Skip to main content

Full text of "Respiratory care : the official journal of the American Association for Respiratory Therapy"

See other formats 


SPECIAL  ISSUE 

ARTIFICIAL  AIRWAYS 
PART  II 


JULY  1  999 
VOLUME  44 
NUMBER  7 

ISSN  0020-1324-RECACP 


A  MONTHLY  SCIENCE  JOURNAL 
44TH  YEAR— ESTABLISHED  1956 


Who  Should  Perform  Intubation? 


Managing  the  Artificial  Airway 


Difficult  Intubation 

Extubation  and  Consequences  of 
Reintubation 

Indications  and  Timing  of  Tracheotomy 

TracheotomyyTracheostomy 


P- 


Complications  of  Endotracheal  Intubation 
and  Tracheostomy 

Communication  and  Swallowing 


Decannulation 


Conference  Summary 


, — . . 1 

f-^.c 

'^ 

2 

T 

^  0 

y    — s 

3    ®X 

>-^'i 

EASIVENT 


You'd  be  surprised  what  New  EasiVent"  will  hold. 

And  so  will  your  patients. 

Any  holding  chamber  will  hold  a  dose  of  respiratory 
medication.  But  only  the  EasiVent"  Valved  Holding  Chamber 
is  designed  to  hold  the  complete  MDI  kit  inside.  Or  any 
other  personal  treasure  of  modest  size. 

Physicians,  respiratory  therapists,  and  patients  indicate  a  preference  for  the 
unique  design  of  EasiVent'".*  Since  EasiVent™  improves  the  portability  of  asthma 
treatment,  it  encourages  patient  compliance. 

NAEPP  guidelines  also  recommend  that  all  patients  using  corticosteroids  use 
a  holding  chamber  to  maximize  dose  delivery.  Which  is  exactly  what  EasiVent™  is 
designed  to  do. 

EasiVent'"  improves  medication  delivery  and  simplifies  patient  training,  with 
advanced  features  such  as  a  dual,  low-resistance  valve,  universal  MDI  port,  graphic 
instructions  printed  on  the  unit,  and  built-in  coaching  signal. 

Help  your  patients  with  compliance.  Specify  the  EasiVent'"  Valved  Holding  Chamber.  t 

It  not  only  holds  the  complete  MDI  kit  inside,  its  advanced  design  also  helps  the  patient 
get  maximum  benefit  from  their  medication.  And  that's  no  fish  story.  'Data  on  file. 


1-800-755-5560 


©1998  DEY. 

All  rights  reserved. 

09-527-00  5/9B 


r^i^^i^  4  4  o  . 


II  neui  rool  for  syOflCyiE  CORE... 

U^CUeORM  REPORTING. 

MANUAL 

FOR  SUBACUTE  CARE 


Prospective  payment  systems  in  post-acute  care 
require  that  respiratory  care  managers  possess  the 
tools  to  identify  the  resources  for  efficient 
administration  of  respiratory  care  services.  The 
Uniform  Reporting  Manual  for  Subacute  Care  is 
the  right  tool. 

The  Uniform  Reporting  Manual  for  Subacute 
Care  is  a  tool  to  determine  productivity,  track 
trends  in  the  utilization  of  respiratory  care  services, 
assist  in  determining  personnel  requirements,  and 
measure  demand  for  and  intensity  of  services. 

The  Uniform  Reporting  Manual  for  Subacute 
Care  includes  time  standards  for  126  activities,  plus 


It's  0  neiii  tool  that  helps  ijou... 


Binder,  122  Pages,  1998.  Number  BK2A. 


Standards,  Non-Allocated  Hours,  and  an  Appendix 
with  worksheets  to  compute  your  own  workload 
hours. 


^K  Determine  productivity 

Promote  standardization  of  care 
Benchmark  and  track  trends 
Match  resources  and  demand 


RUSH  ME  MY  COPY  of  the 

Uniform  Reporting  Manual  for  Subacute  Care  (Item  BK2A) 

$75  for  AARC  Members  •  $115  for  Nonmembers  (add  $8.2^  for  Shipping  and  Handling) 

(Texas  residents  only,  please  add  8.25%  sales  tax) 

□  Payment  enclosed  □  Charge  my  PO  □  Charge  my 


□  VISA      □  MasterCard 


Name. 


AARC  Member  Number . 
Institution 


Add 
City 


ress 


State 


Zip . 


Card/PO  Number 


Expiration  date . 


Signature ^ 

(required  for  Purchase  Order  and  Credit  Card  Orders) 

American  Association  for  Respiratory  Care  •  Order  Department  •  11030  Abies  Lane  •  Dallas,  Texas  75229 
Phone  972-243-2272  Fax:972-484-6010  •  Vist  our  website  at:  www.aarc.org 


9t, 


-m-rsT 


toalaa 


The  Dale  Tracheostomy  Tube  Holder. 
Faster  easier  tube  stabilization  that's  more  secure  and  comfortable. 


A  better  way  is  taking  hold.  For  security, 
safety,  ease  of  use  and  efficiency.  The  Dale 
Tracheostomy  Tube  Holder  triumphs  over 
conventional  methods. 

Unlike  unyielding  and  unwieldy  twill 
ties,  its  narrow  fastener  tabs  permit  fast,  easy. 


reliable  engagement  and  disengagement  of  edema  while  providing  a  safe,  snug,  comfort- 

the  trach  plate.  So  it  saves  time  and  money  and  able  fit.  A  pediatric/neonatal  version  is  also 

helps  prevent  tubes  from  becoming  dislodged,  now  available. 
Latex  Free  It's  sure  to  win  your  approval.  Judge  for 

Its  cotton-lined,  latex-free  neckband  stretches  yourself.  Call  today  for  your  free  evaluation 

to  allow  for  cough  reflex  and  accommodate  sample:  800-343-3980. 


fflpng  you  heal. 


Dale  Medical  Products,  Inc.  508-695-9316  800-343-3980  Fax:  508-695-6587  www.dalemed.com  Velao®  is  a  registered  trademaHc  of  Velcro  USA,  Inc.  ©1999  Dale  Medical  Products,  Inc. 

Circle  107  on  reader  service  card 


JULY  1999  /  VOLUME  44  /  NUMBER  7 


FOR  INFORMATION, 
CONTACT: 

AARC  Membership  or  Other  AARC 
Services 

American  Association  for 

Respiratory  Care 

11 030  Abies  Ln 

Dallas  TX  75229-4593 

(972)  243-2272  •  Fax  (972)  484-2720 

http://www.aarc.org 

Therapist  Registration  or 
Technician  Certification 

National  Board  for  Respiratory 

Care 

8310Nieman  Rd 

LenexaKS  66214 

(913)  599-4200  •  Fax  (913)  541-0156 

http://www.nbrc.org 

Accreditation  of  Education 
Programs 

Committee  on  Accreditation  for 

Respiratory  Care 

1248  Harwood  Rd 

Bedford  TX  76021-4244 

(817)  283-2835  •  Fax  (817)  354-8519 

http://www.coarc.com 

Grants,  Scholarships,  Community 
Projects 

American  Respiratory  Care 

Foundation 

11030  Abies  Ln 

Dallas  TX  75229-4593 

(972)  243-2272  •  Fax  (972)  484-2720 

Government  Affairs  — 

Cheryl  West  MHA  (703-548-8506) 

State  Government  Affairs  — 

Jill  Eicher  IVIPA  (703-548-8538) 
1225  King  St,  Second  Floor 
Alexandria  VA  22314 
Fax  (703)  548-8499 


RE/PIRATORy 
a\RE 


RESPIRATORY  CARE  (ISSN  0020-1324.  USPS  0489- 
190)  is  published  monthly  by  Daedalus  Enterprises  Inc.  at 
1 1030  Abies  Lane,  Dallas  TX  75229-4593.  for  the  Amer- 
ican Association  for  Respiratory  Care.  One  volume  is 
published  per  year  beginning  each  January.  Subscription 
rates  are  $75  per  year  in  the  US;  $90  in  all  other  countries 
(for  airmail,  add  $94). 

The  contents  of  the  Journal  are  indexed  in  Hospital  and 
Health  Administration  Index.  Cumulative  Index  to  Nurs- 
ing and  Allied  Health  Literature,  EMBASE/Exerpta  Med- 
ica.  and  RNdex  Library  Edition.  Abridged  versions  of 
Respiratory  Care  are  also  published  in  Italian. 
French,  and  Japanese,  with  permission  from  Daedalus  En- 
terprises Inc. 

Periodicals  postage  paid  at  Dallas  TX  and  at  additional 
mailing  offices.  POSTMASTER:  Send  address  changes  to 
RESPIRATORY  CARE,  Membership  Office,  Daedalus  En- 
terprises Inc.  1 1030  Abies  Lane,  Dallas  TX  75229-4593. 

Printed  in  the  United  States  of  America 
Copyright  ©  1999,  by  Daedalus  Enterprises  Inc. 


SPECIAL     ISSUE 

JOURNAL  CONFERENCE  ON 

ARTIFICIAL  AIRWAYS 

PART  II 

CO-CHAIRS 

Richard  D  Branson  RRT 
Charles  G  Durbin  Jr  MD 


CONFERENCE  PROCEEDINGS 


Who  Should  Perform  Intubation? 

by  Michael  J  Bishop — Seattle,  Washington 

Managing  the  Artificial  Airway 
by  Dean  R  Hess — Boston,  Massachusetts 

Prediction  of  a  Difficult  Intubation:  Methods  for  Successful  Intubation 
by  Charles  B  Watson — Bridgeport,  Connecticut 


Extubation  and  the  Consequences  of  Reintubation 
by  Robert  S  Campbell — Cincinnati,  Ohio 

Tracheotomy:  Indications  and  Timing 
by  John  E  Heffiier — Charleston,  South  Carolina 

Tracheotomy/Tracheostomy 

by  James  F  Reibel — Charlottesville,  Virginia 

Complications  of  Endotracheal  Intubation  and  Tracheotomy 
by  John  L  Stauffer — Hershey,  Pennsylvania 

The  Effects  of  Tracheostomy  Tube  Placement  on  Communication 

and  Swallowing 

by  Maxine  K  Orringer — Pittsburgh,  Pennsylvania 

Decannulation:  How  and  Where 

by  James  F  Reibel — Charlottesville,  Virginia 

Artificial  Airways:  Conference  Summary 
by  John  E  Hejfner — Charleston,  South  Carolina 


BOOKS,  FILMS,  TAPES,  &  SOFTWARE 

Mechanical  Ventilation:  Physiological  and  Clinical  Applications 
reviewed  by  Catherine  Sassoon — Long  Beach,  California 


Sleep  Disorders  Sourcebook 

reviewed  by  Vishesh  Kapur — Seattle,  Washington 


750 
759 
777 
799 
807 
820 
828 

845 
856 
861 

866 
866 


SIEMENS 


The  greatest  savings  we  offer  you, 
:    benefit  him  first. 


The  less  time  he  has  to  spend  on  a  ventilator,  the  nnore 
he  benefits.  When  you  invest  in  Servo  Ventilator  300A 
technology,  everybody  benefits.  Enroll  in  Siennens 
Clinical  Management  Program™  and  we  guarantee  a 
minimum  5%  reduction  in  ventilator  length  of  stay, 
together  with  associated  cost  savings.  The  Servo  300A 
provides  the  lowest  cost  per  procedure  compared  to 


Servo  300A 

Ventilation 

System 


competitive  devices.  With  proven  99.9%  uptime,  you 
can  maximize  clinical  outcomes  while  lowering  the 
cost  of  care.  And  right  now,  when  you  purchase  your 
Servo  300A,  you  have  the  option  of  paying  nothing  until 
the  year  2000.  Interest  free.  Interested?  For  more 
information,  contact  your  local  Siemens  representative 
or  call  1-800-333-8646. 


Siemens  medical 

Solutions  that  help 


Circle  112  on  reader  service  card 


i"»i-«(|ipiwi«pipi5rJi^W^iww»»'^»'*«'  y*i-""^'l|j^ 


CONTINUED... 


ALSO 
IN  THIS  ISSUE 


871 

AARC  Membership 
Application 

728 

Abstracts  from 
Other  Journals 

880 

Advertisers  Index 
&  Help  Lines 

880 

Author 
Index 

877 

Calendar 
of  Events 

873 

Manuscript 
Preparation  Guide 

870 

New  Products 
&  Services 

878 


Notices 


Professional  Ethics:  A  Guide  for  Rehabilitation  Professionals 

reviewed  by  Ronald  G  Beckett — Hamden,  Connecticut  0  0  7 

Introductory  Medical  Statistics  a  e  n 

reviewed  by  David  Au — Seattle,  Washington  0  0  w 


COMING  IN  SEPTEMBER  1999 

SPECIAL  ISSUE: 

THORACIC  IMAGING 

IN  THE 
NTENSIVE  CARE  UNIT 

GUEST  EDITORS: 

ERIC  J  STERN  MD 

ROBERT  D  TARVER  MD 


RE/PIRATORy 
CARE 


A  Monthly  Science  Journal 
Established  in  1956 

The  Official  Journal  of  the 

American  Association  for 

Respiratory  Care 


"Our  5uper  Hero 


ff 


Adam 

Diagnosis:  Incomplete 

C2  Spinal  Cord  Injury. 


I  can  talk  faster  than  a  speeding  train,  louder  than  a  lion's 

roar,  and  blast  into  classroom  discussions  like  a  rocket! 

If  you  don't  believe  me,  just  ask  my  Teacher! 


This  Moment  of  Super  Hero  Speech  is  Made  Possible  by  the 
Low  Profile  PM V  200 1  Purple  Tracheostomy  &  Ventilator  Speaking  Valve. 

VHSSU-y^^tWt^^^J'tl^.    Product  literature  and  video  available  upon  request.  (800)  634-5397  Website:  www.passy-muir.com  Email:  info@passy-muir.com 


Circle  105  on  reader  service  card 


''"TraB'TSpy 


S' 


EDITORIAL  OFFICE 

600  Ninth  Avenue,  Suite  702 

Seattle  WA  98104 

(206) 223-0558 

Fax (206) 223-0563 

www.rcjoumal.com 


EDITOR  IN  CHIEF 


A  Monthly  Science  Journal 
Established  in  1956 

The  Official  Journal  of  the 

American  Association  for 

Respiratory  Care 


David  J  Pierson  MD 
Harborview  Medical  Center 
University  of  Washington 
Seattle,  Washington 


ASSOCIATE  EDITORS 


Richard  D  Branson  RRT 

University  of  Cincinnati 
Cincinnati,  Ohio 


Charles  G  Durbin  Jr  MD 

University  of  Virginia 
Charlottesville,  Virginia 


EDITORIAL  BOARD 


Dean  R  Hess  PhD  RRT  FAARC 

Massachusetts  General  Hospital 
Harvard  University 
Boston,  Massachusetts 

James  K  Stoller  MD 

The  Cleveland  Clinic  Foundation 

Cleveland,  Ohio 


Thomas  A  Barnes  EdD  RRT 

Northeastern  University 
Boston,  Massachusetts 

Michael  J  Bishop  MD 

University  of  Washington 
Seattle,  Washington 

Bartolome  R  Celli  MD 

Tufts  University 
Boston,  Massachusetts 

Robert  L  Chatbum  RRT 
FAARC 

University  Hospitals  of  Cleveland 
Case  Western  Reserve  University 
Cleveland,  Ohio 

Luciano  Gattinoni  MD 

University  of  Milan 
Milan,  Italy 

John  E  Heffner  MD 

Medical  University  of  South  Carolina 
Charleston,  South  Carolina 

Mark  J  Heulitt  MD 

University  of  Arkansas 
Little  Rock,  Arkansas 


SECTION  EDITORS 


Leonard  D  Hudson  MD 

University  of  Washington 
Seattle,  Washington 

Robert  M  Kacmarek  PhD  RRT 

FAARC 

Massachusetts  General  Hospital 

Harvard  University 

Boston,  Massachusetts 

Toshihiko  Koga  MD 

Koga  Hospital 
Kurume,  Japan 

Marin  H  Kollef  MD 
Washington  University 
St  Louis,  Missouri 

Patrick  Leger  MD 
Clinique  Medicale  Edouard  Rist 
Paris,  France 

Neil  R  Maclntyre  MD  FAARC 

Duke  University 
Durham,  North  Carolina 

John  J  Marini  MD 

University  of  Minnesota 
St  Paul,  Minnesota 


Shelley  C  Mishoe  PhD  RRT 
FAARC 

Medical  College  of  Georgia 
Augusta,  Georgia 

Joseph  L  Rau  PhD  RRT 

Georgia  State  University 
Atlanta.  Georgia 

Catherine  SH  Sassoon  MD 

University  of  California  Irvine 
Long  Beach,  California 

Arthur  S  Slutsky  MD 

University  of  Toronto 
Toronto,  Ontario,  Canada 

Martin  J  Tobin  MD 

Loyola  University 
Maywood,  Illinois 


STATISTICAL  CONSULTANT 

Gordon  D  Rubenfeld  MD 

University  of  Washington 
Seattle.  Washington 


Hugh  S  Mathewson  MD 
Joseph  L  Rau  PhD  RRT 
Drug  Capsule 


Charles  G  Irvin  PhD 

Gregg  L  Ruppel  MEd  RRT  RPFT  FAARC 

PFT  Comer 


Richard  D  Branson  RRT 
Robert  S  Campbell  RRT 
Kittredge  's  Corner 


Jon  Nilsestuen  PhD  RRT  FAARC 
Ken  Hargett  RRT 
Graphics  Corner 


Patricia  Ann  Doorley  MS  RRT 
Charles  G  Durbin  Jr  MD 
Test  Your  Radiologic  Skill 


Abstracts 


Summaries  of  Pertinent  Articles  in  Other  Journals 


Editorials,  Commentaries,  and  Reviews  to  Note 

The  Trials  and  Tribulations  of  Clinical  Practice  Guidelines — Cook  D,  Giacomini  M.  JAMA 
1 999  May  26;28 1  (20):  1 950- 1 95 1 . 

Respiratory  Nursing  Society  Position  Statement  on  Development  of  Non-Chlorofluorocar- 
bon  Metered  Dose  Inhalers— Gift  A.  Heart  Lung  1999  May-Jun;28(3);224-225. 

Guidelines  for  Intensive  Care  Unit  Admission,  Discharge,  and  Triage — Task  Force  of  the 
American  College  of  Critical  Care  Medicine.  Society  of  Critical  Care  Medicine.  Crit  Care  Med 
1999  Mar;27(3):633-638. 

Guidelines  for  Developing  Admission  and  Discharge  Policies  for  the  Pediatric  Intensive 
Care  Unit — American  Academy  of  Pediatrics.  Committee  on  Hospital  Care  and  Section  of 
Critical  Care.  Society  of  Critical  Care  Medicine.  Pediatric  Section  Admission  Criteria  Task  Force. 
Pediatrics  1999  Apr;103(4  Pt  l):840-842. 

Practice  Parameters  for  Hemodynamic  Support  of  Sepsis  in  Adult  Patients  in  Sepsis — Task 
Force  of  the  American  College  of  Critical  Care  Medicine.  Society  of  Critical  Care  Medicine.  Crit 
Care  Med  1999  Mar;27(3):639-660. 

Guidelines  for  Developing  Admission  and  Discharge  Policies  for  the  Pediatric  Intensive 
Care  Unit — Pediatric  Section  Task  Force  on  Admission  and  Discharge  Criteria,  Society  of 
Critical  Care  Medicine  in  conjunction  with  the  American  College  of  Critical  Care  Medicine  and 
the  Committee  on  Hospital  Care  of  the  American  Academy  of  Pediatrics.  Crit  Care  Med  1999 

Apr;27(4):843-845. 


Recent  Advances  in  the  Pharmacotherapy  of 
Smoking — Hughes  JR,  Goldstein  MG,  Hurt 
RD,  Shiffman  S.  JAMA  1999;281(l);72. 

Since  the  1996  publication  of  guidelines  on 
smoking  cessation  from  the  Agency  for  Health 
Care  Policy  and  Research  and  the  American 
Psychiatric  Association,  several  new  treatments 
have  become  available,  including  nicotine  na- 
sal spray,  nicotine  inhaler,  and  bupropion  hy- 
drochloride. In  addition,  nicotine  gum  and  patch 
have  become  available  over-the-counter.  This 
article  reviews  the  published  literature  and  US 
Food  and  Drug  Administration  and  pharmaceu- 
tical company  reports  on  these  therapies.  Based 
on  this  review,  clinical  logic,  and  experience, 
we  conclude  that  pharmacotherapy  should  be 
made  available  to  all  smokers.  All  currently 
available  therapies  appear  to  be  equally  effica- 
cious, approximately  doubling  the  quit  rate  com- 
pared with  placebo.  Concomitant  behavioral  or 
supportive  therapy  increases  quit  rates  and 
should  be  encouraged  but  not  required.  Com- 
bining patch  with  gum  or  patch  with  bupropion 
may  increase  the  quit  rate  compared  with  any 
single  treatment.  Because  patient  characteris- 
tics predictive  of  success  with  a  particular  ther- 


apy are  not  yet  known,  the  best  treatment  choice 
for  an  individual  patient  should  be  guided  by 
the  patient's  past  experience  and  preference  and 
the  product's  adverse  effect  profile. 

Trends  in  Infectious  Disease  Mortality  in  the 
United  States  During  the  20th  Century— 

Arm.strong  GL,  Conn  LA,  Pinner  RW.  JAMA 
1999;281(1):61. 

CONTEXT:  Recent  increa.ses  in  infectious  dis- 
ease mortality  and  concern  about  emerging  in- 
fections warrant  an  examination  of  longer-term 
trends.  OBJECTIVE:  To  describe  trends  in  in- 
fectious di.sease  mortality  in  the  United  States 
during  the  20th  century.  DESIGN  AND  SET- 
TING: De.scriptive  study  of  infectious  disease 
mortality  in  the  United  States.  Deaths  due  to 
infectious  diseases  from  1900  to  1996  were  tal- 
lied by  using  mortality  tables.  Trends  in  age- 
specific  infectious  disease  mortality  were  ex- 
amined by  using  age-specific  death  rates  for  9 
common  infectious  causes  of  death.  SUB- 
JECTS: Persons  who  died  in  the  United  States 
between  1900  and  1996.  MAIN  OUTCOME 
MEASURES:  Crude  and  age-adjusted  mortal- 
ity rates.  RESULTS;  Infectious  di.sease  mortal- 


ity declined  during  the  first  8  decades  of  the 
20th  century  from  797  deaths  per  100000  in 
1900  to  36  deaths  per  100000  in  1980.  From 
1981  to  1995,  the  mortality  rate  increased  to  a 
peak  of  63  deaths  per  100000  in  1995  and  de- 
clined to  59  deaths  per  100000  in  1996.  The 
decline  was  interrupted  by  a  sharp  spike  in  mor- 
tality caused  by  the  1918  influenza  epidemic. 
From  1938  to  1952,  the  decline  was  particu- 
larly rapid,  with  mortality  decreasing  8.2%  per 
year.  Pneumonia  and  influenza  were  responsi- 
ble for  the  largest  number  of  infectious  disease 
deaths  throughout  the  century.  Tuberculosis 
caused  almost  as  many  deaths  as  pneumonia 
and  influenza  early  in  the  century,  but  tubercu- 
losis mortality  dropped  off  sharply  after  1945. 
Infectious  disease  mortality  increased  in  the 
1980s  and  early  1990s  in  persons  aged  25  years 
and  older  and  was  mainly  due  to  the  emergence 
of  the  acquired  immunodeficiency  syndrome 
(AIDS)  in  25-  to  64-year-olds  and,  to  a  lesser 
degree,  to  increases  in  pneumonia  and  influ- 
enza deaths  among  persons  aged  65  years  and 
older.  There  was  considerable  year-to-year  vari- 
ability in  infectious  disease  mortality,  especially 
for  the  youngest  and  oldest  age  groups.  CON- 
CLUSIONS: Although  most  of  the  20th  cen- 


728 


Respiratory  Care  •  July  1999  Vol  43  No  7 


ijour  oriificiol  oiriiiflijs  shills 


PROFESSIONAL  DEVELOPMENT  SOFTWARE  -  $65  EACH 

Requires  Windows  3.1  or  higher  •  Available  on  31/2"  disk  •  PC  Format  only 


Basic  Spirometry  and 
Pulmonary  Function 
Testing  ISfew! 


Discusses  the  rationale  for  the  use  of  basic  PFT  and  the 
techniques  and  use  of  the  basic  forced  exhalation  spirograph. 
Details  how  tracings  are  used  to  illustrate  the  various  lung 
volumes  and  capacities  and  presents  the  use  of  the  spirogram  as 
a  method  to  document  the  difference  between  obstructive  and 
restrictive  lung  disorders. 

Item  PELS 


Advanced  Pulmonary 
Function  Testing  ISfew! 

Introduces  the  measurement  of  the  various  flows  obtainable 
in  a  forced  exhalation  tracing  including  the  FEF25.75  and 
FEF200-1200  I"  addition,  the  measurement  techniques  and  signif- 
icance of  MW,  diffusing  capacity  and  closing  volume  are 
presented.  Also  included  are  methods  for  comparing  and 
contrasting  the  measuring  residual  volume  and  the  tracings 
obtained  in  flow-volume  loop  studies. 
Item  PEL6 


IISPs  (INDIVIDUAL  INDEPENDENT  STUDY  PACKAGES)  -  $12  each 


Classification  of  Mechanical  Ventilators  I 

Outlines  the  basic  concepts  of  ventilator  classification  and  a 
mathematical  model  of  the  respiratory  system  that  provides  the 
basis  for  classifying  ventilator  control  systems.  Also  teaches  the 
specific  criteria  for  determining  whether  a  ventilator  primarily 
controls  pressure,  volume,  or  flow. 
Item  CS18 

Classification  of  Mechanical  Ventilators  II 

You  will  learn  detailed  information  about  the  control  of  ventila- 
tion in  terms  of  switching  from  inspiration  to  expiration.  You 


will  also  be  introduced  to  the  common  drive  mechanisms  used 
in  various  mechanical  devices. 
Item  CS19 

Classification  of  Mechanical  Ventilators  III 

Explores  the  output  waveforms  that  ventilators  produce  and 
their  clinical  implications.  Instructs  in  the  various  modes  of 
ventilation  in  terms  of  the  specific  combinations  of  control 
characteristics  along  with  ventilator  performance  testing  and  the 
practical  application  of  ventilator  classification. 
Item  CS20 


PERSONAL  INSTRUCTION  ON  VIDEOTAPE  -  $49.95  ($99  nonmembers) 
Airway  Management:  Tricks  of  the  Trade 

Learn  how  to  manage  the  obstructed  airway  and  how  to  determine  when  an  artificial  airway  is  necessary.  Also  presented  are  the 
methods  of  assessing  endotracheal  tube  positioning,  monitoring  the  intubated  patient,  and  determining  when  extubation  is  feasible. 
Featuring  Charles  G.  Durbin,  Jr.,  MD,  FCCM,  and  David  J.  Pierson,  MD. 
Item  VC67 

To  place  your  order,  please  call: 


972-243-2271! 


Texas  customers  only,  please  add  8.25%  sales  tax  (including  shipping  charges).  Texas  customers  who  are  exempt  from  sales  tax  must 


supply  an  exemption  certificate.  MasterCard,  Visa,  Institutional  Purchase  Order  or  check  payable  to: 

Doedolus  Enterprises,  Inc 


Handling  &  Shipping  Charges 

$  0  -  $25  IS  $5.25 
$25.01  -  $80.00  IS  $8.25 
$80.01  -  $200.00  IS  $12.25 
$200.01  -  $300.00  IS  $16.25 


ATTN.  Order  Fulfillment  Department 
11030  Abies  Lane  •  Dallas,  Texas  75229 
Phone  972-243-2272  Fax:  972-484-6010 

Discover  other  related  products  within  "Key  to  Professional  Excellence"  @  www.aarc.org 


Abstracts 


tury  has  been  marked  by  declining  infectious 
disease  mortality,  substantial  year-to-year  vari- 
ation as  well  as  recent  increases  emphasize  the 
dynamic  nature  of  infectious  diseases  and  the 
need  for  preparedness  to  address  them. 

Quality  End-of-Life  Care:  Patients'  Perspec- 
tives— Singer  PA,  Martin  DK,  Kelner  M.  JAMA 
I999;281(2):I63. 

CONTEXT:  Quality  end-of-life  care  is  increas- 
ingly recognized  as  an  ethical  obligation  of 
health  care  providers,  both  clinicians  and  orga- 
nizations. However,  this  concept  has  not  been 
examined  from  the  perspective  of  patients.  OB- 
JECTIVE: To  identify  and  describe  elements  of 
quality  end-of-life  care  from  the  patient's  per- 
spective. DESIGN:  Qualitative  study  using  in- 
depth,  open-ended,  face-to-face  interviews  and 
content  analysis.  SETTING:  Toronto,  Ontario. 
PARTICIPANTS:  A  total  of  126  participants 
from  3  patient  groups:  dialysis  patients  (n  = 
48),  people  with  human  immunodeficiency  vi- 
rus infection  (n  =  40),  and  residents  of  a  long- 
term  care  facility  (n  =  38).  OUTCOME  MEA- 
SURES: Participants'  views  on  end-of-life 
issues.  RESULTS:  Participants  identified  5  do- 
mains of  quality  end-of-life  care:  receiving  ad- 
equate pain  and  symptom  management,  avoid- 
ing inappropriate  prolongation  of  dying, 
achieving  a  sense  of  control,  relieving  burden, 
and  strengthening  relationships  with  loved  ones. 
CONCLUSION:  These  domains,  which  char- 
acterize patients'  perspectives  on  end-of-life 
care,  can  serve  as  focal  points  for  improving  the 
quality  of  end-of-life  care. 

Leuliotricne-Receptor  Antagonists — Lip- 
worth  BJ.  Lancet  1999;353(9146):57. 

Leukotriene-receptor  antagonists  are  the  first 
novel  class  of  antiasthma  drugs  to  become  avail- 
able over  the  past  three  decades.  They  have  an 
unique  profile  in  that  they  are  a  hybrid  of  an 
anti-inflammatory  and  bronchodilator  drug,  and 
they  can  be  taken  as  a  tablet  once  or  twice 
daily.  The  published  data  with  leukotriene-re- 
ceptor antagonists  such  as  montelukast  or 
zafirlukast  show  good  antiasthmatic  activity 
over  a  wide  spectrum  of  asthma  severity  either 
as  monotherapy  or  with  inhaled  steroids.  An- 
other potential  spin-off  of  leukotriene-receptor 
antagonists  is  that  they  also  seem  to  be  effec- 
tive in  treating  allergic  rhinitis,  which  commonly 
coexists  in  patients  with  asthma.  Here  I  over- 
view the  clinical  pharmacology  of  leukotriene 
antagonists  and  appraise  the  published  data  from 
clinical  trials,  and  look  at  the  appropriate  posi- 
tion of  these  agents  in  asthma  management 
guidelines. 

Lung  Function  in  Infants  with  Wheezing  and 
Gastroesophageal  Reflux — Sheikh  S,  Gold- 
smith LJ,  Howell  L,  Hamlyn  J,  Eid  N.  Pediatr 
Pulmonol  1999  Apr:27(4):236-241. 


Eighty-four  otherwise  healthy  infants  with  daily 
wheezing  underwent  infant  pulmonary  function 
tests  (IPFTs)  and  24-h  esophageal  pH  probe 
studies.  Fifty-four  (64%)  infants  had  positive 
pH  probe  studies,  and  30  infants  had  negative 
pH  probe  studies.  Many  infants  in  both  groups 
had  evidence  of  peripheral  airflow  obstruction 
at  tidal  breathing  and  on  forced  expiration  as 
measured  by  thoracoabdominal  compression.  In 
infants  with  gastroesophageal  reflux  (GER), 
only  9  of  54  (16.6%)  responded  to  bronchodi- 
lator therapy  compared  to  20  of  30  (66.6%)  in 
the  group  with  negative  pH  probe  studies  (p  < 
0.0005).  In  infants  with  positive  pH  studies, 
family  history  of  asthma  (n  =  16)  correlated 
well  with  positive  response  to  bronchodilators 
(p  <  0.0005),  and  all  infants  exposed  to  mater- 
nal smoking  (n  =  11)  had  no  response  to  bron- 
chodilators. Forty-four  percent  of  infants  with  a 
positive  pH  probe  had  no  gastrointestinal  symp- 
toms suggestive  of  GER.  In  infants  with  a  neg- 
ative pH  probe,  family  history  of  asthma  (n  = 
24)  correlated  well  with  positive  response  to 
bronchodilators  (p  <  0.0005),  and  exposure  to 
maternal  smoking  (n  =  8)  correlated  well  with 
no  response  to  bronchodilator  therapy  p< 
0.0005).  We  conclude  that  silent  GER  is  com- 
mon in  infants  with  persistent  wheezing.  Fur- 
thermore, infants  with  GER  are  less  likely  to 
respond  to  bronchodilator  therapy,  and  expo- 
sure to  maternal  smoking  and  family  history  of 
asthma  may  be  significant  independent  factors. 

Synchronized  Gas  and  Partial  Liquid  Venti- 
lation in  Lung-Injured  Animals:  Improved 
Gas  Exchange  with  Decreased  Effort — Ben- 
del-Stenzel  EM,  Bing  DR,  Meyers  PA,  Connett 
JE,  Mammel  MC.  Pediatr  Pulmonol  1999  Apr; 
27(4):242-250. 

We  hypothesized  that  partial  liquid  ventilation 
(PLV)  with  perflubron  in  spontaneously  breath- 
ing lung-injured  animals  would  increase  respi- 
ratory workload  compared  to  animals  treated 
with  gas  ventilation  (GV),  and  that  a  fully  syn- 
chronized mode,  assist-control  ventilation  (AC), 
would  reduce  the  piglets'  effort  when  compared 
to  intermittent  mandatory  ventilation  (IMV)  or 
synchronized  IMV  (SIMV)  during  both  GV  and 
PLV.  Newborn  piglets  with  saline  lavage-in- 
duced  lung  injury  were  randomized  to  sequen- 
tial 30-min  periods  of  IMV  -^  SIMV  -^  AC 
(n  =  5),  or  AC  -»  SIMV  -^  IMV  (n  =  5) 
during  GV  followed  by  PLV.  Pulmonary  me- 
chanics measurements  and  an  esophageal  pa- 
tient effort  index  (PEI,  defined  as  the  product  of 
the  area  below  baseline  of  the  esophageal  pres- 
sure-time curve  and  respiratory  rate  [RR])  were 
determined  to  estimate  the  patient's  nonme- 
chanical  work  of  breathing,  using  a  computer- 
assisted  lung  mechanics  analyzer.  GV  to  PLV 
comparisons  showed  no  change  in  PEI  (IMV, 
57.8  vs.  49.7;  SIMV,  52.3  vs.  46.8;  AC,  15.7 
vs.  13.7  cm  HjO  x  s/min);  intermode  compar- 
isons showed  significantly  decreased  PEI  in  AC 


vs.  IMV  and  SIMV  during  GV,  and  in  AC  vs. 
SIMV  (AC  vs.  IMV,  p  =  0.06)  during  PLV. 
AC  consistently  resulted  in  the  highest  minute 
ventilation,  lowest  total  respiratory  rate,  most 
physiologic  pH,  and  least  tidal  volume  variabil- 
ity. These  observations  suggest  that  synchroni- 
zation with  AC  during  GV  and  PLV  may  have 
substantial  physiologic  benefits. 

Lung  Function  Measures  and  Their  Rela- 
tionship to  Respiratory  Symptoms  in  7-  and 
8- Year-Old  Children— Droste  JH,  Wieringa 
MH,  Weyler  JJ,  Nelen  VJ,  Van  Bever  HP,  Ver- 
meire  PA.  Pediatr  Pulmonol  1999  Apr;27(4): 
260-266. 

Abnormal  pulmonary  function  in  childhood  is  a 
well-known  risk  factor  for  lung  function  im- 
pairment in  adult  life.  It  is  therefore  of  clinical 
interest  to  recognize  lower  pulmonary  function 
in  childhood.  We  investigated  the  association 
between  asthma-like  respiratory  symptoms  and 
the  lung  function  parameters  FVC,  FEV,,  and 
FEF25_75  in  a  population-based  sample  of  402 
schoolchildren,  aged  7  and  8  years,  using  linear 
regression  analyses.  Without  accounting  for 
other  respiratory  symptoms,  wheeze,  exercise- 
induced  wheeze,  chronic  cough,  and  history  of 
wheezy  bronchitis  or  lower  respiratory  infec- 
tions in  early  childhood  were  significantly  as- 
sociated with  reduced  lung  function.  After  step- 
wise elimination  of  symptoms  from  the 
regression  models,  only  exercise-induced 
wheeze  (FEV,,  -15%pred,  FEF25_,5, 
-21%pred)  and  a  history  of  chronic  cough 
(FEV,,  -5%pred;  FEFj,_„,  -ll%pred)  re- 
mained significant  predictors  of  decreased  lung 
function.  After  adjustment  for  different  vari- 
ability, no  significant  differences  were  seen  be- 
tween the  effects  of  symptoms  on  the  flow  mea- 
surements FEV,  and  FEF25_75.  We  conclude 
that  children  who  report  exercise-induced 
wheeze  and/or  chronic  cough  may  have  a  con- 
siderable deficit  in  lung  function  at  early  school 
age. 

Evaluation  of  Home  Audiotapes  as  an  Ab- 
breviated Test  for  Obstructive  Sleep  Apnea 
Syndrome  (OSAS)  in  Children — Lamm  C, 
Mandeli  J,  Kattan  M.  Pediatr  Pulmonol  1999 
Apr;27(4):267-272. 

Snoring  occurs  commonly  in  children  and  is 
sometimes  associated  with  obstructive  sleep  ap- 
nea syndrome  (OSAS).  Based  on  clinical  his- 
tory alone,  it  is  difficult  to  distinguish  primary 
snoring,  characterized  by  noisy  breathing  dur- 
ing sleep  without  apnea  or  hypoventilation,  from 
snoring  indicative  of  OSAS.  An  overnight  poly- 
somnogram  (PSG)  is  required  to  establish  a  de- 
finitive diagnosis  of  OSAS.  Becau.se  sleep  eval- 
uations are  costly  and  resources  are  limited,  we 
evaluated  whether  a  home  audiotape  recording 
could  accurately  identify  children  with  OSAS. 
We  studied  36  children  referred  by  pediatri- 


730 


Respiratory  Care  •  July  1999  Vol  43  No  7 


ACHIEVERS 


Announcing  an  alUnew  television 
series  devoted  to  ACHIEVERS. 

What  makes  an  ACHIEVER? 


ACHIEVERS  take  charge  of 
their  lives . . .  they  serve  as 
role  models ...  they  view 
challenges  as  opportunities. . . 
they  take  control  of  their 
health  and  fitness. 

Each  week  on  ACHIEVERS, 
you'll  watch  an  intimate 
portrait  of  a  person  who  is 
winning  the  battle  against 
asthma/allergy  You'll  take  a 
journey  through  a  personal 
landscape  -  one  marked 
by  stark  honesty,  increased 
awareness  and  renewed  hope. 

So  watch,  be  inspired,  be 
informed,  be  an  ACHIEVER. 

