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At least 19 recordsLinked to original sources
PubMed2001

The minimum alveolar concentration of enflurane for laryngeal mask airway extubation in deeply anesthetized children.

UNLABELLED: The end-tidal anesthetic gas concentration required to prevent the anesthetized patient from coughing or moving during or immediately after the laryngeal mask airway (LMA) extubation is not known. We sought to determine the minimum alveolar concentration of enflurane required for the removal of the LMA in children. We studied 21 nonpremedicated children between 4 and 11 yr of age, ASA physical status I, undergoing procedures below the umbilicus. General anesthesia was induced with a mask by using sevoflurane, nitrous oxide, and oxygen, and the LMA was inserted. Anesthesia was maintained with enflurane, nitrous oxide, and oxygen. At the end of surgery, a predetermined end-tidal enflurane concentration was achieved, and the LMA was removed. Each concentration at which the LMA extubation was attempted was predetermined by the up-and-down method (with 0.1% as a step size). When LMA removal was accomplished without coughing, clenching teeth, or gross purposeful muscular movements during or within 1 min after removal, it was considered a successful LMA removal. Removal was considered to be unsuccessful in patients who developed breath holding or laryngospasm during or immediately after LMA removal. The minimum alveolar concentration of enflurane at which 50% of children had a successful LMA removal was found to be 1.02% (95% CL, 0.95%-1.11%), and the 95% effective dose for successful extubation was 1.14% (95% CL, 1.07%-1.66%). In conclusion, the LMA removal may be accomplished without coughing or moving at 1.02% end-tidal enflurane concentration in 50% of anesthetized children aged 4-11 yr. IMPLICATIONS: There may be fewer problems associated with the laryngeal mask airway extubation when patients are deeply anesthetized. The purpose of this study was to determine the minimum concentration of enflurane for successful removal of the laryngeal mask in children.

Anesthesia, Inhalation↗
PubMed2005

[Extubation of the difficult airway].

Extubation, like intubation, is a critical moment in general anesthesia. There are no algorithms or ordered sequences of steps for extubation. Rather, the approach to take is strict observation of the patient in a setting equipped with monitors, material for managing the difficult airway, and experienced staff who should be able to establish access immediately, provide oxygen, and facilitate gas exchange, keeping the airway open and safeguarding it in case of a failed extubation attempt. This review will analyze the clinical conditions and pathophysiology associated with extubations at high risk of complications. We will describe strategies for extubating in situations in which a difficult airway is known or suspected.

Algorithms↗
PubMed2000

Extubation from low-rate intermittent positive airways pressure versus extubation after a trial of endotracheal continuous positive airways pressure in intubated preterm infants.

BACKGROUND: Failure of extubation and subsequent reintubation may result in additional stress and trauma to the premature infant. Testing infants about to be extubated with a period of endotracheal CPAP has been suggested as a method of demonstrating readiness for extubation. However, this process has been criticized as increasing the neonate's work of breathing and perhaps increasing the likelihood of extubation failure. OBJECTIVES: In premature infants having their endotracheal tube removed, is direct extubation from low rate intermittent positive pressure ventilation (IPPV) more successful than that following a period of endotracheal continuous positive airway pressure (CPAP)? SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching mainly in the English language. SELECTION CRITERIA: All trials using random or quasi-random allocation of premature infants to endotracheal CPAP or direct extubation following a period of IPPV were included. DATA COLLECTION AND ANALYSIS: Data were extracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk. MAIN RESULTS: Direct extubation from low rate ventilation is associated with a trend to increased chance of successful extubation when compared to extubation after a period of endotracheal CPAP, RR 0.45 (0.19,1.07), RD -0.103 (-0.200,-0.006), NNT 10 (5,167). When only truly randomized trials are considered, this result becomes both statistically significant and clinically important, RR 0.10 (0.01,0.78), RD -0.201 (-0.319,-0.083), NNT 5 (3, 12). Similar differences are seen for the secondary outcome, apnea. REVIEWER'S CONCLUSIONS: Preterm infants no longer requiring endotracheal intubation and IPPV should be directly extubated without a trial of ETT CPAP.

Humans↗
PubMed2000

Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants.

