspecting the larynx and passing the catheter or tube by sight. This is the lack of confidence in the ability promptly and skillfully to expose the larynx with the laryngeal speculum. No one , . . should hesitate for one moment about this procedure, if he will take the trouble to pay attention to a few points . . . The patient’s head must be in full extension . . . The epiglottis must be identified before it is passed. The speculum must pass sufficiently far below the tip of the epiglottis so that the latter does not slip . . . The most important thing of all is the position of the patient, and next to that comes recognition of the epiglottis . . . It has been customary to draw the head over the table to gain the full extension . . . but for the insertion of the insufflation tube, it is quite unnecessary to have the head extend beyond the table, and in fact it is undesirable.’ The use of the nasal route for tracheal intubation, initiated by Rowbotham and Magill, is an important element in the airway management armamentarium of the emergency physician. Magi11 forceps, virtually unchanged since their inception, are still the instrument of choice when the procedure is carried out under laryngoscopic visualization. Nasal tracheal intubation can often be accomplished with less manipulation of the neck than oral intubation. The endotra-
Ivan
545
Magill
cheal tube is, in general, better tolerated for prolonged periods when placed by the nasal route. In addition, the tube is not vulnerable to being bitten by the patient5 In selecting the nostril to be intubated, the nose should be examined to determine whether septal deviation, mucosal hypertrophy, or other factors render one side more patent than the other. The right nostril has been recommended in most circumstances, because difficulty is sometimes encountered in attempting to advance the catheter under direct vision with the left hand holding the laryngoscope.6 Occasionally the tube, when advanced from the nasal end, happens to possess the correct curvature to pass directly through the glottic opening. This obviates the need for utilizing the forceps. This is especially likely when the epiglottis is elevated with a straight-blade laryngoscope. Rowbotham and Magi11 both noted, that “definite attempts to judge this curve and so simplify the procedure have not, however, met with much success.“7 All complications of oral endotracheal intubation apply to this procedure. In addition, there are a number of complications specific to nasal tracheal intubation. The most commonly encountered one is nasal hemorrhage. Epistaxis may result from the avulsion of nasal mucosa covering the septum or turbinates. Hemorrhage thus in-
duced may be minor or profuse. Bleeding may be avoided or diminished through the use of a relatively small-caliber endotracheal tube, proper constriction of the nasal mucosa with cocaine or other topical agents, and through copious lubrication of the tube. Perforation of the posterior pharyngeal wall may be caused, with subsequent submucosal passage of the endotracheal tube. Trauma to the adenoids may also occur. These complications may be avoided by gentle advancement of the tube. Excessive force should not be applied to the tube in an effort to facilitate its passage. The tube should not be grasped directly at the cuff with the Magi11 forceps. This may weaken the balloon and cause its subsequent rupture. Bacteremia has been demonstrated to occur following nasal tracheal intubation.8,9 This is thought to relate either to tissue trauma during the intubation, with entry of nasal organisms into the circulation, or to the transfer of normal nasopharyngeal flora into the trachea.* The bacteremia is transient and would be expected to do little harm to an otherwise healthy individual. However, adverse effects may be produced in certain vulnerable patients, including those who are in shock, suffer from chronic illness, are immunocompromised, or have cardiac valvular abnormalities.
REFERENCES 1. Jackson C: The technique of insertion of intratracheal insufflation tubes. Surg Gynecol Obstet 1913; 17507-509. 2. Rowbotham S: Intratracheal anesthesia by the nasal route for operation on the mouth and lips. Br Med J 1920; 2:590-591. 3. Magi11 IW: Forceps for intratracheal anesthesia. Br Med J 1920; 2:670. 4. Davis DA: Historical Vignettes of Modern Anesthesia. Philadelphia, FA Davis Co, 1968, pp 47-66. 5. Rosen P, Sternbach CL: Atlas of Emergency Medicine. ed 2. Baltimore, Williams and Wilkins, 1983, pp 16-17.
6. Stoelting
RK: Endotracheal intubation. In Miller RD (ed): Anesthesia. New York, Churchill Livingstone, 1981, p 244. 7. Rowbotham ES, Magi11 I: Anesthetics in the plastic surgery of the face and jaws. Proc Roy Soi Med (Sect Anesth) 1921: 14:17-27. 8. Berry FA, Yarbrough S, Yarbrough N, et al: Transient bacteremia during dental manipulation in children. Pediatrics 1973; 51:476-479. 9. Berry FA, Blankenbaker WL, Ball CG: A comparison of bacteremia occurring with nasotracheal and orotracheal intubation. Anesth Analg 1973;52:873-
876.