ACHIEVERS  is  brought  to  you  by 


/f=M 


For  channel  and  times  in  your  area,  check  your 
local  listing  or  go  to  http://www.ktv-i.com 


KALEroOSCOPE 


My-i.com 


Live  on  the  Web.  24  hrs  a  davTl 


Abstracts 


cians  and  otolaryngologists  for  possible  OSAS. 
Parents  completed  a  questionnaire  about  their 
child's  sleep  and  breathing  and  made  a  15-min 
audiotape  of  the  child's  breath  sounds  during 
sleep.  Overnight  PSGs  were  performed  on  all 
patients.  There  were  29  patients  who  completed 
the  study:  1.^  patients  in  the  Primary  Snoring 
group  (apnea/hypopnea  index  <  5)  and  14  pa- 
tients in  the  OSAS  group  (apnea/hypopnea  in- 
dex a  5).  No  significant  statistical  differences 
existed  between  the  two  groups  for  physical 
characteristics  or  questionnaire  responses. 
Seven  observers  analyzed  the  audiotapes  for  the 
presence  of  a  struggle  sound  and  respiratory 
pau.ses.  The  median  sensitivity  of  the  audiotape 
as  a  predictor  of  OSAS  was  71%  (range  43- 
86%),  and  the  median  specificity  was  80% 
(range  67-80%).  The  presence  of  a  struggle 
sound  on  the  audiotape  was  the  parameter  most 
predictive  of  OSAS.  There  was  a  good  level  of 
agreement  among  the  seven  audiotape  observ- 
ers, as  demonstrated  by  a  mean  and  range  kappa 
statistic  of  0.70  (0.50-0.9.3)  for  the  21  pairs  of 
observers.  Using  a  clinical  score  to  predict 
OSAS,  the  sensitivity  was  46%.  and  the  spec- 
ificity was  83%.  We  conclude  that  findings  on 
a  home  audiotape  can  be  suggestive  of  OSAS, 
but  are  not  sufficiently  specific  to  reliably  dis- 
tinguish primary  snoring  from  OSAS. 

Delivery  Room  Management  of  Extremely 
Low  Birth  Weight  Infants:  Spontaneous 
Breathing  or  Intubation? — Lindner  W,  Voss- 
beck  S,  Hummler  H,  Pohlandt  F.  Pediatrics  1 999 
May;  103(5  Pt  l):96l-967. 

Objective.  To  study  the  effect  of  two  different 
delivery  room  (DR)  policies  on  the  rate  of  en- 
dotracheal intubation  and  mechanical  ventila- 
tion (EI/MV)  and  short  term  morbidity  in  ex- 
tremely low  birth  weight  infants  (ELBWI; 
<I000  g,  a  24  weeks).  Methods.  Retrospec- 
tive cohort  study  of  123  inborn  ELBWIs  bom 
in  1994  and  in  1996.  DR  policies  have  changed. 
Until  1994,  ELBWIs  were  intubated  immedi- 
ately after  delivery  when  presenting  the  slight- 
est signs  of  respiratory  distress  or  asphyxia  af- 
ter initial  resuscitation  using  a  face  mask  and  a 
handbag.  During  1995,  the  guidelines  for  respi- 
ratory support  were  changed.  In  1996,  contin- 
uous (15  to  20  seconds),  pressure  controlled 
(20  to  25  cm  HjO)  inflation  of  the  lungs  using 
a  nasal  pharyngeal  tube,  followed  by  continu- 
ous positive  airway  pressure  (CPAP;  4  to  6  cm 
HjO)  was  applied  to  all  ELBWIs  immediately 
after  delivery  to  establish  a  functional  residual 
capacity  and  perhaps  to  avoid  EI/MV.  In  addi- 
tion to  the  changes  in  respiratory  support,  the 
prevention  of  conductive  and  evaporative  heat 
loss  was  improved  in  1996.  For  analysis  of  mor- 
bidity and  mortality,  infants  were  matched  for 
gestational  age  and  birth  weight.  Results.  The 
rate  of  EI/MV  in  the  DR  decreased  from  84% 
in  1994  to  40%  in  1996.  In  1996,  25%  of  the 
ELBWIs  were  never  intubated  (7%  in  1994), 


but  35%  of  the  ELBWIs  needed  secondary  EI/ 
MV,  primarily  because  of  respiratory  distress 
syndrome  (RDS).  Initial  ventilator  settings,  ven- 
tilator days,  mortality,  and  morbidity  were  not 
different  between  ELBWIs  with  EI/MV  in 
the  DR  and  infants  with  secondary  EI/MV  at- 
tributable to  RDS  in  the  intensive  care  unit. 
ELBWIs  with  no  EI/MV  that  was  caused  by 
RDS  had  a  lower  morbidity  (ie,  bronchopulmo- 
nary dysplasia,  intraventricular  hemorrhage 
>grade  2  and/or  periventricular  leukomalacia), 
mortality,  and  fewer  hospital  days  (mean:  79  vs 
105  days).  The  incidence  of  gastrointestinal  ad- 
verse effects  like  feeding  intolerance  or  necro- 
tizing enterocolitis  was  not  increased  in  1996. 
Paco,  W''**  significantly  higher  at  admission  to 
the  neonatal  unit  in  ELBWIs  with  CPAP  in 
1996  (54  ±  15  mm  Hg,  7.2  ±  2.0  kPa)  com- 
pared with  infants  with  EI/MV  in  1994  (38  ± 
1 1  mm  Hg,  5.1  ±  1.  5  kPa.  A  total  of  26%  of 
spontaneously  breathing  infants  had  hypercap- 
nia  (Paco,  —  60  mm  Hg  [8.0  kPa]),  compared 
with  7%  of  infants  with  EI/MV  in  1994.  Within 
the  first  few  hours  of  life,  Paco,  decreased  to  46 
(32  to  57)  mm  Hg  (6. 1  [4.3  to  7".6|  kPa)  in  never 
intubated  ELBWIs  (n  =  17),  but  increased  to 
70  (57  to  81)  mm  Hg  (9.3  [7.6  to  10.8]  kPa)  in 
ELBWIs  (n  =  14)  with  RDS  and  secondary 
EI/MV  (age  5.5  [  1  to  44[  hours).  Conclusions. 
In  our  setting,  the  individualized  intubation  strat- 
egy in  the  DR  restricted  EI/MV  to  those  ELB- 
WIs who  ultimately  needed  it,  without  increas- 
ing morbidity  or  mortality  in  infants  with 
secondary  EI/MV  attributable  to  RDS.  We  spec- 
ulate that  an  individualized  intubation  strategy 
of  the  ELBWI  is  superior  to  immediate  intuba- 
tion of  all  ELBWIs  with  slight  signs  of  respi- 
ratory distress  after  birth. 

Prognostic  Models  of  Thirty-Day  Mortality 
and  Morbidity  After  Major  Pulmonary  Re- 
section— Harpole  DH  Jr,  DeCamp  MM  Jr,  Da- 
ley J,  Hur  K,  Oprian  CA.  Henderson  WG,  Khuri 
SF.  J  Thorac  Cardiovasc  Surg  1999May;l  17(5): 
969-979. 

BACKGROUND:A  part  of  the  prospective, 
multi-institutional  National  Veterans  Affairs 
Surgical  Quality  Improvement  Program  was  de- 
veloped to  predict  30-day  mortality  and  mor- 
bidity for  patients  undergoing  a  major  pulmo- 
nary resection.  Methods:  Perioperative  data 
were  acquired  from  194,319  noncardiac  surgi- 
cal operations  at  1 23  Veterans  Affairs  Medical 
Centers  between  October  I,  1991,  and  August 
31,1 995.  Current  Procedural  Terminology  code- 
based  analysis  was  undertaken  for  major  pul- 
monary resections  (lobectomy  and  pneumonec- 
tomy). Preoperative,  intraoperative,  and 
outcome  variables  were  collected.  The  30-day 
mortality  and  morbidity  models  were  developed 
by  means  of  multivariable  stepwise  logistic  re- 
gression with  the  preoperative  and  intraopera- 
tive variables  used  as  independent  predictors  of 
outcome.  Results:  A  total  of  35 16  patients  (mean 


age  64  ±  9  years)  underwent  either  lobectomy 
(n  =  2949)  or  pneumonectomy  (n  =  567).  Thir- 
ty-day mortality  was  4.0%  for  lobectomy  (119/ 
2949)  and  1 1 .5%  for  pneumonectomy  (65/567). 
The  preoperative  predictors  of  30-day  mortality 
were  albumin,  do  not  resuscitate  status,  trans- 
fusion of  more  than  4  units,  age.  disseminated 
cancer,  impaired  sensorium.  prothrombin  time 
more  than  12  seconds,  type  of  operation,  and 
dyspnea.  When  the  intraoperative  variables  w,^e 
considered,  intraoperative  blood  loss  was  added 
to  the  preoperative  model.  In  the  presence  of 
these  intraoperative  variables  in  the  model,  do 
not  resuscitate  status  and  prothrombin  time  more 
than  12  seconds  were  only  marginally  signifi- 
cant. Thirty-day  morbidity,  defined  as  the  pres- 
ence of  1  or  more  of  the  2 1  predefined  compli- 
cations, was  23.8%  for  lobectomy  (703/2949) 
and  25.7%  for  pneumonectomy  (146/567).  In 
multivariable  models,  independent  preoperative 
predictors  (p  <.05)  of  30-day  morbidity  were 
age,  weight  loss  greater  than  1 0%  in  the  6  months 
before  surgery,  history  of  chronic  obstructive 
pulmonary  disease,  transfusion  of  more  than  4 
units,  albumin,  hemiplegia,  smoking,  and  dys- 
pnea. When  intraoperative  variables  were  added 
to  the  preoperative  model,  the  duration  of  op- 
eration time  and  intraoperative  transfusions  were 
included  in  the  model  and  albumin  became  mar- 
ginally significant.  Conclusions:  This  analy.sis 
identifies  independent  patient  risk  factors  that 
are  associated  with  30-day  mortality  and  mor- 
bidity for  patients  undergoing  a  major  pulmo- 
nary resection.  This  .series  provides  an  initial 
risk-adjustment  model  for  major  pulmonary  re- 
sections. Future  refinements  will  allow  com- 
parative assessment  of  surgical  outcomes  and 
quality  of  care  at  many  institutions. 

Systematic  Review  of  Antistaphylococcal  An- 
tibiotic Therapy  in  Cystic  Fibrosis — McCaf- 
fery  K,  Olver  RE,  Franklin  M,  Mukhopadhyay 
S.  Thorax  1999  May;54(5):380-383. 

BACKGROUND:  The  respiratory  tract  in  pa- 
tients with  cystic  fibrosis  is  frequently  colo- 
nised with  Staphylococcus  aureus.  There  is  great 
diversity  of  clinical  practice  in  this  area  of  cy.s- 
tic  fibrosis.  A  systematic  review  was  conducted 
to  study  the  evidence  relating  antistaphylococ- 
cal therapy  to  clinical  outcoine  in  patients  with 
cystic  fibrosis.  METHODS:  A  .search  strategy 
already  evaluated  for  the  study  of  the  epidemi- 
ology of  cystic  fibrosis  clinical  trials  was  used. 
This  yielded  3188  references  from  which  13 
clinical  trials  of  antistaphylococcal  therapy  were 
identified.  RESULTS:  Substantial  heterogene- 
ity was  observed  between  trials.  In  the  13  clin- 
ical trials  a  total  of  19  antibiotics  were  used  to 
assess  a  wide  variety  of  outcome  measures  (1 1 
clinical,  six  laboratory).  Both  intermittent  and 
continuous  treatment  strategies  were  used.  Spu- 
tum clearance  of  5  aureus  was  more  frequently 
achieved  than  any  other  beneficial  outcome.  A 
beneficial  effect  on  pulmonary  function  was 


732 


Respiratory  Care  •  July  1999  Vol  43  No  7 


rarely  measured  or  observed.  Although  five  ran- 
domised chnical  trials  were  identified,  the  ex- 
tent of  heterogeneity  precluded  the  use  of  meta- 
analysis for  further  synthesis  of  information. 
CONCLUSIONS:  Antistaphylococcal  treat- 
ment achieves  sputum  clearance  of  5  aureus  in 
patients  with  cystic  fibrosis.  Prophylactic  anti- 
staphylococcal treatment  in  young  children  with 
cystic  fibrosis  is  likely  to  be  of  clinical  benefit. 
It  remains  to  be  determined  whether  the  use  of 
"prophylactic"  versus  "intermittent"  antistaphy- 
lococcal therapy  in  cystic  fibrosis  is  associated 
with  improved  lung  function  and/or  chest  ra- 
diographic scores,  an  increase  in  bacterial  re- 
sistance, or  earlier  acquisition  of  Pseudomona.s 
aeruginosa.  A  large  randomised  clinical  trial 
lasting  approximately  two  years  is  urgently  re- 
quired to  address  this  problem. 

Oral  Airway  Resistance  During  Wakefulness 
in  Patients  with  Obstructive  Sleep  Apnoea — 

Amis  TC,  O'Neill  N,  Wheatley  JR.  Thorax  1999 
May;54(5):423-426. 

BACKGROUND:  Patients  with  obstructive 
sleep  apnoea  (OSA)  have  a  number  of  upper 
airway  structural  abnormalities  which  may  in- 
fluence the  resistance  of  the  oral  airway  to  air- 
flow. There  have  been  no  systematic  studies  of 
the  flow  dynamics  of  the  oral  cavity  in  such 
patients.  METHODS:  Inspiratory  oral  airway 
resistance  to  airflow  (RO)  was  measured  in  13 
awake  patients  with  OSA  in  both  the  upright 
and  supine  positions  (neck  position  constant). 
Each  subject  breathed  via  a  mouthpiece  while 
the  nasal  airway  was  occluded  with  a  nasal  mask. 
RESULTS:  In  the  upright  position  the  mean 
(SE)  RO  was  1.26  (0.19)  cm  H,0/L/s  (at  0.4 
L/s)  which  increased  to  2.01  (0.43)  cm  H^O/L/s 
when  supine  (p<0.0.5,  paired  f  test).  The  mag- 
nitude of  this  change  correlated  negatively  with 
the  respiratory  disturbance  index  (r  =  -0.60, 
p  =  0.03).  CONCLUSION:  In  awake  patients 
with  OSA  RO  is  normal  when  upright  but  ab- 
normally raised  when  in  the  supine  position. 

A  Pliysiological  Comparison  of  Flutter  Valve 
Drainage  Bags  and  Underwater  Seal  Systems 
for  Postoperative  Air  Leaks — Waller  DA,  Ed- 
wards JG.  Rajesh  PB.  Thorax  1999  May:54(5): 
442-443. 

BACKGROUND:  A  study  was  undertaken  to 
compare  the  relative  physiological  effects  of 
underwater  seal  (UWS)  versus  flutter  valve  (FV) 
pleural  drainage  systems  in  the  treatment  of  post- 
operative air  leaks.  METHOD:  Fourteen  patients 
with  air  leaks  of  1-1 1  days  duration,  following 
lobectomy  (n  =  5),  buUectomy  (n  =  4),  decor- 
tication (n  =  4),  and  pleural  biopsy  (n  =  I) 
were  analysed.  Intrapleural  pressure  (IPP)  mea- 
surements were  made  using  an  in-line  external 
strain  gauge  connected  directly  to  the  intercos- 
tal tube.  Patients  were  connected  simultaneously 
to  both  UWS  and  FV  drainage  systems  and 


EZTape  is  just  that 
...Easy! 

That's  why  we  made  easy  part  of  its  name. 
EZTape  is  a  superior  endotracheal  tube  securing 
device  that  is  easy  for  the  respiratory  therapist  to  use 
while  providing  ease  for  the  patient. 

Seeing  the  need  for  a  simple,  more  efficient 
method  of  stabilizing  endotracheal  tubes,  EZTape 
was  invented  and  patented  by  one  of  your  own  —  a 
respiratory  therapist. 

Blake  Medical's  EZTape  is  made  of 
hypoallergenic,  wetproof  tape  with  a  special  non- 
adhesive  area  for  the  patient's  neck.  The  simple,  pre- 
cut  design  attaches  in  seconds  and  fits  both  adult  and 
pediatric  patients.  No  more  tearing  tape.  It's  easy! 
Just  call: 

800/989-4553  or  912/388-8080 
for  free  samples 


l^al<e  medical  inc. 


Circle  108  on  reader  service  card 


pressures  were  measured  sequentially,  isolating 
each  system  in  turn.  Maximum  (IPPmax)  and 
minimum  (IPPmin)  intrapleural  pressures  were 
calculated  from  graphic  traces.  The  degree  of 
lung  expansion  was  recorded  by  chest  radiog- 
raphy. RESULTS:  At  resting  tidal  volume 
IPPmax  was  significantly  higher  with  the  UWS 
system  (mean  difference  0.8  mm  Hg,  95%  CI  0 
to  1 .6,  p  =  0.046)  and  IPPmin  was  significantly 
lower  with  the  FV  system  ( 1 .8  mm  Hg,  9.S%  CI 
0.3  to  3.3,  p  =  0.023).  The  lung  was  fully  ex- 
panded in  50%  of  patients  at  the  time  of  study. 
The  mean  difference  in  IPPmin  between  sys- 
tems was  significantly  increased  when  the  lung 
was  fully  expanded  (mean  2.8  mm  Hg,  95%  CI 
0.1  to  5.5,  p  =  0.042).  The  mean  difference  in 
IPPmax  was  not  affected  by  the  degree  of  lung 
expansion  (0.79,  95%  CI  -0.83  to  2.4,  p  = 
0.31).  CONCLUSION:  The  results  of  this  study 
suggest  that,  when  postoperative  air  leak  exists 
without  a  persistent  pleural  space,  the  flutter 
valve  may  provide  a  physiologically  more  ef- 
fective alternative  to  the  underwater  seal  drain- 
age system. 


Reducing  the  Rate  of  Nosocomially  Trans- 
mitted Respiratory  Syncytial  Virus — Karan- 
fil  LV,  Conlon  M,  Lykens  K.  Masters  CF.  For- 
man  M,  Griffith  ME,  et  al.  Am  J  Infect  Control 
1999  Apr;27(2):91-96. 


BACKGROUND:  A  large  number  ( 1 7)  of  nos- 
ocomial respiratory  syncytial  virus  cases  led  to 
the  development  of  control  measures  to  prevent 
transmission  of  respiratory  syncytial  virus 
(RSV)  within  the  Johns  Hopkins  Hospital's 
Children's  Center.  METHODS:  The  control 
plan  is  based  on  a  2-stage  process.  In  stage  1, 
the  staff  are  notified  that  RSV  is  in  the  com- 
munity, and  information  is  distributed  through 
a  communication  tree.  Stage  2  requires  that  na- 
sopharyngeal aspirates  be  obtained  from  all  chil- 
dren <  3  years  of  age  who  have  respiratory 
symptoms.  The  aspirates  are  tested  directly  for 
RSV  antigen  and  cultured  for  RSV.  The  chil- 
dren are  placed  on  pediatric  droplet  precautions 
pending  those  results.  RESULTS:  The  propor- 
tion of  nosocomial  RSV  cases  dropped  from 
16.5%  before  the  use  of  RSV  control  measures 
to  7.2%  after  the  initiation  of  the  control  pro- 
gram. A  case  of  RSV  identified  in  the  hospital 
was  2.6  times  more  likely  to  be  nosocomially 
acquired  before  the  intervention  compared  with 
after  the  intervention.  Approximately  14  cases 
of  RSV  are  prevented  each  year,  which  results 
in  a  savings  of  56  hospital-days  and  more  than 
$84,000  in  direct  hospital-related  charges  alone. 
CONCLUSIONS:  The  nosocomial  spread  of 
RSV  can  be  reduced  by  a  specific  and  feasible 
control  plan  that  includes  early  identification 
and  rapid  isolation  of  potential  RSV  cases. 


Respiratory  Care  •  July  1 999  Vol  43  No  7 


733 


Abstracts 


Bacterial  Contamination  of  the  Hands  of  Hos- 
pital Staff  During  Routine  Patient  Care — 

Pittet  D.  Dharan  S,  Touveneau  S,  Sauvan  V, 
Pemeger  TV,  Arch  Intern  Med  1999  Apr  26; 
159(8):821-826. 

BACKGROUND:  Cross-transmission  of  micro- 
organisms by  the  hands  of  health  care  workers 
is  considered  the  main  route  of  spread  of  nos- 
ocomial infections.  OBJECTIVE:  To  study  the 
process  of  bacterial  contamination  of  health  care 
workers'  hands  during  routine  patient  care  in  a 
large  teaching  hospital.  METHODS:  Structured 
observations  of  417  episodes  of  care  were  con- 
ducted by  trained  external  observers  (S.T.  and 
V.S.).  Each  observation  period  started  after  a 
hand-cleansing  procedure  and  ended  when  the 
health  care  worker  proceeded  to  clean  his  or  her 
hands  or  at  the  end  of  a  coherent  episode  of 
care.  At  the  end  of  each  period  of  observation, 
an  imprint  of  the  5  fingertips  of  the  dominant 
hand  was  taken  and  bacterial  colony  counts  were 
quantified.  Regression  methods  were  used  to 
model  the  intensity  of  bacterial  contamination 
as  a  function  of  method  of  hand  cleansing,  use 
of  gloves  during  patient  care,  duration  and  type 
of  care,  and  hospital  ward.  RESULTS:  Bacte- 
rial contamination  increased  linearly  with  time 
on  ungloved  hands  during  patient  care  (aver- 
age, 1 6  colony-forming  units  [CPUs]  per  minute; 
9.S%  confidence  interval,  11-21  CPUs  per 
minute).  Patient  care  activities  independently 
(p  <  0.05  for  all)  associated  with  higher  con- 
tamination levels  were  direct  patient  contact, 
respiratory  care,  handling  of  body  fluid  secre- 
tions, and  rupture  in  the  sequence  of  patient 
care.  Contamination  levels  varied  with  hospital 
location;  the  medical  rehabilitation  ward  had 
higher  levels  (49  CPUs;  p  =  0.03)  than  did 
other  wards.  Pinally,  simple  hand  washing  be- 
fore patient  care,  without  hand  antisepsis,  was 
also  associated  with  higher  colony  counts  (52 
CPUs;  p  =  0.03).  CONCLUSIONS:  The  dura- 
tion and  type  of  patient  care  affect  hand  con- 
tamination. Furthermore,  because  hand  antisep- 
sis was  superior  to  hand  washing,  intervention 
trials  should  explore  the  role  of  systematic  hand 
antisepsis  as  a  cornerstone  of  infection  control 
to  reduce  cross-transmission  in  hospitals. 

In-Hospital  Cardiopulmonary  Resuscitation: 
Prearrest  Morbidity  and  Outcome — de  Vos 

R,  Koster  RW,  De  Haan  RJ,  Oosting  H,  van  der 
Wouw  PA,  Lampe-Schoenmaeckers  AJ.  Arch 
Intern  Med  1999  Apr  26;l59(8):845-850. 

BACKGROUND:  Considerations  about  the  ap- 
plication of  cardiopulmonary  resuscitation 
(CPR)  should  include  the  expected  probability 
of  survival.  The  survival  probability  after  CPR 
may  be  more  accurately  estimated  by  the  oc- 
currence in  time  of  the  prearrest  morbidity  of 
patients.  OBJECTIVE:  To  identify  risk  factors 
for  poor  survival  after  CPR  in  relation  to  the 
dynamics  of  prearrest  morbidity.  METHODS: 


Medical  records  of  CPR  patients  were  reviewed. 
Prearrest  morbidity  was  established  by  catego- 
rizing the  medical  diagnoses  according  to  3  func- 
tional time  frames:  before  hospital  admission, 
on  hospital  admission,  and  during  hospital  ad- 
mission. Indicators  of  poor  survival  after  CPR 
were  identified  through  a  logistic  regression 
model.  RESULTS:  Included  in  the  study  were 
553  CPR  patients  with  a  median  age  of  68  years 
(age  range,  18-98  years);  21.7%  survived  to 
hospital  discharge.  Independent  indicators  of 
poor  outcome  were  an  age  of  70  years  or  older 
(odds  ratio  [OR] =0.6,  95%  confidence  interval 
[CI]  =  0.4-0.9),  stroke  (OR=0.3, 95%  CI=0. 1- 
0.7)  or  renal  failure  (OR=0.3,  95%  CI=0.1- 
0.8)  before  hospital  admission,  and  congestive 
heart  failure  during  hospital  admission 
(OR=0.4, 95%  CI=0.2-0.9).  Indicators  of  good 
survival  were  angina  pectoris  before  hospital 
admission  (OR  =  2. 1 ,  95%  CI=  1 .3-.3.3)  or  ven- 
tricular dysrhythmia  as  the  diagnosis  on  hospi- 
tal admission  (OR=11.0,  95%  CI=4.1-33.7). 
Ba,sed  on  a  logistic  regression  model,  17.4%  of 
our  CPR  patients  (n=  96)  were  identified  as 
having  a  high  risk  for  a  poor  outcome  (<  10% 
survival).  CONCLUSIONS:  Time  of  prearrest 
morbidity  has  a  prognostic  value  for  survival 
after  CPR.  Patients  at  risk  for  poor  survival  can 
be  identified  on  or  during  hospital  admission, 
but  the  reliability  and  validity  of  the  model  needs 
further  research.  Although  decisions  will  not  be 
made  by  the  model,  its  information  can  be  use- 
ful for  physicians  in  discussions  about  patient 
prognoses  and  to  make  decisions  about  CPR 
with  more  confidence. 

Spontaneous  Breathing  During  Ventilatory 
Support  Improves  Ventilation-Perfusion  Dis- 
tributions in  Patients  with  Acute  Respira- 
tory Distress  Syndrome — Putensen  C,  Mutz 
NJ,  Putensen-Himmer  G,  Zinserling  J.  Am  J 
Respir  Crit  Care  Med  1999  Apr;159(4  Pt  1): 
1241-1248. 

Ventilation-perfusion  (V^/Q)  distributions  were 
evaluated  in  24  patients  with  acute  respiratory 
distress  syndrome  (ARDS),  during  airway  pres- 
sure release  ventilation  (APRV)  with  and  with- 
out spontaneous  breathing,  or  during  pressure 
support  ventilation  (PSV).  Whereas  PSV  pro- 
vides mechanical  assistance  of  each  inspiration, 
APRV  allows  unrestricted  spontaneous  breath- 
ing throughout  the  mechanical  ventilation.  Pa- 
tients were  randomly  assigned  to  receive  APRV 
and  PSV  with  equal  airway  pressure  limits  (Paw) 
(n  =  12)  or  minute  ventilation  (V^-)  (n  =  12). 
In  both  groups  spontaneous  breathing  during 
APRV  was  associated  with  increases  (p  <  0.05) 
in  right  ventricular  end-diastolic  volume,  stroke 
volume,  cardiac  index  (CI),  P„o,,  oxygen  deliv- 
ery, and  mixed  venous  oxygen  tension  (Pvo,) 
and  with  reductions  (p  <  0.05)  in  pulmonary 
vascular  resistance  and  oxygen  extraction.  PSV 
did  not  consistently  improve  CI  and  ?„„,  when 
compared  with  APRV  without  spontaneous 


breathing.  Improved  V^/Q  matching  during 
spontaneous  breathing  with  APRV  was  evi- 
denced by  decreases  in  intrapulmonary  shunt 
(equal  Paw:  33  ±  4  to  24  ±  4%;  equal  V^: 
32  ±  4  to  25  ±  2%)  (p  <  0.05),  dead  space 
(equal  Paw:  44  ±  9  to  38  ±  6%;  equal  W^: 
44  ±  9  to  38  ±  6%)  (p  <  0.05),  and  the  dis- 
persions of  ventilation  (equal  Paw:  0.96  ±  0.23 
to  0.78  ±  0.22;  equal  V^:  0.92  ±  0.23  to  0.79  ± 
0.22)  (p  <  0.05),  and  pulmonary  blood  flow 
distribution  (equal  Paw:  0.89  ±  0.12  to  0.72  ± 
0.10;  equal  V^:  0.94  ±  0.19  to  0.78  ±  0.22) 
(p  <  0.05).  PSV  did  not  improve  V^/Q  distri- 
butions when  compared  with  APRV  without 
spontaneous  breathing.  These  findings  indicate 
that  uncoupling  of  spontaneous  and  mechanical 
ventilation  during  APRV  improves  V^^/Q  match- 
ing in  ARDS  presumably  by  recruiting  nonven- 
tilated  lung  units.  Apparently,  mechanical  as- 
sistance of  each  inspiration  during  PSV  is  not 
sufficient  to  counteract  the  V^/Q  maldistribu- 
tion caused  by  alveolar  collapse  in  patients  with 
ARDS. 

The  Attributable  Morbidity  and  Mortality 
of  Ventilator-Associated  Pneumonia  in  the 
Critically  III  Patient— Heyland  DK,  Cook  DJ, 
Griffith  L,  Keenan  SP,  Brun-Buisson  C.  Am  J 
Respir  Crit  Care  Med  1999  Apr;  159(4  Pt  1): 
1249-1256. 

To  evaluate  the  attributable  morbidity  and  mor- 
tality of  ventilator-associated  pneumonia  (VAP) 
in  intensive  care  unit  (ICU)  patients,  we  con- 
ducted a  prospective,  matched  cohort  study.  Pa- 
tients expected  to  be  ventilated  for  >  48  h  were 
prospectively  followed  for  the  development  of 
VAP.  To  determine  the  excess  ICU  stay  and 
mortality  attributable  to  VAP,  we  matched  pa- 
tients with  VAP  to  patients  who  did  not  de- 
velop clinically  suspected  pneumonia.  We  also 
conducted  sensitivity  analyses  to  examine  the 
effect  of  different  populations,  onset  of  pneu- 
monia, diagno.stic  criteria,  causative  organisms, 
and  adequacy  of  empiric  treatment  on  the  out- 
come of  VAP.  One  hundred  and  .seventy-seven 
patients  developed  VAP.  As  compared  with 
matched  patients  who  did  not  develop  VAP, 
patients  with  VAP  stayed  in  the  ICU  for  4.3  d 
(95%  confidence  interval  [CI]:  1.5  to  7.  0  d) 
longer  and  had  a  trend  toward  an  increase  in 
risk  of  death  (absolute  risk  increase:  5.8%;  95% 
CI:  -2.4  to  14.0  d;  relative  risk  (RR)  increase: 
32.3%;  95%  CI:  -20.6  to  85.1%).  The  attrib- 
utable ICU  length  of  stay  was  longer  for  med- 
ical than  for  surgical  patients  (6.  5  versus  0.7  d, 
p  <  0.004),  and  for  patients  infected  with  "high 
risk"  organisms  as  coinpared  with  "low  risk" 
organisms  (9. 1  d  versus  2.9  d).  The  attributable 
mortality  was  higher  for  medical  patients  than 
for  surgical  patients  (RR  increase  of  65%  ver- 
sus -27.3%,  p  =  0.  04).  Results  were  similar 
for  three  different  VAP  diagnostic  criteria.  We 
conclude  that  VAP  prolongs  ICU  length  of  stay 
and  may  increase  the  risk  of  death  in  critically 


734 


RESPIRATORY  Care  •  JuLY  1999  VoL  43  No  7 


ill  patients.  The  attributable  risk  of  VAP  ap- 
pears to  vary  with  patient  population  and  in- 
fecting organism. 

Isocapnic  Hyperpnea  Accelerates  Carbon 
Monoxide  Elimination — Fisher  JA.  Rucker  J, 
Somnier  LZ,  Vesely  A,  Lavine  E,  Greenwald 
Y,  et  al.  Am  J  Respir  Crit  Care  Med  1999  Apr; 
159(4  Pt  1):1289-1292. 

A  major  impediment  to  the  use  of  hyperpnea  in 
the  treatment  of  CO  poisoning  is  the  develop- 
ment of  hypocapnia  or  discomfort  of  COj  in- 
halation. We  examined  the  effect  of  nonrebreath- 
ing  isocapnic  hyperpnea  on  the  rate  of  decrease 
of  carboxyhemoglobin  levels  (COHb)  in  five 
pentobarbital-anesthetized  ventilated  dogs  first 
exposed  to  CO  and  then  ventilated  with  room 
air  at  normocapnia  (control).  They  were  then 
ventilated  with  100%  O,  at  control  ventilation, 
and  at  six  times  control  ventilation  without  hy- 
pocapnia ("isocapnic  hyperpnea")  for  at  least 
42  min  at  each  ventilator  setting.  We  measured 
blood  gases  and  COHb.  At  control  ventilation, 
the  half-time  for  elimination  of  COHb  (tl/2) 
was  212  ±  17  min  (mean  ±  SD)  on  room  air 
and  42  ±  3  min  on  100%  O,.  The  tl/2  de- 
creased to  18  ±  2  min  (p  <  0.0005)  during 
isocapnic  hyperpnea.  In  two  similarly  prepared 
dogs  treated  with  hyperbaric  Oj,  the  tl/2  were 
20  and  28  min.  We  conclude  that  isocapnic 
hyperpnea  more  than  doubles  the  rate  of  COHb 
elimination  induced  by  normal  ventilation  with 
100%  O,.  Isocapnic  hyperpnea  could  improve 
the  efficacy  of  the  standard  treatment  of  CO 
poisoning,  1 00%  Oj  at  atmospheric  or  increased 
pressures. 

Can  Intensive  Support  Improve  Continuous 
Positive  Airway  Pressure  Use  in  Patients  with 
the  Sleep  Apnea/Hypopnea  Syndrome? — 

Hoy  CJ,  Vennelle  M,  Kingshott  RN,  Engleman 
HM.  Douglas  NJ.  Am  J  Respir  Crit  Care  Med 
1999  Apr;159(4  Pt  1):1096-1 100. 

Continuous  positive  airway  pressure  (CPAP) 
therapy  is  widely  prescribed  for  patients  with 
the  sleep  apnea/hypopnea  syndrome  (SAHS), 
but  the  use  of  CPAP  for  such  patients  is  disap- 
pointingly low.  We  postulated  that  providing 
intensive  educational  programs  and  nursing  sup- 
port to  SAHS  patients  might  improve  CPAP 
use  and  outcomes.  We  also  examined  the  hy- 
pothesis that  CPAP  use  would  be  greater  among 
patients  who  had  initiated  their  own  referral 
than  among  those  asked  to  seek  help  by  a  part- 
ner. We  randomized  80  consecutive,  new  pa- 
tients with  SAHS  to  receive  either  usual  sup- 
port or  additional  nursing  input  including  CPAP 
education  at  home  and  involving  their  partners, 
a  3-night  trial  of  CPAP  in  our  institution's  sleep 
center,  and  additional  home  visits  once  they 
had  begun  CPAP.  The  primary  outcome  vari- 
able was  objective  CPAP  use;  symptoms,  mood, 
and  cognitive  function  were  also  assessed  after 


BREATHING  SIMULATOR 

A  Spontaneously  Breathing  Lung  Model 


Breathing  Simulator  in  use  witli  a  Ventilator 


•  Simulates  spontaneous  &  passive  patients 

•  Simulates  a  wide  range  of  lung  parameters 

•  Adjustable  airway  resistance,  lung  compliance, 
breath  rate  &  patient  effort 

•  Mathematical  lung  model 

•  Data  collection  &  fast  repeatable  setups 

•  Automate  tests  with  a  script  file 
'  Helps  meet  new  GMP  design  control  requirements 


'  Development  of  respiratory  therapy  devices        •  Production  testing 


IQSEIEMBE 


m 


HANS  RUDOLPH,  inc. 

MAKERS  OF  RESPmATORY  VALVES  SINCE  1933 

TEL:  (816)  363-5522  U.S.A.  &  CANADA  (800)  456-6695 
FAX:  816-822-1414   E-Mail:  hrierudolphkc.com   www.rudolphkc.com 
7205  CENTRAL,  KANSAS  CITY,  MISSOURI  64114  U.S.A. 


Circle  104  on  reader  service  card 


6  mo.  CPAP  use  over  6  mo  was  greater  (p  = 
0.003)  among  patients  receiving  intensive  than 
among  those  receiving  standard  support  (5.4  ± 
0.3  versus  3.9  ±  0.  4  h/night  [mean  ±  SEM]), 
with  greater  improvements  (p  <  0.05)  in  SAHS 
symptoms,  mood,  and  reaction  time  in  the  in- 
tensively supported  group.  CPAP  use  was 
greater  (p  =  0.002)  among  patients  who  initi- 
ated their  own  referrals.  CPAP  use  and  out- 
comes of  therapy  can  be  improved  by  provision 
of  a  nurse-led  intensive  CPAP  education  and  sup- 
port program.  CPAP  use  is  lower  among  patients 
whose  partners  ask  them  to  seek  treatment. 

Long-Term  Use  of  CPAP  Therapy  for  Sleep 
Apnea/Hypopnea  Syndrome — McArdle  N, 
Devereux  G,  Heidarnejad  H,  Engleman  HM, 
Mackay  TW,  Douglas  NJ.  Am  J  Respir  Crit 
Care  Med  1999  Apr;  159(4  Pt  l):l  108-1 1 14. 

Patients  with  the  sleep  apnea/hypopnea  syn- 
drome (SAHS)  treated  by  nasal  continuous  pos- 
itive airway  pressure  (CPAP)  need  to  use  CPAP 
long-term  to  prevent  recurrence  of  symptoms. 
It  is  thus  important  to  clarify  the  level  of  long- 
term  CPAP  use  and  the  factors  influencing  long- 
term  use.  We  examined  determinants  of  objec- 
tive CPAP  use  in  I,  211  consecutive  patients 
with  SAHS  who  were  prescribed  a  CPAP  trial 
between  1986  and  1997.  Prospective  CPAP  use 
data  were  available  in  1,  155  (95.4%),  with  a 


median  follow-up  of  22  mo  (interquartile  range 
[IQRl,  12  to  36  mo).  Fifty-two  (4.5%)  patients 
refused  CPAP  treatment  (these  were  more  often 
female  and  current  smokers);  1 . 1 03  patients  took 
CPAP  home,  and  during  follow-up  20%  stopped 
treatment,  primarily  because  of  a  lack  of  ben- 
efit. Methods  of  survival  analysis  showed  that 
68%  of  patients  continued  treatment  at  5  yr. 
Independent  predictors  of  long-term  CPAP  use 
were  snoring  history,  apnea/hypopnea  index 
(AHI),  and  Epworth  score;  86%  of  patients  with 
Epworth  >  10  and  an  AHI  a  30  were  still 
using  CPAP  at  3  yr.  Average  nightly  CPAP  use 
within  the  first  3  mo  was  .strongly  predictive  of 
long-term  use.  We  conclude  that  long-term 
CPAP  use  is  related  to  disease  severity  and 
subjective  sleepiness  and  can  be  predicted 
within  3  mo. 


Patient  Perception  of  Sleep  Quality  and  Eti- 
ology of  Sleep  Disruption  in  the  Intensive 
Care  Unit — Freedman  NS,  Kotzer  N,  Schwab 
RJ.  Am  J  Respir  Crit  Care  Med  1999  Apr;I59(4 

Pt  1):1 155-1 162. 

The  etiology  of  sleep  disruption  in  patients  in 
intensive  care  units  (ICUs)  is  poorly  understood, 
but  is  thought  to  be  related  to  environmental 
stimuli,  especially  noise.  We  sampled  203  pa- 
tients (121  males  and  82  females)  from  differ- 
ent ICUs  (cardiac  [CCU],  cardiac  stepdown 


Respiratory  Care  •  July  1999  Vol  43  No  7 


7.\5 


Abstracts 


[CICU],  medical  [MICU],  and  surgical  [SICU]) 
by  questionnaire  on  the  day  of  their  discharge 
from  the  unit,  to  determine  the  perceived  effect 
of  environmental  stimuli  on  sleep  disturbances 
in  the  ICU.  Perceived  ICU  sleep  quality  was 
significantly  poorer  than  baseline  sleep  at  home 
(p  =  0.0001 ).  Perceived  sleep  quality  and  day- 
time sleepiness  did  not  change  over  the  course 
of  the  patients'  stays  in  the  ICU,  nor  were  there 
any  significant  differences  (p  >  0.05)  in  these 
parameters  among  respective  units.  Disruption 
from  human  interventions  and  diagnostic  test- 
ing were  perceived  to  be  as  disruptive  to  sleep 
as  was  environmental  noise.  In  general,  patients 
in  the  MICU  appeared  to  be  more  susceptible  to 
sleep  disruptions  from  environmental  factors 
than  patients  in  the  other  ICUs.  Our  data  show 
that;  ( I )  poor  sleep  quality  and  daytime  sleep- 
iness are  problems  common  to  all  types  of  ICUs, 
and  affect  a  broad  spectrum  of  patients;  and  (2) 
the  environmental  etiologies  of  sleep  disruption 
in  the  ICU  are  multifactorial. 