BACKGROUND: Preterm infants being extubated following a period of intermittent positive pressure ventilation via an endotracheal tube are at risk of developing respiratory failure as a result of apnea, respiratory acidosis and hypoxia. Nasal continuous positive airway pressure appears to stabilise the upper airway, improve lung function and reduce apnea and may therefore have a role in facilitating extubation in this population. OBJECTIVES: In preterm infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation (IPPV), does management with nasal continuous positive airways pressure (NCPAP) lead to an increased proportion remaining free of additional ventilatory support, compared to extubation directly to headbox oxygen? SEARCH STRATEGY: Searches were made of the Oxford Database of Perinatal Trials, Medline, previous reviews including cross references, abstracts of conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language and expert informant searches in the Japanese language by Prof. Ogawa. SELECTION CRITERIA: All trials utilising random or quasi-random patient allocation, in which NCPAP (delivered by any method) was compared with headbox oxygen for post-extubation care were included. Methodological quality was assessed independently by the two authors. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. Prespecified subgroup analysis to determine the impact of different levels of NCPAP, differences in duration of IPPV and use of aminophylline were also performed using the same package. MAIN RESULTS: Nasal CPAP, when applied to preterm infants being extubated following IPPV, reduces the incidence of adverse clinical events (apnea, respiratory acidosis and increased oxygen requirements) indicating the need for additional ventilatory support. A reduction in the incidence of chronic lung disease at 28 days of age is also seen in the group extubated to NCPAP. REVIEWER'S CONCLUSIONS IMPLICATIONS FOR PRACTICE: nasal CPAP is effective in preventing failure of extubation and reducing oxygen use at 28 days of life in preterm infants following a period of endotracheal intubation and IPPV. Implication for research: further definition of the patient gestational age and weight groups in whom these results apply is required. Optimal levels of NCPAP as well as methods of administration remain to be determined.

Humans↗
PubMedDate not supplied

[Comparison between an upper airway obstruction score and airway endoscopy to detect airway injury associated with endotracheal intubation in children].

OBJECTIVE: To compare an upper airway obstruction score vs. airway endoscopy to detect moderate or severe airway injury associated with endotracheal intubation in children. METHODS: Prospective study. Airway endoscopy and clinical evaluation were performed after extubation. Airway injuries identified on endoscopy or according to the upper airway obstruction score were classified as minor, moderate or severe. The obstruction score was assessed in terms of sensitivity, specificity, positive and negative predictive values and likelihood ratio to detect moderate or severe injuries. RESULTS: Among 215 patient, endoscopy was normal in 10.2%. Minor lesions were diagnosed in 54.9% of the patients, followed by moderate (24.2%) and severe (10.7%) lesions. In 163 patients with upper airway obstruction, the score classified injuries as minor in 23.3%, moderate in 41.4% and severe in 11.2%. A score > or = 4 had a sensitivity of 73.3% (95% CI: 67.4-79.2) to detect moderate or severe injuries and a specificity of 58.6% (95% CI: 52.0-65.2) to exclude patients without moderate or severe lesions. The positive predictive value of a score > or = 4 was 48.7% (95% CI: 42.0-55.4). In patients with a score < or = 3 the chance of not presenting moderate or severe injuries was 80.4% (95% CI: 75.1-85.7). The probability of a patient with moderate or severe injuries to present a score > or = 4 was 73.3% compared to patients without those injuries (41.4%) (1.8 fold higher). CONCLUSIONS: The score reliably ruled out moderate or severe airway injury in patients with minor upper airway distress. On the other hand, scores > or = 4 presented a low specificity. Clinical evaluation can be useful to rule out patients with minor airway injuries.

Airway Obstruction↗
PubMed2006

[Pulmonary edema due to upper airway obstruction after extubation].

We report a patient who developed pulmonary edema due to airway obstruction after extubation. A 22-year-old man underwent removal of the nails for thoracoplasty under general anesthesia combined with epidural anesthesia. Upper airway obstruction occurred after extubation. SpO2 decreased to 70%. Insertion of an oral airway relieved the airway obstruction. However, inspiratory wheezing was heard over both lung fields. Chest X-ray taken 90 minutes after the event revealed pulmonary edema. Pulmonary edema gradually resolved after intravenous furosemide and oxygen inhalation by mask.

Adult↗
PubMed1986

Treatment of tracheomalacia: eight years' experience.

