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Сообщение от alex_md
Rev Esp Anestesiol Reanim 2002 Apr;49(4):205-8 (ISSN: 0034-9356)
Villalonga A; Metje M; Torres-Bahi S; Aragones N; Navarro M; March X
Servicio de Anestesiologia, Reanimacion y Terapeutica del Dolor, Hospital Universitari Doctor Josep Trueta de Girona, Avda. Francia, s/n, 17007 Girona.
The trachea of a 74-year-old man undergoing left pneumonectomy could not be intubated in two attempts after induction of anesthesia with midazolam, fentanyl, propofol and rocuronium. Difficult intubation had not been foreseen, but inspection through the laryngoscope revealed Cormack and Lehane grade IV conditions. Because a small-caliber fiberoptic bronchoscope was unavailable for intubation with a double-lumen endobronchial tube, we inserted a No. 9 orotracheal tube with a 6 mm bronchoscope as far as the left main bronchus. Intubation was aided by a universal adaptor for fiberoptics with a face mask and a Williams cannula. We were then able to ventilate the patient manually with 100% oxygen during bronchoscopy. As selective ventilation was required during surgery, a No. 11 Cook-type airway exchange catheter was inserted into the left main bronchus, the tracheal tube was removed, and was used to guide a No. 39F left double-lumen endobronchial tube through the bronchus. Insertion was uncomplicated and selective ventilation was satisfactory. The technique described is a new application for the Cook exchange catheter that allows selective bronchial in difficult cases when a small-caliber fiberoptic bronchoscope is unavailable.
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Спасибо. В этой заметке идет речь о небольшой модификации известной методики, которую мы применяем каждый день. Алаверды! Ниже приведу пример более поздней статьи, которая частично объясняет мои затруднения:
Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea during Awake Fiberoptic Orotracheal Intubation.
Anesthesiology. 102(5):910-914, May 2005.
Johnson, Dana M. B.S. *; From, Aaron M. B.S. +; Smith, Russell B. M.D. ++; From, Robert P. D.O. [S]; Maktabi, Mazen A. M.D. [//]
Abstract:
Background: Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiberoptic orotracheal intubation is often impeded. The goal of this study was to identify the sites and mechanisms that inhibit the passing of the ETT into the trachea.
Methods: Forty-five consenting patients underwent a clinically indicated awake fiberoptic orotracheal intubation. After topical anesthesia, nerve block, or both, an awake fiberoptic orotracheal intubation was performed. The placement of the FB and advancement of the ETT over the FB were videotaped using a second nasally inserted FB. An otolaryngologist later reviewed the videotaped data.
Results: The right arytenoid or the interarytenoid soft tissues inhibited advancement of the ETT in 42 and 11% of all patients, respectively. In all cases in which the FB was located on the right side of the larynx, failure of ETT advancement almost always occurred at the right arytenoid. Withdrawing the ETT and rotating it 90[degrees] counterclockwise resulted in successful intubation on the second, third, and fourth attempts in 26.6, 20, and 0.7% of patients, respectively.
Conclusion: The right arytenoid frequently inhibits advancement of the ETT over the FB into the trachea during awake fiberoptic orotracheal intubation. The FB position in the larynx before tube advancement and the orientation of the ETT are relevant factors in failure of advancement of the ETT into the trachea. The authors recommend positioning the FB in the center of the larynx and orienting the bevel of the ETT to face posteriorly during the first attempt at intubation.
(C) 2005 American Society of Anesthesiologists, Inc.