The  Effect  of  Mode,  Inspiratory  Time,  and 
Positive  End-Expiratory  Pressure  on  Partial 
Liquid  Ventilation — Fujino  Y,  Kirmse  M,  Hess 
D.  Kacmarek  RM.  Am  J  Respir  Crit  Care  Med 
1999  Apr;159(4  Pt  1);1087-1095. 

Partial  liquid  ventilation  (PLV)  has  been  shown 
to  be  an  effective  means  of  improving  oxygen- 
ation in  the  injured  lung.  However,  little  is 
known  about  how  approach  to  ventilation  dur- 
ing PLV  affects  gas  exchange  and  pulmonary 
mechanics.  We  hypothesized  that  gas  exchange 
and  pulmonary  mechanics  would  be  best  with 
positive  end-expiratory  pressure  (PEEP)  set 
above  the  lower  inflection  point  (LIP)  of  the 
pressure-volume  (P-V)  curve  regardless  of  mode 
of  ventilation  or  inspiratory  to  expiratory  time 
(I:E)  ratio  and  that  the  efficiency  of  ventilation 
would  be  greatest  with  volume-controlled  ven- 
tilation (VCV)  compared  with  pressure-con- 
trolled ventilation  (PCV)  and  with  long  inspira- 
tory time  as  compared  with  short  inspiratory 
time.  Lung  injury  was  induced  in  14  sheep  by 
lavage,  10  of  which  were  studied.  Sheep  were 
then  assigned  to  high-PEEP  (Group  H,  n  =  5) 
and  low-PEEP  (Group  L,  n  =  5)  groups.  In 
Group  H  applied  PEEP  was  set  at  the  LIP  and 
in  Group  L  applied  PEEP  was  set  at  5  cm  HiO 
after  the  lung  was  filled  with  perflubron  (PFB). 
We  randomly  compared  VCV  and  PCV  with 
I;E  ratios  of  1 :2,  1:1,  and  2: 1 .  Peak  inspiratory 
pressure  and  V^  were  adjusted  to  maintain  a 
constant  end-inspiratory  plateau  pressure  (Ppi,,,) 
of  about  25  cm  H^O  in  both  groups  and  a  con- 
stant total  PEEP  of  about  5  cm  H,0  in  Group  L 
and  about  12  cm  HjO  in  Group  H.  There  were 
no  differences  in  oxygenation  among  modes  in 
Group  H.  In  Group  L  VCV  2: 1  and  all  of  the 
PCV  modes  in  Group  L  had  a  lower  P.,,,,  than 
VCV  I;l  (p  <  0.05).  P,„,,  and  V, At  were 
significantly  different  (p  <  0.05)  among  modes. 
ViAt  was  highest  during  PCV  I  ;2  with  PEEP 


of  5  cm  HjO  (p  <  0.05).  Quasi-static  compli- 
ance in  Group  H  was  higher  than  in  Group  L 
(p  <  0.05).  We  conclude  that  during  low  PEEP 
gas  exchange  deteriorated  in  VCV  with  long 
inspiratory  time  and  in  PCV.  Oxygenation  was 
enhanced  during  VCV  1 ;  I  when  compared  with 
VCV  at  longer  I:E  ratios  or  PCV  at  any  I;E 
ratio.  With  PEEP  set  at  the  LIP,  adequate  gas 
exchange  and  improved  lung  mechanics  could 
be  obtained  in  all  modes  assessed. 

Pressure- Volume  Curves  and  Compliance  in 
Acute  Lung  Injury:  Evidence  of  Recruitment 
Above  the  Lower  Inflection  Point — Jonson  B, 
Richard  JC,  Straus  C,  Mancebo  J,  Lemaire  F. 
Brochard  L.  Am  J  Respir  Crit  Care  Med  1999 
Apr;  159(4  Pt  I  ):1 172-1 178. 

Measuring  elastic  pressure-volume  (Pel-V) 
curves  of  the  respiratory  system  and  the  volume 
recruited  by  a  positive  end-expiratory  pressure 
(PEEP)  allows  one  to  study  the  pressure  range 
over  which  recruitment  occurs  in  acute  lung 
injury  (ALI),  and  to  explain  how  recruitment 
affects  the  compliance.  Pel-V  curves  were  mea- 
sured with  the  low  flow  inflation  technique  in 
1 1  patients  mechanically  ventilated  for  ALI. 
Curve  I  was  recorded  during  inflation  from  the 
volume  attained  after  a  prolonged  expiration  (6 
s)  at  PEEP  (9.0  ±  2.2  cm  H,0),  and  Curve  II 
after  expiration  to  the  elastic  equilibrium  vol- 
ume at  zero  end-expiratory  pressure  (ZEEP). 
By  using  the  end-expiratory  volume  of  the 
breaths,  the  curves  were  aligned  on  a  common 
volume  axis  to  determine  the  effect  of  a  single 
complete  expiration.  In  each  patient.  Curve  II 
(from  ZEEP)  was  shifted  toward  lower  volumes 
than  Curve  I.  The  volume  shift,  probably  due  to 
derecruitment,  was  205  ±  100  mL  at  15  cm 
H,0  (p  <  0.0 1 )  and  78  ±  93  mL  at  30  cm  H,0 
(p  <  0.01);  thus,  during  inflation  from  ZEEP, 
the  volume  deficit  was  successively  regained 
over  a  pressure  range  up  to  at  least  30  cm  HjO. 
At  any  pressure,  compliance  was  higher  on  the 
curve  from  ZEEP  than  from  PEEP,  by  10.0  ± 
8.7  mL/cm  H^O  at  15  cm  HjO  (p  <  0.01),  and 
by  5.4  ±  5.5  at  30  cm  H,0  (p  <  0.01).  It  is 
concluded  that  in  ALI,  a  single  expiration  to 
ZEEP  leads  to  lung  collapse.  High  compliance 
during  insufflation  from  ZEEP  indicates  that 
lung  recruitment  happens  far  above  the  lower 
inflection  point  of  the  Pel-V  curve. 

The  Presence  and  Sequence  of  Endotracheal 
Tube  Colonization  in  Patients  Undergoing 
Mechanical  Ventilation — Feldman  C,  Kassel 
M,  Cantrell  J,  Kaka  S.  Morar  R,  Goolam  Ma- 
homed A,  Philips  JI.  Eur  Respir  J  1999  Mar; 
13(3):.546-.55l. 

Endotracheal  tube  colonization  in  patients  un- 
dergoing mechanical  ventilation  was  investi- 
gated. In  the  first  part  of  this  prospective  study, 
the  airway  access  tube  was  examined  for  the 
presence  of  secretions,  airway  obstruction  and 


bacterial  colonization,  in  cases  undergoing  ex- 
tubation  or  tube  change.  In  the  second  part  of 
the  study,  the  sequence  of  oropharyngeal,  gas- 
tric, respiratory  tract  and  endotracheal  tube  col- 
onization was  investigated  by  sequential  swab- 
bing at  each  site  twice  daily  for  5  days  in 
consecutive  noninfected  patients.  In  the  first 
part,  it  was  noted  that  all  airway  access  lubes  of 
cases  undergoing  extubation  had  secretions  lin- 
ing the  interior  of  the  distal  third  of  the  tube 
which  were  shown  on  scanning  electron  mi- 
croscopy to  be  a  biofilm.  Gram-negative  micro- 
organisms were  isolated  from  these  secretions 
in  all  but  three  cases.  In  the  second  part,  it  was 
noted  that  the  sequence  of  colonization  in  pa- 
tients undergoing  mechanical  ventilation  was 
the  oropharynx  (36  h),  the  stomach  (3660  h), 
the  lower  respiratory  tract  (60-84  h),  and  there- 
after the  endotracheal  tube  (60-96  h).  Nosoco- 
mial pneumonia  occurred  in  1 3  patients  and  in 
eight  cases  identical  organisms  were  noted  in 
lower  respiratory  tract  secretions  and  in  secre- 
tions lining  the  interior  of  the  endotracheal  tube. 
The  endotracheal  tube  of  patients  undergoing 
mechanical  ventilation  becomes  colonized  rap- 
idly with  micro-organisms  commonly  associ- 
ated with  nosocomial  pneumonia,  and  which 
may  represent  a  persistent  source  of  organisms 
causing  such  infections. 

Aerosol  Recovery  from  Large- Volume  Res- 
ervoir Delivery  Systems  Is  Highly  Dependent 
on  the  Static  Properties  of  the  Reservoir — 

van  der  Veen  MJ,  van  der  Zee  JS.  Eur  Respir  J 
1999  Mar;13(3):668-672. 

In  this  study,  the  role  of  electrostatic  fields  on 
aerosol  recovery  from  a  system  with  a  large 
collapsible  reservoir  (30  L)  was  investigated.  In 
addition,  the  efficacy  of  the  reservoir  method 
for  bronchial  challenge  procedures  was  as.sessed 
in  vivo.  Aerosol  recovery  was  determined  by 
measuring  the  fraction  of  aerosol  (0.05% 
99mTc-tagged  human  albumin  solution)  re- 
trieved from  the  reservoir.  Before  aerosol  re- 
covery experiments,  electrostatic  fields  in  the 
reservoir  were  measured.  Aerosol  recovery  var- 
ied significantly  with  wall  thickness  of  the  res- 
ervoir and  presence  of  an  antistatic  coating 
(range  6.0-70.3%).  A  clo.se  inverse  relation- 
ship was  found  between  the  mean  electrostatic 
field  in  the  reservoir  and  aerosol  recovery.  The 
nebulized  provocative  concentration  of  hista- 
mine causing  a  20%  fall  in  forced  expiratory 
volume  in  one  second  in  asthmatics  was  found 
to  be  approximately  half  that  of  a  standard 
method  when  compared  with  the  reservoir  sys- 
tem (mean  ratio  2.24  (95%  confidence  interval, 
1.60-3.12)).  Recovery  from  an  aerosol  deliv- 
ery sy.stem  with  a  relatively  large  collapsible 
aerosol  reservoir  was  highly  dependent  on  the 
electrostatic  field  in  the  reservoir.  In  these  sys- 
tems the  use  of  electrostatic  field  dissipative 
material  for  the  reservoir  is  therefore  recom- 
mended. 


736 


Respiratory  Care  •  July  1999  Vol  43  No  7 


Abstracts 


Washing  Plastic  Spacers  in  Houseliold  De- 
tergent Reduces  Electrostatic  Charge  and 
Greatly  Improves  Delivery — Pierart  F, 
Wildhaber  JH.  Vrancken  I,  Devadason  SG,  Le 
Souef  PN.  Eur  Respir  J  1999  Mar;13(3):673- 
678. 

Ionic  detergents  reduce  electrostatic  charge  on 
plastic  spacers,  thereby  improving  in  vitro  drug 
delivery.  The  aim  of  this  study  was  to  gain 
practical  information  on  the  use  of  detergents 
and  to  evaluate  the  relevance  of  this  informa- 
tion on  in  vivo  drug  deposition.  Measurement 
of  electrostatic  charge  and  salbutamol  particle 
size  distribution  was  carried  out  on  detergent- 
coated  and  noncoated  plastic  spacers.  The  effi- 
ciency of  four  household  detergents  was  com- 
pared, and  the  influence  of  dilution  and  the 
duration  of  the  antistatic  effect  were  studied.  In 
addition,  the  level  of  radiolabelled  salbutamol 
deposition  in  the  lungs  of  eight  healthy  adults 
was  compared  after  inhalation  through  a  new 
versus  a  detergent-coated  spacer.  In  vitro,  all 
tested  detergents  reduced  the  electrostatic  charge 
on  the  spacer  surface.  This  resulted  in  a  mean 
increase  of  37.4%  (range  33.5-41.2)  in  small 
particle  (<  6.8  microm)  salbutamol  output  com- 
pared with  water-rinsed/drip-dried  spacers.  Di- 
lution had  no  influence  on  the  results  and  the 
effect  lasted  for  at  least  four  weeks.  In  vivo,  the 
mean  lung  deposition  of  radiolabeled  salbuta- 
mol in  healthy  subjects  was  45.6%  (range  43.4- 
49.5)  through  a  detergent-coated  spacer  com- 
pared to  1 1. 5%  (range  7.6-1 7. 9)  through  a  static 
spacer  (p  <  0.001).  In  conclusion,  hou.sehold 
detergents  offer  a  simple  and  practical  solution 
to  the  problem  of  static  on  plastic  spacers  and 
significantly  improve  both  in  vitro  and  in  vivo 
delivery  of  salbutamol. 

Physiological  Basis  of  Improvement  After 
Lung  Volume  Reduction  Surgery  for  Severe 
Emphysema:  Where  Are  We? — Marchand  E, 
Gayan-Ramirez  G,  De  Leyn  P,  Decramer  M. 
Eur  Respir  J  1999  Mar;13(3):686-696. 

Lung  volume  reduction  surgery  has  become  an 
accepted  therapeutic  option  to  relieve  the  symp- 
toms of  selected  patients  with  severe  emphy- 
sema. In  a  majority  of  these  patients,  it  causes 
objective  as  well  as  subjective  functional  im- 
provement. A  proper  understanding  of  the  phys- 
iological determinants  underlying  these  benefi- 
cial effects  appears  very  important  in  order  to 
better  select  patients  for  the  procedure  that  is 
f.         currently  largely  carried  out  on  an  empirical 
;         basis.  Lung  volume  reduction  surgery  has  two 
'  .       distinct  effects.  Firstly,  it  causes  an  increa.sed 
i         elastic  recoil,  which  at  least  partially  explains 
the  enhanced  maximal  expiratory  flow.  Sec- 
ondly, it  is  associated  with  a  reduction  of  hy- 
perinflation which  allows  for  an  increase  in 
global  inspiratory  muscle  strength  and  in  dia- 
phragmatic contribution  to  tidal  volume  as  well 
as  a  decrease  in  the  inspiratory  elastic  load  im- 


posed by  the  chest  wall.  Taken  together,  these 
effects  result  in  a  reduced  work  of  breathing 
and  in  an  enhanced  maximal  ventilation  which 
both  contribute  to  the  increa.sed  exercise  capac- 
ity and  reduced  dyspnoea  after  surgery.  The 
improved  lung  recoil  and  the  reduced  hyperin- 
flation after  volume  reduction  surgery  were  the 
primary  postulates  upon  which  the  usual  selec- 
tion criteria  for  the  procedure  were  based.  It  is 
now  likely  that  these  are  correct.  Nevertheless, 
some  patients  do  not  benefit  from  lung  volume 
reduction  surgery  and  the  current  literature  does 
not  allow  for  a  refinement  of  the  selection  pro- 
cess from  a  physiological  point  of  view.  The 
exact  mechanisms  underlying  the  improvement 
in  lung  recoil,  lung  mechanics,  and  respiratory 
muscle  function  remain  incompletely  under- 
stood. Moreover,  the  effects  of  lung  volume 
reduction  surgery  on  gas  exchange  and  pulmo- 
nary haemodynamics  still  need  to  be  more  fully 
investigated.  An  analysis  of  the  characteristics 
of  patients  who  do  not  benefit  from  the  proce- 
dure and  the  development  of  an  animal  model 
for  lung  volume  reduction  surgery  would  prob- 
ably help  address  these  important  issues. 

Effects  of  Randomized  Assignment  to  a 
Smoking  Cessation  Intervention  and 
Changes  in  Smoking  Habits  on  Respiratory 
Symptoms  in  Smokers  with  Early  Chronic 
Obstructive  Pulmonary  Disease:  The  Lung 
Health  Study— Kanner  RE,  Connett  JE,  Wil- 
liams DE,  Buist  AS.  Am  J  Med  1999  Apr; 
106(4):4I0-4I6. 

PURPOSE:  To  evaluate  the  effects  of  randomly 
assigning  smokers  who  have  early  chronic  ob- 
structive pulmonary  disease  (COPD)  to  a  smok- 
ing-cessation  intervention  on  the  symptoms  of 
chronic  cough,  chronic  phlegm  production, 
wheezing  and  shortness  of  breath,  and  to  deter- 
mine the  effects  of  quitting  smoking  on  these 
symptoms.  SUBJECTS  AND  METHODS:  A 
total  of  5,887  male  and  female  smokers  35  to 
60  years  of  age  with  early  COPD  [defined  as  a 
forced  expiratory  volume  in  the  first  second 
(FEV,)  of  55%  to  90%  of  predicted  and  FEV,/ 
forced  vital  capacity  (FVC)  <  0.70]  were  en- 
rolled in  a  5-year  clinical  trial.  Two-thirds  of 
participants  were  randomly  assigned  to  smok- 
ing-intervention  groups  and  one-third  to  a  usu- 
al-care group.  The  intervention  groups  attended 
1 2  intensive  smoking-cessation  .sessions  that  in- 
cluded behavior  modification  techniques  and  the 
use  of  nicotine  chewing  gum.  One  intervention 
group  was  treated  with  ipratropium  bromide  by 
inhaler;  the  other  intervention  group  received 
placebo  inhalers.  The  usual-care  group  was  ad- 
vi.sed  to  stop  smoking.  All  participants  were 
followed  annually.  Smoking  status  was  bio- 
chemically validated  by  salivary  cotinine  mea- 
surements or  exhaled  carbon  monoxide  values. 
RESULTS:  Validated  5-year  sustained  smok- 
ing cessation  occurred  in  22%  of  participants  in 
the  intervention  compared  with  only  5%  of  par- 


ticipants in  the  usual-care  group.  At  the  end  of 
the  study,  the  prevalence  of  each  of  the  four 
symptoms  in  the  two  intervention  groups  was 
significantly  less  than  in  the  usual-care  group 
(p  <  0.0001).  For  example,  among  participants 
who  did  not  report  cough  at  baseline,  15%  of 
those  in  the  intervention  groups  had  cough  at 
least  3  months  during  the  year,  compared  with 
23%  of  those  in  usual  care.  Sustained  quitters 
had  the  lowest  prevalence  of  all  four  symp- 
toms, whereas  continuous  smokers  had  the  great- 
est prevalence  of  these  symptoms.  Changes  in 
symptoms  occurred  primarily  in  the  first  year 
after  smoking  cessation.  Respiratory  symptoms 
were  associated  with  greater  declines  in  FEV, 
during  the  study  (p  <  0.001).  Ipratropium  bro- 
mide had  no  long-term  effects  on  respiratory 
symptoms.  CONCLUSIONS:  In  this  prospec- 
tive randomized  trial  using  an  intention-to-treat 
analysis,  smokers  with  early  COPD  who  were 
assigned  to  a  smoking-cessation  intervention 
had  fewer  respiratory  symptoms  after  5  years  of 
follow-up. 

Scintigraphy  for  Evaluating  Early  Aspira- 
tion After  Oral  Feeding  in  Patients  Receiv- 
ing Prolonged  Ventilation  Via  Tracheosto- 
my—Schonhofer  B,  Barchfeld  T,  Haidl  P, 
Kohler  D.  Intensive  Care  Med  1999  Mar;25(3): 
311-314. 

OBJECTIVE:  In  tracheotomised  patients  the  in- 
cidence of  aspiration  is  difficult  to  determine 
because  investigators  often  apply  different  cri- 
teria. In  this  study  a  scintigraphic  method  was 
used  to  visualise  feeding  aspiration  directly  and 
the  results  were  compared  with  clinical  evidence 
of  a.spiration.  DESIGN:  Prospective  study  in 
difficult-to-wean  patients  with  tracheostomy. 
SETTING:  Respiratory  ICU.  PATIENTS  AND 
METHODS:  The  study  population  consisted  of 
62  con.secutive  patients  ( 1 6  females,  age:  64. 1  ± 
11.1  years).  All  patients  were  tracheotomised 
and  had  previously  been  long-term  ventilated  in 
other  ICUs  due  to  weaning  failure.  The  scinti- 
graphic test  was  performed  during  spontaneous 
breathing.  The  standard  nutrition  consisted  of  a 
liquid,  semi-liquid  and  solid  meal  which  was 
labelled  with  l(X)  MBq  99mTc-human  .serum 
albumin.  MEASUREMENTS  AND  RESULTS: 
Scintigraphic  aspiration  (SA)  was  defined  as 
positive  if  radioactivity  was  detected  in  the  bron- 
chial .system  using  a  scintillation  camera.  Fur- 
thermore, aspiration  was  proven  clinically  (CA). 
CA  and  SA  yielded  identical  results  in  54  of  the 
62  patients  [  10  positive  (16%)  and  in  44  nega- 
tive (71%)].  CA,  but  not  SA,  was  seen  in  4/62 
(6.5%)  and  SA,  but  not  CA,  was  found  in  4/62 
(6.5%)  patients.  CONCLUSIONS:  Our  data  re- 
emphasise  that  aspiration  in  tracheotomised  pa- 
tients is  common  (in  our  study  approximately 
30%).  The  scintigraphic  method  failed  to  iden- 
tify all  tracheotomised  patients  with  clinically 
significant  aspiration;  however,  it  did  suggest 
that  some  patients  had  subclinical  aspiration. 


Respiratory  Care  •  July  1999  Vol  43  No  7 


737 


DIHGNOSIS:  Hnxjety  Overlood  Due  to 
Ouestionoble  Compliance 

PRESCRIPTION:  HNem  Set  of  Nonuols 
to  Help  You  Reocli  Full  Complldnce 


Uniform  Reporting 
Manual  for  Acute  Care 

Provides  you  with  nationally 

recognized  standards  for 

documenting  workload 

units  and  time  standards. 

Includes  patient 

assessment  activities  and  covers 

bronchial  hygiene,  supplemental  oxygen,  airway  care, 

diagnostic  tests,  and  cardiovascular  diagnostics.  In 

addition,  there  are  chapters  on  "Clinical  Activities 

Without  Time  Standard"  and  "Management  Support 

Activities."  Written  by  the  AARC,  1990,  updated  1993. 

Binder,  165  pages. 

ItemBKl  $65.00   ($85.00   nonmembers) 


Uniform  Reporting  Manual  for 
Diagnostic  Services  New! 

This  manual  identifies  diagnostic  procedures  commonly 
performed  within  sleep,  pulmonary,  blood  gas,  and  non- 
invasive cardiology  laboratories  and  time  standards  for 
their  performance.  It  is  a  tool  to  determine  productivity, 
track  trends  in  the  utilization  of  services,  assist  in 
determining  personnel  requirements,  and  measure  demand 
for  and  intensity  of  service.  It  also  provides  a  foundation 
for  benchmarking  efficiency  indicators  within  the  industry. 
188  pages.  Available  August,  1999. 
ITEMPM88  $99.00   ($13  5.00   Nonmembers) 


Uniform  Reporting 
Manual  for  Subacute 
Care 

Use  this  tool  to  determine 
productivity,  track  trends  in  the 
utilization  of  respiratory  care 
services,  assist  in  determining 
personnel  requirements,  measure  demand  for  and  intensity 
of  services,  and  meet  the  requirements  of  prospective 
payment  systems  (PPS).  Written  by  the  AARC  1998.  Binder. 
ItemBK2  $75.00   ($115.00   nonmembers) 


Ki'Miiiiiiiin  (■[ 


Respiratory  Care 

Patient-Driven 

Protocols 

Written  by  UCSD  faculty,  one  of 
the  country's  leading  institutions  ir 
^^     the  development  of  protocols.  This 

book  serves  as  an  excellent 
resource  in  the  processes  of  developing, 
implementing,  or  refining  care  plans.  Features  25 
complete  protocols  with  an  introduction  on  how  to 
implement  PDPs  in  your  facility.  Authors  include  Jan 
PhiUips-Clar,  BS,  RRT;  Richard  Ford,  BS,  RRT;  Timothy 
Morris,  MD;  and  David  Burns,  MD.  Paperback.  205  pages. 
Published  in  1998. 
ItemPASOl  $85.00   ($99.00   nonmembers) 


Shipping  Charges 
$  8.25  for  one  item 
$10.25  for  two  items 
$14.25  for  three  or  more 


To  place  your  order,  please  call: 

972-a43-!!a72 


Texas  customers  only,  please  add  8.25%  sales  tax  (including  shipping  charges).  Texas  customers  who  are  exempt  from  sales  tax  must 
supply  an  exemption  certificate.  MasterCard,  Visa,  Institutional  Purchase  Order  or  check  payable  to: 


Doedolus  Enterprises.  Inc 


ATTN.  Order  Fulfillment  Department 
11030  Abies  Lane  •  Dallas,  Texas  75229 
Phone  972-243-2272  Fax:  972-484-6010 

Discover  other  related  products  within  "Key  to  Professional  Excellence"  @  www.aarc.org 


Abstracts 


Dynamic  Measurement  of  Intrinsic  PEEP 
Does  Not   Represent   tlie  Lowest  Intrinsic 

PEEP — Fujino  Y,  Nishimura  M,  Uchiyama  A, 
Taenaka  N,  Yoshiya  I.  Intensive  Care  Med  1999 

Mar;25(3):274-278. 

OBJECTIVE:  Dynamic  intrinsic  PEEP  (PEEPi- 
dyn)  is  thie  airway  pressure  required  to  over- 
come expiratory  tlow  and  is  considered  to  rep- 
resent the  lowest  regional  PEEPi.  However, 
there  are  few  data  to  validate  this  assumption. 
We  investigated  if  PEEPi-dyn  represents  the 
lowest  PEEPi.  SETTING:  The  animal  labora- 
tory at  the  Osaka  University  Medical  School. 
MEASUREMENTS  AND  RESULTS:  We  com- 
pared static  PEEPi  (PEEPi-stat)  and  PEEPi-dyn 
in  healthy  animals.  Five  adult  white  rabbits 
(2.77 ±0.05  kg)  were  anesthetized,  tracheos- 
tomized,  and  intubated  with  several  different 
sizes  of  endotracheal  tubes  (ETT)  (2.0,  2.5,  3.0, 
3.5,  or  4.0  mm  i.d.).  The  animals  were  para- 
lyzed and  ventilated  (Siemens  Servo  9(K)C). 
Baseline  ventilator  settings  were  at  a  rate  of 
50/min,  inspiratory:expiratory  (I:E)  ratio  of  2:1 
or  4: 1 ,  and  minute  ventilation  was  manipulated 
to  create  3  or  5  cm  HjG  PEEPi-stat.  PEEPi-stat 
was  measured  using  the  expiratory  hold  button 
of  the  ventilator.  PEEPi-dyn  showed  large  vari- 
ations. In  all  ventilator  settings,  PEEPi-dyn  was 
higher  than  PEEPi-stat  (p  <  0.001).  The  larger 
the  ETT,  the  higher  the  PEEPi-dyn  at  an  l:E 
ratio  of  2:1  (p  <  0.05).  The  higher  the  minute 
ventilation,  the  greater  the  difference  between 
PEEPi-stat  and  PEEPi-dyn.  The  tidal  volume 
and  the  difference  showed  a  significant  corre- 
lation (r^  =  0.514,  p  <  0.001).  CONCLU- 
SIONS: The  value  of  PEEPi-dyn  was  depen- 
dent on  ventilatory  settings,  and  PEEPi-dyn  does 
not  necessarily  represent  (he  lowest  regional 
PEEPi  within  the  lungs. 

Bronchodilator  Delivered  by  Metered  Dose 
Inhaler  and  Spacer  Improves  Respiratory 
System  Compliance  More  Than  Nebulizer- 
Delivered  Bronchodilator  in  Ventilated  Pre- 
mature Infants — Sivakumar  D.  Bosque  E. 
Goldman  SL.PediatrPulmonoll  999  Mar;27(3): 
208-212. 

We  compared  the  change  in  passive  respiratory 
system  compliance  (Crs)  and  resistance  (Rrs) 
after  albuterol  aerosol  treatment  administered 
by  either  low-flow  nebulizer  (NEB)  or  a  me- 
tered dose  inhaler  (MDl)  and  spacer  into  a  ven- 
tilator circuit.  We  hypothesized  that  albuterol 
delivered  to  ventilated  infants  older  than  7  days 
of  life  by  an  MDI  and  a  spacer  would  improve 
Crs  more  than  albuterol  delivered  by  a  low- 
flow  nebulizer.  The  treatments  were  adminis- 
tered 6  hr  apart  to  premature  infants  with  Crs  £ 
0.8  mL/cm  H2O  per  kg,  requiring  ventilation 
after  7  days  of  age.  Patients  served  as  their  own 
controls  and  treatment  order  was  randomized. 
Eighteen  studies  were  performed  in  eight  in- 
fants before  and  1   and  3  hr  after  treatment. 


Differences  between  methods  were  compared 
by  analyses  of  variance.  Mean  (range)  birth 
weight  and  study  age  were  888  (619-1,283)  g 
and  12  (7-29)  days,  respectively.  Mean  respi- 
ratory system  compliance  increased  by  34%  with 
MDI  and  by  1 1  %  with  NEB  at  1  hr  after  treat- 
ment (p  <  0.02).  By  3  hr  after  treatment,  Crs 
returned  to  baseline  with  both  methods  of  aero- 
sol delivery.  There  was  no  significant  differ- 
ence in  Rrs  between  the  two  methods  at  1  and 
3  hr  after  treatment.  We  conclude  that  albuterol 
delivered  by  MDI  improves  Crs  more  than  low- 
tlow  NEB  in  ventilated  premature  infants. 

Effect  of  Neck  Position  on  Endotracheal  Tube 
Location  in  Low  Birth  Weight  Infants — Rost 
JR,  Frush  DP,  Auten  RL.  Pediatr  Pulmonol  1999 

Mar:27(3):  199-202. 

Neck  position  can  affect  the  position  of  the  tip 
of  the  endotracheal  tube  (ETT)  in  normal  neo- 
nates; this  has  not  been  .systematically  investi- 
gated in  low  birth  weight  (LBW)  neonates.  It 
was  our  intention  to  determine  the  effect  of 
neck  flexion  and  extension  on  ETT  position  in 
LBW  infants.  Eight  LBW  orotracheally-intu- 
bated  infants  underwent  postmortem  anteropos- 
terior chest  radiographs  with  the  neck  in  a  neu- 
tral position,  in  55  degrees  flexion,  and  in  55 
degrees  extension.  Measurements  from  the  tho- 
racic inlet  to  the  ETT  were  obtained  in  each 
position.  The  ETT  always  moved  caudad  with 
neck  flexion  (p  =  0.001)  and  cephalad  with 
neck  extension  (p  =  0.001 ).  The  mean  extent  of 
ETT  displacement  was  3. 1  mm  (SD,  1 .7  mm) 
with  neck  flexion,  and  7.4  mm  (SD,  5.2  mm) 
with  extension  (p  <  0.05).  We  conclude  that  in 
LBW  infants:  1)  the  direction  of  ETT  move- 
ment with  neck  flexion  and  extension  is  pre- 
dictable and  identical  to  that  seen  in  term  in- 
fants and  children,  and  2)  neck  flexion  should 
not  be  a  principal  consideration  in  management 
of  ETT  location. 

Cost  Reduction  and  Outcome  Improvement 
in  the  Intensive  Care  Unit — Marx  WH,  De- 
Maintenon  NL,  Mooney  KF,  Mascia  ML,  Medi- 
cis  J.  Franklin  PD,  et  al.  J  Trauma  1999  Apr: 
46(4):625-629;  discussion  629-630. 

OBJECTIVE:  Decreasing  reimbursement  pro- 
vided by  third-party  payors  necessitates  reduc- 
tion of  costs  for  providing  critical  care  services. 
If  academic  medical  centers  are  to  remain  via- 
ble, methods  must  be  instituted  that  allow  cost 
reduction  through  practice  change.  METHODS: 
We  used  short  cycle  improvement  methodol- 
ogy to  rapidly  achieve  these  goals.  Short  cycle 
improvement  methodology  involves  identifying 
the  areas  for  improvement,  defining  a  mecha- 
nism to  evaluate  outcome,  initiating  an  improve- 
ment plan  on  a  small  number  of  patients,  and 
repeating  the  cycle  with  new  adjustments  based 
on  outcome.  Baseline  data  on  areas  for  improve- 
ment was  prospectively  collected,  and  proto- 


cols to  initiate  change  were  developed  and  tested 
by  short  improvement  cycles.  Outcomes  were 
evaluated,  protocols  were  modified,  and  another 
cycle  was  performed.  This  methodology  was 
continued  until  the  desired  goals  had  been 
achieved.  To  adjust  outcomes  for  severity  of 
illness.  Acute  Physiology  and  Chronic  Health 
Evaluation  II  methodology  was  used.  Using  this 
methodology,  we  focused  on  three  areas  for 
improvement.  Standing  orders  for  laboratory 
studies,  electrocardiograms,  and  chest  x-ray 
films  were  eliminated.  Protocols  were  devel- 
oped for  the  appropriate  use  of  sedation,  anal- 
gesics, and  neuromuscular  blocking  agents.  Fi- 
nally, a  protocol  for  weaning  from  mechanical 
ventilation  was  developed  to  allow  respiratory 
therapists  to  proceed  through  the  weaning  pro- 
cess, which  was  ordered  by  a  physician.  RE- 
SULTS: Laboratory  tests  were  reduced  by  65% 
(from  510  to  180  tests  per  day)  with  an  annual 
cost  .savings  of  $21,593.  Chest  x-ray  reduction 
of  56%  resulted  in  an  annual  savings  of  $3,941. 
There  was  a  75%  reduction  in  cost  of  neuro- 
muscular blocking  agents.  The  use  of  neuro- 
muscular blocking  agents  resulted  in  a  75%  re- 
duction in  drug  costs.  Ventilator  hours  were 
reduced  by  35%  from  140  to  90  hours.  The 
average  length  of  overall  intensive  care  unit 
stay  was  reduced  by  1.5  days  (5.0  to  3.5  days). 
The  cost  per  patient  day  decreased  with  an  an- 
nualized cost  savings  of  4%  per  patient  day. 
Unexpected  outcomes  included  a  reduction  in 
intensive  care  unit  days  from  54  days  at  base- 
line to  7  days  at  the  6-month  interval.  The  in- 
fection rates  for  blood  stream  infections,  uri- 
nary tract  infections,  and  nosocomial  pneumonia 
were  reduced.  Using  national  nosocomial  in- 
fection data,  these  rates  represented  a  reduction 
from  the  fiftieth  percentile  to  the  twenty-fifth 
percentile  for  all  measured  indicators.  Acute 
Physiology  and  Chronic  Health  Evaluation  II 
scores  were  19.54  at  baseline  and  increased  to 
21.2  (p  =  0.001)  at  the  6-month  interval.  Mor- 
tality rates  were  16.7%  at  baseline  and  were 
17.6%  (p  =  0.89)  at  the  6-month  interval.  CON- 
CLUSION: We  concluded  that  utilization  of 
short  cycle  improvement  methodology  provided 
an  ongoing  method  for  reducing  costs  of  criti- 
cal care  services  in  our  patient  population  with 
no  change  in  mortality. 

Extracorporeal  Life  Support  in  Pulmonary 
Failure  After  Trauma — Michaels  AJ,  Schrie- 
ner  RJ,  Kolla  S,  Awad  SS,  Rich  PB,  Reickert  C, 
et  al.  J  Trauma  1999  Apr;46(4):638-645. 

OBJECTIVE:  To  present  a  series  of  30  adult 
trauma  patients  who  received  extracorporeal  life 
support  (ECLS)  for  pulmonary  failure  and  to 
retrospectively  review  variables  related  to  their 
outcome.  METHODS:  In  a  Level  I  trauma  cen- 
ter between  1989  and  1997,  ECLS  with  contin- 
uous heparin  anticoagulation  was  instituted  in 
30  injured  patients  older  than  15  years.  Indica- 
tion was  for  an  estimated  mortality  risk  greater 


Respiratory  Care  •  July  1999  Vol  43  No  7 


Abstracts 


than  80%,  defined  by  a  PaOj-FiOj  ''^tio  'ess  than 
100  on  100%  FiQj,  despite  pressure-mode  in- 
verse ratio  ventilation,  optimal  positive  end-ex- 
piratory pressure,  reasonable  diuresis,  transfu- 
sion, and  prone  positioning.  Retrospective 
analysis  included  demographic  information 
(age,  gender.  Injury  Severity  Score,  injury  mech- 
anism), pulmonary  physiologic  and  gas-ex- 
change values  (pre-ECLS  ventilator  days 
[VENT  days],  PaOj'FiOj  ratio,  mixed  venous  ox- 
ygen saturation  [S^.oJ,  and  blood  gas),  pre- 
ECLS  cardiopulmonary  resuscitation,  compli- 
cations of  ECLS  (bleeding,  circuit  problems, 
leukopenia,  infection,  pneumothorax,  acute  re- 
nal failure,  and  pressors  on  ECLS),  and  sur- 
vival. RESULTS:  The  subjects  were  26.3±2.1 
years  old  (range,  15-59  years),  50%  male,  and 
had  blunt  injury  in  83.3%.  Pulmonary  recovery 
sufficient  to  wean  the  patient  from  ECLS  oc- 
curred in  17  patients  (56.7%),  and  50%  sur- 
vived to  discharge.  Fewer  VENT  days  and  more 
normal  S^qj  *^''s  associated  with  survival.  The 
presence  of  acute  renal  failure  and  the  need  for 
venoarterial  support  (venoarterial  bypass)  were 
more  common  in  the  patients  who  died.  Bleed- 
ing complications  (requiring  intervention  or  ad- 
ditional transfusion)  occurred  in  58.6%  of  pa- 
tients and  were  not  associated  with  mortality. 
Early  use  of  ECLS  (VENT  days  £  5)  was  as- 
sociated with  an  odds  ratio  of  7.2  for  survival. 
Fewer  VENT  days  was  independently  associ- 
ated with  survival  in  a  logistic  regression  model 
(p  =  0.029).  Age,  Injury  Severity  Score,  and 
faOj'PiOi  ■'a''"  ^^■'^  ""'  related  to  outcome. 
CONCLUSION:  ECLS  has  been  safely  used  in 
adult  trauma  patients  with  multiple  injuries  and 
severe  pulmonary  failure.  In  our  series,  early 
implementation  of  ECLS  was  associated  with 
improved  survival.  Although  this  may  repre- 
sent selection  bias  for  less  intractable  forms  of 
acute  respiratory  distress  syndrome,  it  is  our 
experience  that  early  institution  of  ECLS  may 
lead  to  improved  oxygen  delivery,  diminished 
ventilator-induced  lung  injury,  and  improved 
survival. 

Kinetics  of  Absorption  Atelectasis  During 
Anesthesia:  A  Mathematical  Model — Joyce 
CJ,  Williams  AB.  J  Appl  Physiol  1999  Apr; 
86(4):1I16-1125. 

Recent  computed  tomography  studies  show  that 
inspired  gas  composition  affects  the  develop- 
ment of  anesthesia-related  atelectasis.  This  sug- 
gests that  gas  absorption  plays  an  important  role 
in  the  genesis  of  the  atelectasis.  A  mathemati- 
cal model  was  developed  that  combined  models 
of  gas  exchange  from  an  ideal  lung  compart- 
ment, peripheral  gas  exchange,  and  gas  uptake 
from  a  closed  collapsible  cavity.  It  was  assumed 
that,  initially,  the  lung  functioned  as  an  ideal 
lung  compartment  but  that,  with  induction  of 
anesthesia,  the  airways  to  dependent  areas  of 
lung  closed  and  these  areas  of  lung  behaved  as 
a  closed  collapsible  cavity.  The  main  parameter 


of  interest  was  the  time  the  unventilated  area  of 
lung  took  to  collapse;  the  effects  of  preoxygen- 
ation and  of  different  inspired  gas  mixtures  dur- 
ing anesthesia  were  examined.  Preoxygenation 
increased  the  rate  of  gas  uptake  from  the  un- 
ventilated area  of  lung  and  was  the  most  im- 
portant determinant  of  the  time  to  collapse.  In- 
creasing the  inspired  Oj  fraction  during 
anesthesia  reduced  the  time  to  collapse.  Which 
inert  gas  (Nj  or  NjO)  was  breathed  during  an- 
esthesia had  minimal  effect  on  the  time  to  col- 
lapse. See  the  related  editorial:  Kinetics  of  Ab- 
sorption Atelectasis  During  Anesthesia:  A 
Mathematical  Model.  Hedenstierna  G.  J  Appl 
Physiol  1999  Apr:86(4):l  114-1115. 

