전신마취를 시행한 구강외과 환자에서 어려운 기관내삽관: 후향적 연구

권오선,김철홍,Kwon, O-Seon,Kim, Cheul-Hong 대한치과마취과학회 2008 Journal of Dental Anesthesia and Pain Medicine Vol.8 No.2

Background: This retrospective study aims to describe the airway management and to search predictive parameter for difficult intubation in 700 patients undergoing oromaxillary surgery. Methods: The medical records of 700 patients undergone oromaxillary surgery were reviewed for airway management during perioperative period. The cases of difficult intubation were selected and those radiologic findings were reviewed. The mandibular depth (MD), mandibular length (ML), thyromental distance (TMD) were measured. Results: In 41 cases difficult intubation were recorded in anesthetic record. The grade of Cormack and Lehane was III in 36 patients and IV in 5 cases. The MD of difficult intubation cases was $4.2{\pm}3.2\;cm$. The ML of difficult intubation cases was $10.1{\pm}3.8\;cm$. The TMD of difficult intubation cases was $5.9{\pm}4.3\;cm$. Under the fiberoptic guided awake intubation was undertaken in 75 patient. In none of the cases was failed nasotracheal intubation. Conclusions: The patients undergoing oromaxillar surgery have a potentially difficult airway but, if managed properly during perioperative preiod, morbidity and mortality can be reduced or avoided. The radiologic findings were poor predict for difficult intubation. The fiberoptic guided awake intubation is a safe alternative to direct laryngoscopic intubation.

Encountering unexpected difficult airway: relationship with the intubation difficulty scale

양홍석,고원욱,김하정,김경선,노영진 대한마취통증의학회 2016 Korean Journal of Anesthesiology Vol.69 No.3

Background: An unexpected difficult intubation can be very challenging and if it is not managed properly, it may expose the encountered patient to significant risks. The intubation difficulty scale (IDS) has been used as a validated method to evaluate a global degree of intubation difficulty. The aims of this study were to evaluate the prevalence and characteristics of unexpected difficult intubation using the IDS. Methods: We retrospectively reviewed 951 patients undergoing elective surgery in a single medical center. Patients expected to have a difficult intubation or who had history of difficult intubation were excluded. Each patient was assessed by the IDS scoring system with seven variables. Total prevalence of difficult intubation and the contributing individual factors were further analyzed. Results: For the 951 patients, the difficult intubation cases presenting IDS > 5 was 5.8% of total cases (n = 55). The prevalence of Cormack-Lehane Grade 3 or 4 was 16.2% (n = 154). Most of the difficult intubation cases were managed by simple additional maneuvers and techniques such as stylet application, additional lifting force and laryngeal pressure. Conclusions: Unexpected difficult airway was present in 5.8% of patients and most was managed effectively. Among the components of IDS, the Cormack-Lehane grade was most sensitive for predicting difficult intubation.