Between 1978 and 1985, 21 patients were treated for tracheomalacia, (group I) and 4 for tracheobronchomalacia (group II). The median age at treatment was 7 months (range 1 to 96 months). Indications for surgery in group I were, "dying spells" (n = 12), recurrent pneumonia (n = 4), intermittent respiratory obstruction (n = 3) and inability to extubate airway (n = 2). 18 had esophageal atresia repair. Treatment in group I was aortopexy (n = 19), three of whom also required an external airway splint; two had an airway splint only. Airway obstruction was relieved in all. Group II patients required surgery because they could not be extubated; none had esophageal atresia. Aortopexy in all and splinting in one failed in 3 of 4 patients. Aortopexy is the primary treatment of tracheomalacia. External airway splinting may be used where aortopexy is inadequate. A satisfactory treatment for tracheobronchomalacia has not yet been devised.

Aorta↗
PubMed2000

[Airway obstruction after general anesthesia in a patient with the first and second branchial arch syndrome].

A 20-year-old female with the first and second branchial arch syndrome underwent plastic surgery. Due to her mandibular hypoplasia and trismus, tracheal intubation was difficult even with a broncho-fiberscope. Fentanyl 100 micrograms was used for nasal intubation. Anesthesia was maintained with nitrous oxide (4 l.min-1), oxygen (2 l.min-1) and sevoflurane (0.5-3%). There were no troubles during surgery. The trachea was extubated after recovery of consciousness and spontaneous respiration. Five minutes after extubation, airway was obstructed suddenly after massive nasal bleeding. Sudden massive bleeding might have caused airway obstruction. Emergency insertion of an 18 G needle followed by Mini-trach II into the trachea through the cryothyroidal ligament improved her respiratory condition. The case suggests that preparing the instrument for the emergency cryothyroidal ligament puncture (for instance Mini-trach II) is useful for a patient with a risk of bleeding in the airway and with difficult intubation.

Adult↗
PubMed2004

[Postoperative laryngeal edema presumably due to hypoalbuminemia causing acute airway obstruction after extubation in a patient after nephrectomy].

We report here a case of upper airway obstruction occurring after extubation in a 55-yr-old 60 kg man after elective nephrectomy. Anesthesia was maintained with O2 (33%), N2O, sevoflurane (1.5-2%), and propofol infusion (2 mg x kg(-1) x hr(-1)). Blood loss was 1,965 ml, part of which was substituted by blood transfusion and albumin infusion. After surgery, the patient recovered uneventfully and could be extubated shortly. Twenty minutes after extubation, he developed dyspnea progressively with stridor and became cyanotic despite the use of oxygen mask and assisted ventilation. Oxygen saturation decreased gradually, and bradycardia (<30 beats x min(-1)) and severe hypotension were also observed. Cardiopulmonary resuscitation using epinephrine was immediately started. Re-intubation of the trachea was difficult due to severe edema, but eventually performed using a tube of a smaller size (internal diameter 7.0 mm). Subsequent investigations using a fiberscope confirmed extensive soft tissue swelling, maximal at the level of the vocal cord and extending up- and down-wards to the trachea, indicating that the obstruction is caused by severe laryngeal edema. We believe that edema may have been caused by hypoalbuminemia (1.3 g x dl(-1)) at the end of operation. Therefore, it should be noted that hypoalbuminemia may cause laryngeal edema leading to acute airway obstruction.

Acute Disease↗
PubMed2001

A technique for maintenance of airway access in infants with a difficult airway following tracheal extubation.

Tracheal extubation of patients with a difficult airway represents a challenge to anaesthesiologists and intensive care physicians. While a variety of techniques designed to maintain access to the airway in case of the need for tracheal reintubation have been described in adults, no reports have been published in infants and young children. We describe an approach to this issue in a young child with severe micrognathia.

Abnormalities, Multiple↗
PubMed2003

Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an 'inhalation bolus' technique.