Pulmonary  Perfusion  Is  More  Uniform  in  the 
Prone  Than  in  the  Supine  Position:  Scintig- 
raphy in  Healthy  Humans — Nyren  S,  Mure 
M,  Jacobsson  H,  Larsson  S  A,  Lindahl  SG.  J  Appl 
Physiol  1999  Apr;86(4):l  135-1 141. 

The  main  purpose  of  this  study  was  to  find  out 
whether  the  dominant  dorsal  lung  perfusion 
while  supine  changes  to  a  dominant  ventral  lung 
perfusion  while  prone.  Regional  distribution  of 
pulmonary  blood  flow  was  determined  in  10 
healthy  volunteers.  The  subjects  were  studied 
in  both  prone  and  supine  positions  with  and 
without  lung  distension  caused  by  10  cm  HjO 
of  continuous  positive  airway  pressure  (CPAP). 
Radiolabeled  macroaggregates  of  albumin, 
rapidly  trapped  by  pulmonary  capillaries  in  pro- 
portion to  blood  flow,  were  injected  intrave- 
nously. Tomographic  gamma  camera  examina- 
tions (single-photon-emission  computed 
tomography)  were  performed  after  injections  in 
the  different  positions.  All  data  acquisitions  were 
made  with  the  subject  in  the  supine  position. 
CPAP  enhanced  perfusion  differences  along  the 
gravitational  axis,  which  was  more  pronounced 
in  the  supine  than  prone  position.  Diaphrag- 
matic sections  of  the  lung  had  a  more  uniform 
pulmonary  blood  flow  distribution  in  the  prone 
than  supine  position  during  both  normal  and 
CPAP  breathing.  It  was  concluded  that  the  dom- 
inant dorsal  lung  perfusion  observed  when  the 
subjects  were  supine  was  not  changed  into  a 
dominant  ventral  lung  perfusion  when  the  sub- 
jects were  prone.  Lung  perfusion  was  more  uni- 
formly distributed  in  the  prone  compared  with 
in  the  supine  position,  a  difference  that  was 
more  marked  during  total  lung  distension 
(CPAP)  than  during  normal  breathing. 

Multicentre  Randomised  Controlled  Trial  of 
Nursing  Intervention  for  Breathlessness  in 
Patients  with  Lung  Cancer — Bredin  M,  Cor- 
ner J,  Krishnasamy  M,  Plant  H,  Bailey  C, 
A'Hem  R.  BMJ  1999  Apr  3;318(7188):901- 
904. 

OBJECTIVE:  To  evaluate  the  effectiveness  of 
nursing  intervention  for  breathlessness  in  pa- 
tients with  lung  cancer.  DESIGN:  Patients  di- 


agnosed with  lung  cancer  participated  in  a  mul- 
ticentre randomised  controlled  trial  where  they 
either  attended  a  nursing  clinic  offering  inter- 
vention for  their  breathlessness  or  received  best 
supportive  care.  The  intervention  consisted  of  a 
range  of  strategies  combining  breathing  con- 
trol, activity  pacing,  relaxation  techniques,  and 
psychosocial  support.  Best  supportive  care  in- 
volved receiving  standard  management  and 
treatment  available  for  breathlessness,  and 
breathing  assessments.  Participants  completed 
a  range  of  self  assessment  questionnaires  at  base- 
line, 4  weeks,  and  8  weeks.  SETTING:  Nursing 
clinics  within  6  hospital  settings  in  the  United 
Kingdom.  PARTICIPANTS:  119  patients  diag- 
nosed with  small  cell  or  non-small  cell  lung 
cancer  or  with  mesothelioma  who  had  com- 
pleted first  line  treatment  for  their  disease  and 
reported  breathlessness.  OUTCOME  MEA- 
SURES: Visual  analogue  scales  measuring  dis- 
tress due  to  breathlessness,  breathlessness  at  best 
and  worst,  WHO  performance  status  scale,  hos- 
pital anxiety  and  depression  scale,  and  Rotter- 
dam symptom  checklist.  RESULTS:  The  inter- 
vention group  improved  significantly  at  8  weeks 
in  5  of  the  1 1  items  assessed:  breathlessness  at 
best,  WHO  performance  status,  levels  of  de- 
pression, and  two  Rotterdam  symptom  check- 
list measures  (physical  symptom  distress  and 
breathlessness)  and  showed  slight  improvement 
in  3  of  the  remaining  6  items.  CONCLUSION: 
Most  patients  who  completed  the  study  had  a 
poor  prognosis,  and  breathlessness  was  typi- 
cally a  symptom  of  their  deteriorating  condi- 
tion. Patients  who  attended  nursing  clinics  and 
received  the  breathlessness  intervention  expe- 
rienced improvements  in  breathlessness,  per- 
formance status,  and  physical  and  emotional 
states  relative  to  control  patients. 

Effects  of  Ventilator  Resetting  on  Indirect 
Calorimetry  Measurement  in  the  Critically 
III  Surgical  Patient— Brandi  LS,  Bertolini  R, 
Santini  L,  Cavani  S.  Crit  Care  Med  1999  Mar; 

27(3):53 1-539. 

OBJECTIVE:  To  evaluate  the  effect  of  acute 
changes  in  minute  ventilation  (Vg)  on  oxygen 
consumption  (Vq^,  carbon  dioxide  production 
(Vc-oj).  respiratory  quotient,  and  energy  expen- 
diture during  volume-controlled  mechanical 
ventilation  in  the  critically  ill  surgical  patient. 
The  effects  on  some  oxygen  transport  variables 
were  assessed  as  well.  DESIGN:  Prospective, 
randomized  clinical  study  SETTING:  Adult  sur- 
gical intensive  care  unit  of  a  university  teaching 
hospital.  PATIENTS:  Twenty  adult  critically  ill 
surgical  patients  were  studied  during  volume- 
controlled  mechanical  ventilation.  INTERVEN- 
TIONS: After  a  basal  period  of  stability  (no 
changes  over  time  in  body  temperature,  energy 
expenditure,  blood  gases,  acid-base  status,  car- 
diac output,  and  ventilatory  parameters),  Vg  was 
then  randomly  either  increased  or  reduced 
( ±  35%)  by  a  change  in  tidal  volume  ( Vj),  while 


740 


Respiratory  Care  •  July  1999  Vol  43  No  7 


respiratory  rale  and  inspiratory/expiratory  ratio 
were  kept  constant.  Settings  were  then  main- 
tained for  120  mins.  During  the  study,  patients 
were  sedated  and  paralyzed.  MEASURE- 
MENTS AND  MAIN  RESULTS:  Vo,,  Vco^. 
and  respiratory  quotient  were  measured  contin- 
uously by  a  Nellcor  Puritan  Bennett  7250  met- 
abolic monitor  (Nellcor  Puritan  Bennett,  Carls- 
bad, CA).  Hemodynamic  and  oxygen  transport 
parameters  were  obtained  every  15  mins  during 
the  study.  Despite  large  changes  in  V^,  Vq,  and 
energy  expenditure  did  not  change  significantly 
either  in  the  increased  or  in  the  reduced  Vg 
groups.  After  15  mins.  V^o,  and  respiratory 
quotient  changed  significantly  after  ventilator 
resetting.  V(~„,  increased  by  10.5  ±  1.1%  (from 
2.5  ±0.10  to  2.8  ±  0.12  mLymin/kg,p<  0.01) 
in  the  increased  Vp;  group  and  decreased  by 
12.4  ±  2.1%  (from  2.7  ±  0.17  to  2.4  ±  0.16 
mL/min/kg,  p<  0.01)  in  the  reduced  V,,  group. 
Similarly,  respiratory  quotient  increased  by 
16.2%  ±  2.2%  (from  0.87  ±  0.02  to  1.02  ± 
0.02,  p  <  0.01)  and  decreased  by  17.2%  ± 
1.8%  (from  0.88  ±  0.02  to  0.73  ±  0.02,  p  < 
0.01 ).  V|-.„,  normalized  in  the  reduced  Vp  group, 
but  remained  higher  than  baseline  in  the  in- 
creased V|.;  group.  Respiratory  quotient  did  not 
normalize  in  both  groups  and  remained  signif- 
icantly different  from  baseline  at  the  end  of  the 
study.  Cardiac  index,  oxygen  delivery,  and 
mixed  venous  oxygen  saturation  increased, 
while  oxygen  extraction  index  decreased  sig- 
nificantly in  the  reduced  Vg  group.  Neither  of 
the  mentioned  parameters  changed  significantly 
in  the  increased  V^  group.  CONCLUSIONS; 
We  conclude  that,  during  controlled  mechani- 
cal ventilation,  the  time  course  and  the  magni- 
tude of  the  effect  on  gas  exchange  and  energy 
expenditure  measurements  caused  by  acute 
changes  in  Vp  suggest  that  V^,  and  energy  ex- 
penditure measurements  can  be  used  reliably  to 
evaluate  and  quantify  metabolic  events  and  that 
V(.(,,  and  respiratory  quotient  measurements  are 
useless  for  metabolic  purposes  at  least  for  120 
mins  after  ventilator  resetting.  See  the  related 
editorial:  Effects  of  Ventilator  Resetting  on 
Indirect  Calorimetry  Measurement:  The  Im- 
portance of  Patience.  Kirkland  L.  Crit  Care 
Med  1999  Mar:27(3):459-460. 

Pulmonary  Function  Monitoring  During 
Adenosine  Myocardial  Perfusion  Scintigra- 
phy in  Patients  with  Chronic  Obstructive  Pul- 
monary Disease — Johnston  DL,  Scanlon  PD, 
Hodge  DO,  Glynn  RB,  Hung  JC,  Gibbons  RJ. 
Mayo  Clin  Proc  1999  Apr;74(4);339-346. 

OBJECTIVE:  To  determine  whether  adenosine 
could  be  safely  administered  to  patients  with 
chronic  obstructive  pulmonary  disease  (COPD) 
lor  coronary  vasodilatation  during  perfusion 
scintigraphy  without  causing  bronchospasm. 
MATERIAL  AND  METHODS:  The  study  was 
divided  into  two  phases.  In  the  monitoring  phase, 
patients  with  COPD  were  pretreated  with  an 


^ 


^/^A 


Mechanical 
Ventilation 


principles  and  applications 
8th  Annual  Course 

•    Highlights  of  recent  developments 
"Hands-on"  small  group  workshops 
•    Close  faculty  interaction 
•    Intensive  tutorials 

September  16-19, 1999 

Minneapolis,  Minnesota,  USA 

Course  director:  John  Marini,  MD 
Guest  lecturers: 


Richard  Albert,  MD 
Marcelo  Amato,  MD 
Lluis  Blanch,  MD 
Richard  Branson,  RRT 
John  Downs,  MD 


Dean  Hess,  PhD,  RRT 
Giorgio  lotti,  MD 
Nicholas  Hill,  MD 
Robert  Kacmarek,  PhD,  RRT 
David  Pierson,  MD 


For  further  information,  contact  Continuing  Medical  Education, 

University  of  Minnesota,  107  Radisson  Hotel  Metrodome, 

615  Washington  Avenue  SE,  Minneapolis,  Minnesota  55414  (USA) 

Telephone  (612)626-7600:    FAX:  (612)626-7766 


Circle  110  on  reader  service  card 


inhaled  bronchodilator  (albuterol)  and  had  pul- 
monary function  monitored  during  the  infusion 
of  a  graduated  dose  of  adenosine.  Eligibility  for 
entry  into  this  phase  of  the  study  was  deter- 
mined on  the  basis  of  results  of  pulmonary  func- 
tion testing  (PPT)  during  resting.  Once  we  had 
shown  that  adenosine  could  be  safely  adminis- 
tered to  patients  with  COPD,  an  implementa- 
tion phase  was  begun.  Entry  did  not  require 
resting  PFT,  and  patients  were  administered 
adenosine  without  monitoring  of  pulmonary 
function.  Differences  between  patients  with  nor- 
mal pulmonary  function  or  mild  COPD  and  those 
with  more  severe  COPD  were  analyzed  statis- 
tically. RESULTS:  Of  94  patients  entered  into 
the  monitoring  phase,  none  had  obvious  bron- 
chospasm. The  dosage  of  adenosine  was  re- 
duced in  four  patients  because  of  a  decrease  in 
forced  expiratory  volume  in  1  second  (FEV,) 
of  20%  in  comparison  with  baseline  (FEV,  be- 
fore administration  of  albuterol).  The  mean 
FEV,  decrea.sed  slightly  from  1.83  L  after  ad- 
ministration of  albuterol  to  1.78  L  during  the 
maximal  adenosine  dose.  Patients  with  a  re- 
mote history  of  asthma,  positive  result  of  a 
methacholine  challenge  test,  or  mild  COPD 
(FEV  I  60  to  80%  of  the  maximal  predicted  value 
for  age)  did  not  differ  significantly  in  their  re- 
sponse to  infusion  of  adenosine  from  those  with 
moderate  or  severe  COPD  (FEV,  30  to  59%  of 
the  maximum  predicted  for  age).  Of  117  pa- 


tients in  the  implementation  phase,  2  had  bron- 
chospasm during  infusion  of  adenosine  that  was 
quickly  terminated  by  stopping  the  administra- 
tion in  one  patient  and  reducing  the  dose  of 
adenosine  in  the  other.  CONCLUSION:  This 
study  shows  that  adenosine  can  be  safely  ad- 
ministered intravenously  to  selected  patients 
with  known  or  suspected  COPD  to  produce  cor- 
onary vasodilatation  for  myocardial  perfusion 
imaging.  Patients  who  are  within  the  guidelines 
established  for  this  study  should  be  considered 
for  adenosine  coronary  vasodilatation  with  use 
of  bronchodilator  pretreatment,  a  graduated  dose 
of  adenosine,  and  regular  chest  auscultation  dur- 
ing the  infusion. 

Adult  Immunizations:  Recommendations  for 

Practice— Reid  KC,  Grizzard  TA,  Poland  GA. 
Mayo  Clin  Proc  1999  Apr:74(4):377-384. 

Each  year  in  the  United  States,  50,000  to  90,000 
adults  die  of  pneumococcal  disease,  influenza, 
and  hepatitis  infections.  These  figures  vastly 
exceed  mortality  due  to  vaccine-preventable  dis- 
eases in  children.  In  addition,  adult  immuniza- 
tions are  cost-effective  and  lifesaving  measures. 
Nonetheless,  surveys  reveal  that  both  physicians 
and  patients  underuse  adult  immunizations  as 
an  effective  means  of  disease  prevention.  The 
goal  of  achieving  higher  adult  immunization 
rates  is  critically  dependent  on  improving  the 


Respiratory  Care  •  July  1999  Vol  43  No  7 


741 


Abstracts 


attitudes  and  practices  of  health-care  providers. 
In  this  article,  we  review  several  vaccines  rou- 
tinely used  in  the  practice  of  adult  medicine. 

Hyperbaric  Oxygen  Therapy  for  Massive  Ar- 
terial Air  Embolism  During  Cardiac  Oper- 
ations— Ziser  A,  Adir  Y,  Lavon  H,  Shupak  A. 
J  Thorac  Cardiovasc  Surg  1999  Apr;117(4): 
818-821. 

BACKGROUND:  Massive  arterial  air  embo- 
lism is  a  rare  but  devastating  complication  of 
cardiac  operations.  Several  treatment  modali- 
ties have  been  proposed,  but  hyperbaric  oxygen 
is  the  specific  therapy.  METHODS:  The  Israel 
Naval  Medical  Institute  is  the  only  referral  hy- 
perbaric center  in  this  country  for  acute  care 
patients.  We  reviewed  our  experience  in  the 
hyperbaric  oxygen  treatment  of  massive  arterial 
air  embolism  during  cardiac  operations.  RE- 
SULTS: Seventeen  patients  were  treated  be- 
tween 1985  and  1998.  Eight  patients  (47.1%) 
experienced  a  complete  neurologic  recovery;  6 
patients  (35.3%)  remained  unconscious  at  dis- 
charge, and  3  patients  (17.6%)  died.  Mean  (± 
SD)  delay  from  the  end  of  the  operation  to  hy- 
perbaric therapy  was  9.6  ±7.4  hours  (range, 
1-20  hours).  This  delay  was  4.0  ±  3.4  hours 
(1-12  hours)  for  patients  who  had  a  full  neu- 
rologic recovery,  12.8  ±  7.1  hours  (5-20  hours) 
for  patients  with  severe  neurologic  disability, 
and  18.0  ±  2.0  hours  (16-20  hours)  for  pa- 
tients who  died  (1-way  analysis  of  variance; 
p  =  0.002).  The  source  of  variance  among  the 
groups  mainly  resulted  from  the  short  delay  for 
patients  who  experienced  complete  recovery 
compared  with  the  other  2  groups  (Tukey  test). 
All  5  patients  who  were  treated  within  3  hours 
from  the  operation  and  50%  (2  of  4  patients)  of 
those  patients  treated  3  to  5  hours  from  opera- 
tion experienced  a  full  neurologic  recovery. 
With  a  delay  of  9  to  20  hours,  only  1  of  8 
patients  had  a  full  neurologic  recovery.  The  as- 
sociation between  outcome  and  treatment  de- 
lay was  found  to  be  statistically  significant  (T 
=  0.65  with  exact  2-sided  p  value  =  0.0007). 
CONCLUSION:  Hyperbaric  oxygen  therapy 
should  be  administered  as  soon  as  possible  after 
massive  arterial  air  embolism  during  cardiac 
operations. 

Prospective  Multicenter  Study  of  Relapse 
Following  Treatment  for  Acute  Asthma 
Among  Adults  Presenting  to  the  Emergency 
Department.  MARC  Investigators.  Multi- 
center  Asthma  Research  Collaboration. 
Emerman  CL,  Woodruff  PG,  Cydulka  RK, 
Gibbs  MA,  Pollack  CV  Jr,  Camargo  CA  Jr. 
Chest  1999  Apr;115(4):919-927. 

STUDY  OBJECTIVE:  To  identify  factors  as- 
sociated with  relapse  following  treatment  for 
acute  asthma  among  adults  presenting  to  the 
emergency  department  (ED).  DESIGN:  Pro- 
spective inception  cohort  study  performed  dur- 


ing October  1996  to  December  1996  and  April 
1997  to  June  1997,  as  part  of  the  Multicenter 
A.sthma  Research  Collaboration.  SETTING: 
Thirty-six  EDs  in  18  states.  PATIENTS:  ED 
patients,  aged  18  to  54  years,  with  physician 
diagnosis  of  acute  asthma.  For  the  present  anal- 
ysis, we  restricted  the  cohort  to  patients  sent 
home  from  the  ED  (n  =  971),  then  further  ex- 
cluded patients  with  comorbid  respiratory  con- 
ditions (n  =  32).  This  left  939  eligible  subjects 
to  have  follow-up  data.  Interventions:  None. 
MEASUREMENTS  AND  RESULTS:  Two 
weeks  after  being  sent  home  from  the  ED,  pa- 
tients were  contacted  by  telephone.  A  relapse 
was  defined  as  an  urgent  or  unscheduled  visit  to 
any  physician  for  worsening  asthma  symptoms 
during  the  14-day  follow-up  period.  Complete 
follow-up  data  were  available  for  641  patients, 
of  whom  17%  reported  relapse  (95%  confidence 
interval,  14  to  20).  There  was  no  significant 
difference  in  peak  expiratory  flow  rate  (PEER) 
between  patients  who  suffered  relapse  and  those 
who  did  not.  In  a  multivariate  logistic  regres- 
sion analysis  (controlling  for  age,  gender,  race, 
and  primary  care  provider  status),  patients  who 
suffered  relapse  were  more  likely  to  have  a  his- 
tory of  numerous  ED  (odds  ratio  [OD]  1.3  per 
5  visits)  and  urgent  chnic  visits  (OR  1.4  per  5 
visits)  for  asthma  in  the  past  year,  use  a  home 
nebulizer  (OR  2.2),  report  multiple  triggers  of 
their  asthma  (OR  1 . 1  per  trigger),  and  report  a 
longer  duration  of  symptoms  (OR  2.5  for  1  to  7 
days).  CONCLUSION:  Among  patients  sent 
home  from  the  ED  following  acute  asthma  ther- 
apy, 17%  will  have  a  relapse  and  PEER  does 
not  predict  who  will  develop  this  outcome.  By 
contrast,  several  historical  features  were  asso- 
ciated with  increased  risk.  Further  research 
should  focus  on  ways  to  decrease  the  relapse 
rate  among  these  high-risk  patients.  The  clini- 
cian may  wish  to  consider  these  historical  fac- 
tors when  making  ED  decisions.  See  the  related 
editorial:  Emergency  Department  Care  of  the 
Asthma  Patient:  Predicting  "Bounce-Back" 
Patients.  Varon  J,  Fromm  RE  Jr.  Chest  1999 
Apr:I15(4):909-9U. 

Effect  of  Continuously  Nebulized  Ipratro- 
pium Bromide  Plus  Albuterol  on  Emergency 
Department  Length  of  Stay  and  Hospital  Ad- 
mission Rates  in  Patients  with  Acute  Bron- 
chospasm:  A  Randomized,  Controlled  Tri- 
al— Weber  EJ,  Levitt  MA,  Covington  JK, 
Gambrioli  E.  Chest  1999  Apr;l  15(4):937-944. 

OBJECTIVE:  To  compare  the  outcome  of  pa- 
tients with  acute  bronchospasm  treated  with  con- 
tinuously nebulized  albuterol  plus  ipratropium 
bromide  vs  albuterol  alone.  SETTING:  The 
Emergency  Department  (ED)  at  the  University 
of  California  San  Francisco  Medical  Center. 
PARTICIPANTS:  Patients  >  18  years  old  pre- 
senting to  the  ED  with  acute  bronchospasm  and 
a  peak  expiratory  flow  rate  (PEER)  of  <  70% 
predicted.  INTERVENTIONS:  This  was  a  pro- 


spective, randomized,  double-blind,  placebo- 
controlled  trial.  Subjects  were  treated  with  ei- 
ther a  combination  of  albuterol  (10  mg/h)  plus 
ipratropium  bromide  (1.0  mg/h)  or  albuterol 
alone  via  continuous  nebulization  for  a  maxi- 
mum of  3  h.  Vital  signs,  Borg  dyspnea  score, 
and  PEER  were  recorded  hourly.  Primary  out- 
come measures  were  improvement  in  PEFR, 
hospital  admission  rates,  and  length  of  stay  in 
the  ED.  MEASUREMENTS  AND  RESULTS: 
Data  was  analyzed  for  67  subjects.  The  mean 
age  (±  SD)  was  47.5  ±18.8,  and  mean  initial 
PEFR  was  44.8±  12.5%  of  predicted.  The  me- 
dian length  of  stay  for  all  subjects  was  225  min, 
and  31%  of  all  subjects  were  admitted.  Patients 
given  combination  therapy  averaged  6.3% 
greater  improvement  in  PEFR  compared  with 
control  subjects  (95%  confidence  interval  [CI], 
-15%  to  27%.  The  odds  ratio  for  admission 
with  combination  therapy  was  0.88  (95%  CI, 
0.28  to  2.8).  The  median  length  of  stay  in  the 
ED  was  35  min  shorter  for  those  receiving  com- 
bination treatment  (210  vs  245  min;  p  =  0.03). 
However,  when  adjusted  for  initial  PEFR,  there 
was  no  statistically  significant  difference  (p  = 
0.26).  CONCLUSION:  Although  the  direction 
of  all  three  outcome  measures  favored  combi- 
nation therapy,  there  was  no  statistically  signif- 
icant difference  between  ED  patients  with  acute 
bronchospasm  receiving  continuous  albuterol 
plus  ipratropium  bromide  and  those  receiving 
albuterol  alone.  See  the  related  editorial:  Bron- 
chodilator  Therapy  in  Status  Asthmaticus.  Tee- 
ter JG.  Chest  1999  Apr;115(4):91 1-912. 

The  Laboratory-Clinical  Interface:  Point-of- 
Care  Testing— Kost  GJ,  Ehrmeyer  SS,  Cher- 
now  B,  Winkelman  JW,  Zaloga  GP,  Dellinger 
RP,  Shirey  T.  Chest  1999  Apr;l  15(4):1 140- 
1154. 

POC  testing  provides  an  opportunity  for  clini- 
cians and  laboratorians  to  work  together  to  con- 
sider how  best  to  serve  the  patients  within  an 
individual  institution.  Each  health  system  has 
unique  characteristics  relative  to  patient  popu- 
lation, as  well  as  a  unique  laboratory  structure. 
If  physicians,  nurses,  laboratorians,  and  pathol- 
ogists work  collaboratively,  the  best  interests  of 
patients  will  be  served.  In  some  institutions  that 
cater  to  specific  patient  groups,  POC  testing 
may  offer  clear  and  distinct  advantages.  In  other 
institutions  with  sophisticated  transport  systems 
and  established  rapid  response  capabilities,  the 
quality  resulting  from  central  laboratory  testing 
may  outweigh  any  advantages  of  bedside  test- 
ing. Clearly,  attention  to  regulatory  issues,  QC 
issues,  the  importance  of  proper  documenta- 
tion, proficiency  testing,  performance  enhance- 
ment, and  cost-effectiveness  is  requisite.  As  the 
technology  for  diagnostic  testing  advances 
through  more  microcomputerization,  micro- 
chemistry,  and  enhanced  test  menus,  the  con- 
cept of  POC  testing  will  need  perpetual  revis- 
iting. We  hope  that  the  information  provided 


742 


Respiratory  Care  •  July  1999  Vol  43  No  7 


EXPIIND 

ijour  hnouiledoe 


ijour  skills 


Airway  Management:  Tricks  of  the  Trade 

Learn  how  to  manage  the  obstructed  airway  and  how  to 
determine  when  an  artificial  airway  is  necessary.  Also  presented 
are  the  methods  of  assessing  endotracheal  tube  positioning, 
monitoring  the  intubated  patient,  and  determinmg  when 
extubation  is  feasible.  Featuring  Charles  G.  Durbm,  Jr.,  MD, 
FCCM,  and  David  J.  Pierson,  MD. 
Item  VC67  $49.95  ($99  nonmembers) 


Respiratory  Care  Patient-Driven  Protocols 

Written  by  UC^D  faculty,  one  of  the  country's  leading  institutions  in  the 

development  of  protocols.  This  book  serves  as  an  excellent  resource  in  the  processes 

of  developing,  implementing,  or  refining  care  plans.  Features  25  complete  protocols 

with  an  mtroduction  on  how  to  implement  PDPs  in  your  facility.  Authors  include 

Jan  PhiUips-Clar,  BS,  RRT;  Richard  Ford,  BS,  RRT;  Timothy  Morns,  MD;  and  David 

Burns,  MD.  Paperback.  205  pages.  Published  m  1998. 
Item  PA801  $85.00  ($99.00  nonmembers) 


Tracheal  Intubation  I: 
Upper  Airway  Anatomy  and 
Goals  of  Intubation 

After  completing  this  IISP,  you  will  understand  the  rationale  for 
tracheal  intubation  and  be  able  to  identify  the  important  landmarks  of 
upper  airway  anatomy. 
Item  CP4    $12  (  $16  nonmembers) 

Tracheal  Intubation  II: 
Routes  of  Intubation 

Describes  the  four  routes  of  tracheal  intubation  and  some  advantages 
and  hazards  of  each.  Also  presents  the  process  for  selecting  the  most 
suitable  route  in  a  given  situation. 
Item  CP5  $12  (  $16  nonmembers) 


To  place  your  order,  please  call: 

972-243-2272 

Texas  customers  only,  please  add  8.25%  sales  tax  (including  shipping  charges).  Texas  custorners  who  are  exempt  from  sales  tax  must 
supply  an  exemption  certificate.  MasterCard,  Visa,  Institutional  Purchase  Order  or  check  payable  to: 


Handling  &  Shipping  Charges 
$  0  -  $15  IS  $4.25 
$15.01  -  $25.00  IS  $5.25 
$25.01  -  $60.00  IS  $7.25 
$60.01 -$100.00  IS  $9  J5 


Doedolus  Enterprises,  Inc 


ATTN.  Order  Fulfillment  Department 

11030  Abies  Lane  •  Dallas,  Texas  75229 

Phone  972-243-2272  Fax:  972-484-6010 

Discover  other  related  products  within  "Key  to  Professional  Excellence"  @  www.aarc.org 


Abstracts 


here  will  aid  clinicians,  laboratorians,  and  ad- 
ministrators in  their  quest  to  best  serve  their 
patients.  See  the  related  editorial:  Point-of-Care 
Blood  Testing:  More  Than  Simply  Changing 
Venue.  Shapiro  BA.  Chest  1999  Apr:  115(4): 
917-918. 


The  Clinical  Utility  of  Invasive  Diagnostic 
Techniques  in  the  Setting  of  Ventilator-As- 
sociated Pneumonia.  Canadian  Critical  Care 
Trials  Group— Heyland  DK,  Cook  DJ,  Mar- 
shall J,  Heule  M,  Guslits  B,  Lang  J,  Jaeschke  R. 
Chest  1999  Apr;l  15(4):  1076-1084. 

OBJECTIVE:  To  evaluate  the  clinical  utility  of 
bronchoscopy  with  protected  brush  catheter 
(PBC)  and  BAL  for  patients  with  ventilator- 
associated  pneumonia  (VAP).  DESIGN:  Pro- 
spective cohort  study.  SETTING:  Ten  tertiary 
care  ICUs  in  Canada.  PATIENTS:  Ninety-two 
mechanically  ventilated  patients  with  a  clinical 
suspicion  of  VAP  who  underwent  bronchos- 
copy were  compared  with  49  patients  with  a 
clinical  suspicion  of  pneumonia  who  did  not. 
INTERVENTIONS:  None.  MEASURE- 
MENTS AND  RESULTS:  We  compared  anti- 
biotic use,  duration  of  mechanical  ventilation, 
ICU  stay,  and  mortality.  In  addition,  for  pa- 
tients who  received  bronchoscopy,  we  admin- 
istered a  questionnaire  (before  and  after  bron- 
choscopy) to  evaluate  the  effect  of  PBC  or  BAL 
on  (I)  physician  perception  of  the  probability 
of  VAP,  (2)  physician  confidence  in  the  diag- 
nosis of  VAP,  and  (3)  changes  to  antibiotic 
management.  After  bronchoscopy  results  be- 
came available,  from  the  physician's  perspec- 
tive, the  diagnosis  of  VAP  was  deemed  much 
less  likely  (p  <  0.001),  confidence  in  the  diag- 
nosis increased  (p  =  0.03),  and  level  of  comfort 
with  the  management  plan  increased  (p  =  0.02). 
Following  the  results  of  invasive  diagnostic 
tests,  in  the  group  that  underwent  bronchos- 
copy, patients  were  receiving  fewer  antibiotics 
(31/92  vs  9/49,  p  =  0.05)  and  more  patients  had 
treatment  with  all  their  antibiotics  discontinued 
(18/92  vs  3/49,  p  =  0.04)  compared  with  the 
group  that  did  not  undergo  bronchoscopy.  Du- 
ration of  mechanical  ventilation  and  ICU  stay 
were  similar  between  the  two  groups,  but  mor- 
tality was  lower  in  the  group  that  underwent 
bronchoscopy  with  PBC  or  BAL  (18.5%  vs 
34.7%,  p  =  0.03).  CONCLUSIONS:  Invasive 
diagno.stic  testing  may  increase  physician  con- 
fidence in  the  diagnosis  and  management  of 
VAP  and  allows  for  greater  ability  to  limit  or 
discontinue  antibiotic  treatment.  Whether  per- 
forming PBC  or  BAL  affects  clinically  impor- 
tant outcomes  requires  further  study.  See  the 
related  editorial:  Not  a  Matter  of  Life  and 
Death!  Johanson  WG  Jr.  Che.\t  1999  Apr; 
115(4):9I6-917. 

Safety  of  Long-Term  Treatment  with  HFA 
Albuterol— Ramsdell  JW,  Klinger  NM,  Ek- 


holm  BP,  Colice  GL.  Chest  1999  Apr;l  15(4): 
945-951. 

BACKGROUND:  Chlorofluorocarbons  (CFCs) 
used  as  propellants  in  metered-dose  inhalers  de- 
plete stratospheric  ozone,  which  results  in  se- 
rious public  health  concerns.  Albuterol  has  been 
reformulated  in  the  non-ozone-depleting  pro- 
pellant,  hydrofluoroalkane-134a  (HFA  albu- 
terol). OBJECTIVES:  The  primary  objective 
was  to  compare  the  safety  of  HFA  albuterol  to 
an  albuterol  product  formulated  in  chlorofluo- 
rocarbon  propellants  (CFC  albuterol)  during  1 
year  of  treatment  in  asthmatics.  Bronchodilator 
efficacy  of  the  two  products  was  assessed  as  a 
secondary  objective.  METHODS:  The  results 
from  two  open-label,  parallel-group  trials  of  sim- 
ilar design  in  asthmatics  requiring  short-acting 
beta-agonists  for  symptom  control  were  com- 
bined. Patients  took  two  puffs  bid  of  either  HFA 
albuterol  or  CFC  albuterol  for  I  year.  Addi- 
tional puffs  of  study  drug  were  allowed  as  needed 
to  control  asthma  symptoms.  Adverse  events 
were  recorded  at  clinic  visits.  Patients  self-ad- 
ministered study  drug  at  quarteriy  visits  and 
underwent  serial  spirometry  during  a  6-h  period 
postdose.  Bronchodilator  efficacy  variables, 
based  on  FEV,  respon.se  to  study  drug,  were 
proportion  of  responders,  time  to  onset  of  ef- 
fect, peak  percent  change,  time  to  peak  effect, 
duration  of  effect,  and  area  under  the  curve. 
Differences  between  products  and  changes  over 
time  in  efficacy  variables  were  assessed  using 
an  analysis  of  variance  model.  Regression  anal- 
yses with  FEV,  as  a  covariate  were  performed 
post-hoc  to  analyze  changes  in  bronchodilator 
efficacy  over  time.  RESULTS:  Demographic 
and  baseline  characteristics  were  similar  for  pa- 
tients receiving  HFA  albuterol  (n  =  337)  and 
CFC  albuterol  (n  =  132).  Total  reported  ad- 
verse events  were  similar  for  the  two  treatments. 
Differences  in  only  four  individual  adverse 
events  were  noted:  the  HFA  albuterol  group 
reported  more  gastroenteritis  and  dizziness;  the 
CFC  albuterol  group  reported  more  epistaxis 
and  expectoration.  Adverse  events  attributed  to 
study  drug  use  were  infrequent.  No  serious  ad- 
verse events  were  related  to  study  drug  use. 
Predose  FEV,  at  quarterly  visits  increased  to  a 
small  extent  in  both  groups  from  month  0  to 
month  12.  The  bronchodilator  efficacy  of  HFA 
albuterol  was  comparable  to  that  of  CFC  albu- 
terol at  the  quarteriy  visits,  but  decreased  from 
baseline  for  both  products  over  the  12  months 
of  treatment.  Use  of  inhaled  corticosteroids,  na- 
sal corticosteroids,  or  theophylline  did  not  ex- 
plain the  increase  in  predose  FEV,  over  time 
and  did  not  protect  patients  from  developing 
reduced  bronchodilator  efficacy  by  month  12. 
The  change  in  predose  FEV,  did  not  entirely 
account  for  the  reduced  bronchodilator  efficacy 
over  time.  CONCLUSIONS:  HFA  albuterol  has 
a  safety  profile  similar  to  that  of  CFC  albuterol 
during  chronic,  scheduled  u.se,  and  both  drugs 
are  well  tolerated.  HFA  albuterol  and  CFC  al- 


buterol provided  comparable  bronchodilator  ef- 
ficacy, but  bronchodilator  efficacy  decreased 
for  both  products  with  I  year  of  use. 

Clickhaler  (A  Novel  Dry  Powder  Inhaler) 
Provides  Similar  Bronchodilation  to  Pressur- 
ized Metered-Dose  Inhaler,  Even  at  Low 
Flow  Rates— Newhouse  MT,  Nantel  NP, 
Chambers  CB,  Pratt  B,  Parry-Billings  M.  Chest 
1999  Apr;ll5(4):952-956. 

STUDY  OBJECTIVE:  Comparison  of  the  bron- 
chodilator response  to  an  albuterol  novel  dry 
powder  inhaler  (DPI)  (Clickhaler  |CH];  ML 
Laboratories  PLC;  St.  Albans,  UK)  activated  at 
various  inspiratory  flow  rates  and  to  an  albu- 
terol pressurized  metered-dose  inhaler  (pMDI) 
by  patients  with  moderate  to  moderately  severe 
stable  a.sthma.  DESIGN:  Randomized,  double- 
blind,  placebo-controlled  comparison  of  the 
bronchodilator  response  to  albuterol  DPI  (200 
microg)  at  inspiratory  flow  rates  of  approxi- 
mately 15,  30,  and  60  L/min  in  patients  with 
.stable  a.sthma  with  demonstrated  reversibility 
to  albuterol.  Active  (albuterol  via  pMDI  inhaled 
at  30  L/min)  and  placebo  controls  were  included. 
SETTING:  Single  center  study  at  the  chest/al- 
lergy unit  of  a  teaching  hospital  in  Canada.  PA- 
TIENTS: Sixteen  patients  with  moderate  to 
moderately  severe  stable  asthma.  MEASURE- 
MENTS AND  RESULTS:  Efficacy  end  points 
were  FEV,,  FVC,  FEV,/FVC.  maximum  expi- 
ratory flow,  and  forced  expiratory  flow  between 
25%  and  75%  of  vital  capacity.  Safety  end  points 
included  heart  rate,  BP,  and  tremor.  There  was 
no  significant  difference  between  the  broncho- 
dilator response  to  albuterol  via  the  CH  at  15, 
30,  and  60  L/min  inspiratory  flow  rate  and,  at 
all  flow  rates,  no  significant  difference  was 
found  comparing  albuterol  CH  with  the  pMDI. 
All  of  the  techniques  for  delivering  albuterol 
provided  significantly  better  bronchodilatation 
than  placebo.  Adverse  events  were  minimal  and 
did  not  differ  between  CH  and  pMDI  or  be- 
tween the  various  flow  rates  inhaled  through 
the  CH.  CONCLUSION:  A  novel  passive  al- 
buterol DPI  (CH)  provides  a  similar  broncho- 
dilator response  at  15,  30,  and  60  L/min  in- 
spiratory flow  rates  compared  with  a  pMDI  used 
optimally. 

Efficacy  of  Salmeterol  Xinafoate  in  the  Treat- 
ment of  COPD— Mahler  DA,  Donohue  JF,  Bar- 
bee  RA,  Goldman  MD,  Gross  NJ,  Wisniewski 
ME,  et  al.  Chest  1999  Apr;  1 15(4):957-965. 

