The intubating laryngeal mask airway in failed fibreoptic intubation.

PURPOSE: Prediction of difficult tracheal intubation is not always reliable and management with fibreoptic intubation is not always successful. We describe two cases in which blind intubation through the intubating laryngeal mask airway (ILMA FasTrach) succeeded after fibreoptic intubation failed. CLINICAL FEATURES: The first patient, a 50 yr old man, was scheduled for elective craniotomy for intracerebral tumour. Difficulty with intubation was not anticipated. Manual ventilation was easily performed following induction of general anesthesia, but direct laryngoscopy revealed only the tip of the epiglottis. Intubation attempts with a styletted 8.0 mm endotracheal tube and with the fibreoptic bronchoscope were unsuccessful. A #5 FasTrach was inserted through which a flexible armored cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. The second patient, a 43 yr old man, presented with limited mouth opening, swelling of the right submandibular gland that extended into the retropharynx and tracheal deviation to the left. He was scheduled for urgent tracheostomy. Attempted awake fibreoptic orotracheal intubation under topical anesthesia showed gross swelling of the pharyngeal tissues and only fleeting views of the vocal cords. A #4 FasTrach was easily inserted, a clear airway obtained and a cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. CONCLUSION: The FasTrach may facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.

Anaesthetic management of a patient with a large neck mass.

Large thyroid masses present several potential difficulties for anaesthetists. These include distortion of the airway, endocrine disturbances, and metastatic effects. A typical case is presented and the anaesthetic management and considerations are described.

Oxygenation in patients with chronic airflow obstruction after cessation of exercise.

Although oxygenation has been widely investigated in patients with chronic airflow obstruction both at rest and during exercise, very little is known about their oxygenation in the postexercise recovery period. Recently, it has been shown that PaO2 may in fact be higher during the initial 20 to 120 seconds recovery phase, compared to rest and peak exercise levels. Since it is not established to what extent this improvement persists, we investigated the changes in oxygenation during this phase in patients with CAO. We measured arterial blood gas values, expired gases and ventilation at rest, peak exercise and during the first seven minutes of recovery in 18 male patients with moderate-severe CAO. Mean rest PaO2 (77 mm Hg) and peak exercise PaO2 (76 mm Hg) did not change significantly. Compared to peak exercise, PaO2 was significantly higher during recovery at one minute (93 mm Hg, p = 0.005) and at four minutes (91 mm Hg, p = 0.005), but not at seven minutes (86 mm Hg, p = 0.155) after exercise. All of the recovery PaO2 levels were significantly higher than resting PaO2. These results indicate that during the postexercise recovery period, oxygenation is better than at peak exercise or at rest. Regression analysis of the data predicts that oxygenation may return to resting levels 8 to 9 minutes after cessation of exercise.

Simultaneous use of membrane oxygenation and high-frequency jet ventilation in acute pulmonary failure.

A 16-yr-old female suffering acute, rapidly progressive combined respiratory and cardiac failure that was unresponsive to conventional volume-cycled ventilation, was stabilized with the simultaneous short-term use of veno-venous membrane oxygenation and high-frequency jet ventilation. Percutaneously introduced cannulas afforded rapid vascular access for membrane oxygenation, minimal wound problems during the perfusion, and easy decannulation. This is the first reported combined use of high-frequency jet ventilation and extracorporeal membrane oxygenation, and the first reported percutaneous initiation of veno-venous bypass. The patient remained alive and well 4 months after therapy.