BACKGROUND: The concept of an 'inhalation bolus' can be used to optimize inhaled drug administration. We investigated the depth of anaesthesia, haemodynamic stability, and recovery time in morbidly obese patients resulting from bispectral index (BIS)-guided sevoflurane or desflurane administration and BIS-triggered inhalation boluses of sevoflurane or desflurane combined with titration of remifentanil. METHODS: Fifty morbidly obese patients undergoing laparoscopic gastroplasty received either BIS-guided sevoflurane or desflurane anaesthesia in combination with a remifentanil target-controlled infusion. Intraoperative haemodynamic stability and BIS control were measured. Immediate recovery was recorded. RESULTS: Intraoperatively, the BIS was between 40 and 60 for a greater percentage of time in the sevoflurane (78 (13)% of case time) than in the desflurane patients (64 (14)% of case time), owing to too profound anaesthesia in the desflurane patients at the start of the procedure. However, fewer episodes of hypotension were found in the desflurane group, without the occurrence of more hypertensive episodes. During immediate recovery, eye opening, extubation, airway maintenance, and orientation occurred sooner in the desflurane group. CONCLUSIONS: Immediate recovery was significantly faster in the desflurane group. Overall hypnotic controllability measured by BIS was less accurate with desflurane. Overall haemodynamic controllability was better when using desflurane. Fewer episodes of hypotension were found in the desflurane group. The use of the inhalation bolus was found to be appropriate in both groups without causing severe haemodynamic side effects. Minimal BIS values were significantly lower after a desflurane bolus.

Adult↗
PubMed2002

An evidence-based review on the use of corticosteroids in peri-operative and critical care.

With complex and extensive pharmacological effects, corticosteroids are widely used in many clinical situations. A survey conducted to define the role of corticosteroids in various settings of peri-operative and critical care gave strong evidence to support that the use of corticosteroid is absolutely indicated in patients with adrenal insufficiency, asthma, anaphylaxis, acute spinal cord injury, and increased ICP resulting from brain tumors. As the benefits of corticosteroids are much in evidence, their uses are recommended to extend to postoperative antiemesis, acute respiratory failure (such as ARDS, COPD, and fat embolism), increased ICP associated with brain abscess, thyroid storm, and refractory hypothermia. Beneficial effect could be expected in septic shock with high-dose corticosteroids. Despite extensive reports on their versatile usefulness, evidence-based review did not recommend the use of corticosteroids in increased ICP associated with traumatic head injury and cerebral infarct, cardiac arrest, post-extubation airway edema, and aspiration pneumonia due to poor effectiveness let alone further worsening of the conditions. Great caution must be taken in clinical situations where administration of corticosteroids is considered contraindicated such as systemic fungal infection, hypersensitivity to the drug, intramuscular injection in idiopathic thrombocytopenia purpura, vaccination with live virus.

Adrenal Cortex Hormones↗
PubMed2000

Elective use of nasal continuous positive airways pressure following extubation of preterm infants.

UNLABELLED: The aim of this study was to determine whether elective use of nasal continuous positive airways pressure (CPAP) following extubation of preterm infants was well tolerated and improved short- and long-term outcomes. A randomized comparison of nasal CPAP to headbox oxygen was undertaken and a meta-analysis performed including similar randomized trials involving premature infants less than 28 days of age. A total of 150 infants (median gestational age 30 weeks, range 24-34 weeks) were randomized in two centres. Fifteen nasal CPAP infants and 25 headbox infants required increased respiratory support post-extubation and 15 nasal CPAP infants and nine headbox infants required reintubation (non significant). Eight infants became intolerant of CPAP and were changed to headbox oxygen within 48 h of extubation; 19 headbox infants developed apnoeas and respiratory acidosis requiring rescue nasal CPAP, 3 ultimately were re-intubated. Seven other trials were identified, giving a total number of 569 infants. Overall, nasal CPAP significantly reduced the need for increased respiratory support (relative risk, 0.57, 95% CI 0.43-0.73), but not for re-intubation (relative risk 0.89, 95% CI 0.68-1.17). Nasal CPAP neither influenced significantly the intraventricular haemorrhage rate reported in four studies (relative risk 1.0, 95% CI 0.55, 1.82) nor that of oxygen dependency at 28 days reported in six studies (relative risk 1.0, 95% CI 0.8, 1.25). In two studies nasal CPAP had to be discontinued in 10% of infants either because of intolerance or hyperoxia. CONCLUSION: Elective use of nasal continuous positive airways pressure post-extubation is not universally tolerated, but does reduce the need for additional support.

Female↗
PubMed1991

Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates.