STUDY  OBJECTIVES:  To  examine  and  com- 
pare the  efficacy  and  safety  of  salmeterol  xin- 
afoate, a  long-acting  inhaled  beta2-adrenergic 
agonist,  with  inhaled  ipratropium  bromide  and 
inhaled  placebo  in  patients  with  COPD.  DE- 
SIGN: A  stratified,  randomized,  double-blind, 
double-dummy,  placebo-controlled,  parallel 
group  clinical  trial.  SETTING:  Multiple  sites  at 
clinics  and  university  medical  centers  through- 


744 


Respiratory  Care  •  July  1999  Vol  43  No  7 


Now  Earn 


out  the  United  States.  PATIENTS:  Four  hun- 
dred eleven  symptomatic  patients  with  COPD 
with  FEV|  s  65%  predicted  and  no  clinically 
significant  concurrent  disease.  Interventions; 
Comparison  of  inhaled  salmeterol  (42  microg 
twice  daily),  inhaled  ipratropium  bromide  (36 
microg  four  times  a  day),  and  inhaled  placebo 
(2  puffs  four  times  a  day)  over  12  weeks.  RE- 
SULTS: Salmeterol  xinafoate  was  significantly 
(p  <  0.0001)  better  than  placebo  and  ipratro- 
pium in  improving  lung  function  at  the  recom- 
mended doses  over  the  12-week  trial.  Both  sal- 
meterol and  ipratropium  reduced  dyspnea 
related  to  activities  of  daily  living  compared 
with  placebo;  this  improvement  was  associated 
with  reduced  use  of  supplemental  albuterol. 
Analyses  of  time  to  first  COPD  exacerbation 
revealed  salmeterol  to  be  superior  to  placebo 
and  ipratropium  (p  <  0.05).  Adverse  effects 
were  similar  among  the  three  treatments.  CON- 
CLUSIONS; These  collective  data  support  the 
use  of  salmeterol  as  first-line  bronchodilator 
therapy  for  the  long-term  treatment  of  airflow 
obstruction  in  patients  with  COPD. 

The  Combination  of  Ipratropium  and  Albu- 
terol Optimizes  Pulmonary  Function  Revers- 
ibility Testing  in  Patients  with  COPD— Dor- 

insky  PM.  Reisner  C,  Ferguson  GT,  Menjoge 
SS,  Serby  CW,  Witek  TJ  Jr.  Chest  1999  Apr; 
115(4):966-971. 

STUDY  OBJECTIVES:  To  determine  whether 
the  combination  of  ipratropium  bromide  and 
albuterol  results  in  greater  and  more  consistent 
pulmonary  function  test  (PFT)  response  rates 
than  ipratropium  bromide  or  albuterol  alone  in 
patients  with  COPD.  DESIGN:  Retrospective 
review  of  two  recently  completed  3-month,  ran- 
domized, double-blind,  parallel,  multicenter. 
phase  III  trials.  SETTING:  Outpatient.  PA- 
TIENTS: A  total  of  1 ,067  stable  patients  with 
COPD.  INTERVENTIONS:  Ipratropium  bro- 
mide (36  microg  qid),  albuterol  base  (180  mi- 
crog qid),  or  an  equivalent  combination  of  ipra- 
tropium bromide  and  albuterol  sulfate  (42 
microg  and  240  microg  qid,  respectively).  MEA- 
SUREMENTS AND  RESULTS:  PFT  response 
rates  were  analyzed  using  12%  and  15%  in- 
creases in  FEV|  compared  with  baseline  values 
and  were  measured  in  the  various  treatment 
groups  on  days  1,  29,  57,  and  85  in  these  trials. 
Regardless  of  whether  a  1 2%  or  a  1 5%  increase 
in  FEV|  was  used  to  define  a  positive  response, 
an  equivalent  combination  of  ipratropium  bro- 
mide and  albuterol  sulfate  was  superior  to  the 
individual  agents  (p  <  0.05;  all  comparisons 
within  30  min).  In  addition,  a  15%  or  more 
increase  in  FEV,  was  seen  in  >  80%  of  pa- 
tients who  received  the  combination  of  ipratro- 
pium and  albuterol  sulfate  during  the  initial  PFT 
and  continued  to  be  observed  3  months  after 
initial  testing.  CONCLUSIONS:  Use  of  a  com- 
bination of  ipratropium  bromide  and  albuterol 
sulfate  is  superior  to  the  individual  agents  in 


CONTINUING 
EDUCATION 


Credit 


from  the  AARC  on  the  Internet! 


sign  on  to  oup  weh  site  at 
ii.Mre.»P«  anH  cuck  o" 
CRCE  OnllMl 


The  American  Association  for 
Respiratory  Care  now  allows 
you  to  earn  continuing 
education  credit  hours  over  the 
Internet  through  its  interactive 
CRCE  Online  Web  Site. 

•  Quality  educational  learning 
modules. 

•  Self-assessment  exams  to 
test  your  comprehension 
along  the  way. 

•  Credits  automatically  posted 
on  your  annual  AARC 
transcript. 

•  Final  test  graded  on-line  with 
immediate  feedback. 

•  Certificate  prints  directly  to 
your  printer  when  you  pass. 


identifying  PFT  reversibility  in  patients  with 
COPD. 


A  Comparative  Analysis  of  Arranging  In- 
Flight  Oxygen  Aboard  Commercial  Air  Car- 
riers— Stoller  JK,  Hoisington  E,  AugerG.  Chest 
1999  Apr;ll5(4):991-995. 

INTRODUCTION:  As  air  travel  has  become 
more  commonplace  in  today's  society,  so  too 
has  air  travel  by  oxygen-using  individuals.  Be- 
cause there  is  little  oversight  or  standardization 
of  in-fiight  oxygen  by  the  Federal  Aviation  Ad- 
mini.stration,  individual  airlines'  policies  and 
practices  may  vary  greatly.  On  the  premise  that 
such  variation  may  cause  confusion  by  prospec- 
tive air  travelers,  we  undertook  the  current  study 
to  describe  individual  air  carriers'  policies  and 
practices  and  to  provide  guidance  to  future  air 
travelers.  METHODS;  Data  were  collected  by 
a  series  of  telephone  calls  placed  by  the  study 
investigators  to  all  commercial  air  carriers  listed 
in  the  1997  Cleveland  Metropolitan  Yellow 
Pages.  The  callers  were  registered  respiratory 
therapists  who  identified  themselves  as  inexpe- 
rienced oxygen-requiring  travelers  wishing  to 
arrange  in-flight  oxygen  for  an  upcoming  trip. 
Standard  questions  were  asked  of  each  carrier 
that  included  the  following:  Did  the  carrier  have 
a  special  "help  desk"  to  assi.st  with  oxygen  ar- 
rangements? What  oxygen  systems,  liter  flow 


options,  and  interface  devices  were  available? 
What  was  the  charge  for  oxygen?  How  was  the 
charge  determined?  What  documentation  from 
the  physician  was  required?  How  much  notifi- 
cation was  required  by  the  airline  before  the 
actual  night?  In  addition  to  recording  these  re- 
sponses, the  total  amount  of  time  spent  on  the 
telephone  by  the  caller  was  logged  along  with 
the  number  of  telephone  calls  and  number  of 
people  spoken  to  in  arranging  in-flight  oxygen. 
To  compare  oxygen  charges  between  airlines, 
we  calculated  charges  based  on  a  "standard  trip," 
which  was  defined  as  a  nonstop,  round-trip  last- 
ing 6  h  in  which  the  traveler  used  a  flow  rate  of 
2  L/min.  RESULTS:  Of  the  33  commercial  air 
carriers  listed  in  the  directory,  1 1  were  US- 
based  carriers  and  22  were  international-based 
carriers.  Seventy-six  percent  of  the  airlines  of- 
fered in-flight  oxygen.  For  the  25  carriers  of- 
fering in-flight  oxygen,  mean  phone  time  re- 
quired to  make  the  arrangements  was  9.96±4.8 
min  (range,  3  to  20  min).  No  more  than  two 
telephone  calls  were  required  to  make  oxygen 
arrangements.  Most  carriers  required  48-  to  72-h 
advance  notice,  with  a  single  carrier  requiring 
1  -month  advance  notice.  Most  carriers  required 
some  notification  of  oxygen  needs  by  the  trav- 
eler's physician.  There  was  a  great  variation  in 
oxygen  device  and  liter  flow  availability.  Liter 
flow  options  ranged  from  only  two  flow  rates 
(36%  of  carriers)  to  a  range  of  1  to  15  L/min 


Respiratory  Care  •  July  1999  Vol  43  No  7 


745 


Abstracts 


(one  carrier).  All  carriers  offered  nasal  cannula, 
which  was  the  only  device  available  for  21  car- 
riers (84%).  Actual  charges  for  in-flight  oxygen 
also  varied  greatly.  Six  carriers  supplied  oxy- 
gen free  and  18  carriers  charged  a  fee  (range, 
$64  to  $1,500).  One  airline  allowed  the  traveler 
to  bring  one  "E"  cylinder  with  no  fee  assessed. 
For  14  of  the  18  carriers  that  charged,  the  charge 
for  the  standard  trip  ranged  from  $1(X)  to  $250. 
CONCLUSIONS:  ( 1 )  As  expected  from  the  lack 
of  standard  regulations,  the  availability,  costs, 
and  ease  of  implementing  in-flight  oxygen  vary 
greatly  among  commercial  air  carriers.  (2)  Be- 
cause the  expense  of  in-flight  oxygen  is  usually 
borne  by  the  traveler  (rather  than  by  insurers), 
prospective  travelers  should  consider  charges 
for  oxygen  use  when  choosing  an  airline.  (3)  In 
the  context  that  the  current  study  shows  sub- 
stantial variation  in  oxygen  policies,  costs,  and 
services  among  commercial  air  carriers  and  that 
such  policies  may  change  over  time,  our  find- 
ings encourage  the  prospective  air  traveler  need- 
ing in-flight  oxygen  to  "shop  around." 

Immediate  and  Long-Term  Results  of  Bron- 
chial Artery  Embolization  for  Life-Threat- 
ening Hemoptysis — Mai  H,  Rullon  I,  Mellot 
F,  Brugiere  O,  Sleiman  C,  Menu  Y,  Fournier 
M.  Chest  1999  Apr;115(4):996-1001. 

STUDY  OBJECTIVES:  Bronchial  artery  em- 
bolization (BAE)  has  been  established  as  an 
effective  technique  in  the  emergency  treatment 
of  life-threatening  hemoptysis,  but  few  data  con- 
cerning long-term  results  and  complications  of 
the  procedure  are  available.  The  aim  of  this 
study  was  to  analyze  retrospectively  the  expe- 
rience of  BAE  in  our  center  with  particular  em- 
phasis on  medium-term  and  long-term  results 
and  on  morbidity.  SETTING:  University  hos- 
pital. PATIENTS:  Fifty-six  patients  underwent 
bronchial  arteriography  from  1986  to  1996  in 
our  center  for  the  management  of  life-threaten- 
ing hemoptysis.  Of  them,  BAE  was  performed 
in  46  patients.  Their  mean  age  was  51  years 
(range,  19  to  89  years).  The  most  frequent  eti- 
ologies of  hemoptysis  were  active  or  inactive 
tuberculosis,  bronchiectasis,  or  idiopathic  he- 
moptysis. RESULTS:  BAE  resulted  in  an  im- 
mediate cessation  of  hemoptysis  in  43  of  the 
initial  56  patients  (77%).  During  the  first  month 
after  BAE,  four  patients  who  died  from  causes 
other  than  hemoptysis  or  who  were  referred  to 
surgery  were  excluded  from  follow-up  and  in 
the  39  remaining  patients,  a  complete  cessation 
of  hemoptysis  was  observed  in  32  patients.  A 
remission  was  noted  in  28  of  the  29  patients 
followed  up  between  30  and  90  days  after  BAE. 
Long-term  control  of  bleeding  was  achieved  in 
25  of  the  initial  56  patients  (45%)  followed  up 
beyond  3  months  after  BAE  (median  follow-up 
of  1 3  months;  range,  3  to  76  months).  Overall, 
complications  of  BAE  consisted  of  two  epi- 


sodes of  mediastinal  hematoma  and  three  epi- 
sodes of  neurologic  damage,  two  of  which 
improved  without  permanent  sequelae.  CON- 
CLUSION: We  conclude  that  BAE  may  result 
in  long-term  as  well  as  immediate  control  of 
life-threatening  hemoptysis  but  that  complica- 
tions are  not  unusual.  See  the  related  editorial: 
Bronchial  Artery  Embolotherapy  for  Control 
of  Acute  Hemoptysis:  Analysis  of  Outcome. 
White  RI  Jr.  Chest  1999  Apr:115(4):9I2-9l5. 

Late  Outcome  from  Percutaneous  Tracheos- 
tomy Using  the  Portex  Kit — Leonard  RC, 
Lewis  RH,  Singh  B,  van  Heerden  PV.  Chest 
1999  Apr;I15(4):1070-1075. 

OBJECTIVE:  To  assess  late  outcome  follow- 
ing percutaneous  tracheostomy  using  the  Por- 
tex kit  (Hythe,  Kent,  UK).  DESIGN:  Prospec- 
tive observational  cohort  study.  SETTING: 
Teaching  hospital.  PATIENTS:  Forty-nine  con- 
secutive patients  who  underwent  percutaneous 
tracheostomy  in  the  ICU  using  the  Portex  kit 
and  who  survived  6  months  after  the  procedure. 
INTERVENTIONS:  Questionnaires  regarding 
six  symptoms  were  sent  to  all  49  surviving  pa- 
tients; the  39  respondents  were  invited  to  attend 
for  review.  Thirteen  patients  underwent  pulmo- 
nary function  testing,  of  whom  1 0  also  under- 
went fiberoptic  laryngotracheoscopy  under  lo- 
cal anesthesia.  RESULTS:  The  most  common 
symptom  was  a  minor  change  in  voice.  One 
patient  had  required  treatment  for  symptomatic 
tracheal  stenosis  by  the  time  of  review;  one  was 
referred  for  revision  of  a  tethered  scar.  Pulmo- 
nary function  testing  was  easily  performed  by 
all  patients  and  revealed  no  evidence  of  upper 
airway  obstruction.  Tracheoscopy  likewise 
showed  no  evidence  of  tracheal  stenosis.  CON- 
CLUSIONS: One  of  49  patients  had  developed 
tracheal  stenosis.  None  of  the  patients  attending 
for  detailed  review  showed  any  sign  of  late  com- 
plications other  than  one  tethered  scar. 

The  Incidence  of  and  Clinical  Variables  As- 
sociated with  Vancomycin-Resistant  Entero- 
coccal  Colonization  in  Mechanically  Venti- 
lated Patients — Bhorade  SM,  Christenson  J, 
Pohlman  AS,  Arnow  PM,  Hall  JB.  Chest  1999 
Apr,115(4):l085-1091. 

STUDY  OBJECTIVES:  (1)  To  determine  in 
our  ICU  the  incidence  of  vancomycin-resistant 
enterococcus  (VRE)  colonization  in  mechani- 
cally ventilated  patients  without  a  history  of 
VRE  infection  or  colonization;  and  (2)  to  de- 
termine the  risk  factors  and  outcome  variables 
associated  with  VRE  colonization  in  these  pa- 
tients. DESIGN:  A  prospective  cohort  study  con- 
ducted between  January  1996  and  March  1998. 
SETTING:  Medical  and  cardiac  critical  care 
units  in  a  tertiary  care  urban  university  hospital. 
PATIENTS:  Mechanically  ventilated  patients 


without  evidence  of  pneumonia  at  the  onset  of 
ventilation.  INTERVENTIONS:  None.  MEA- 
SUREMENTS AND  RESULTS:  Patients  un- 
derwent rectal  cultures  by  standard  methods  on 
day  1,  day  3  or  4,  day  6  or  7,  and  day  14  of 
intubation  to  detect  VRE.  Thirteen  of  83  pa- 
tients ( 1 6%)  had  rectal  cultures  positive  for  VRE 
(VRE+)  at  some  point  while  being  mechani- 
cally ventilated  during  their  stay  in  the  ICU.  In 
comparison,  approximately  15  of  2,100  medi- 
cal ICU  patients  (0.7%)  had  clinical  VRE  in- 
fections as  determined  by  the  hospital's  infec- 
tion control  program  during  a  2-year  period. 
VRE-t-  patients  had  a  higher  incidence  of  im- 
munosuppression than  padents  who  had  rectal 
cultures  negative  for  VRE  (VRE-)  (9  of  1 3  [69%] 
vs  16  of  70  [23%],  respectively;  p  <  0.01)  and 
neutropenia  (4  of  13  [31%]  vs  5  of  70  [7%], 
respectively;  p  <  0.01).  Hospital  length  of  stay 
(LOS)  was  longer  in  VRE-)-  patients  than  in 
VRE-  patients  (27±17  days  vs  17±14  days, 
respectively;  p  =  0.05),  whereas  pre-ICU  hos- 
pital LOS  and  ICU  LOS  were  similar  in  both 
patient  groups.  Five  of  67  patients  (7%)  were 
VRE -I-  on  day  1  of  intubation,  suggesting  col- 
onization at  a  prior  site  of  care.  Three  of  29 
patients  who  had  subsequent  rectal  cultures  con- 
verted to  VRE -I-  while  in  the  ICU.  This  group 
had  a  higher  incidence  of  immunosuppression 
and  neutropenia,  and  received  more  vancomy- 
cin compared  with  the  patients  who  remained 
VRE-  (p  <  0.01).  However,  there  was  no  sig- 
nificant difference  in  the  use  of  other  broad- 
spectrum  antibiotics  (such  as  antipseudomonal 
penicillins,  third-generation  cephalosporins, 
quinolones,  and  clindamycin),  enteral  tube  feed- 
ings, or  sucralfate  between  the  two  groups.  In 
addition,  a  topical  antibiotic  paste  (a  gentami- 
cin,  nystatin,  polymixin  slurry)  that  was  placed 
in  the  oropharynx  to  prevent  bacterial  over- 
growth was  not  found  to  increase  the  incidence 
of  VRE  colonization  in  this  patient  population. 
CONCLUSIONS:  The  incidence  of  VRE  colo- 
nization was  surprisingly  high:  16%  in  mechan- 
ically ventilated  patients  in  a  hospital  in  which 
VRE  was  not  previously  known  to  be  endemic. 
Risk  factors  for  the  acquisition  of  VRE  coloni- 
zation included  immunosuppression,  neutrope- 
nia, and  vancomycin  use.  Increased  LOSs  and 
hospital  costs  were  seen  in  VRE -I-  patients  com- 
pared to  VRE-  patients.  Whether  VRE  coloni- 
zation is  a  contributor  to  severe  disease  that 
leads  to  prolonged  hospitalization  and  increased 
resource  allocation  or  whether  it  is  simply  a 
marker  of  disease  severity  cannot  be  determined 
from  this  study.  To  the  extent  that  specific  an- 
tibiotic protocols  are  used  to  reduce  antibiotic- 
resistant  flora  in  the  ICU,  monitoring  the  inci- 
dence of  VRE  in  the  stool  specimens  of 
immunocompromised,  mechanically  ventilated 
patients  can  be  a  simple  and  u.seful  tool  to  as- 
sess one  effect  of  these  strategies. 


746 


Respiratory  Care  •  July  1999  Vol  43  No  7 


Loohino  for  updated  infomiflhon  about 
troclieosomij/rroctieotoiiiii  procedures? 

Chech  out  these  items  and  yet  current! 

INTERACTIVE  CLINICAL  SKILLS  SOFTWARE  -  $65  each 

Requires  Windows  3.1  or  higher  •  Available  on  31/2"  disk  •  PC  Format  only 


Hhest  Trauma  Simulation 

imulates  a  62-year-old  man  involved  in  a  motor  vehicle 
ccident.  The  user  must  perform  initial  assessment  and 
ecommend  initial  therapy  to  stabilize  the  patient.  In  the  course 
f  the  treatment,  the  patient  undergoes  surgery  for  a  thoraco- 
smy  and  is  then  placed  on  a  mechanical  ventilator.  The  user  is 
sked  to  recommend  initial  ventilator  settings.  Subsequent 
ecision-making  sections  include  recommending  fiberoptic 
ronchoscopy,  making  further  ventilator  changes  based  on 
lBG  values,  and  evaluating  the  patient  for  possible  extubation. 
tem  SPIO 

Status  Asthmaticus  Simulation 

nvolves  the  initial  assessment  of  a  35-year-old  man  with  a 
istory  of  allergic  asthma.  Low-flow  oxygen  is  administered 
litially,  followed  by  bronchodilator  therapy.  As  the  simulation 
rogresses,  the  patient  is  intubated  and  receives  mechanical 
entilation.  The  user  is  required  to  make  initial  settings  and 
djustments  according  to  ABG  results  and  patient  response. 
lIso  included  in  the  simulation  is  a  switch  to  IMV  mode, 
edation,  and  eventual  extubation  and  placement  on  a  40  per 
ent  aerosol  mask. 
tem  SP12 


Acute  Respiratory  Distress  Syndrome 
(ARDS)  Simulation 

This  simulation  presents  a  30-year-old  man  36  hours  after 
emergency  surgery  for  excision  of  a  large  duodenal  ulcer;  the 
patient  is  now  restless  and  complaining  of  dyspnea.  The 
simulation  proceeds  through  initial  oxygen  therapy,  followed 
by  increasing  F[o,,  and  then  CPAP.  The  patient  is  eventually 
intubated  and  placed  on  a  mechanical  ventilator,  where 
deteriorating  ABGs  and  static  compliance  call  for  increasing 
PEEP,  which  is  gradually  increased  to  25  cmwp.  ABGs, 
compliance,  and  shunt  studies  are  used  to  evaluate  the 
effectiveness  of  the  PEEP  therapy. 
Item  SP15 

Epiglottitis  Simulation 

Presents  a  4-year-old  girl  entering  the  ER  with  a  "cold"  and 
elevated  temperature.  A  lateral  neck  x-ray  reveals  massive 
edema  of  the  epiglottis,  whereupon  the  child  is  taken  to  surgery 
and  intubated.  The  user  is  asked  to  recommend  appropriate 
airway  and  size  for  the  patient.  After  further  assessment,  CPAP 
is  initiated  with  room  air,  and  two  days  later  the  patient  is 
evaluated  for  extubation  and  postextubation  therapy. 
Item  SP16 


IISPs  (INDIVIDUAL  INDEPENDENT  STUDY  PACKAGES)  -  $12  each 

($16  Non-members) 


Hhest  Tubes  and  Pleural  Drainage 

lelps  you  understand  the  purpose  of  pleural  drainage, 
low  it  might  affect  the  patient's  respiratory  status,  and  what 
irecautions  you  must  take  when  working  with  patients 
/ho  are  receiving  pleural  drainage, 
tem  CP3 


fracheal  Intubation  I: 
Jpper  Airway  Anatomy 
ind  Goals  of  Intubation 

Vfter  completing  this  IISP,  you  will 
inderstand  the  rationale  for  tracheal 
ntubation  and  be  able  to  identify  the 
mportant  landmarks  of  upper  airway 
natomy. 
tem  CP4 


Equipment  Procedures  for  Intubation 

Identifies  all  equipment  required  to  perform  either  oral  or  nasal 
tracheal  intubation,  while  explaining  necessary  steps  before  and 
after  intubation.  Discusses  common  errors  and  differences  in 
procedures  for  infants  and  pediatric  patients. 
Item  CP6 


To  place  your  order,  please  call: 


972-243-2272 


Tracheal  Intubation  II: 
Routes  of  Intubation 

Describes  the  four  routes  of  tracheal 

intubation  and  some  advantages  and 

hazards  of  each. 

Also  presents  the  process  for 

selecting  the  most  suitable  route 

in  a  given  situation. 

Item  CP5 


Texas  customers  only,  please  add  8.25%  sales  tax  (including  shipping  charges).  Texas  customers  who  are  exempt  from  sales  tax  must 
'  '''         '"         ^  :d.  Visa,  Institutional  Purchase  Order  or  check  payable  to: 


LING  &  Shipping  Charges 

•  $25  IS  $5.25 

31  -  $80.00  IS  $8.25 
31  -  $200.00  IS  $12.25 
1.01  -  $300.00  IS  $16.25 


supply  an  exemption  certificate.  MasterCard 

Doedolus  Enterprises,  Inc 


ATTN.  Order  Fulfillment  Department 
1 1030  Abies  Lane  •  Dallas,  Texas  75229 
Phone  972-243-2272  Fax:972-484-6010 

Discover  other  related  products  within  "Key  to  Professional  Excellence"  @  www.aarc.org 


'HAL  AJE.WAYf. 


Part  ir  of  II  Special  Issues 


Presented  by  the  Editorial  Board  of  the 

Respiratory  Care  journal 


Containing  the  manuscripts  and  discussions  from  the  Journal 
Conference  held  December  4-6,  1998,  Cancun,  Mexico 


Supported  by  the  American  Association  for  Respiratory  Care 


Conference  faculty  members — front  row,  from  left:  Michael  ]  Bishop  MD,  Maxine  Orringer  MA  CCC-SLP.  Charles  G  Durbin 
]r  MD,  Charles  B  Watson  MD,  Richard  D  Branson  RRT,  William  E  Hurford  MD.  Second  row,  from  left:  John  L  StaufPer  MD, 
Ann  E  Thompson  MD,  James  K  Stoiler  MD.  Ray  Ritz  RRT.  James  F  Reibel  MD,  John  E  Heffner  MD,  Robert  S  Campbell  RRT, 
Dean  R  Hess  PhD  RRT  FAARC.      ::^^!^^^^sm^mmimsmemmmsimKmmiiimmmimmmmiBmimssmi^^mmHmm 


CO-CHAIRS   AND   GUEST   EDITORS 

Richard  D  Branson  RRT — Cincinnati,  Oiiio 
and  Ciiarles  G  Durbin  Jr  MD — Charlottesville,  Virginia 


FACULTY 


Michael )  Bishop  MD 
Seattle,  Washington 

Richard  D  Branson  RRT 
Cincinnati.Ohio 

Robert  S  Cambeii  RRT 
Cincinnati, Ohio 

Charles  G  Durbin  jr  MD 

Charlottesville,  Virginia 

John  E  Heffner  MD 
Charleston,  South  Carolina 


Dean  R  Hess  PhD  RRT  FAARC 

Boston,  Massachusetts 

William  E  Hurford  MD 
Boston,  Massachusetts 

Maxine  Orringer  MA  CCC-SLP 

Pittsburgh,  Pennsylvania 

James  F  Reibel  MD 

Charlottesville,  Virginia 


Ray  Ritz  RRT 

Boston,  Massachusetts 

John  L  Stauffer  MD 
Hershey,  Pennsylvania 

James  K  Stoiler  MD 
Cleveland,  Ohio 

Ann  E  Thompson  MD 
Pittsburgh,  Pennsylvania 

Charles  B  Watson  MD 
Bridgeport,  Connecticut 


Conference  Proceedings 


Who  Should  Perform  Intubation? 


Michael  J  Bishop  MD 


Introduction 

Legal  Issues 

Practice  Guidelines 

Intubation  Training  and  Studies  of  Intubation  Performance 

A  Two-Tiered  Approacli  to  Airway  Management 

Summary 

[Respir  Care  1999;44(7):750-755]  Key  words:  intratracheal  intubation,  airway 

obstruction,  cardiopulmonary  resuscitation,  practice  guidelines. 


Introduction 

Clearing  and  maintaining  a  patent  airway  is  first  and 
foremost  during  resuscitation.  "Airway"  is  the  "A"  in  the 
ABC's  of  resuscitation.  Perhaps  because  of  the  importance 
of  opening  the  airway,  it  is  a  skill  that  often  becomes  an 
area  of  controversy  and  "turf  wars."  Failure  to  manage  the 
airway  adequately  tends  to  lead  to  criticism,  recrimina- 
tions, and  a  significant  number  of  medical  malpractice 
actions.'  Such  failures  are  especially  likely  to  occur  during 
intubations  outside  of  the  operating  room  (OR),  where 
conditions  are  not  as  controlled,  patients  are  more  likely  to 
be  on  the  floor  or  on  soft  beds,  vomitus  may  be  present, 
and  other  conditions  may  be  sub-optimal.^-^  This  article 
explores  the  questions  of  what  personnel  are  qualified  to 
manage  the  airway  during  in-hospital  resuscitations,  and 
what  training  they  should  have. 

Since  precedents  seem  clearly  established  for  paramed- 
ical personnel  to  perform  outside-of-hospital  intubation, 
the  present  discussion  considers  resuscitations  and  endo- 
tracheal intubations  that  occur  in  the  hospital  but  outside 
of  the  OR.  In-hospital  OR  intubations  are  generally  carried 
out  by  the  anesthesia  staff,  who  have  been  extensively 
trained  in  airway  management.  Thus,  the  outside-of-OR 
patient  seems  to  be  the  subject  of  greatest  controversy. 


Michael  J  Bishop  MD  is  affiliated  with  the  Department  of  Anesthesiol- 
ogy, Veterans  Administration  Puget  Sound  Health  Care  System,  and  with 
the  University  of  Washington  School  of  Medicine,  Seattle,  Washington. 

Correspondence:  Michael  J  Bishop  MD,  Department  of  Anesthesiology, 
Puget  Sound  Veterans  Affairs  Health  Care  System,  1I2A,  1660  South 
Columbian  Way,  Seattle  WA  98108.  E-mail:  bish@u. washington.edu. 


Decisions  about  who  performs  intubation  need  to  be 
site-specific.  Within  the  academic  medical  center,  there 
may  be  many  groups  vying  to  perform  intubation  in  order 
to  satisfy  training  requirements  (Table  1 ).  Conversely,  small 
community  hospitals  may  have  a  dearth  of  individuals 
interested  in  undergoing  the  required  training. 

Numerous  articles  exist  concerning  the  question  of  who 
should  perform  endotracheal  intubation."  Most  of  these 
articles  assess  the  likelihood  of  the  tube  ending  up  in  the 
trachea,  with  various  comparisons  made  as  to  whether  the 
letters  after  the  intubator's  name  are  MD,  RRT,  or  EMT. 
This  review  summarizes  the  existing  literature  and  legal 
issues,  and  proposes  a  two-tiered  system  in  which  respi- 
ratory therapists  are  allowed  to  perform  endotracheal  in- 
tubations. 

Legal  Issues 

Regulatory  and  legal  literature  provide  relatively  little 
guidance  in  determining  who  should  manage  the  airway, 
and  there  are  no  legal  precedents  as  to  who  should  manage 
the  airway  or  who  should  perform  endotracheal  intubation. 
A  search  of  a  legal  database  (Westlaw,  West  Publishing 
Co,  Eagan,  Minnesota)  revealed  no  appellate  decisions 
bearing  directly  on  this  question.  However,  what  is  clear  is 
that  nonphysician  personnel  who  undertake  medical  ser- 
vices are  subject  to  the  same  standards  of  performance  as 
the  physicians  who  would  usually  perform  the  same  ser- 
vice (Belmon  v  St  Frances  Cabrini  Hospital,  All  So  2d 
541  [1983]). 

The  only  legal  decision  relating  to  a  failed  intubation 
was  in  the  case  of  a  patient  who  arrested;  the  respiratory 
therapist  was  unable  to  intubate  the  patient,  and  the  patient 


750 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Who  Should  Perform  Intubation? 


Table  1 .      Groups  Vying  for  Intubation  Experience 

Respiratory  therapy  students 

Respiratory  therapists  (pediatric  and  neonatal  transport  teams) 

Respiratory  therapists  (resuscitation  team) 

Student  nurse  anesthetists 

Flight  team  personnel 

Critical  care  fellows 

Resident  physicians 

Anesthesiology 

Surgery 

Thoracic  diseases — pulmonary  medicine 

Pediatrics 
Medical  students 


Table  2.      Required  Skills  for  Intubation  Certification 


From  Reference  4. 


was  intubated  by  a  physician.  The  hospital  was  found 
Hable  for  the  original  failed  intubation,  but  the  basis  of  the 
liability  was  the  lack  of  immediate  availability  of  a  Macin- 
tosh #4  laryngoscopy  blade  for  the  respiratory  therapist, 
not  the  personnel  involved  {Dickson  v  Taylor,  431  SE  2d 
778  [1993]). 

Medico-legal  cases  often  revolve  around  the  "standard 
of  care."  The  standard  of  care  is  not  a  written  code  but  is 
defined  on  an  ad  hoc  basis  by  a  judge  or  jury  during  the 
case.^  The  standard  may  vary  from  region  to  region,  state 
to  state,  or  even  within  states.  In  terms  of  "standard-of- 
care,"  the  standard  might  vary  between  a  major  tertiary 
urban  trauma  center  and  a  rehabilitation  hospital.  It  would 
be  a  reasonable  assumption  that  the  former  would  be  pre- 
pared to  handle  the  complexities  of  the  airway  in  a  patient 
with  major  head  and  neck  trauma  requiring  possible  sur- 
gical intervention,  whereas  for  the  latter,  the  standard  of 
care  might  be  basic  life  support  until  community  paramed- 
ics arrive. 


Cognitive 


Procedural 


Access  airway  for  difficult 

intubation 
Describe  views  of  larynx 
Understand  indications 

and  contraindications 

of  muscle  relaxants 
Plan  for  failed  intubation 
Identification  of  successful 

intubation 

1)  Using  bulb  syringe 

2)  Using  end-tidal  CO2 


Bag  and  mask  ventilation 
Application  of  cricoid  pressure 
Intubation  using  Macintosh  and  Miller 

blades 
Intubation  over  a  gum  elastic  bougie 
Placement  of  a  laryngeal  mask  airway 


ation,'  and  the  American  Association  for  Respiratory  Care 
Clinical  Practice  Guideline  for  Resuscitation  in  Acute  Care 
Hospitals.*  Both  of  these  sources  address  the  training  of 
individuals  involved  in  airway  management  during  resus- 
citation. 

Who  should  manage  the  airway  during  in-hospital  re- 
suscitation? In  teaching  hospitals,  it  often  seems  that  ev- 
eryone wants  to  get  in  on  the  act.  In  community  hospitals, 
there  may  be  no  anesthesiologist  on  duty  during  off-hours, 
or  the  anesthesiologists  may  all  be  occupied  in  the  oper- 
ating room.'  The  key  questions  then  are  (1)  Who  is  avail- 
able to  manage  the  airway?  (2)  Who  has  the  educational 
background  to  do  so?  and  (3)  Who  has  the  skills  to  do  so? 

While  no  specific  guidelines  are  available,  the  Advanced 
Cardiac  Life  Support  manual  notes  "As  soon  as  practical 
during  the  resuscitative  effort,  the  trachea  should  be  intu- 
bated by  trained  personnel  . . .  who  either  perform  intuba- 
tions frequently  or  are  retrained  frequently."^ 

Intubation  Training  and 
Studies  of  Intubation  Performance 


Practice  Guidelines 

There  are  no  absolute  standards  determining  who  should 
intubate,  but  some  guidelines  do  exist.  Practice  guidelines 
are  created  to  assist  practitioners  and  institutions  in  mak- 
ing appropriate  decisions  and  to  provide  them  with  input 
regarding  presumed  optimal  practice.  They  are  generally 
created  by  a  group  of  experts  whose  combined  experience 
exceeds  that  of  any  of  the  individuals  involved  in  their 
development.  Guidelines  are  not  standards,^''  and  follow- 
ing a  guideline  or  a  standard  obviously  can  never  guaran- 
tee a  desirable  outcome.  Also,  guidelines  differ  from  writ- 
ten standards  in  that  they  permit  a  practitioner  or  an 
institution  to  exercise  judgment  within  reasonable  limits. 

Existing  guidelines  relevant  to  airway  management  dur- 
ing resuscitation  include  the  Advanced  Cardiac  Life  Sup- 
port guidelines  published  by  the  American  Heart  Associ- 


Endotracheal  intubation  is  within  the  respiratory  thera- 
pist's scope  of  practice,  but  intubation  by  therapists  is 
dependent  on  local  and  regional  practice.  Almost  all  reg- 
istry-level respiratory  therapy  programs  instruct  students 
in  the  technique,  and  300  of  400  accredited  respiratory 
care  education  programs  teach  intubation. 'o  Certainly  all 
therapists  are  routinely  trained  in  evaluation  of  tube  place- 
ment, tube  manipulation,  and  measurements  of  cuff  pres- 
sures and  volumes.  The  exam  content  outline  for  registry 
status  from  the  National  Board  for  Respiratory  Care  in- 
cludes endotracheal  intubation  as  part  of  the  exam  con- 
tent.* Table  2  lists  the  cognitive  and  procedural  skills  we 
feel  are  critical  in  order  to  competently  perform  emer- 


National  Board  for  Respiratory  Care  Registry  Examination  content 
outline.  National  Board  for  Respiratory  Care,  Lenexa,  Kansas. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


751 


Who  Should  Perform  Intubation? 


gency  endotracheal  intubation.  At  our  institution  we  place 
great  emphasis  on  instructing  therapists  in  backup  plans  in 
case  initial  intubation  attempts  are  unsuccessful. 

A  survey  of  non-OR  emergency  airway  management 
reported  that  in  1 34  hospitals  with  anesthesiology  residen- 
cies, respiratory  therapists  were  responsible  for  floor  in- 
tubations in  only  one  of  the  hospitals."  However,  these 
hospitals  were  all  greater  than  200  beds,  and  the  majority 
were  more  than  500  beds.  Thus,  they  were  likely  to  have 
routinely  available  full-time  in-hospital  physicians  with 
airway  training.  Furthermore,  the  vast  majority  of  hospi- 
tals do  not  have  anesthesiology  training  programs.  The 
number  of  anesthesiology  training  programs  in  the  United 
States  has  declined  in  each  of  the  last  3  years  and  as  of 
July  1 999  has  declined  to  approximately  1 40,  representing 
only  a  small  minority  of  hospitals  in  the  country.*  Many  of 
the  existing  programs  have  cut  back  on  the  number  of 
residents  being  trained,  limiting  staffing. 

The  frequency  of  failed  intubation  in  the  anesthesia  lit- 
erature is  generally  well  under  1%.'2-|4  Of  course,  these 
are  under  well  controlled  conditions  in  the  OR  and  may 
not  apply  outside  of  the  OR.  Given  that  the  rate  of  failed 
intubations  is  low,  any  study  to  demonstrate  a  difference 
among  personnel  in  intubation  skills  would,  in  order  to  be 
valid,  require  enormous  numbers  of  patients.  Consider  the 
following  statistical  example:  If  anesthesiologists  had  a 
true  failed  intubation  rate  of  2%,  and  we  assumed  a  para- 
medic group  to  have  a  true  failure  rate  double  that,  a 
patient  population  of  approximately  1 ,000  patients  would 
need  to  be  studied  before  this  100%  difference  in  failure 
rate  became  statistically  significant  at  the  p  <  0.05  level ! 
Thus,  the  most  likely  conclusion  of  such  studies  will  be 
that  there  is  no  difference,  but  such  studies  are  often  flawed 
by  insufficient  numbers  of  patients. 

One  of  the  most  widely  cited  papers  supporting  the  use 
of  nonanesthesiologists  found  that  there  was  no  difference 
in  complication  rates  during  emergency  room  intubation 
whether  the  procedure  was  performed  by  anesthesiology 
staff  or  by  emergency  department  staff. '^  Reanalysis  of 
these  data  reveals  several  critical  flaws.  Staff  included  as 
anesthesiology  staff  included  obstetric  and  surgery  resi- 
dents who  were  rotating  through  the  service  and  thus  had 
little  specialized  training.  In  addition,  all  levels  of  anes- 
thesiology training  were  included.  Therefore,  complica- 
tions may  have  resulted  from  attempts  by  junior  residents 
with  no  real  specialized  training.  The  study  found  that  14 
of  23  patients  intubated  by  emergency  department  staff 
died,  and  1 2  of  20  intubated  by  anesthesiology  staff  died 
(no  significant  difference).  This  seems  a  poor  indicator  of 
who  holds  greater  competence.  A  second  piece  of  evi- 


*  Information  from  the  American  Association  of  Anesthesia  Program 
Directors,  Parle  Ridge,  lUinois. 


dence  offered  by  these  authors  is  that  there  were  compli- 
cations in  20  of  23  patients  intubated  by  the  emergency 
department,  and  in  14  of  23  intubated  by  the  anesthesiol- 
ogy staff.  Again,  they  note  no  significant  difference  by 
chi-square  analysis.  If  the  more  appropriate  Fisher's  exact 
test  is  used,  we  find  p  <  0.05.  Given  that  the  complication 
rate  was  nearly  43%  higher  in  the  emergency  department 
group,  these  data  could  be  reinterpreted  as  supporting  the 
routine  use  of  anesthesiologists!  That  this  has  become  one 
of  the  most  widely  cited  papers  on  the  topic  is  unfortunate, 
and  demonstrates  the  difficulties  in  citing  studies  when 
"turf  wars"  arise. 