기관내 삽관이 힘든 경우에서 Bonfils Intubation Fibrescope 사용의 임상적인 효과

이덕희,권일치 영남대학교 의과대학 2007 Yeungnam University Journal of Medicine Vol.24 No.2

직접 후두경하에 기관내 삽관의 난이도를 Cormack & Lehane 등급에 따라 분류하여 등급 3 또는 4에 해당하는 환자 40명을 대상으로 하였다. 모든 환자들이 적절한 마취 심도에 도달한 후 직접 후두경으로 성대와 후두개의 노출 여부를 판단하여 Cormack & Lehane 등급 3 또는 4에 해당되면 직접 후두경을 제거하고 대신 Bonfils intubation fibrescope으로 기관 내 삽관을 시도하였다. 기관내 삽관의 성공 여부, 삽관 시도 횟수, 삽관에 소용되는 시간, 턱에서 갑상연골의 상부 방패패임까지의 길이(thyromental distance), 턱에서 흉골 상부까지의 길이(sternomental distance) 그리고 SpO₂가 90%이하로 감소하는 지의 여부를 기록하였다. 이 외에 기관내 삽관동안 폐내흡인, 역류, 기관지경련, 기도 폐쇄, 경추 손상 그리고 치아 손상 여부 등이 발생하는지를 관찰하였다. Cormack & Lehane 등급 3에서는 96.9%의 기관내 삽관 성공률을 보였으며 등급 4에서는 50%의 성공률을 나타내어 등급 간 통계적으로 유의한 차이가 있었다(P<0.01). 기관내 삽관에 소요된 시간은 등급 3에서 20 (10-49[7-300])초였고 등급 4에서 180 (31-300[10-300])초로 통계적으로 유의하였다(P=0.01). 기관내 삽관시 SpO₂가 90% 이하로 감소된 경우는 등급 3에서 3.1%, 등급 4에서 50%로 통계적으로 유의한 차이를 나타내었다(P<0.01). 기관내 삽관 성공률과 삽관에 소요된 시간으로 보아 Bonfils intubation fibrescope은 Cormack & Lehane 등급 3인 환자에서 유용한 기도 관리 장비로 보이나 등급 4인 환자에서는 항상 선택적으로 사용할 수 있는 기도 관리 장비라고는 할 수 없으며, 기관내 삽관 시 다른 대체 장비가 필요할 가능성도 있음을 알아야 하겠다. Background: This study was undertaken to evaluate the effectiveness of the Bonfils intubation fibrescope for cases of difficult tracheal intubation. Materials and Methods : For patients with an ASA physical status 1 or 2 betwen the ages of 20-90, direct laryngoscopy was performed and the layngoscopic view graded according to the Cormack and Lehane classification. Forty patients with Cormack and Lehane grade 3 or 4 were intubated using the Bonfils intubation fibrescope. During intubation, the success rates for tracheal intubation, overall time to intubation, number of attempts and adverse effects were recorded. The Thyromental and sternomental distances were recorded after the orotracheal intubation. Results : The success rates were significantly higher in Cormack and Lehane grade 3 (96.9%) patients compared to grade 4 (50%) (P<0.01). The time to intubation was significantly faster in patients with grade 3 compared to grade 4 (20 (10-49[7-300]) sec vs. 180 (31-300[10-300]) sec, P=0.01). The number of cases with a SpO₂<90% was significantly lower in patients with grade 3 (3.1%) compared to grade 4 (50%) (P<0.01). Conclusion : In patients with Cormack and Lehane grade 3, tracheal intubation using the Bonfils intubation fibrescoper appears to be an effective technique for the management of a difficult intubation. However, the Bonfils intubation fibrescope can not always be used for the management of a difficult intubation in grade 4 patients; for these patients other effective instruments should be considered for difficult intubations.

기관내삽관이 곤란한 환자에서 굴곡성 기관지경의 이용

정기운,김진윤,박선규 중앙대학교 의과대학 의과학연구소 1996 中央醫大誌 Vol.21 No.1

Airway management is essential for general anesthesia and endotracheal intubation is the most useful and safe method to keep airway in general anesthesia. Numerous anatomic and pathologic abnormalities may lead to difficult intubation. Failed endotracheal intubation may lead to organ ischemia and then it imminently endangers the patient's life and necessitates the other methods to ventilation. In case of failed conventional endotracheal intubation, various methods are used. These methods include blind nasotracheal intubation, retrograde catheter insertion, laryngeal mask airway, and flexible fiberoptic bronchoscopic intubation. We try to the flexible fiberoptic bronchoscopic inbation in expected difficult intubation, especially cervial fracture and cervical postburn contracture. In 20 patients, we review the clinical evaluation of awake fiberoptic broncoscopic inbubation with Mallampati classfication, hemodnamic variables, discomfort during intubation procedure and postoperative complications. We measured the changes of arterial pressure and heart rate during flexible fiberoptic broncoscopic intubation. The results were as follows ; 1. The most of patients revealed Mallampati class Ⅰ or Ⅱ. 2. The most of patients could not extend the neck because Halo traction and postburn contracture. 3. The systolic, diastolic and mean arterial pressure decreased significantly at 3 and/or 5 min. following intubation. 4. The heart rate increased significantly at 1 min and 3 min. following intubation. 5. Any bleeding or edema of pharnyx and larynx were not found in postoperative fiberoptic laryngoscopic views. 6. In postopertive interviews, a few(2/20) patients complained discomfort during procedures. In conlusion, the flexible fiberoptic intubation is effective and safe alternative of the conventional intubation in difficult intubation.