A prospective randomized trial was performed in 58 neonates comparing nasal continuous positive airway pressure (NCPAP) vs oxyhood following extubation of neonates weighing less than 1 kg. All neonates had been ventilated for the treatment of respiratory distress syndrome for at least 24 hours and weighed less than 1 kg at the time of extubation. Clinical criteria for elective extubation included improving pulmonary status, fraction of inspired oxygen (FIO2) less than or equal to 0.35, mean airway pressure less than or equal to 7 cm H2O, ventilator rate less than or equal to 20 breaths per minute, and weight at least 80% of birth weight. Informed consent was obtained and neonates were randomized to NCPAP or oxyhood following extubation. Success was defined as remaining free of additional ventilatory support for at least 5 days. Failure criteria included FIO2 greater than or equal to 0.60 to maintain pulse oximetry greater than or equal to 93%, PaCO2 greater than or equal to 60 mm Hg, pH less than or equal to 7.23, or moderate to severe apnea. Results demonstrate that 22 (76%) of 29 neonates were successfully extubated to NCPAP while only 6 (21%) of 29 were successfully extubated to oxyhood (P less than .0001). There were no differences in baseline characteristics between the two groups. Of the 23 neonates who failed oxyhood, 21 were then given a trial of NCPAP and 58% (12/21) remained extubated. Data indicate that using selected clinical criteria for elective extubation of neonates weighing less than 1 kg, NCPAP facilitates successful extubation.

Humans↗
PubMed1999

Efficacy and safety of the laryngeal mask airway vs Guedel airway following tracheal extubation.

PURPOSE: To compare the safety and efficacy of the laryngeal mask airway (LMA) with the Guedel airway during the recovery period. METHODS: In a prospective randomised trial in the Post Anesthesia Care Unit (PACU), 52 patients (ASA 1 and 2) were randomised to receive either a laryngeal mask airway (LMA: n = 26) or a Guedel airway (n = 26) during the recovery period after middle ear surgery. Ease of airway maintenance was graded and the presence of coughing was noted. Peripheral arterial oxygen saturation (SpO2) was measured continuously by pulse oximetry in the PACU. Readings were taken on arrival (time 0) and for five minutes afterwards. RESULTS: There was no difference in sex, age, weight or incidence of smoking between the two groups. In the LMA group 25 patients required no airway manipulation and only one patient required repositioning of the LMA. In the Guedel group severe difficulty maintaining the airway was experienced in two patients, moderate difficulty in five patients and mild difficulty in 12 patients. Seven patients required no airway manipulation. The LMA group showed higher ease of airway maintenance scores, (P = < 0.0001) and less coughing (P = 0.0496). At time 0 and at one minute the LMA group had higher median SpO2 (97% and 97%) than the Guedel group (95% and 96%), (P = 0.0002 and 0.0362). There was no further difference in SpO2. CONCLUSIONS: The LMA provides easier airway maintenance, less coughing and initially higher median SpO2 when compared with the Guedel airway in the recovery period.

Adult↗
PubMed1993

Comparison of mask and nasal continuous positive airway pressure after extubation and mechanical ventilation.

OBJECTIVE: To examine the effects of continuous positive airway pressure applied via face masks and nose masks on the change in functional residual capacity and gas exchange. DESIGN: Descriptive and prospective study. SETTING: Intensive care unit of a university hospital. PATIENTS: Ten patients with acute lung injury who had required mechanical ventilation. INTERVENTIONS: Continuous positive airway pressure at a level of 10 cm H2O applied in random order via face and nose masks. MEASUREMENTS AND MAIN RESULTS: Both continuous positive airway pressure methods resulted in an almost identical increase of functional residual capacity. During nasal continuous positive airway pressure, the increase in functional residual capacity was 294 +/- 82 mL. During mask continuous positive airway pressure, the increase in functional residual capacity was 290 +/- 85 mL. PaO2 increased and the alveolar-arterial oxygen tension/alveolar oxygen tension quotient decreased significantly during mask continuous positive airway pressure and nasal continuous positive airway pressure at a level of 10 cm H2O. Two patients showed a periodic change in their breathing patterns; they took a few breaths at an increased lung volume, followed by one deep expiration caused by mouth opening. Change in mask pressure was negligible in these two patients. Using a visual analog scale (10 = highly comfortable; 0 = severely uncomfortable), the patients rated nasal continuous positive airway pressure (8.6 +/- 0.9) significantly more comfortable than mask continuous positive airway pressure (2.6 +/- 0.8). CONCLUSION: The major advantages of continuous positive airway pressure (the improvement of functional residual capacity and oxygen transfer) can also be achieved with nasal continuous positive airway pressure in the postextubation period in patients who have been mechanically ventilated for acute lung injury.

Acute Disease↗