Most  physicians  receive  little  training  in  airway  man- 
agement, so  the  alternative  provider  to  an  anesthesiologist 
should  be  someone  specifically  trained  in  these  skills,  rather 
than  a  physician  without  airway  management  training.  Cer- 
tified registered  nurse  anesthetists  routinely  perform  en- 
dotracheal intubation.  Since  the  1970s,  paramedics  in  some 
regions  have  been  trained  in  intubation.  In  1977,  DeLeo"' 
reported  a  91%  success  rate  by  paramedical  personnel  in  a 
field  intubation,  versus  89%  for  physicians.  Paramedic  suc- 
cess rates  in  other  studies  have  generally  ranged  from  90 
to  98%."  One  study  found  that  unsuccessful  intubations 
by  field  personnel  were  generally  in  patients  who  could 
not  be  intubated  by  emergency  room  physicians.'** 

What  data  do  we  have  concerning  respiratory  thera- 
pists? In  1981,  McLaughlin  and  Scott  reported  that  50 
consecutive  patients  were  intubated  on  an  emergency  basis 
by  respiratory  therapists.'*  The  therapists  each  had  per- 
formed 12  operating  room  intubations  and  2  supervised 
emergency  intubations  prior  to  the  start  of  the  study.  Ten 
percent  of  these  cases  required  more  than  5  minutes  for 
intubation.  This  seems  surprisingly  high.  Twenty-five  dif- 
ferent therapists  were  involved,  raising  the  possibility  that 
even  though  the  initial  training  was  adequate,  there  may 
have  been  insufficient  opportunity  for  reinforcement  of  the 
teaching. 

Another  1981  study  in  a  community  hospital  found  a 
complication  rate  of  18%  when  respiratory  therapy  per- 
sonnel performed  intubations  and  57%  when  a  physician 
attempted  the  intubation. **  When  the  data  are  examined 
more  closely,  it  becomes  clear  that  the  high  physician 
complication  rate  was  due  to  a  greater  than  50%  initial 
esophageal  placement  by  nonanesthesiologist  physicians. 
Therapists  had  a  10%  initial  esophageal  placement.  No 
data  are  given  as  to  whether  this  was  recognized  in  all 
cases.  In  any  case,  this  study  again  supports  the  success  of 
nonphysician  providers  when  compared  with  nonanesthe- 
siology  physicians. 

Thalman  et  al  report^"  that  at  Duke  University  Medical 
Center,  where  respiratory  therapists  have  performed  intu- 
bation for  many  years,  the  therapists  were  successful  in 
791  of  833  intubations  (95%)  with  anesthesiologists  avail- 
able for  backup  as  needed.  A  key  feature  of  this  service 


752 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Who  Should  Perform  Intubation? 


Table  3.      Reported  Results  for  Intubations  Conducted  Outside  of  the  Operating  Room 


Author 


Intubators 


Setting 


Experience  {%  failure) 


Mascia  &  Matjasko'' 
McLaughlin  &  Scott'' 
Conley  &  Smith'' 


Anesthesiologists 

Therapists 

Therapists 

Anesthesiologists 

Certified  nurse  anesthetists 

Other  physicians 

Critical  care  physicians 

Therapists 

Therapists 

House  physicians  or  anesthesiologists 

Paramedics 
Paramedics 


In-hospital  13/613  failed  (2) 

In-hospital  50/50  intubated,  but  10%  required  longer  than  5  minutes 

In-hospital  3/74  failed  (4) 

0/30  failed 

0/5  failed 

4/34  failed  (12) 

0/297,  13  required  >  4  attempts,  2  required  10  attempts 

42/833  (5) 

18/178  (10) 

1/97  failed  (1) 

20%  required  >  4  attempts 

70/779  (8) 

74/785  failed  (9) 


Schwartz  et  al"" 
Thalman  et  al"" 
Zyla  &  Carson^' 
Stauffer  et  al^' 

Stewart  et  aP" 
DeLeo"" 

From  Hussey  JD,  Bishop  MJ,  Massey  L.  Lakshniinarayan  S.  Joy  J.  Finley  J.  Two-tiered  response  for  emergency  airway  managemenl  by  respiratory  therapists  and  anesthesiologists.  Respir  Care  1998: 

43(7)552-556. 


Intensive  care  unit 
In-hospital 
In-hospital 
In-hospital 

Field  cardiac  arrest 
Field 


was  a  core  group  of  therapists  designated  for  airway  sup- 
port. In  a  large  institution,  having  a  highly  trained  sub- 
group of  therapists  may  be  a  useful  strategy. 

The  Respiratory  Care  Department  at  Butterworth  Hos- 
pital, Grand  Rapids,  Michigan,  published  their  experience 
as  back-up  providers  of  endotracheal  intubation  following 
failed  attempts  by  nonanesthesiologist  physicians.-'  Their 
success  rate  of  90%  is  remarkable  given  that  these  were 
cases  in  which  a  physician  had  already  failed.  In  the  case 
where  the  therapist  failed,  most  patients  were  eventually 
intubated  by  an  anesthesiologist  or  required  a  tracheos- 
tomy. The  providers  in  this  study  all  performed  12-15 
successful  OR  intubations  and  kept  up  their  skills  by  per- 
forming a  minimum  of  15  intubations  every  2  years. 

Table  3  summarizes  the  data  from  9  studies  of  outside- 
of-OR  intubations.  Clearly,  the  vast  majority  of  intuba- 
tions can  be  performed  successfully  by  therapists.  What  is 
an  acceptable  rate  for  failure?  Ten  percent  would  obvi- 
ously be  far  too  high  if  all  patients  died  as  a  result  of  the 
failed  intubation.  However,  when  an  esophageal  intuba- 
tion is  recognized,  consequences  can  usually  be  minimized 
by  returning  to  mask  ventilation.  In  rare  cases,  surgical 
access  to  the  airway  may  be  required.  With  the  advent 
during  the  last  10  years  of  reliable  devices  for  detecting 
esophageal  intubation,  unrecognized  misplacement  should 
virtually  disappear,  and  the  reported  rates  of  initial  intu- 
bation failure  seem  less  and  less  worrisome. 
*  Whether  respiratory  therapists  should  be  providers  of 
intubation  services  on  a  routine  basis  should  probably  de- 
pend on  the  level  of  other  personnel  available.  It  would 
seem  reasonable  to  use  the  most  skilled  practitioners  in  the 
hospital.  Few  would  disagree  that  anesthesiologists,  accus- 
tomed to  performing  several  intubations  a  day,  have  the 
highest  skill  level.  However,  cost  considerations,  as  well 


as  their  preoccupation  in  the  operating  room,  may  prevent 
having  an  anesthesiologist  routinely  available.  Under  those 
circumstances,  the  practitioner  with  the  next  greatest  ex- 
perience and  familiarity  with  intubation  and  airway  main- 
tenance should  probably  be  designated.  With  appropriate 
training  and  skill  maintenance,  this  will  often  be  the  re- 
spiratory therapist.  Furthermore,  respiratory  therapists  have 
the  ability  to  manage  the  airway  should  intubation  fail, 
since  they  have  substantially  more  experience  in  bag-and- 
mask  ventilation  than  most  physicians. 

A  Two-Tiered  Approach  to  Airway  Management 

At  the  Puget  Sound  Veterans  Affairs  Health  Care  Sys- 
tem we  recently  implemented  a  two-tiered  response  sys- 
tem for  emergency  airway  management.  This  system  was 
developed  based  on  the  experience  that  the  most  complex 
intubations  tended  to  be  urgent  rather  than  emergency. 
Cardiac  arrest  cases  rarely  require  pharmacologic  inter- 
vention to  produce  muscle  relaxation  or  sedation,  whereas 
unstable  but  not  arrested  patients  are  at  high  risk  of  dete- 
rioration. A  study  of  emergency  room  intubations  found 
that  9  of  22  nonarrested  patients  required  prolonged  at- 
tempts at  intubation  versus  only  3  of  2 1  patients  who  had 
suffered  cardiac  arrest,-'  supporting  the  concept  that  the 
nonarrest  patients  were  more  complex. 

Our  model  was  designed  to  have  respiratory  therapists 
intubate  the  trachea  of  patients  suffering  cardiac  arrest, 
with  the  anesthesiologist  available  for  backup  consulta- 
tion. When  the  anesthesiologist  was  not  in-hospital,  the 
consultations  took  place  by  telephone  as  needed.  Patients 
requiring  intubation  for  respiratory  failure,  airway  main- 
tenance, or  other  progressive  conditions  were  considered 
more  complex  situations,  and  an  anesthesiologist  was  rou- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


753 


Who  Should  Perform  Intubation? 


Need  for  tracheal 
intubation  identified 


Emergency  (<  30  minute 
response  needed) 

y 

" 

In  house 

anesthesiologist 

notified 

Out  of  house 
anesthesiologist  notified 

' 

' 

' 

Anesthesiologist 
performs  airway 
management  or 
supervises  respiratory 
therapist. 

Respiratory  therapist 
manages  airway  and 
intubates. 
Anesthesiologist 
provides  consultation  by 
mobile  phone. 

Urgent  (30  minute 
delay  acceptable) 


Anesthesiologist  notified 
and  proceeds  to  hospital 


rri 


Patient 
deteriorates 


Patient  remains 
stable  until 
anesthesiologist 


Fig.  1 .  Algorithm  for  two-tiered  response  system  for  emergency  airway  management.  This  was  the  basic  model  for  the  procedure  to  be 
followed  when  the  need  was  identified  for  tracheal  intubation  outside  of  the  operating  room.  (Modified  From  Hussey  JD,  Bishop  MJ,  Massey 
L,  Lakshminarayan  S,  Joy  J,  Finley  J.  Two-tiered  response  for  emergency  airway  management  by  respiratory  therapists  and  anesthesiol- 
ogists. Respir  Care  1 998;43[7]552-556.) 


164  Out-of-operating 
room  intubations 


89  Cardiac  arrests 


n^ 


75  Non-code  cases 


39  -  Anesthesiologist 
present  (all  intubated) 


50  -  No  anesthesiologist 


nzn 


65  -  Anesthesiologist 
present  (all  intubated) 


10  Emergency  (no 
anesthesiologist) 
(all  intubated) 


48  Successful  intubations 


Fig.  2.  Results  of  the  164  consecutive  intubations  performed  outside  of  the  operating  room  during  the  first  18  months  of  implementation 
of  the  model  shown  in  Fig.  1.  (Modified  From  Hussey  JD,  Bishop  MJ,  Massey  L,  Lakshminarayan  S,  Joy  J,  Finley  J.  Two-tiered  response 
for  emergency  airway  management  by  respiratory  therapists  and  anesthesiologists.  Respir  Care  1998;43[7]552-556.) 


tinely  present  for  such  cases.  The  complete  algorithm  for 
this  model  is  shown  in  Figure  1 .  The  results  of  the  first  1 8 
months  of  using  this  model  are  shown  in  Figure  2.  Of  164 
patients,  162  were  successfully  intubated,  which  compares 
favorably  with  the  published  experience  summarized  in 
Table  3. 

The  training  required  for  respiratory  therapists  to  intu- 
bate depends  on  the  nature  of  the  patients  to  be  intubated 
and  the  availability  of  physician  support.  Training  in  the 
pharmacology  of  sedative  drugs,  neuromuscular  blocking 
drugs,  and  drugs  required  for  hemodynamic  support  would 


require  extensive  coursework,  and  administration  of  such 
drugs  is  not  generally  within  the  scope  of  practice  of  the 
respiratory  therapist.  Our  two-tiered  response  system  lim- 
its the  need  for  such  training,  since  a  physician  trained  in 
intubation  is  always  available,  via  cell  telephone  if  not  in 
person.  Furthermore,  a  house  medical  officer  is  always 
present  at  all  arrests  and  can  provide  assistance  as  needed. 
However,  even  in  arrest  and  near-arrest  situations,  there 
still  may  arise  a  need  for  neuromuscular  blockade  to  fa- 
cilitate intubation.  Neuromuscular  blocking  drugs  have 
been  shown  to  increase  the  success  rate  of  field  intubations 


754 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Who  Should  Perform  Intubation? 


and  may  be  critical  for  intubation  success  in  the  patient 
who  has  remaining  muscle  tone.-^  Consequently,  training 
should  be  provided  in  understanding  the  onset  of  action  of 
succinylcholine,  as  well  as  a  nondepolarizing  muscle  re- 
laxant. In  our  institution,  we  have  provided  each  therapist 
with  a  laminated  card  noting  a  suitable  dose  of  succinyl- 
choline, or,  for  patients  with  a  history  of  neurologic  deficit 
or  bum,  the  appropriate  dose  of  a  nondepolarizing  relax- 
ant. This  card  can  then  be  shown  to  the  medical  house 
officer  to  order  the  drug,  even  if  they  are  not  completely 
familiar  with  the  dose. 

There  is  no  set  answer  to  deciding  how  much  training  is 
required  before  an  individual  is  prepared  to  intubate  pa- 
tients independently.  One  report  used  12  intubations  as  a 
minimum  for  therapist  certification.''*  In  our  institution, 
the  supervising  anesthesiologist  must  provide  final  certi- 
fication that  all  skills  have  been  achieved.  This  requires  a 
mean  of  31  ±  17  (mean  ±  SD)  attempts,  with  a  range  of 
15-46.  This  mean  correlates  well  with  a  study  of  anesthe- 
siology trainees  learning  to  perform  intubation:  the  learn- 
ing curve  is  steep  initially,  with  an  80%  success  rate  after 
30  intubations,  but  then  flattens  out,  with  only  gradually 
increasing  success  rates  with  further  training.-'' 

Summary 

The  literature  clearly  suggests  that  respiratory  therapists 
are  generally  well  qualified  to  conduct  endotracheal  intu- 
bations. While  the  respiratory  therapist  certainly  does  not 
possess  the  knowledge  of  pharmacology  and  underlying 
conditions  that  a  physician  does,  many  respiratory  thera- 
pists have  more  intubation  experience  than  the  some  phy- 
sicians, and  most  respiratory  therapists  can  provide  rapid 
and  efficient  airway  management  with  a  high  degree  of 
safety.  Anesthesiologists  and  certified  registered  nurse 
anesthetists  have  the  most  intubation  experience,  but  are 
not  always  available,  and  respiratory  therapists  can  per- 
form intubations  at  a  lower  cost.  For  this  reason,  we  rec- 
ommend a  two-tiered  system  in  which  the  respiratory  ther- 
apist is  permitted  to  conduct  intubations  in  the  context  of 
rapidly-available  consultation  from  the  anesthesiologist. 

REFERENCES 

1.  Cheney  FW,  Posner  KL.  Caplan  RA.  Adverse  respiratory  events 
infrequently  leading  to  malpractice  suits,  a  closed  claims  analysis. 
Anesthesiology  1991  ;75(6):932-939. 

2.  Mon  TC,  Tiernan  JF.  Airway  related  complications  of  emergency 
intubation  (abstract).  Chest  1993;104:48S. 

3.  Mascia  MF.  Maljasko  MJ.  Emergency  airway  management  by  an- 
esthesiologists (abstract).  Anesthesiology  I993;79(3):A1054. 

4.  Buck  C,  Southorn  PA.  Who  should  perfonn  endotracheal  intubation? 
A  summary  of  i.ssues.  (editorial)  Respir  Care  I994;39(l):17-I8. 

5.  Gin.sburg  WH  Jr.  When  does  a  guideline  become  a  standard?  The 
new  American  Society  of  Anesthesiologists  guidelines  give  us  a 
clue.  Ann  Emerg  Med  1993:22(1 2):  189 1 -1896. 


6.  Practice  guidelines  for  management  of  the  difficult  airway.  A  report  by 
the  American  Scx'iety  of  Anesthesiologists  Task  Force  on  Management 
of  the  Difficult  Airway.  Anesthesiology  1993;78(3):597-602. 

7.  Guidelines  for  cardiopulinonary  resuscitation  and  emergency  cardiac 
care.  Emergency  Cardiac  Care  Committee  and  Subcommittees.  Amer- 
ican Heart  Association.  Part  111.  Adult  advanced  cardiac  life  support. 
JAMA  1992:268(16):2I99-2241.  PiihUshecl  ermiiim  JAMA  1994: 
27I(IJ):984. 

8.  Clinical  Practice  Guidelines.  Resu.scitation  in  acute  care  hospitals. 
Respir  Care  1993;38(1 1):1 179-1 188. 

9.  Conley  JM.  Smith  DJ.  Emergency  endotracheal  intubation  by  respi- 
ratory care  personnel  in  a  community  hospital.  Respir  Care  1981; 
26(4):3.36-338. 

10.  Kacmarek  RM.  The  role  of  the  respiratory  therapist  in  emergency 
care.  Re.spir  Care  1992;37(6):.'i23-530.  Discussion;  530-532. 

1 1 .  Nayyar  P,  Lisbon  A.  Non-operating  room  emergency  airway  man- 
agement and  endotracheal  intubation  practices;  a  survey  of  anesthe- 
siology program  directors.  Anesth  Anal  1997:85(1  );62-68. 

12.  Benumof  JL.  Management  of  the  difficult  adult  airway.  With  special 
emphasis  on  awake  tracheal  intubation.  Anesthesiology  1991:75(6); 
1087-1 1 10.  Published  erratum  Anesthesiology  1993:78(1  ):224. 

13.  Samsoon  GL,  Young  JR.  Difficult  tracheal  intubation;  a  retrospec- 
tive .study.  Anaesthesia  1987;42(5);487^90. 

14.  Lyons  G.  Failed  intubation;  six  years'  experience  in  a  teaching  ma- 
ternity unit.  Anaesthesia  1985:4()(8);759-762. 

15.  Taryle  DA.  Chandler  JE.  Good  JT,  Potts  DE.  Sahn  SA.  Emergency 
room  intubations — complications  and  survival.  Chest  1979:75(5); 
541-543. 

16.  DeLeo  BC.  Endotracheal  intubation  by  rescue  squad  personnel.  Heart 
Lung  l977;6(5);851-854. 

17.  Pepe  PE,  Copass  MK.  Joyce  TH.  Prehospital  endotracheal  intuba- 
tion; rationale  for  training  emergency  medical  personnel.  Ann  Emerg 
Med  1985:14(1 1);1085-1092. 

18.  Jacobs  LM.  Berrizbeitia  LD.  Bennett  B.  Madigan  C.  Endotracheal 
intubation  in  the  prehospital  phase  of  emergency  medical  care.  JAMA 
1983:250(I6);2I75-2I77. 

19.  McLaughlin  AJ  Jr,  Scott  W.  Training  and  evaluation  of  respiratory 
therapists  in  emergency  intubation.  Respir  Care  198l:26(4);333- 
335. 

20.  Thalman  JJ.  Rinaldo-Gallo  S.  Maclnlyre  NR.  Analysis  of  an  endo- 
tracheal intubation  service  provided  by  respiratory  care  practitioners. 
Respir  Care  1993;38(5);469^73. 

21.  Zyla  EL,  Carson  J.  Respiratory  care  practitioners  as  secondary  pro- 
viders of  endotracheal  intubation;  one  hospital's  experience.  Respir 
Care  1994:39(1  );.30-33. 

22.  Schwartz  DE.  Matthay  MA,  Cohen  NH.  Death  and  other  complica- 
tions of  emergency  airway  management  in  critically  ill  adults;  a 
prospective  investigation  of  297  tracheal  intubations.  Anesthesiol- 
ogy 1995:82(2);367-376. 

23.  Stauffer  JL,  Olson  DE,  Petty  TL.  Complications  and  conse- 
quences of  endotracheal  intubation  and  tracheostomy;  a  prospective 
study  of  150  critically  ill  adult  patients.  Am  J  Med  1981:7()(1);65- 
76. 

24.  Stewart  RD.  Paris  PM.  Winter  PM,  Pelton  GH.  Cannon  GM.  Field 
endotracheal  intubation  by  paramedical  personnel,  success  rates  and 
complications.  Chest  1984:85(3);341-345. 

25.  Murphy-Macabobby  M,  Marshall  WJ.  Schneider  C.  Dries  D.  Neu- 
romuscular blockade  in  aeromedical  airway  management.  Ann  Emerg 
Med  l992:21(6);664-669. 

26.  Konrad  C,  Schupfer  G,  Wietlisbach  M,  Gerber  H.  Learning  manual 
skills  in  anesthesiology;  is  there  a  recommended  number  of  cases 
for  anesthetic  procedures'?  Anesth  Analg  1998:86(3);635-639. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


75.^ 


Who  Should  Perform  Intubation? 


Discussion 

Hurford:  That  was  a  very  nice  pre- 
sentation of  the  situation  at  your  hos- 
pital, and  I  imagine  it  parallels  the  sit- 
uation at  hospitals  where  there  is  either 
no  emergency  department  or  a  not- 
very-busy  one,  and  where  intubation 
is  relatively  infrequent,  as  it  is  in  your 
institution.  The  frequency  of  intuba- 
tion events  occurring  when  there  is  no 
anesthesiologist  present  is  extremely 
low,  it  seemed,  by  your  data,  a  rela- 
tively rare  event — 1.5  per  month  or 
something  like  that.  Obviously,  other 
hospitals  are  different.  Level  1  trauma 
centers  have  young,  healthy,  salvage- 
able people  arrive  at  the  emergency 
department  in  respiratory  distress.  Ev- 
erybody wants  to  play  like  the  TV 
show  ER.  Those  types  of  scenarios  are 
much  more  dangerous  to  health  care 
in  general  today,  because  you're  los- 
ing a  certain  proportion  of  salvage- 
able patients.  Pediatric  ERs  are  an- 
other case  in  point.  The  types  of 
patients  in  the  hospital  (difficult  air- 
way patients,  ear-nose-throat  patients, 
for  example),  are  also  important.  In 
our  hospital,  for  example,  we  have  sim- 
ilar difficulties  where  we  are  so  large 
that  we  cannot  supply  anesthesiolo- 
gists to  outlying  facilities,  neighbor- 
hood health  care  centers,  or  doctors' 
offices  that  are  3  blocks  away  when 
they  want  a  code  response  team.  We'  ve 
had  to  work  out  a  code  response  team 
to  try  to  do  that,  but  one  of  the  options 
that  has  been  described,  and  certainly 
occurs  in  rehab  hospitals  and  chronic 
care  hospitals,  is  to  call  9 1 1  and  have 
the  paramedics  come. 

Bishop:  That's  actually  the  response 
plan  in  our  hospital  for  the  outlying 
buildings.  For  instance,  radiation  on- 
cology is  in  an  outlying  building.  We 
have  a  couple  of  other  facilities  that 
are  in  outlying  buildings,  and  that's 
the  plan.  We  had  a  code  call  in  one  of 
the  outlying  buildings  on  our  campus, 
and  not  only  were  the  paramedics  there 
before  anybody  from  the  main  hospi- 
tal, they  also  had  the  equipment  to 


take  care  of  things  that  occur  in  the 
field.  We  didn't  have  suction;  they  had 
a  portable  suction  set  up.  They  were 
used  to  doing  things  in  the  field,  and  I 
think  that's  absolutely  right. 

Hurford:  Is  there  a  point  in  a  hos- 
pital's activity  level  at  which  an  emer- 
gency department  physician  or  in- 
house  anesthesiologist  becomes  cost- 
effective?  Or  is  it  never  reasonable  to 
have  an  additional  person  in-house  to 
cover  codes? 

Bishop:  I  think  it  depends  on  the 
particular  way  you've  set  things  up. 
We've  set  it  up  so  that  the  frequency 
of  emergency  intubations  is  pretty  low. 
I  think  you  just  have  to  make  the  cal- 
culations. Look  at  the  value  added, 
and  go  through  it  for  your  individual 
situation.  I  think  you  brought  the  point 
up  that,  obviously,  at,  say,  an  outpa- 
tient 5-doctor  facility,  you're  not  go- 
ing to  have  a  highly  trained  intubator, 
but  at  a  place  like  Massachusetts  Gen- 
eral Hospital  or  Harborview  the  equa- 
tion is  absolutely  clear.  I  would  say 
that  there  are  some  added  benefits  in 
any  case  to  having  trained  the  respi- 
ratory therapists  in  the  OR,  because, 
in  general,  the  respiratory  therapists 
are  usually  among  the  first  responders 
to  a  code,  and  I  believe  it  has  resulted 
in  excellent  initial  bag-and-mask  ven- 
tilation. 

Hurford:  No  argument  there.  Now, 
your  current  frequency  of  events  cer- 
tainly isn't  enough  to  keep  up  compe- 
tency. What  sort  of  program  do  you 
have  for  continuing  education  of  the 
respiratory  therapists? 

Bishop:  Gee,  that's  next  year's  pa- 
per! We're  actually  doing  a  study  on 
that  right  now,  and  one  of  the  things 
that  I've  proposed  when  we  set  this 
program  up  was  that  I  wanted  to  set 
up  a  core  group  of  maybe  8  therapists 
(2  for  each  shift)  who  would  be  trained 
and  retrained  and  would  be  doing  them 
to  keep  up  competency.  Our  respira- 
tory therapy  group  managers  wanted 


everyone  to  be  trained,  and  it  turns 
out  they  were  probably  right  to  insist 
that  everyone  get  trained,  because  hav- 
ing a  trained  assistant  is  very  useful. 
We  have  a  core  group  who  are  doing 
most  of  the  intubations,  and  we  have 
another  group  of  therapists  who  are 
trained  but  not  really  actively  doing 
the  intubations.  This  year  we  have  re- 
quired everyone  to  come  back  for  re- 
training and  recertification.  We're  do- 
ing a  study  with  an  observer  who 
determines  which  skills  have  and  have 
not  been  retained,  to  see  whether  do- 
ing the  intubations  on  the  ward  has 
resulted  in  enough  retention  of  skills. 
Hopefully,  we'll  have  more  informa- 
tion about  skill  retention,  but  for  the 
moment,  we  decided  everybody  had 
to  come  back  to  the  OR  for  retraining. 
It's  not  a  huge  expense,  but  it's  a  fair 
bit  of  effort;  it  sometimes  means  push- 
ing aside  the  medical  students  and  den- 
tal residents,  or  whoever  has  come  to 
the  operating  room  to  intubate. 

Durbin:  The  following  question  is 
intended  to  be  provocative.  A  promi- 
nent ethicist  was  concerned  that  by 
substituting  respiratory  therapists  for 
anesthesiologists  in  emergency  intu- 
bations, a  hospital  in  New  York  was 
violating  the  Geneva  Convention  by 
experimenting  on  patients  without 
their  consent.  Is  this  a  concern  about 
your  study?  Didn't  you  just  substitute 
one  process  of  care  for  another  with- 
out any  evidence  that  they  were  equiv- 
alent? In  fact,  you  started  off  by  say- 
ing it  would  be  hard  to  show  by  any 
scientific  method  that  they're  really 
equivalent.  I  have  heard  you  say  at 
public  meetings  before  that  an  anes- 
thesiologist is  still  the  most  skilled  per- 
son in  that  environment.  Is  this  change 
ethically  acceptable  without  asking  pa- 
tient consent?  Lest  there  be  any  mis- 
understanding, I  want  to  make  it  clear 
that  1  think  therapists  have  a  unique 
role  in  airway  intubation  in  that  they 
are  credentialed,  certified,  and  recer- 
tified to  do  the  procedure.  They  are 
carefully  watched  under  an  organiza- 
tional process,  whereas  physicians  and 


756 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Who  Should  Perform  Intubation? 


residents,  in  general,  are  not  similarly 
certified.  I  think  the  therapist's  care- 
ful preparation  is  a  huge  advantage 
for  respiratory  care.  The  most  quali- 
fied person  should  be  responsible  for 
critical  skills  such  as  airway  manage- 
ment, and  therapists  have  a  broad  view 
of  airway  management,  while  most 
other  physicians  do  not.  Most  patients 
are  helped  by  expert  management  of 
the  airway,  not  just  by  intubation, 
and  1  think  that  the  global  approach 
to  airway  management  is  the  unique 
and  important  skill  that  respiratory 
therapists  bring,  and  they  definitely 
should  be  part  of  it. 

Bishop:  I  think  you  have  to  look  at 
it  as  we  do  everything  else.  You  look 
at  the  cost  and  benefits.  I  think  we 
have  certain  requirements  for  Level  1 
trauma  centers  that  we  don't  have  for 
other  hospitals.  We  calculated  the  like- 
lihood of  what  we  thought  was  an  ad- 
verse event,  and  felt  that  it  fell  within 
acceptable  guidelines,  but  the  truth  is 
that  I've  had  anesthesia  residents  on 
call  in-house  after  2  weeks  of  train- 
ing, and  they  were  responsible  for  the 
airway.  Now,  the  ones  we  put  on  call 
those  first  few  days,  we  usually  would 
call  them  in  advance  and  ask  them  if 
they  did  rotations  through  anesthesia 
as  a  medical  student,  and  we  try  to  use 
the  most  trained  ones,  but  still  we're 
not  talking  about  huge  amounts  of 
training.  We  now  at  least  have  quality 
control  in  advance — we  have  observed 
the  therapists.  I  think  the  level  of  care 
is  a  lot  higher  than  in  many  other  places 
where  whatever  physician  happens  to 
show  up  may  be  attempting  the  intu- 
bation at  a  code.  In  fact,  one  signifi- 
cant problem  we  had  to  work  through 
was  first  or  second  year  medical  res- 
ident saying  "Oh,  you're  a  respiratory 
therapist?  /'//  do  the  intubation." 
We've  trained  the  respiratory  thera- 
pists to  say  "No,  the  hospital  policy  is 
that  I'm  supposed  to  take  care  of  that. 
If  the  anesthesiologist  gets  here  and 
wants  to  supervise  you,  that's  fine,  but 
it's  my  job  to  do  this." 


Thompson:  I  really  like  the  way 
you've  developed  your  program,  in 
part  because  it  makes  me  more  com- 
fortable in  our  own  transition  from  a 
physician-led  transport  team  to  a 
nurse/therapist  team.  You  give  me  con- 
fidence that  we're  doing  the  right 
thing.  I  have  concerns  about  the  knowl- 
edge of  some  anesthesia  residents.  At 
least  with  respect  to  pediatric  man- 
agement, I  find  that  their  ability  to 
anticipate,  recognize,  and  treat  physi- 
ologic instability  is  limited.  Do  you 
see  this? 

Bishop:  Yes.  I  think  I'd  like  to  be 
there  for  a  lot  of  the  cases.  Patients 
get  intubated  and  ventilated,  and  sud- 
denly they're  relatively  hypovolemic. 
Yes,  that's  a  problem.  We  try  to  edu- 
cate people.  It's  something  we  espe- 
cially try  to  make  our  therapists  aware 
of,  especially  in  the  bronchospastic  pa- 
tient— don't  overventilate  them. 

Thompson:  It's  most  concerning 
when  they  take  on  the  mantle  of  air- 
way expert,  but  fail  to  attend  to  the 
physiologic  rather  than  technical  as- 
pects of  airway  management. 

Bishop:  One  thing  I  think  we've 
made  very  clear  is  that  when  the  ther- 
apist is  doing  the  intubation,  they  are 
there  to  do  the  intubation.  But,  most 
of  the  physiologic  management  of  the 
patient  is  still  up  to  the  primary  service, 
and  I  know  I'll  have  some  disagreement 
on  that:  I  can  tell  you  that  from  the  last 
Journal  Conference  1  attended,  where 
therapist  involvement  in  other  aspects 
of  resuscitation  was  a  fairly  controver- 
sial subject.  But  we've  emphasized  that 
that's  really  the  primary  service  provider 
who  is  going  to  care  for  that. 

Thompson:  In  many  hospitals  there 
may  be  no  formally  trained  person 
available  to  handle  airway  emergen- 
cies. What  about  the  smaller  commu- 
nity hospitals  that  don't  have  any  phy- 
sicians in-house  on  a  regular  basis? 
What  recommendations  would  you 
make  for  these  institutions?  What  are 


the  opportunities  to  spread  your  good 
efforts  to  more  places?  What  can  we 
do  to  develop  a  guideline  or  perhaps 
even  a  standard  for  hospitals? 

Bishop:  I  think  the  first  problem 
with  that  is  that  it  takes  a  lot  of  work 
from  the  anesthesiologists  and  the  ther- 
apists. Another  question  is  the  finan- 
cial one.  I  think  Medicare  pays  some- 
thing like  $45  to  $50  for  an  intubation. 
The  intubation  is  going  to  take  a  couple 
hours  of  someone's  time  by  the  time 
they  go  in,  assess  the  patient,  write  the 
note.  etc.  1  would  think  that  in  small 
private  hospitals  there  would  be  finan- 
cial disincentive  to  call  someone  in  to 
intubate  for  a  code  call.  I'm  able  to  do 
it  because  I  have  residents  on  hand,  but 
different  models  might  have  to  be  set 
up  for  the  80-bed  hospital  in  rural  Texas. 

Stauffer:  Your  excellent  presenta- 
tion and  this  discussion  raise  questions 
about  the  whole  issue  of  training,  cre- 
dentialing,  and  proficiency  for  physi- 
cians in  various  disciplines  in  airway 
management.  I'm  thinking  particularly 
about  training  in  primary  care  fields 
like  pediatrics,  general  internal  medi- 
cine, family  medicine,  and  so  forth. 
To  my  knowledge,  there  aren't  any 
national  standards  or  guidelines  that 
would  indicate  how  much  training  a 
physician  should  have  in  intubation, 
how  much  in  applying  for  staff  priv- 
ileges in  insfitutions,  and  how  much 
in  maintaining  proficiency.  To  be  pro- 
vocative, let  me  ask  if  we  should  even 
be  training  internal  medicine  residents 
in  endotracheal  intubation  rather  than 
in  use  of  alternative  airway  methods 
such  as  laryngeal  mask  airways? 

Bishop:  The  reality  for  most  of  them 
is  that  they  would  be  very  unlikely  to 
use  that  skill  with  any  frequency.  For 
the  pulmonary  fellows,  we  now  re- 
quire an  anesthesia  rotation  because 
they're  going  to  be  involved  with  some 
frequency.  But,  no.  There's  no  national 
standard  for  anything.  As  you  know, 
once  a  person  receives  an  MD  they 
can,  legally  speaking,  go  do  hernia  sur- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


757 


Who  Should  Perform  Intubation? 


gery  tomorrow  if  they  can  get  a  hos- 
pital or  ambulatory  surgery  facility  to 
allow  them  on  their  staff.  1  think  it  would 
be  impossible  to  legislate  for  every  pro- 
cedure, but  that's  part  of  what  hospital 
credentialing  and  privileging  is  about. 

Hurford:  The  problems  you  point 
out  are  important  ones,  and  we  face 
them  as  well.  One  response  to  them 
was  a  series  of  conferences  that  we 
had  in  1994  and  1995  to  establish 
guidelines  for  the  Massachusetts  Gen- 
eral Hospital,  Brigham  and  Women's 
and  Children's,  Deaconess,  and  Bos- 
ton Children's  Hospital  anesthesia  de- 
partments for  endotracheal  intubation. 
They  were  a  bit  more  extensive  than 
you  use  at  the  Veterans  Administra- 
tion hospital  in  that  our  anesthesia  re- 
sponders  had  to  have  at  least  6  months 
of  operating  room  experience  prior  to 
carrying  the  bag,  which  would  be  about 
300-400  endotracheal  intubations  or 
at  least  episodes  of  airway  manage- 
ment. They  did  not  respond  to  pedi- 
atric airways  as  a  primary  responder, 
just  as  a  secondary  responder.  The  pri- 
mary responder  was  always  a  pediat- 


ric intensivist  (fellow  or  staff),  with 
the  anesthesia  responder  coming  sec- 
ondarily on  a  clear  chain  of  command 
to  help  the  pediatrician.  Board  certi- 
fied surgeons  and  surgeons  with 
greater  than  3  years  of  operating  room 
experience,  were  also  permitted  to  han- 
dle the  airway.  We  do  not  teach  our 
anesthesiologists  how  to  do  cricothy- 
roidotomies  or  recommend  jet  venti- 
lation as  a  rescue  method.  Instead,  we 
decided  to  focus  our  teaching  on  la- 
ryngeal mask  airways.  Interestingly, 
these  guidelines  have  been  adopted  by 
all  the  various  Harvard  hospitals  as 
our  minimal  standards  for  response  to 
airways. 

Bishop:  It  was  nice  you  were  able 
to  set  up  those  standards  at  Harvard 
hospitals,  but  in  rural  communities, 
that  isn't  going  to  work. 

Hurford:  I  agree.  Standards  or 
guidelines  must  be  different  for  dif- 
ferent places. 

Stoller:  I  would  like  to  make  one 
comment  that  follows  Dr  Thompson's 


question,  regarding  the  generic  issue 
of  how  to  extend  best  practices  from 
larger  centers  to  smaller  institutions. 
Although  there  are  many  problems  as- 
sociated with  the  amalgamation  of 
health  care  institutions,  there  are  also 
some  opportunities. 

Watson:  This  is  a  complex  issue; 
there's  no  real  consensus,  and  there's 
a  great  deal  of  variation  from  group  to 
group.  This  in  mind,  a  rhetorical  ques- 
tion: What  is  the  difference  between 
tracheal  intubation  and  any  otheremer- 
gency  lifesaving  procedure  (for  exam- 
ple, chest  tube  insertion,  of  which  I've 
probably  done  5  in  my  professional 
life  and,  despite  this,  feel  very  com- 
fortable doing)?  Why  do  we  expect 
more  of  our  intubators  in  a  code  situ- 
ation than  we  do  of  the  fellow  who 
puts  the  pacemaker  in? 

Durbin:  My  answer  is  that  if  you 
fail  at  intubation,  everybody  knows  it, 
and  the  recriminations  follow  very 
quickly,  whereas  those  other  proce- 
dures are  considered  adjuvant  to  life. 


758 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


Dean  R  Hess  PhD  RRT  FAARC 


Introduction 

Assessing  Proper  Endotracheal  Tube  Position 

Recognition  of  Esophageal  Intubation 

Recognition  of  Bronchial  Intubation 
Securing  the  Endotracheal  Tube 
Cuff  Issues 
Secretion  Clearance 

Hypoxemia 

Atelectasis 

Airway  Trauma 

Contamination 

Arrhythmias 

Selective  Bronchial  Suctioning 

Increased  Intracranial  Pressure 

Coughing  and  Bronchospasm 
Closed  Suction  Catheters 
Saline  Instillation 
Summary 

[RespirCare  1999;44(7):759-772]  Keywords:  colorimetric  capnometry,  esoph- 
ageal detector  device,  endobronchial  intubation,  esophageal  intubation,  un- 
planned extubation,  airway  cuff  pressure,  airway  cuff  leak,  endotracheal  suc- 
tion, airway  management. 


Introduction 

Management  of  the  airway  is  one  of  the  most  important 
aspects  of  critical  care  practice.  There  is  potential  for  se- 
rious morbidity  and  mortality  related  to  mismanagement 
of  the  airway.'  Airway  complications  can  generally  be 
avoided  by  appropriate  attention  to  detail.  Every  critical 
care  clinician  has  a  responsibility  to  assess  the  airway  and 
make  appropriate  interventions  to  avoid  airway-related 
complications.  This  paper  reviews  assessing  proper  airway 


Dean  R  Hess  is  affiliated  with  Respiratory  Care  Services,  Department  of 
Anaesthesia  and  Critical  Care,  Massachusetts  General  Hospital,  Harvard 
Medical  School,  Boston,  Massachusetts. 