어려운 기관 내 삽관이 예상되는 환자의 기도관리 -증례 보고-

오세리,이진한,O, Se-Ri,Lee, Jin-Han 대한치과마취과학회 2010 Journal of Dental Anesthesia and Pain Medicine Vol.10 No.2

Difficult airway management including difficult intubation, difficult ventilation and difficult mask ventilation is a life threatening issue during anesthesia care. A 23-year-old woman with Treacher Collins syndrome was scheduled for distraction osteogenesis. She had hypoplasia of mandible and malar bone, bilateral deformities of auricles with partial deafness and antimongoloid slant of the palpebral fissures. A 56-year-old woman with mandibular hypoplasia due to childhood trauma was scheduled for distraction osteogenesis. She had a history of difficult intubation. We anticipated a difficult intubation and ventilation. Fiberoptic bronchoscopic guided awake intubation was selected for anesthesia induction. After intravenous injection of midazolam and remifentanil, 10% lidocaine pump spray on the pharyngolarynx with a direct laryngoscope and on the nasal canal. However fiberoptic bronchoscopic guided awake intubation was failed due to severe gag reflex. After intravenous injection of propofol and remifentanil using the target controlled infusion (TCI), mask ventilation was easily performed and, after intravenous injection of vecuronium, fiberoptic bronchoscopic guided intubation was easily performed using a wire reinforced endotracheal tube. The operation was completed successfully without any adverse events.

Orotracheal intubation in a patient with difficult airway by using fiberoptic nasotracheal intubation: A case report

Yun, Hye Joo,So, Eunsun,Karm, Myong-Hwan,Kim, Hyun Jeong,Seo, Kwang-Suk The Korean Dental Society of Anesthsiology 2018 Journal of Dental Anesthesia and Pain Medicine Vol.18 No.2

In cases of a difficult intubation where numerous intubation methods, including laryngoscopy, have failed, yet oral intubation is still necessary, the method of tube exchange after fiberoptic nasal intubation may be attempted. Fiberoptic nasal intubation allows intubation to be performed relatively easily when the laryngeal view grade is poor. We report a case in which our attempt at oral intubation for total maxillectomy with laryngoscopy and fiberoptic oral intubation had failed due to an unexpected difficult airway; subsequently, we successfully completed the surgery by performing fiberoptic nasal intubation to secure the airway, followed by using a tube exchanger to exchange to an oral endotracheal tube.

성대 피열사이 유착에 의한 기관내 삽관의 곤란 —증례보고—

박상진,송선옥,황창재 대한마취통증의학회 2008 Korean Journal of Anesthesiology Vol.53 No.3

Interarytenoid adhesion of the vocal cords, with a triangular anterior opening and a smaller posterior rounded opening, is one of the complications of intubation. The vocal cords are tethered to each other and they are restricted with narrow abduction, causing difficult intubation. A 57-year-old woman was scheduled to undergo lung wedge resection. The patient had experienced a prolonged intubation 15 years previously. Thereafter, she had undergone two operations and intubation was difficult to perform with using small size endotracheal tubes (6.5 and 6.0 mm inner diameter, respectively). Despite this past medical history, anesthesia was performed without further evaluation because of the patient's refusal. After the failure of an initial trial of intubation with a double lumen endobronchial tube, we tried to intubate with a small sized endotracheal tube (5.0 mm). But it was impossible to pass the tube through the vocal cords. Endobronchial endoscopy revealed interarytenoid adhesion of her vocal cords. After tracheostomy, she received wedge resection. Therefore, the possibility of difficult intubation due to interarytenoid adhesion of the vocal cords should be considered for a patient with a past history of intubation.