Correspondence:  Dean  R  Hess  PhD  RRT  FAARC.  Respiratory  Care 
Services,  Ellison  401,  Massachusetts  General  Hospital,  55  Fruit  Street. 
Boston  MA  02114.  E-mail:  dhess@partners.org. 


position,  securing  the  endotracheal  tube,  cuff-related  is- 
sues, and  secretion  management. 

Assessing  Proper  Endotracheal  Tube  Position 

Misplacement  of  the  endotracheal  tube  is  a  serious  com- 
plication, and  potentially  life-threatening  if  not  recog- 
nized.^-'' After  placement,  endotracheal  tubes  can  become 
misplaced  due  to  chewing,  coughing,  bucking,  tongue 
movement,  or  head  movement.'  The  tube  can  move  ceph- 
alad  into  the  pharynx  and  potentially  into  the  esopha- 
gus, or  caudad  into  a  main  bronchus  (usually  the  right 
bronchus). 

Recognition  of  Esophageal  Intubation 

Several  methods  are  used  to  differentiate  esophageal 
and  tracheal  intubation  (Table  1).*'**  Unfortunately,  none 
of  these  techniques  is  foolproof  and  all  have  been  shown 


Respiratory  Care  •  July  1999  Vol  44  No  7 


759 


Managing  the  Artificial  Airway 


Table  1 .      Techniques  to  Differentiate  Tracheal  from  Esophageal 
Intubation 


Direct  visualization 

Chest  movement 

Breath  sounds 

Epigastric  auscultation  and  observation 

Exhaled  tidal  volumes  with  spontaneous  breathing 

Gastric  contents  in  tube 

"Feel"  of  manual  ventilation 

Condensation  in  tube 

Lighted  stylette 

Chest  x-ray 

Pulse  oximetry 

End-tidal  COj 

Esophageal  detection  device 


Note: 

None  of  the  techniques  has  been  shown  to  be  reHable  in 

all  circumstances. 

tracheal 

tracheal 

intubation 

intubation 

itt 

4- 

1    1    1    1    1 

I  u  n 

M 

3- 

lllll 

llui 

O 

o 

2- 

1  1   1   I   n              esophageal 

1 1 1 H 

1- 

0-J 

U\\\    .™'°" 

__Um 

Fig.  1.  Capnogram  from  an  animal  with  the  endotracheal  tube 
placed  into  the  trachea  and  into  the  esophagus.  (From  Reference 
10,  with  permission.) 


to  fail  under  certain  circumstances.  Assessing  expired  car- 
bon dioxide  (COj)  is  considered  by  many  to  be  the  stan- 
dard for  detection  of  esophageal  intubation.'-"  This  ap- 
proach assumes  that  no  COj  is  present  in  the  stomach  and, 
therefore,  absence  of  exhaled  COj  indicates  esophageal 
placement  of  the  airway  (Fig.  1).  Quantitative  and  quali- 
tative approaches  are  available  for  COj  detection.*'^  Fig- 
ure 2  shows  a  colorimetric  end-tidal  COj  detector.  This 
device  uses  paper  impregnated  with  a  pH-sensitive,  non- 
toxic chemical  indicator.  The  paper  reversibly  changes 
color  in  the  presence  of  COj.'^"-^^ 

A  limitation  of  COj  detection  methods  is  that  exhaled 
COj  concentration  is  determined,  in  part,  by  pulmonary 
blood  flow.  When  pulmonary  blood  flow  is  low  or  absent, 
exhaled  COj  concentration  is  low  or  absent,  and  in  this 
circumstance  CO2  measurement  cannot  assist  in  the  deter- 
mination of  proper  tracheal  placement. 2**  '♦^ 

A  method  that  does  not  use  CO2  detection  is  the  esoph- 
ageal detection  device  (EDD).*^-,^  jhg  eDD  (Fig.  3)  uses 
either  a  syringe  or  an  inflatable  bulb  attached  to  the  prox- 
imal endotracheal  tube.  If  the  endotracheal  tube  is  in  the 
esophagus,  attempts  to  aspirate  air  from  the  tube  should 
collapse  the  unsupported  walls  of  the  esophagus  around 
the  end  of  the  endotracheal  tube  and  create  a  vacuum  in 
the  endotracheal  tube.  If  the  tube  is  in  the  trachea,  the 


Fig.  2.  Colorimetric  end-tidal  CO2  detector  used  to  assess  endo- 
tracheal tube  position. 


tracheal  rings  prevent  tracheal  collapse  and  air  should  be 
readily  withdrawn  from  the  tube.  The  accuracy  of  the  EDD 
to  differentiate  tracheal  from  esophageal  intubation  has 
been  reported  by  many  investigators.  The  EDD  accurately 
indicates  esophageal  intubation  in  nearly  100%  of  cases. 
Unfortunately,  the  EDD  also  indicates  esophageal  intuba- 
tion in  some  cases  in  which  the  endotracheal  tube  is  cor- 
rectly placed  in  the  trachea.'*''-''^-'''*  The  reasons  for  this 
false  indication  of  esophageal  intubation  are  unclear,  but 
may  relate  to  obesity,  cuff  inflation,  or  secretions  in  the 
airway. 

Recognition  of  Bronchial  Intubation 

A  rate  of  endotracheal  tube  malposition  as  high  as  30% 
has  been  reported.''''  The  ideal  position  for  the  endotra- 
cheal tube  is  in  the  mid-trachea,  5  cm  from  the  carina,  with 
the  head  in  a  neutral  position.''^  Endobronchial  intubation 
leads  to  atelectasis  of  the  nonventilated  lung,  hypoxemia, 
and  hyperinflation  of  the  contralateral  lung.  Conversely, 
care  must  be  taken  to  prevent  placement  of  the  endotra- 
cheal tube  too  cephalad  in  the  trachea,  which  can  result  in 
injury  to  the  larynx  upon  cuff  inflation.  Techniques  that 
are  commonly  used  to  detect  endobronchial  misplacement 
of  the  tube  include  auscultation,  depth  of  insertion  of  the 
tube,  bronchoscopy,  and  chest  radiography.  Cuff  palpation 
in  the  suprasternal  notch  has  also  been  used  to  confirm  that 
the  endotracheal  tube  tip  is  a  safe  distance  from  the  cari- 
na.''^ In  the  cuff  palpation  method,  the  endotracheal  tube  is 
withdrawn  or  advanced  while  gentle  digital  pressure  is 


760 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


B 


r 


■,mF 


Fig.  3.  A:  Squeeze-bulb  esophageal  detection  device.  B:  Syringe 
esophageal  detection  device.  C:  Squeeze  bulb  esophageal  detec- 
tion device  attached  to  endotracheal  tubes  placed  into  the  trachea 
(left)  and  the  esophagus  (right).  Note  that  the  bulb  on  the  tube 
placed  into  the  esophagus  (right)  does  not  inflate.  (Fig.  3C  from 
Salem  MR,  Wafai  Y,  Joseph  NJ,  Baraka  A,  Czinn  EA.  Efficacy  of 
the  self-inflating  bulb  in  detecting  esophageal  intubation:  does  the 
presence  of  a  nasogastric  tube  or  cuff  deflation  make  a  differ- 
ence? Anesthesiology  1994;  80(1):42-48,  with  permission.) 

applied  to  the  suprasternal  space.  The  pilot  balloon  is  si- 
multaneously palpated  with  the  other  hand.  When  the  pilot 
balloon  distends  with  pressure  applied  to  the  suprasternal 
notch,  the  tube  is  secured.  Comparison  of  this  method  to 
chest  radiography  or  bronchoscopy  has  not  been  reported. 
Of  concern  is  that  this  method  could  result  in  placement  of 
the  tube  at  a  position  too  cephalad  in  the  trachea,  which 
could  result  in  cuff  injury  to  laryngeal  structures. 


Guidelines  have  been  published  for  proper  depth  of  in- 
sertion of  endotracheal  tubes.  For  orotracheal  tubes,  Ea- 
gle^^  suggested  the  following  depth  of  insertion: 

teeth  to  midpoint  of  trachea  =  height  (cm)/ 10  -I-  2 

For  nasotracheal  tubes,  the  following  was  suggested  by 
Eagle-'**: 

external  naris  to  midpoint  of  trachea  = 
height  (cm)/ 10  +  8 

Owen  and  Cheney'''^  examined  endotracheal  tube  position 
in  388  men  and  190  women  admitted  to  a  critical  care  unit. 
They  reported  that  securing  endotracheal  lubes  at  the  23 
cm  mark  in  men  and  the  21  cm  mark  in  women  (measured 
at  the  upper  incisor  teeth  or  gums)  significantly  reduced 
the  likelihood  of  endobronchial  placement.  These  results 
have  been  confirmed  by  others.*" 

Several  studies  have  compared  physical  assessment  with 
radiographic  determination  of  endotracheal  tube  position. 
Gray  et  al'''  reported  a  30%  incidence  of  endotracheal  tube 
malposition,  as  determined  by  chest  radiograph.  Brunei  et 
al  aF  reported  that  14%  of  patients  required  endotracheal 
tube  repositioning  based  on  radiographic  findings  follow- 
ing intubation  in  the  intensive  care  unit  (ICU)  and  5%  had 
endobronchial  intubation.  Schwartz  et  aH  reported  an  en- 
dotracheal tube  malposition  rate  of  15.5%  of  emergency 
intubations  performed  in  an  ICU,  with  a  greater  risk  for 
malpositioning  in  women.  These  data  suggest  that,  al- 
though physical  findings  are  useful  in  determination  of 
endotracheal  tube  position,  with  many  patients  a  chest 
radiograph  is  necessary  to  correctly  position  the  endo- 
tracheal tube. 

The  position  of  the  endotracheal  tube  changes  with 
changes  in  head  position  (Fig.  4).  Conrardy  et  al"'  found 
that  the  distal  tip  of  the  endotracheal  tube  moves  about  2 
cm  toward  the  carina  with  flexion  of  the  neck  and  about  2 
cm  away  from  the  carina  with  neck  extension.  Thus, 
knowledge  of  head  and  neck  position  is  important  for 
proper  radiographic  interpretation  of  endotracheal  tube 
position. 

KoUef  et  aP  reported  a  46%  incidence  of  endotracheal 
tube  misplacement  in  246  patients,  and  that  74%  of  all 
endotracheal  tube  misplacements  occurred  after  the  day  of 
initial  intubation.  This  suggests  that  endotracheal  tube  po- 
sition should  be  assessed  regularly.  When  proper  endotra- 
cheal tube  position  has  been  established,  the  distance  mark- 
ing on  the  endotracheal  tube  (measured  at  the  upper  teeth 
or  gums  for  oral  intubation  or  at  the  external  naris  for  nasal 
intubation)  should  be  recorded.  This  measurement  should 
be  reconfirmed  on  a  regular  basis  (eg,  every  8-12  hours) 
or  with  any  intervention  that  might  cause  tube  movement 
(eg,  change  of  patient  position,  patient  transport,  move- 
ment of  tube  during  mouth  care,  resecuring  the  tube). 


Respiratory  Care  •  July  1999  Vol  44  No  7 


76  J 


Managing  the  Artificial  Airway 


hard  palate 


base  of 
tongue 


flexion 

B 

neutral 


endotracheal  p-j 

tube  ^^^ 

neutral  extension 


extension 


Fig.  4.  A:  The  effect  of  flexion  and  extension  of  the  neck  on  en- 
dotracheal tube  movement.  (From  Reference  61 ,  with  permission.) 
B:  With  flexion  and  extension  of  the  neck,  the  tip  of  the  endotra- 
cheal tube  can  move  about  2  cm  in  either  direction.  (From  Refer- 
ence 61 ,  with  permission.) 


Securing  the  Endotracheal  Tube 

An  important  aspect  of  airway  management  is  adequately 
securing  the  tube  to  avoid  accidental  extubation  or  move- 
ment into  a  main  bronchus.  Unplanned  extubation  (acci- 
dental extubation  or  self-extubation)  rates  of  2-13%  have 
been  reported.*-'^"  Although  reintubation  is  not  necessary 
for  every  case  of  unplanned  extubation,  the  reintubation 
rate  for  unplanned  extubation  is  greater  than  that  for  planned 
extubation. ''^•'^•''•*  Unplanned  extubation  can  result  in  se- 
rious complications,  and  deaths  have  been  reported.*^'^* 
Using  multivariate  analysis,  Boulain''^  identified  4  factors 
contributing  to  unplanned  extubation:  (1)  chronic  respira- 
tory failure,  (2)  orotracheal  intubation,  (3)  lack  of  intra- 
venous sedation,  and  (4)  endotracheal  tube  fixation  with 
only  thin  adhesive  tape.  Quality  improvement  programs 
have  been  reported  to  decrease  the  incidence  of  unplanned 
extubation. ^■''2-7''-7<'  A  common  feature  of  these  programs 
was  an  improved  method  for  securing  the  endotracheal 
tube. 

Several  methods  are  used  to  secure  endotracheal 
tubes. <'2.77- 86  One  common  and  inexpensive  method  uses 
adhesive  cloth  tape  around  the  tube,  upper  lip,  and  face.^^ 


The  adhesive  tape  strength  on  endotracheal  tubes  varies,^'' 
so  it  is  important  to  use  a  tape  that  adequately  adheres  to 
the  endotracheal  tube.  One-inch  tape  is  cut  long  enough  to 
go  around  the  circumference  of  the  patient's  head  1.5-2 
times.  So  as  to  prevent  the  tape  from  sticking  to  the  pa- 
tient's neck,  a  second  piece  of  tape  is  cut  long  enough  to 
fit  over  the  midportion  of  the  first  piece,  thus  creating  a 
section  with  no  adhesive  showing  on  either  side.  The  tape 
is  then  placed  around  the  patient's  neck.  The  skin  surface 
is  dried  and  tincture  of  benzoin  is  placed  on  both  cheeks 
where  the  tape  will  contact  the  skin.  The  tape  is  pulled 
snug  against  the  neck  and  applied  on  the  patient's  cheeks 
up  to  the  edge  of  the  endotracheal  tube.  The  remaining 
tape  is  split  longitudinally  so  that  at  least  two  inches  of 
tape  is  available  to  be  wrapped  around  the  endotracheal 
tube  at  the  lips.  The  end  of  the  tape  can  be  folded  back  on 
itself  to  form  a  tab,  which  facilitates  later  removal  of  the 
tape.  Some  clinicians  wrap  both  ends  of  the  split  tape 
around  the  tube,  whereas  others  wrap  one  piece  around  the 
tube  and  the  other  piece  is  passed  over  the  lip  and  fastened 
to  the  contralateral  cheek.  Care  is  taken  to  apply  the  tape 
snugly  but  not  so  tight  as  to  produce  facial  skin  break- 
down. The  advantage  of  this  method  is  that  the  tape  passes 
completely  around  the  neck — a  method  that  is  usually  pref- 
erable to  techniques  in  which  one  or  two  pieces  of  tape  are 
used  to  tape  the  tube  to  the  patient's  cheeks.  A  similar 
method  can  be  used  for  nasally  placed  tubes.  The  endo- 
tracheal tube,  gastric  tube,  and  oral  airway  (if  present) 
should  be  separately  taped  so  that  one  device  can  be  re- 
positioned or  removed  without  affecting  the  other.  The 
tube  should  not  be  affixed  to  the  mandible,  because  doing 
so  increases  the  likelihood  of  tube  movement  resulting 
from  jaw  movement.  Although  a  bite  block  (an  oral  airway 
is  commonly  used  for  this  purpose)  is  useful  to  prevent 
biting  on  the  tube,  this  is  often  not  needed.  The  bite  block 
decreases  patient  comfort  and  makes  effective  mouth  care 
more  difficult. 

Another  common  technique  for  securing  the  endotra- 
cheal tube  uses  twill  tape.'**  With  this  method,  a  1 -meter 
length  of  twill  tape  is  folded  in  half  and  looped  around  the 
endotracheal  tube.  The  ends  are  brought  through  this  loop 
and  tightened  around  the  tube.  One  end  of  the  twill  tape  is 
passed  around  the  patient's  head  below  one  ear  and  the 
other  end  is  passed  above  the  other  ear.  The  two  ends  are 
tied  in  a  bow  on  the  cheek.  Sometimes  this  is  repeated  with 
a  second  piece  of  twill  tape  so  that  two  ties  are  used  to 
secure  the  endotracheal  tube.  Barnason  et  al'*''  compared 
the  use  of  twill  tape  and  adhesive  tape  to  secure  endotra- 
cheal tubes,  and  reported  that  these  methods  are  compa- 
rable in  preventing  unplanned  extubation  and  maintaining 
oral  mucosal  and  skin  integrity. 

Several  devices  for  securing  endotracheal  tubes  are  com- 
mercially available.''''-^'*  The  principal  advantage  of  these 
is  the  speed  with  which  they  can  be  applied,  and  they  are 


762 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


therefore  popular  for  field  use.  For  the  ICU,  the  adhesive 
tape  or  twill  tape  approach  is  effective  and  inexpensive. 
Some  designs  of  commercial  endotracheal  tube  holders 
can  make  certain  procedures  more  difficult  (eg,  prone  po- 
sitioning). 

Securing  the  endotracheal  tube  can  be  particularly  prob- 
lematic in  burn  patients,  who  often  have  facial  swelling 
and  may  have  burn  injuries  to  the  face  and  head.  Achauer 
et  al****  described  methods  in  which  the  endotracheal  tube  is 
affixed  to  a  wire  that  is  anchored  to  a  tooth,  several  teeth, 
the  nasal  spine,  or  the  mandible.  Perrotta  et  al**''  reported  a 
similar  method  for  children  with  facial  burns,  in  which  the 
tube  is  attached  to  a  standard  dental  arch  bar  that  is  se- 
cured to  maxillary  teeth  with  stainless  steel  wire.  Note  that 
these  approaches  have  the  potential  to  cause  dental  injury, 
and  make  it  more  difficult  to  remove  the  tube  in  emer- 
gency situations  (eg,  if  the  tube  becomes  occluded). 

The  position  of  the  endotracheal  tube  in  the  mouth  should 
be  adjusted  periodically  to  provide  mouth  care  and  to  pre- 
vent pressure  sores  to  the  lips,  gums,  or  mouth.  Two  peo- 
ple should  be  present  when  the  endotracheal  tube  is  unse- 
cured for  this  care:  one  is  responsible  for  maintaining  tube 
position  and  the  other  is  responsible  for  providing  mouth 
care  and  resecuring  the  tube.  In  some  units,  it  is  common 
practice  to  trim  the  excess  endotracheal  tube  length,  which 
decreases  the  risk  of  tube  malposition  or  kinking;  how- 
ever, it  is  important  to  determine  that  the  tube  is  properly 
positioned  before  trimming.  A  swivel  connector  between 
the  endotracheal  tube  and  the  breathing  circuit  should  be 
used,  and  there  should  be  support  for  the  breathing  circuit 
so  that  it  does  not  promote  tube  movement. 

Cuff  Issues 

High  tracheal  wall  pressures  exerted  by  the  inflated  cuff 
of  the  endotracheal  or  tracheostomy  tube  can  produce  tra- 
cheal mucosal  injury.''"'^*  The  tracheal  capillary  perfusion 
pressure  is  normally  25-35  mm  Hg.  Because  the  pressure 
transmitted  from  the  cuff  to  the  tracheal  wall  is  usually 
less  than  the  pressure  in  the  cuff,  it  is  generally  agreed  that 
25  mm  Hg  (34  cm  HoO)  is  the  maximum  acceptable  in- 
tracuff  pressure.  If  the  cuff  pressure  is  too  low,  silent 
aspiration  is  more  likely. '"o""  Bemhard  et  al""  reported  a 
greater  risk  for  aspiration  with  cuff  pressures  less  than  1 8 
mm  Hg  (25  cm  HjO).  Based  on  this  evidence,  it  seems 
reasonable  to  maintain  cuff  pressures  at  20-25  mm  Hg 
(25-35  cm  HiO)  to  minimize  the  risks  of  tracheal  wall 
injury  and  aspiration.  Cuff  pressure  is  affected  by  airway 
pressure,  and  cuff  pressure  increases  linearly  with  airway 
pressure. '"- 

The  cuff  is  typically  inflated  using  a  minimum  occlu- 
sion pressure  or  a  minimum  leak  technique.""""  With  the 
minimum  occlusion  pressure  method,  the  cuff  is  inflated  to 
a  volume  that  just  eliminates  an  end-inspiratory  leak  dur- 


Prassur* 
Gauge 


Fig.  5.  Equipment  set-up  to  measure  cuff  pressure.  (From  Refer- 
ence 105,  with  permission.) 


Digital  P-V  Gauge* 

I.LINCKRODT 


Fig.  6.  Commercially  available  device  to  measure  cuff  pressure. 

ing  positive  pressure  ventilation.  With  the  minimum  leak 
technique,  the  cuff  is  inflated  with  a  volume  that  allows  a 
small  leak  to  occur  at  end-inspiration.  With  either  method, 
a  leak  around  the  cuff  is  assessed  by  auscultation  over  the 
suprasternal  notch  or  the  lateral  neck.  Although  no  com- 
parison of  these  approaches  to  cuff  inflation  have  been 
reported,  it  may  be  prudent  to  use  a  minimal  occlusion 
pressure  to  decrease  the  risk  of  silent  aspiration  of  pha- 
ryngeal secretions. 

Monitoring  cuff  pressure  is  a  standard  for  respiratory 
care  practice.  Intracuff  pressure  should  be  monitored  and 
recorded  at  least  once  per  shift,  and  more  often  if  the  tube 
position  is  changed,  if  the  volume  of  air  in  the  cuff  is 
changed,  or  if  a  leak  occurs.**''  Cuff  pressure  is  measured 
with  a  syringe,  stopcock,  and  manometer  (Fig.  5),"''' '"<' 
which  allows  simultaneous  measurement  and  adjustment 
of  cuff  pressure.  Methods  in  which  the  manometer  is  at- 
tached directly  to  the  pilot  balloon  are  discouraged  be- 
cause they  cause  air  to  escape  from  the  cuff  to  pressurize 
the  manometer.  Commercially  available  systems  can  also 
be  used  to  measure  cuff  pressure  (Fig.  6). 

A  common  cause  of  high  cuff  pressure  is  the  selection 
of  too  small  an  endotracheal  tube,  in  which  case  higher 
cuff  pressure  is  needed  to  achieve  a  seal.  If  the  volume  of 
air  in  the  cuff  required  to  achieve  a  seal  exceeds  the  nom- 
inal volume  of  the  cuff,  the  selected  endotracheal  tube  size 
is  too  small.  The  nominal  cuff  volume  is  the  volume  below 
which  the  cuff  pressure  is  <  25  mm  Hg  ex-vivo.  Another 
common  cause  of  high  cuff  pressure  is  malposition  of  the 


Respiratory  Care  •  July  1999  Vol  44  No  7 


763 


Managing  the  Artificial  Airway 


,  severed  one-way  valve  and  inflating  tube 

1.. 


Fig.  7.  Method  to  maintain  cuff  pressure  if  1-way  valve  and  inflat- 
ing tube  are  severed.  (From  Reference  107.) 


endotracheal  tube,  particularly  cephalad  positioning,  in 
which  the  cuff  is  inflated  in  the  larynx  or  pharynx.  Other 
causes  of  high  cuff  pressure  include  overfilling  of  the  cuff, 
tracheal  dilation,  and  use  of  a  low-volume  high  pressure 
cuff. 

Occasionally,  the  pilot  tube  may  be  severed.  To  correct 
this  problem,  a  short  blunt  needle  can  be  passed  into  the 
pilot  tube  and  a  stopcock  attached  to  the  needle  hub  to  add 
and  maintain  air  in  the  cuff  until  the  tube  can  be  replaced 
(Fig.  7).  107.108  Cuff  leaks  can  also  occur,  and  a  continuous 
flow  of  gas  into  the  cuff  can  be  used  to  temporarily  main- 
tain cuff  inflation  until  the  tube  can  be  changed.""^ 

Kearl  et  al""  reported  that  a  large  number  of  endotra- 
cheal tubes  removed  for  presumed  cuff  rupture  were  ac- 
tually flawless.  They  speculated  that  tube  malposition  might 
be  the  reason  clinicians  sometimes  incorrectly  conclude 
that  the  cuff  has  ruptured.  The  cuff  inflation  method  shown 
in  Figure  5  represents  a  simple  way  to  determine  cuff 
rupture.  If  a  leak  occurs  during  this  maneuver,  there  may 
be  a  ruptured  cuff  or  incompetent  pilot  balloon.  The  cause 
of  an  observed  leak  can  be  further  assessed  by  clamping 
the  pilot  tube.  If  a  leak  disappears  with  the  clamp  in  place, 
then  the  pilot  balloon  or  valve  is  incompetent.  Figure  8 
shows  an  algorithm  for  cuff  management. 

Secretion  Clearance 

Intubated  patients  should  be  suctioned  whenever  phys- 
ical examination  reveals  the  presence  of  secretions  in  the 
airway." '"2  Because  suctioning  is  an  uncomfortable  and 
potentially  hazardous  procedure,  it  should  be  performed 
only  when  indicated,  and  not  at  a  fixed  frequency."^  The 
upper  airway  should  also  be  suctioned  periodically  to  re- 
move oral  secretions. 

Several  general  features  apply  to  all  suction  catheters: '"'"^ 
(1)  they  should  be  long  enough  to  enter  the  mainstem 


bronchi — usually  22  inches  (56  cm);  (2)  a  thumb  port  is 
provided  at  the  proximal  end  of  the  catheter  to  control 
suction  to  the  catheter;  (3)  the  catheter  must  be  rigid  enough 
to  allow  passage  through  an  artificial  airway,  but  flexible 
enough  to  prevent  damage  to  the  airway  mucosa;  (4)  to 
prevent  damage  to  the  airway  mucosa,  the  catheter  should 
also  have  smooth,  molded  ends,  one  or  more  side  holes 
near  the  catheter  tip,  minimal  frictional  resistance  when 
passed  through  the  airway;  and  (5)  the  catheter  should  be 
transparent  so  that  the  aspirated  secretions  can  be  assessed. 
There  are  numerous  recognized  potential  complications  of 
airway  suctioning,' '  '"4'  is  ^jj^j  g  suction  technique  should 
be  used  to  minimize  these  complications. 

Hypoxemia 

The  causes  of  suction-related  hypoxemia  are:  (1)  inter- 
ruption of  mechanical  ventilation  during  the  suctioning 
procedure  (loss  of  ventilation,  inspired  oxygen,  and  posi- 
tive end-expiratory  pressure),  (2)  the  aspiration  of  gas  from 
the  respiratory  tract  during  the  application  of  suction,  (3) 
the  entrainment  of  room  air  into  the  lungs,  (4)  the  duration 
of  the  suction  procedure,  and  (5)  suction-related  atelecta- 
gjg  111,116-121  Hyperoxygenation  is  the  best  technique  to 
avoid  suction-related  hypoxemia,  and  should  be  used  with 
all  suction  procedures. '^-'-'^  This  is  most  commonly  ac- 
complished by  increasing  the  fraction  of  inspired  oxygen 
(Fio,)  to  1 .0,  but  increasing  the  F|o,  by  0.20  may  be  ade- 
quate.'^^ 

Hyperinflation  and/or  hyperventilation  to  prevent  suc- 
tion-related hypoxemia'^**  should  be  used  cautiously  be- 
cause of  the  possibility  of  over-distention  lung  injury.'-**  A 
recruitment  maneuver  (eg,  40  cm  HjO  for  40  seconds) 
following  the  suction  procedure  has  been  recommended, 
particularly  for  patients  with  acute  respiratory  distress  syn- 
drome requiring  high  levels  of  positive  end-expiratory  pres- 
sure.'-''" In  some  critical  care  units,  a  manual  ventilator 
(resuscitator)  is  used  for  hyperinflation  and  hyperoxygen- 
ation during  suctioning  procedures.  Several  studies  report 
that  this  method  might  be  inferior  to  hyperinflation  and 
hyperoxygenation  using  the  ventilator.'""'''''  It  has  also 
been  shown  that  manual  ventilators  found  at  the  bedside  of 
mechanically  ventilated  patients  can  be  a  source  of  con- 
tamination of  the  lower  respiratory  tract.'""'  One  of  the 
difficulties  related  to  use  of  a  manual  ventilator  during 
suctioning  is  that  tidal  volume  delivery  and  airway  pres- 
sure are  not  usually  measured.  Singer  et  al'-^''  reported  that 
lung  hyperinflation  is  frequently  not  achieved  by  manual 
ventilation,  and  that  adverse  hemodynamic  sequelae  can 
result  if  hyperinflation  is  achieved.  Glass  et  al'"'''  reported 
that  when  nurses  used  a  manual  ventilator  during  endotra- 
cheal suctioning,  the  mean  F,o,  was  0.71,  the  mean  respi- 
ratory rate  was  3 1  breaths  per  minute,  and  the  mean  tidal 
volume  was  626  mL. 


764 


Respiratory  Care  •  July  1 999  Vol  44  No  7 


Managing  the  Artificial  Airway 


assess  for  presence 

of  leak  around  cuff;  at 

_^  least  once  per  shift,  with  tube 

movement,  with  gross  leak,  or 

when  cuff  volume  is  changed 

no  leak 


20 -25  mm  Hg 


i' 


-  assess  cuff  pressure  - 


leak  present         add  air  .^ 
to  cuff 


<  20  mm  Hg 


I  >25  mm  Hg 


no  leak 


remove  air  from  cuff 
until  pressure  is  25  mm  Hg 


assess  for  presence 


of  leak  around  cuff 

leak  present 


i' 


^ ^°      ^^^^    — — ^  assess  tube  position- 
present 


repositioned 


I  position  satisfactory 


assess  tube  size- 


1 


size  appropriate 


small  tube        change  to  larger 

size  if  possible 


set  cuff  pressure 
at  25  mm  Hg    ■♦ 


assess  for  leak  in  cuff  system;  add 
air  to  cuff  and  assess  cuff  pressure 

i 

pressure  loss 
I  yes 


no 


add  air  to  cuff  and 

clamp  pilot  tube 

I  no  leak 

place  stop  cock  on  pilot 
balloon;  remove  clamp ' 

no  leak 


incompetent  1  -way  valve  - 
Fig.  8.  Algorithm  for  management  of  the  endotracheal  tube  cuff. 


leak 


leak 


_^        ruptured  cuff; 
change  tube  if  possible 


incompetent  pilot  balloon; 

-►  change  tube  if  possible  or ► 

clamp  pilot  tube 


change  tube  if  possible  or 
"^use  stop  cock  on  pilot  balloon 


The  duration  of  suction  also  affects  the  degree  of  hy- 
poxemia.'-" The  duration  of  a  suction  attempt  should  be  as 
short  as  possible.  The  suction  procedure  should  be  termi- 
nated at  15  seconds,  with  resumption  of  ventilation  and 
hyperoxygenation. 


Atelectasis 

Atelectasis  during  suctioning  can  occur  as  the  result  of 
evacuation  of  gases  from  the  lower  respiratory  tract.  This 
is  more  likely  when  excessive  suction  pressures  are  used 
and  when  the  size  of  the  suction  catheter  is  large  in  rela- 
tion to  the  size  of  the  endotracheal  or  tracheostomy  tube.'^^ 


The  suction  pressure  should  be  no  greater  than  required  to 
adequately  remove  secretions,  and  not  greater  than  100 
mm  Hg  for  infants,  125  mm  Hg  for  children,  and  150  mm 
Hg  for  adults.  Suction  catheters  are  available  in  a  variety 
of  sizes.  Catheter  size  is  determined  by  outside  diameter  in 
French  units,  which  refers  to  the  circumference  of  the 
tube.  Because  circumference  equals  the  value  of  tt  (3.14) 
multiplied  by  the  diameter,  French  size  can  be  estimated 
by  multiplying  the  diameter  times  3.  The  outside  diameter 
of  the  suction  catheter  should  not  exceed  V2--A  of  the 
inside  diameter  of  the  artificial  airway.  A  14-F  catheter  is 
usually  acceptable  for  adult  patients.  Too  small  a  catheter 
will  limit  the  effectiveness  of  secretion  removal,  but  too 
large  a  catheter  will  increase  the  risk  of  complications. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


76:' 


Managing  the  Artificial  Airway 


Airway  Trauma 


Airway  edema,  hyperemia,  mucosal  ulceration,  hemor- 
rhage, and  decreased  mucociliary  transport  have  been  re- 
ported with  airway  suctioning. '^'^•''"'  These  effects  are  re- 
lated to  operator  technique  and  the  amount  of  suction 
pressure  used.  Intermittent  suction,  rather  than  continuous 
suction,  may  be  less  traumatic  to  airway  mucosa,  but  there 
is  little  evidence  for  this.""-"'^  The  catheter  tip  should  be 
smooth,  molded,  and  atraumatic. ''*''■*■'  Side  holes  near  the 
tip  of  the  catheter  minimize  trauma  to  the  airway  mucosa. 
Pneumothorax  secondary  to  bronchial  perforation  by  a  suc- 
tion catheter  has  been  reported  in  infants.'-*''  '•*''  In  infants, 
the  suction  catheter  should  not  be  inserted  more  than  one 
cm  beyond  the  tip  of  the  endotracheal  tube. '•"*■'■*''  A  similar 
practice  should  be  used  for  patients  with  recent  tracheal 
reconstructive  surgery  or  pneumonectomy. 

Contamination 


irrigation 
port 


ventilator 
connection 


f 


catheter  in 
slieath 


endotracheal 
tube 

Fig.  9.  Closed  suction  system. 


suction 
control 


Contamination  of  the  lower  respiratory  tract  can  occur 
during  tracheal  suctioning,  but  this  complication  can  be 
avoided  by  using  sterile  technique  during  the  procedure. 
Care  must  be  taken  during  suctioning  to  avoid  contami- 
nation of  the  suction  catheter,  the  ventilator  circuit,  or  the 
valve  of  the  manual  ventilator.  Care  should  also  be  taken 
to  avoid  contamination  of  the  clinician  performing  the 
suctioning. 

Arrliythmias 

Arrhythmias  can  occur  during  tracheal  suctioning, ''^"-'"'^ 
possibly  as  a  result  of  hypoxemia  or  vagal  stimulation. 
This  complication  can  often  be  avoided  by  hyperoxygen- 
ating  the  patient  during  suctioning.  Aerosolized  atropine 
has  also  been  used  to  prevent  suction-related  arrhythmias. '  ^ ' 

Selective  Broncliial  Suctioning 

Because  the  left  main  bronchus  has  a  smaller  diameter 
than  the  right  and  leaves  the  trachea  at  a  more  acute  angle, 
the  suction  catheter  is  more  likely  to  enter  the  right  main 
bronchus.'''-'  Therefore,  secretions  are  more  likely  to  be 
suctioned  from  the  right  lung  than  the  left.  Several  tech- 
niques can  be  used  for  selective  endobronchial  suctioning 
(particularly  the  left  bronchus).  These  include  the  use  of 
curved  tip  catheters,'^''-''''*  turning  the  head  to  the  side''''"'" 
(eg,  turning  the  head  to  the  right  to  facilitate  suctioning  of 
the  left  bronchus),  and  lateral  positioning"''  (eg.  turning 
the  patient  onto  the  left  side  to  facilitate  passage  of  the 
catheter  into  the  left  main  bronchus).  The  most  successful 
method  for  selective  endobronchial  suctioning  is  the  use  of 
a  curved-tip  catheter.  If  a  curved-tip  catheter  with  a  guide 
mark  is  used,  successful  endobronchial  placement  rates  of 


nearly  90%  have  been  reported. '""''  Factors  that  affect  the 
success  rate  of  selectively  introducing  a  catheter  into  a 
main  bronchus  include  ( 1 )  the  anatomy  of  the  carinal  bi- 
furcation, (2)  the  body  and  head  position  of  the  patient,  (3) 
the  route  of  tracheal  tube  placement  (endotracheal  or  tra- 
cheostomy), (4)  the  shape  and  direction  of  the  bevel  of  the 
endotracheal  tube,  (5)  the  configuration  and  rigidity  of  the 
suction  catheter,  and  (6)  the  location  of  the  tip  of  the 
endotracheal  tube.'-''''  Curved  tip  catheters  may  be  more 
effective  with  tracheostomy  tubes  than  with  endotracheal 
tubes. '5S-' 59 

Increased  Intracranial  Pressure 

Increased  intracranial  pressure  (ICP)  can  occur  during 
tracheal  suctioning, "'2-"''  which  can  be  clinically  impor- 
tant in  patients  with  closed  head  injuries.  When  suctioning 
patients  who.se  ICP  is  being  monitored,  ICP  should  be 
observed  closely  during  the  suctioning  procedure.  Preoxy- 
genation, hyperventilation,  and  pharmacologic  support  may 
be  necessary  when  suctioning  patients  with  elevated  ICP. 

Coughing  and  Broncliospasm 

Tracheal  suctioning  is  very  irritating  and  uncomfortable 
for  the  patient.  The  presence  of  the  catheter  in  the  trachea 
can  induce  coughing,  and  may  stimulate  bronchospasm  in 
patients  with  reactive  airways."'**"'* 

Closed  Suction  Catheters 

With  the  closed  suction  system  (Fig.  9)  the  catheter 
becomes  part  of  the  ventilator  circuit.  Closed  system  suc- 


766 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


Table  2.      Indications  for  Use  of  Closed  Suction 

■     High  ventilator  requirements:  positive  end-expiratory  pressure  >I0 
cm  HjO,  mean  airway  pressure  a20  cm  H2O,  inspiratory  time 
>  1 .5  s,  fraction  of  inspired  oxygen  &0.60 

•  Mechanically  ventilated  patients  receiving  frequent  suctioning  (a6/ 

day) 

•  Hemodynamic  instability  associated  with  ventilator  disconnection 

•  Mechanically  ventilated  patients  with  active  tuberculosis 

•  Patients  receiving  inhaled  agents  that  cannot  be  interrupted  by 

ventilator  disconnection  (eg.  nitric  oxide,  heliox) 


tion  catheters  are  available  from  several  manufacturers — in 
adult,  pediatric,  and  neonatal  sizes. '^"'''^  The  effective- 
ness of  secretion  clearance  is  similar  for  closed  system 
catheters  and  conventional  suction  technique.'^-*  In  some 
hospitals,  the  use  of  closed  suction  catheters  has  been  an 
emotional  issue.  At  the  Massachusetts  General  Hospital,  a 
committee  of  respiratory  therapists,  nurses,  physical  ther- 
apists, and  physicians  recommended  the  indications  for 
closed  suction  catheters  listed  in  Table  2. 

Several  studies  have  evaluated  the  ability  of  closed  suc- 
tion to  maintain  adequate  oxygenation  during  suctioning. 
Craig  et  al'^'  evaluated  the  effect  of  ventilator  mode  with 
the  use  of  closed  suction.  They  found  that  with  preoxy- 
genation, desaturation  did  not  occur  with  either  assist/con- 
trol or  intermittent  mandatory  ventilation  when  a  closed 
suction  catheter  was  used.  Without  preoxygenation,  how- 
ever, desaturation  occurred  on  assist/control  ventilation — 
but  not  on  intermittent  mandatory  ventilation — when  the 
closed  system  catheter  was  u.sed.  These  data  are  supported 
by  a  bench  study  that  reported  that  closed  suction  can 
produce  large  intermittent  drops  in  airway  pressure,  par- 
ticularly with  a  low  inspiratory  flow  setting  and  in  the 
control  mode.'^''  Carlon  et  al'^^  reported  no  clinically  im- 
portant difference  in  oxygenation  between  a  closed  system 
catheter  and  a  conventional  suction  technique,  even  in 
patients  receiving  >  10  cm  HjO  positive  end-expiratory 
pressure.  Clark  et  al'''**  found  that  mixed  venous  oxygen- 
ation was  higher  in  patients  suctioned  with  closed  suction, 
and  Mattar  et  al'^"*  reported  better  oxygen  delivery  with 
closed  suction  compared  to  open  suction.  Johnson  et  al"*" 
reported  that  closed  suction  produced  significantly  fewer 
physiologic  disturbances  (such  as  dysrhythmias  and  de- 
saturation)  than  open  suction.  Harshbarger  et  a!"*'  reported 
that  use  of  a  closed  suction  catheter  without  hyperoxygen- 
ation  prevented  desaturation  in  most,  but  not  all,  patients. 
The  incidence  of  both  patient  contamination  and  environ- 
mental contamination  has  been  reported  to  be  less  with  the 
use  of  closed  suction  systems. "*--'**■* 
(  A  problem  that  has  been  reported  with  closed  suction 
catheters  is  the  catheter  remaining  in  the  airway  following 
a  suction  procedure,  or  migrating  into  the  airway  between 
suction  procedures.'**''  This  can  be  of  particular  concern 


during  pressure  ventilation,  in  which  the  patient's  tidal 
volume  could  be  considerably  compromised.  Care  must 
also  be  taken  to  avoid  accidental  patient  lavage  when  the 
catheter  is  rinsed  with  saline. 