응급실에서 시행된 기도삽관의 현황과 난이도의 예측

정성필,임태호,장문준,김승호,이한식 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.3

Background : This study was designed to describe the current trends of emergency tracheal intubation and predict difficult airway intubations in emergency department (ED) at a teaching hospital in Korea. Methods : All patients who was taken endotracheal intubation in ED during a 1-year period (Mar 1997 through Feb 1998) were included in the study population. Medical records of the patients were retrospectively reviewed. Among them, 56 patients were prospectively evaluated parameters to predict difficult airway intubations. Results : During the study period, a total of 413 patients(1.5%) required endotracheal intubation. Except for 2 cases, all patients intubated orotracheally, and 298(72%) patients were intubated by emergency medicine resident. Pharmacologic adjuncts were used in 200(48%) patients, the neuromuscular blocking agent(NMBA) was used in 16(3.8%). Commonly used drugs were thiopental and vecuronium. The difficult intubation was not associated with presence of denture, length and circumference of neck, and mental status. The visibility of vocal cord on laryngoscopy significantly correlated to the difficult airway. Conclusion : At this institution, the majority of ED intubation were performed by emergency physicians and NMBA was not routinely used. The visibility of vocal cord during the direct laryngoscopy could be a predictor of difficult intubation in ED.

Clinical Research Article : Factors affecting difficult Lightwand intubation: a prospective double-blind trial

( Youn Suk Lee ),( Sang Seok Lee ),( Jun Heum Yon ),( Jeoung Hyuk Lee ) 대한마취과학회 2009 Korean Journal of Anesthesiology Vol.56 No.1

Background: Unanticipated difficulties during tracheal intubation are related to perioperative morbidity and mortality, but the success of direct laryngoscopic intubation depends largely on clinician`s experience and the upper airway anatomy. The lightwand was introduced as alternative intubation technique, but the indicators of difficult lightwand intubation (DLWI) have not been identified. Accordingly authors conducted this study to identify subject factors that affect DLWI, and to compare these with those of difficult laryngoscopic intubation. Methods: Seventy-three healthy subjects requiring tracheal intubation for elective surgery were enrolled. Anatomic factors, such as, body mass index (BMI), Mallampati classification (MC), inter-incisor gap, thyromental distance, neck circumference, extent of head and neck motion, and Cormack-Lehane grade (CL) were determined and evaluated in terms of their abilities to predict DLWI, which was described using intubation time and number of intubation attempts. Multiple regression analyses were performed to identify predictors using a variable selection technique. Results: Only MC and BMI were found to predict DLWI. The weighted sum of time and number of attempts (r2=0.854, P=0.000) was found to be better predictor of DLWI than their product (r2=0.734, P=0.000). Cormack-Lehane grade was not found to be significantly related to DLWI (P=0.093). Conclusions: Of the anatomic factors examined, only Mallampati classification and body mass index were found to predict difficult lightwand intubation. (Korean J Anesthesiol 2009;56:18~24)

진단받지 않은 후두개와 후두개곡사이낭종으로 인한 어려운 기관 내 삽관

이정하(Jung Ha Lee),허봉하(Bong Ha Heo),윤대훈(Dae Hun Yun) 조선대학교 의학연구원 2020 The Medical Journal of Chosun University Vol.45 No.1

Laryngeal cyst in adults is a rare condition. However, if these cysts are unexpectedly discovered after anesthesia induction, an emergency situation immediately poses a life-threatening condition if proper airway management is not done. The authors report that in the case of difficult intubation tubes after anesthesia induction caused by laryngeal cyst, which was not diagnosed as asymptomatic, the oral intubation was successful without complication using the Clarus Video System (Clarus Medical, USA), an semi-rigid optical stylet. A 67-year-old male presented for laparoscopic radical prostatectomy. We discovered an undiagnosed epiglottic cyst obscuring laryngeal inlet. Fortunately, mask ventilation was possible, and after failed attempts of direct laryngoscopy, we could perform oral semi-rigid optical stylet-aided intubation. We experienced difficult intubation due to laryngeal cyst, which had no symptoms of respiratory closures before anesthesia, and in such cases it is believed that systematic preparation for “difficult airways” should be made to prevent hypoxic damage that can result from unexpected intubation failure.