Although  the  closed  catheter  system  costs  many  times 
more  than  a  conventional  suction  catheter,  it  is  used  for 
many  more  suctioning  attempts  than  a  conventional  cath- 
eter.'™ One  study  reported  a  cost  savings  of  $6,600  in  one 
year  when  closed  suction  was  substituted  for  an  open  suc- 
tion procedure."*^  Johnson  et  al"*"  reported  that  closed 
suction  costs  $1.88  per  patient  per  day  less  than  open 
suction,  and  that  closed  suction  required  60  seconds  less 
clinician  time  than  open  suction. 

Manufacturers  recommend  changing  closed  suction  cath- 
eter systems  on  a  daily  basis.  However,  recent  evidence 
suggests  that  this  practice  is  not  necessary.  Kollef  et  al"*'' 
compared  daily  change  to  no  routine  change  of  closed 
suction  catheters,  and  found  no  significant  differences  in 
hospital  mortality,  length  of  stay,  or  ventilator-associated 
pneumonia.  Further,  they  reported  large  cost  savings  with 
the  practice  of  no  routine  closed  suction  catheter  changes. 
At  the  Massachusetts  General  Hospital,  we  compared  daily 
and  weekly  changes  of  closed  suction  catheters  in  our 
medical  ICU,"***  and  found  no  difference  in  ventilator- 
associated  pneumonia  between  the  groups,  and  a  signifi- 
cant cost  savings  with  weekly  changes  of  the  closed  suc- 
tion system.  Our  current  practice  is  to  change  both  ventilator 
circuits'**''  and  closed  suction'****  systems  weekly. 

Saline  Instillation 

Saline  is  often  instilled  into  the  airway  as  part  of  the 
suction  procedure  to  facilitate  the  removal  of  secre- 
tions.'''"''^' However,  this  practice  is  controversial. ''^-  Typ- 
ically, more  saline  is  instilled  than  is  retrieved  by  subse- 
quent suction  attempts.  This  may  result  in  an  increase  in 
the  volume  of  secretions  and  a  worsening  of  airway  ob- 
struction. Ackerman''^"*  reported  that  saline  instillation  dur- 
ing suctioning  had  an  adverse  effect  on  arterial  oxygen 
saturation.  Hagler  and  Traver''*''  reported  that  a  5  mL  sa- 
line instillation  dislodged  large  numbers  of  bacteria  from 
the  endotracheal  tube  lumen,  thus  increasing  the  likelihood 
of  washing  organisms  from  the  endotracheal  tube  into  the 
lower  respiratory  tract.  Saline  instillation  may  be  useful  to 
loosen  and  remove  thick  secretions  in  certain  patients,  but 
this  procedure  should  be  used  judiciously  and  should  not 
be  a  routine  procedure. 

Summary 

Managing  the  airway  is  an  important  aspect  of  respira- 
tory care  practice.  It  involves  attention  to  detail,  such  as 
regular  assessment  of  tube  position,  adequately  securing 
the  endotracheal  tube,  and  monitoring  cuff  pressure.  Man- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


76: 


Managing  the  Artificial  Airway 


aging  the  airway  should  also  protect  the  patient  from  harm 
due  to  inappropriate  cuff  pressure,  inadvertent  extubation, 
and  suction-related  complications. 


ACKNOWLEDGEMENTS 

I  would  like  to  thank  the  respiratory  therapists  and  physicians  at  the 
Massachusetts  General  Hospital,  who  have  taught  me  much  about  airway 
management.  In  particular,  I  would  like  to  thank  Ray  Rilz,  who  has  been 
a  friend  and  who  has  appropriately  tempered  my  ideas  and  enthusiasm 
with  reason  and  prudence. 


REFERENCES 

1.  Stauffer  JL.  Monitoring  the  use  of  tracheal  tubes.  In:  Tobin  MJ. 
editor.  Principles  and  practice  of  intensive  care  monitoring.  New 
York:  McGraw-Hill,  1998:667-682. 

2.  Brunei  W,  Coleman  DL,  Schwartz  DE,  Peper  E,  Cohen  NH.  As- 
sessment of  routine  chest  roentgenograms  and  the  physical  exam- 
ination to  confirm  endotracheal  tube  position.  Chest  1989:96(5): 
1043-1045. 

3.  Kollef  MH,  Legare  EJ,  Damiano  M.  Endotracheal  tube  misplace- 
ment: incidence,  ri.sk  factors,  and  impact  of  a  quality  improvement 
program.  South  Med  J  l994;87(2):248-254. 

4.  Schwartz  DE,  Lieberman  JA,  Cohen  NH.  Women  are  at  greater  risk 
than  men  for  malpositioning  of  the  endotracheal  tube  after  emer- 
gent intubation.  Crit  Care  Med  1994:22(7):  1 127-1 131. 

5.  Ripoll  I,  Lindholm  C,  Carroll  R,  Grenvik  A.  Spontaneous  disloca- 
tion of  endotracheal  tubes.  Anesthesiology  1978;49(l):50-52. 

6.  Birmingham  PK.  Cheney  FW,  Ward  RJ.  Esophageal  intubation:  a 
review  of  detection  techniques  (review).  Anesth  Analg  1986:65(8): 
886-891. 

7.  Hess  D,  Eitel  D.  Monitoring  during  resuscitation.  Respir  Care  1 992; 
37(7):739-766.  Discus.sion:766-768. 

8.  Cardoso  MM,  Banner  MJ,  Melker  RJ,  Bjoraker  DG.  Portable  de- 
vices used  to  detect  endotracheal  intubation  during  emergency  sit- 
uations: a  review.  Crit  Care  Med  1998:26(5):957-964. 

9.  Hess  DR.  Capnometry.  In:  Tobin  MJ,  editor.  Principles  and  practice 
of  intensive  care  monitoring.  New  York:  McGraw-Hill;  1998:377- 
400. 

10.  Murray  IP,  Modell  JH.  Early  detection  of  endotracheal  tube  acci- 
dents by  monitoring  carbon  dioxide  concentration  in  respiratory 
gas.  Anesthesiology  1983;59(4):344-346. 

1 1 .  Linko  K,  Paloheimo  M,  Tammisto  T.  Capnography  for  detection  of 
accidental  oesophageal  intubation.  Acta  Anaesthesiol  Scand  1983; 
27(3):  199-202. 

1 2.  Bhende  MS,  Thompson  AE,  Howland  DF.  Validity  of  a  disposable 
end-tidal  carbon  dioxide  detector  in  verifying  endotracheal  tube 
position  in  piglets.  Crit  Care  Med  l99l;l9(4):566-568. 

13.  Bhende  MS.  Thompson  AE.  Gastric  juice,  drugs,  and  end-tidal 
carbon  dioxide  detectors  (letter).  Pediatrics  1992:90(6):  1005. 

14.  Bhende  MS,  Thompson  AE,  Orr  RA.  Utility  of  an  end-tidal  carbon 
dioxide  detector  during  stabilization  and  transport  of  critically  ill 
children.  Pediatrics  1992;89(6  Pt  I):I042-I044. 

15.  Bhende  MS.  Colorimetric  end-tidal  carbon  dioxide  detector  (re- 
view). Pediatr  Emerg  Care  1995;1  l(l):58-61. 

16.  Goldberg  JS,  Rawle  PR,  Zehnder  JL,  Sladen  RN.  Colorimetric 
end-tidal  carbon  dioxide  monitoring  for  tracheal  intubation.  Anesth 
Analg  1990;7()(2):191-194. 

17.  Higgins  D,  Forrest  ET,  Lloyd-Thomas  A.  Colorimetric  end-tidal 
carbon  dioxide  monitoring  during  transfer  of  intubated  children. 
Intensive  Care  Med  1991;l7(l):63-64. 


18.  Higgins  DJ,  Addy  V.  Efficacy  of  the  FEF  colorimetric  end-tidal 
carbon  dioxide  detector  in  children  (letter).  Anesth  Analg  1993; 
76(3):683-684. 

19.  Jones  BR,  Dorsey  MJ.  Sensitivity  of  a  disposable  end-tidal  carbon 
dioxide  detector.  J  Clin  Monit  199l;7(3):268-270. 

20.  Kelly  JS,  Wilhoit  RD,  Brown  RE,  James  R.  Efficacy  of  the  FEF 
colorimetric  end-tidal  carbon  dioxide  detector  in  children.  Anesth 
Analg  l992;75(l):45-50. 

21.  O' Flaherty  D,  Donnan  G,  Giesecke  AH.  The  end-tidal  carbon  di- 
oxide detector  for  confirming  tracheal  intubation  in  animals  iletter). 
Anaesth  Intensive  Care  1992;20(2):248. 

22.  O'Flaherty  D,  Adams  AP.  The  end-tidal  carbon  dioxide  detector: 
assessment  of  a  new  method  to  distinguish  oesophageal  from  tra- 
cheal intubation.  Anaesthesia  1990;45(8):653-*55. 

23.  O'Flaherty  D,  Adams  AP.  False-positives  with  the  end-tidal  carbon 
dioxide  detector  (letter).  Anesth  Analg  I992;74(3):467^68. 

24.  Ornato  JP,  Shipley  JB.  Racht  EM,  Slovis  CM,  Wrenn  KD,  Pepe  PE, 
et  al.  Multicenter  study  of  a  portable,  hand-size,  colorimetric  end- 
tidal  carbon  dioxide  detection  device.  Ann  Emerg  Med  1992:21(5): 
518-523. 

25.  Rosenberg  M,  Block  CS.  A  simple,  disposable  end-tidal  carbon 
dioxide  detector.  Anesth  Prog  1991;38(l):24-26. 

26.  Strunin  L,  Williams  T.  The  FEF  end-tidal  carbon  dioxide  detector 
(letter).  Anesthesiology  1989;71(4):62 1-622. 

27.  Petroianu  GA,  Maleck  WH,  Bergler  WF.  Altmannsberger  S.  Rufer 
R.  Preliminary  observations  on  the  Colibri  CO,-indicator.  Am  J 
Emerg  Med  1998;16(7):677-680. 

28.  Barton  C,  Callaham  M.  Lack  of  correlation  Ijetween  end-tidal  car- 
bon dioxide  concentrations  and  P,,co,  in  cardiac  arrest.  Crit  Care 
Med  I99I;I9(1):108-1I0. 

29.  Callaham  M,  Barton  C.  Prediction  of  outcome  of  cardiopulmonary 
resuscitation  from  end-tidal  carbon  dioxide  concentration.  Crit  Care 
Med  1990;l8(4):.358-362. 

30.  Fletcher  R.  End-tidal  carbon  dioxide  as  a  noninvasive  monitor  of 
circulatory  status  during  cardiopulmonary  resuscitation  (letter).  Crit 
Care  Med  1989;I7(9):970-971. 

31.  Garnett  AR,  Ornato  JP,  Gonzalez  ER,  Johnson  EB.  End-tidal  car- 
bon dioxide  monitoring  during  cardiopulmonary  resuscitation. 
JAMA  1987;257(4):5I2-515. 

32.  Higgins  D,  Hayes  M.  Denman  W.  Wilkinson  DF.  Effectiveness  of 
using  end-tidal  carbon  dioxide  concentration  to  monitor  cardiopul- 
monary resuscitation.  BMJ  I990;300(6724):581. 

33.  Isserles  SA,  Breen  PH.  Can  changes  in  end-tidal  P(^o,  measure 
changes  in  cardiac  output?  Anesth  Analg  1991;73(6):808-814. 

34.  Lepilin  MG.  Vasilyev  AV,  Bildinov  OA.  Rostovtseva  NA.  End- 
tidal  carbon  dioxide  as  a  noninvasive  monitor  of  circulatory  status 
during  cardiopulmonary  resu.scitation:  a  preliminary  clinical  study. 
Crit  Care  Med  1987;l5(l0):958-959. 

35.  Nielsen  M,  Fitchett  A.  End-tidal  carbon  dioxide  as  a  noninvasive 
monitor  during  cardiopulmonary  resuscitation  (letter).  Crit  Care 
Med  1989;  17(1 2):  1365. 

36.  Nielsen  MS,  Fitchet  A,  Saunders  DA.  Monitoring  cardiopulmonary 
resu.scitation  by  end  tidal  carbon  dioxide  concentration  (letter).  BMJ 
1990;300(6730):10I2-IOI3. 

37.  Nielsen  M,  Fitchet  A,  Saunders  D.  Predictive  value  of  end-tidal 
carbon  dioxide  during  cardiopulmonary  resuscitation  (letter).  Crit 
Care  Med  1991;19(6):841. 

38.  O'Leary  M,  Ferguson  C.  Intraoperative  use  of  end-tidal  carbon 
dioxide  tension  to  assess  cardiac  output  (letter).  J  Thorac  Cardio- 
vasc  Surg  1995:1 10(1  ):287. 

39.  Ornato  JP,  Garnett  AR,  Glauser  FL.  Relation.ship  between  cardiac 
output  and  the  end-tidal  carbon  dioxide  tension.  Ann  Emerg  Med 
1990;I9(10):1 104-1 106. 


768 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


40.  Sanders  AB.  Kern  KB.  Otto  CW,  Milander  MM,  Ewy  GA.  End- 
tidal  carbon  dioxide  monitoring  during  cardiopulmonary  resuscita- 
tion. A  prognostic  indicator  for  survival.  J  AM  A  1 989;262(  1 0):  1 347- 
I35I. 

41.  Sayah  AJ,  Peacock  WF,  Overton  DT.  End-tidal  CO,  measurement 
in  the  detection  of  esophageal  intubation  during  cardiac  arrest.  Ann 
Emerg  Med  l990;l9(8):857-860. 

42.  White  RD,  Asplin  BR.  Out-of-hospital  quantitative  monitoring  of 
end-tidal  carbon  dioxide  pressure  during  CPR.  Ann  Emerg  Med 
l994:23(l);25-30. 

43.  Levine  RL,  Wayne  MA,  Miller  CC.  End-tidal  carbon  dioxide  and 
outcome  of  out-of-hospital  cardiac  arrest.  N  Engl  S  Med  1997; 
337(5):301-306. 

44.  Kasper  CL.  Deem  S.  The  self-inflating  bulb  to  detect  esophageal 
intubation  during  emergency  airway  management.  Anesthesiology 
l998;88(4):898-902. 

45.  Ardagh  M,  Moodie  K.  The  esophageal  detector  device  can  give 
false  positives  for  tracheal  intubation.  J  Emerg  Med  1998:16(5): 
747-749. 

46.  Zaleski  L,  Abello  D,  Gold  MI.  The  esophageal  detector  device. 
Does  it  work?  Anesthesiology  1993;79(2):244-247. 

47.  Williams  KN,  Nunn  JF.  The  oesophageal  detector  device:  a  pro- 
spective trial  on  100  patients.  Anaesthesia  1989:44(5):4I2-4I4. 

48.  Wee  M.  The  oesophageal  detector  device.  Assessment  of  a  new 
method  to  distinguish  oesophageal  from  tracheal  intubation.  An- 
aesthesia 1988:43(1  ):27-29. 

49.  Pelucio  M,  Halligan  L,  Dhindsa  H.  Out-of-hospital  experience  with 
the  syringe  esophageal  detector  device.  Acad  Emerg  Med  1997; 
4(6):463^68. 

50.  Donahue  PL,  The  esophageal  detector  device:  an  assessment  of 
accuracy  and  ease  of  use  by  paramedics.  Anaesthesia  1994:49(10): 
863-865. 

51.  Bozeman  WP,  Hexter  D,  Liang  HK.  Kelen  GD.  Esophageal  detec- 
tor device  versus  detection  of  end-tidal  carbon  dioxide  level  in 
emergency  intubation.  Ann  Emerg  Med  1996:27(5):595-599. 

52.  Oberly  D,  Stein  S,  Hess  D,  Eitel  D,  Simmons  M.  An  evaluation  of 
the  esophageal  detector  device  using  a  cadaver  model.  Am  J  Emerg 
Med  l992;10(4):3l7-320. 

53.  Marley  CD  Jr.  Eitel  DR,  Anderson  TE,  Mum  AJ.  Patterson  GA. 
Evaluation  of  a  prototype  esophageal  detection  device.  Acad  Emerg 
Med  1995:2(6):503-507. 

54.  Marley  CD.  Eitel  DR,  Koch  MF.  Prehospital  use  of  a  prototype 
esophageal  detection  device:  a  word  of  caution.  Prehosp  Dis  Med 
1996;11:223-227. 

55.  Gray  P.  Sullivan  G,  Ostryzniuk  P,  McEwen  TA,  Rigby  M,  Roberts 
DE.  Value  of  postprocedural  chest  radiographs  in  the  adult  inten- 
sive care  unit.  Crit  Care  Med  1992:20(1 1):1513- 1518. 

56.  Henschke  CI,  Yankelevitz  DF,  Wand  A,  Davis  SD,  Shiau  M.  Ac- 
curacy and  efficacy  of  chest  radiography  in  the  intensive  care  unit. 
Radiol  Clin  North  Am  1996;34(1):21-3I. 

57.  Pollard  RJ,  Lobato  EB.  Endotracheal  tube  location  verified  reliably 
by  cuff  palpation.  Anesth  Analg  1995:81(0:135-138. 

58.  Eagle  CC.  The  relationship  between  a  person's  height  and  appro- 
priate endotracheal  tube  length.  Anaesth  Intensive  Care  1992:20(2): 
156-160. 

59.  Owen  RL,  Cheney  FW.  Endobronchial  intubation:  a  preventable 
complication.  Anesthesiology  1987:67(2):255-257. 

60.  Roberts  JR,  Spadafora  M,  Cone  DC.  Proper  depth  placement  of  oral 
endotracheal  tubes  in  adults  prior  to  radiographic  confirmation. 
Acad  Emerg  Med  1995:2(1  ):20-24. 

61.  Conrardy  PA.  Goodman  LR.  Lainge  F,  Singer  MM.  Alteration  of 
endotracheal  tube  position:  flexion  and  extension  of  the  neck.  Crit 
Care  Med  1976:4(1):7-12. 


62. 

63. 

64. 
65. 

66. 

67. 

68. 

69. 

70. 

71. 

72. 
73. 

74. 
75. 

76. 

77. 
78. 
79. 

80. 

81. 

82. 
83. 

84. 


Tominga  GT,  Rudzwick  H,  Scannell  G,  Waxman  K.  Decreasing 
unplanned  extubations  in  the  surgical  intensive  care  unit.  Am  J  Surg 
1995:170(6):586-590. 

Boulain  T.  Unplanned  extubations  in  the  adult  intensive  care  unit: 
a  prospective  multicenter  study.  Association  des  Reanimateurs  du 
Centre-Ouest.  Am  J  Respir  Crit  Care  Med  1998;157:1131-1137. 
Listello  D,  Sessler  CN.  Unplanned  extubation:  clinical  predictors 
for  reintubation.  Chest  1994:105(5):  1496-1503. 
Scott  PH,  Eigen  H.  Moye  LA.  Georgitis  J,  Laughlin  JJ.  Predict- 
ability and  consequences  of  spontaneous  extubation  in  a  pediatric 
ICU.  Crit  Care  Med  1985:13(4):228-232. 

Chri.stie  JM.  Dethlefsen  M,  Cane  RD.  Unplanned  endotracheal  ex- 
tubation in  the  intensive  care  unit.  J  Clin  Anesth  1996:8(4):289- 
293. 

Little  LA.  Koenig  JC  Jr.  Newth  CJ.  Factors  affecting  accidental 
extubations  in  neonatal  and  pediatric  intensive  care  patients.  Crit 
Care  Med  1990;18(2):163-165. 

Rivera  R,  Tibballs  J.  Complications  of  endotracheal  intubation  and 
mechanical  ventilation  in  infants  and  children.  Crit  Care  Med  1992; 
20(2):  193-199. 

Vassal  T,  Anh  NG,  Gabillet  JM,  Guidet  B,  Staikowsky  F.  Offen- 
stadt  G.  Prospective  evaluation  of  self-extubations  in  a  medical 
intensive  care  unit.  Intensive  Care  Med  1993;19(6):340-342. 
Taggart  JA,  Lind  MA.  Evaluating  unplanned  endotracheal  extuba- 
tions. Dimens  Crit  Care  Nurse  1994:13(3):1 14-125. 
Whelan  J,  Simpson  SQ,  Levy  H.  Unplanned  extubation:  predictors 
of  successful  termination  of  mechanical  ventilatory  support.  Chest 
1994;105(6):1808^18I2. 

Coppolo  DP,  May  JJ.  Self-extubations:  a  12-month  experience. 
Chest  1990:98(1):  165-1 69. 

Atkins  PM,  Mion  LC,  Mendelson  W.  Palmer  RM.  Slomka  J,  Franko 
T.  Characteristics  and  outcomes  of  patients  who  self-extubate  from 
ventilatory  support:  a  case-control  study.  Chest  1997:1 12(5):  1317- 
1323. 

Betbese  AJ,  Perez  M.  Bak  E.  Rialp  G.  Mancebo  J.  A  prospective 
study  of  unplanned  endotracheal  extubation  in  intensive  care  unit 
patients.  Crit  Care  Med  1998:26(7):!  180-1 186. 
Chiang  AA.  Lee  KC,  Lee  JC,  Wei  CH.  Effectiveness  of  a  contin- 
uous quality  improvement  program  aiming  to  reduce  unplanned 
extubation:  a  prospective  study.  Intensive  Care  Med  1996:22(1 1): 
1269-1271. 

Sessler  CN.  Unplanned  extubations:  Making  progress  using  CQI 
(editorial).  Intensive  Care  Med  I997;23(2):I43-I45. 
Kaplow  R,  Bookbinder  M.  A  comparison  of  four  endotracheal  tube 
holders.  Heart  Lung  1994:23(1  ):59-66. 

Levy  H,  Griego  L.  A  comparative  study  of  oral  endotracheal  tube 
securing  methods.  Chest  1993:1()4(5):1537-1540. 
Tasota  FJ,  Hoffman  LA,  Zullo  TG,  Jamison  G.  Evaluation  of  two 
methods  used  to  stabilize  oral  endotracheal  tubes.  Heart  Lung  1987; 
16(2):  140-146. 

Volsko  TA,  Chatburn  RL.  Comparison  of  two  methods  for  securing 
the  endotracheal  tube  in  neonates.  Respir  Care  I997;42(3):288- 
291. 

King  HK.  A  new  device:  Tube  Securer.  An  endotracheal  tube  holder 
with  integrated  bite-block.  Acta  Anaesthesiol  Sin  1997:35(4):257- 
259. 

Gonzales  JG.  Securing  an  endotracheal  tube  (letter).  Anesthesiol- 
ogy 1986:65(3):347. 

Young  TM.  Securing  the  endotracheal  tube:  a  method  for  use  with 
the  plastic  'Nosworthy"  connector.  Anaesthesia  1 976:3 1(8):  1094— 
1095. 

Clarke  T.  Evans  S,  Way  P,  Wulff  M.  Church  J.  A  comparison  of 
two  methods  of  securing  an  endotracheal  tube.  Aust  Crit  Care  1998; 
ll(2):45-50. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


769 


Managing  the  Artificial  Airway 


85.  Barnason  S,  Graham  J,  Wild  MC,  Jensen  LB,  Rasmussen  D,  Schulz 
P,  at  al.  Comparison  of  two  endotracheal  tube  securement  tech- 
niques on  unplanned  extubation,  oral  mucosa,  and  facial  skin  in- 
tegrity. Heart  Lung  1998;27(6):409^17. 

86.  Bishop  MJ,  Ritz  RH.  Airway  management.  In:  Pierson  DJ,  Kac- 
marek  RM,  editors.  Foundations  of  respiratory  care.  New  York: 
Churchill  Livingstone;  1992. 

87.  Fenje  N,  Steward  DJ.  A  study  of  tape  adhesive  strength  on  endo- 
tracheal tubes.  Can  J  Anacsth  1988;35(2):  198-201. 

88.  Achauer  BM,  Mueller  G,  Van  derkam  VM.  Prevention  of  acciden- 
tal extubation  in  burn  patients.  Ann  Plast  Surg  1997;38(3):280-282. 

89.  Perrotta  VJ,  Stem  JD,  Lo  AK,  Mitra  A.  Arch  bar  stabilization  of 
endotracheal  tubes  in  children  with  facial  burns.  J  Bum  Care  Re- 
habil  1995;16(4):437-439. 

90.  Cooper  JD,  Grillo  HC.  The  evolution  of  tracheal  injury  due  to 
ventilatory  assistance  through  cuffed  tubes:  a  pathologic  study.  Ann 
Surg  1969;169(3):334-348. 

91.  Cooper  JD,  Grillo  HC.  Experimental  production  and  prevention  of 
injury  due  to  cuffed  tracheal  tubes.  Surg  Gynecol  Obstet  1969; 
129(6):1235-1241. 

92.  Cooper  JD,  Grillo  HC.  Analysis  of  problems  related  to  cuffs  on 
intratracheal  tubes.  Chest  1972;62(2):21S-27S. 

93.  Grillo  HC,  Cooper  JD,  Geffm  B,  Pontoppidan  H.  A  low-pressure 
cuff  for  tracheostomy  tubes  to  minimize  tracheal  injury.  J  Thorac 
Cardiovasc  Surg  1971;62(6):898-907. 

94.  Knowlson  GT,  Bassett  HF.  The  pressures  exerted  on  the  trachea  by 
endotracheal  inflatable  cuffs.  Brit  J  Anaesth  I970;42(10):834-837. 

95.  Dobrin  P,  Canfield  T.  Cuffed  endotracheal  tubes:  mucosal  pressures 
and  tracheal  wall  blood  flow.  Am  J  Surg  1977;133(5):562-568. 

96.  Bernhard  WN,  Yost  L,  Joynes  D,  Cothalis  S,  Turndorf  H.  Intracuff 
pressures  in  endotracheal  and  tracheostomy  tubes:  related  cuff  phys- 
ical characteristics.  Chest  l985;87(6):720-725. 

97.  Dunn  CR,  Dunn  DL,  Moser  KM.  Determinants  of  tracheal  injury  by 
cuffed  tracheostomy  tubes.  Chest  1974;65{2):  128-135. 

98.  Seegobin  RD,  van  Hasselt  GL.  Endotracheal  cuff  pressure  and  tra- 
cheal mucosal  blood  flow:  endoscopic  study  of  effects  of  four  large 
volume  cuffs.  Br  Med  J  1984;288(6422):965-968. 

99.  Honeybourne  D,  Costello  JC,  Barham  C.  Tracheal  damage  after 
endotracheal  intubation:  comparison  of  two  types  of  endotracheal 
tubes.  Thorax  1982;37(7):50O-502. 

100.  Pavlin  EG,  VanNimwegan  D,  Hornbein  TF.  Failure  of  a  high- 
compliance  low-pressure  cuff  to  prevent  aspiration.  Anesthesiology 
I975;42(2):216-219. 

101.  Bernhard  WN,  Cottrell  JE,  Sivakumaran  C,  Patel  K,  Yost  L,  Turn- 
dorf H.  Adjustment  of  intracuff  pressure  to  prevent  aspiration.  An- 
esthesiology 1979;50(4):363-366. 

102.  Guyton  DC,  Barlow  MR,  Besselievre  TR.  Influence  of  airway  pres- 
sure on  minimum  occlusive  endotracheal  tube  cuff  pressure.  Crit 
Care  Med  l997;25{l):91-94. 

103.  Crimlisk  JT,  Horn  MH,  Wilson  DJ,  Marino  B.  Artificial  airways:  a 
survey  of  cuff  management  practices.  Heart  Lung  1996;25(3):225- 
235. 

104.  Off  D,  Braun  SR,  Tompkins  B,  Bush  G.  Efficacy  of  the  minimal 
leak  technique  of  cuff  intlation  in  maintaining  proper  intracuff  pres- 
sures for  patients  with  cuffed  artificial  airways.  Respir  Care  1983; 
28(9):1I15-1120. 

105.  Hess  DR,  Branson  RD.  Airway  and  suction  equipment.  In:  Branson 
RD,  Hess  PR,  Chatbum  RL,  editors.  Respiratory  care  equipment. 
Philadelphia:  Lippincott  Williams  &  Wilkins;  1999:157-186. 

106.  Cox  PM  Jr,  Schatz  ME.  Respiratory  therapy.  Pressure  measurements 
in  endo&acheal  cuffs:  a  common  error.  Chest  1974;65:84-87. 

107.  Sills  J.  An  emergency  cuff  inflation  technique.  Respir  Care  1986; 
3I(3):199-201. 


108.  Ho  AM,  Contardi  LH.  What  to  do  when  an  endotracheal  tube  cuff 
leaks.  J  Trauma  1990;40{3):486-487. 

109.  Tinkoff  G,  Bakow  ED,  Smith  RW.  A  continuous-flow  apparatus  for 
temporary  inflation  of  damaged  endotracheal  tube  cuffs.  Respir 
Care  1990;35(5):423-426. 

110.  Kearl  RA,  Hooper  RG.  Massive  airway  leaks:  an  analysis  of  the 
role  of  endotracheal  tubes.  Crit  Care  Med  1993;21(4):518-521. 

111.  AARC  Clinical  Practice  Guideline.  Endotracheal  suctioning  of  me- 
chanically ventilated  adults  and  children  with  artificial  airways. 
Respir  Care  1993;38(5):500-504. 

1 12.  Hess  D,  Kacmarek  RM.  Technical  aspects  of  the  patient-ventilator 
interface.  In:  Tobin  MJ,  editor.  Principles  and  practice  of  mechan- 
ical ventilation.  New  York:  McGraw-Hill;  1994. 

113.  Tarnow-Mordi  W.  Is  routine  endotracheal  suction  justified?  (edi- 
torial) Arch  Dis  Child  1991:66(4  Spec  No.):374-375. 

1 14.  Demers  RR,  Saklad  M.  Minimizing  the  harmful  effects  of  mechan- 
ical aspiration.  Heart  Lung  1973;2(4):542-545. 

1 15.  Demers  RR.  Complications  of  endotracheal  suctioning  procedures. 
Respir  Care  1982;27(4):453^57. 

1 16.  Boutros  AR.  Arterial  blood  oxygenation  during  and  after  endotra- 
cheal suctioning  in  the  apneic  patient.  Anesthesiology  1970:32(2): 
114-118. 

117.  Ehrhart  IC,  Hofman  WF,  Loveland  SR.  Effects  of  endotracheal 
suction  versus  apnea  during  interruption  of  intermittent  or  contin- 
uous positive  pressure  ventilation.  Crit  Care  Med  1981;9(6):464— 
468. 

118.  Fell  T,  Cheney  FW.  Prevention  of  hypoxia  during  endotracheal 
suction.  Ann  Surg  1971;174(l):24-28. 

1 19.  Kerem  E,  Yatsiv  I,  Goitein  KJ.  Effect  of  endotracheal  suctioning  on 
arterial  blood  gases  in  children.  Intensive  Care  Med  1990;  16(2): 
95-99. 

120.  Berman  IR,  Stahl  WM.  Prevention  of  hypoxic  complications  during 
endotracheal  suctioning.  Surgery  1968;63(4):586-587. 

121.  Barnes  CA,  Kirchhoff  KT.  Minimizing  hypoxemia  due  to  endotra- 
cheal suctioning:  a  review  of  the  literature  (review).  Heart  Lung 
1986:15(2):  164-176. 

122.  Buchanan  LM,  Baun  MM,  The  effect  of  hyperinflation,  inspiratory 
hold,  and  oxygenation  on  cardiopulmonary  status  during  suctioning 
in  a  lung-injured  model.  Heart  Lung  1986;  15(2):  127- 134. 

123.  Skelley  BF,  Deeren  SM,  Powaser  MM.  The  effectiveness  of  two 
preoxygenation  methods  to  prevent  endotracheal  suction-induced 
hypoxemia.  Heart  Lung  1980;9(2):316-323. 

124.  Naigow  D,  Powaser  MM.  The  effect  of  different  endotracheal  suc- 
tion procedures  on  arterial  blood  gases  in  a  controlled  experimental 
model.  Heart  Lung  1977;6(5):808-816. 

125.  Adlkofer  RM,  Powaser  MM.  The  effect  of  endotracheal  suctioning 
on  arterial  blood  gases  in  patients  after  cardiac  surgery.  Heart  Lung 
1978;7(6):101 1-1014. 

126.  Wainwright  SP,  Gould  D.  Endotracheal  suctioning:  an  example  of 
the  problems  of  relevance  and  rigour  in  clinical  research  (review). 
J  Clin  Nurs  1996;5(6):389-398. 

1 27.  Rogge  JA.  Bunde  L,  Baun  MM.  Effectiveness  of  oxygen  concen- 
trations of  less  than  100%  before  and  after  endotracheal  suction  in 
patients  with  chronic  obstructive  pulmonary  disea.se.  Heart  Lung 
1 989;  18(0:64-71. 

128.  Goodnough  SK.  The  effects  of  oxygen  and  hyperinflation  on  arte- 
rial oxygen  tension  after  endotracheal  suctioning.  Heart  Lung  1985; 
14(1):11-17. 

129.  Dreyfuss  D.  Saumon  G.  Ventilator-induced  lung  injury:  lessons 
from  experimental  studies  (review).  Am  J  Respir  Crit  Care  Med 
1998;  157(0:294-323. 

130.  Amato  MB,  Barbas  CS,  Medeiros  DM,  Schettino  G  de  P,  Lorenzi 
Filho  G,  Kairalla  RA.  et  al.  Beneficial  effects  of  the  "open  lung 
approach"  with  low  distending  pressures  in  acute  respiratory  dis- 


770 


Respiratory  Care  •  July  1 999  Vol  44  No  7 


Managing  the  Artificial  Airway 


135. 


136. 


tress  syndrome:  a  prospective  randomized  study  on  mechanical 
ventilation.  Am  J  Respir  Crit  Care  Med  1995:152(6  Pt  0:1835- 
1846. 

131.  Preusser  BA.  Stone  KS.  Gonyon  DS.  Winningham  ML.  Groch  KF, 
Karl  JE.  Effects  of  two  methods  of  preoxygenation  on  mean  arterial 
pressure,  cardiac  output,  peak  airway  pressure,  and  postsuctioning 
hypoxemia.  Heart  Lung  1988;  17(3 1:290-299. 

132.  Pierce  JB.  Piazza  DE.  Differences  in  postsuctioning  arterial  blood 
oxygen  concentration  values  using  two  postoxygenation  methods. 
Heart  Lung  1987:16(1  ):.34-,^8. 

133.  Baker  PO.  Baker  JP.  Koen  PA.  Endotracheal  suctioning  techniques 
in  hypoxemic  patients.  Respir  Care  1983:28(  12):l.56.3-1568. 

1 34.  Glass  C,  Grap  MJ.  Corley  MC.  Wallace  D.  Nurses'  ability  to  achieve 
hyperinflation  and  hyperoxygenation  with  a  manual  resuscitation 
bag  during  endotracheal  suctioning.  Heart  Lung  1993;22(2):158- 
165. 

Singer  M.  Verniaat  J.  Hall  G.  Latter  G.  Palel  M.  Hemodynamic 
effects  of  manual  hyperventilation  in  critically  ill  mechanically  ven- 
tilated patients.  Chest  1 994: 1 06(4):  1 182-1 187. 
Weber  DJ.  Wilson  MB.  Rutala  WA.  Thomann  CA.  Manual  venti- 
lation bags  as  a  source  for  bacterial  colonization  of  intubated  pa- 
tients. Am  Rev  Respir  Dis  1990:142(4):892-894. 

137.  Rindfleisch  SA,  Tyler  ML.  Duration  of  suctioning:  an  important 
variable.  Respir  Care  1983;28(4):457-459. 

138.  Baier  H.  Begin  R.  Sackner  MA.  Effect  of  airway  diameter,  suction 
catheters,  and  the  bronchofiberscope  on  airllow  in  endotracheal  and 
tracheo.stomy  tubes.  Heart  Lung  1976:5(2):235-238. 

139.  Amikam  B.  Landa  J.  West  J.  Sackner  MA.  Bronchofiberscopic 
observations  of  the  tracheobronchial  tree  during  intubation.  Am 
Rev  Respir  Dis  l972;105(5):747-755. 

140.  Landa  JF.  Kwoka  MA.  Chapman  GA.  Brito  M.  Sackner  MA.  Effects 
of  suctioning  on  mucociliary  transport.  Chest  1980;77(2):202-207. 

141.  Fluck  RR  Jr.  Suctioning-intermittent  or  continuous?  (editorial).  Re- 
spir Care  l985:.30(IO):8.37-838. 

142.  Czamik  RE,  Stone  KS,  Everhart  CC  Jr,  Preusser  BA.  Differential 
effects  of  continuous  versus  intermittent  suction  on  tracheal  tissue. 
Heart  Lung  1991;20(2):144-151. 

143.  Link  WJ.  Spaeth  EE.  Wahle  WM.  Penny  W.  Glover  JL.  The  influ- 
ence of  suction  catheter  tip  design  on  tracheobronchial  trauma  and 
fluid  aspiration  efficiency.  Ane.sth  Analg  1976:55(2):290-297. 

144.  Sackner  MA.  Landa  JF,  Greeneltch  N,  Robinson  MJ.  Pathogenesis 
and  prevention  of  tracheobronchial  damage  with  suction  proce- 
dures. Chest  l973:64(3):284-290. 

145.  Jung  RC.  Gottlieb  LS.  Comparison  of  tracheobronchial  suction  cath- 
eters in  humans:  visualization  by  fiberoptic  bronchoscopy.  Chest 
1976;69{2):179-18l. 

146.  Vaughan  RS.  Menke  JA.  Giacoia  GP.  Pneumothorax:  a  complica- 
tion of  endotracheal  tube  suctioning.  J  Pediatr  1978;92(4):633-634. 

147.  Grosfeld  JL.  Lemons  JL,  Ballantine  TV.  Schreiner  RL.  Emergency 
thoracotomy  for  acquired  bronchopleural  fistula  in  the  premature 
infant  with  respiratory  distress.  J  Pediatr  Surg  1980;15(4):4I6-42I. 

148.  Bailey  C.  Kattwinkel  J.  Teja  K.  Buckley  T.  Shallow  versus  deep 
endotracheal  suctioning  in  young  rabbits:  pathologic  effects  on  the 
tracheobronchial  wall.  Pediatrics  I988;82(5):746-751. 

149.  Anderson  KD.  Chandra  R.  Pneumothorax  secondary  to  perforation 
of  sequential  bronchi  by  suction  catheters.  J  Pediatr  Surg  1976; 
11(51:687-693. 

150.  Shim  C,  Fine  N.  Fernandez  R.  Williams  MH  Jr.  Cardiac  arrhyth- 
mias resulting  from  tracheal  suctioning.  Ann  Intern  Med  1969: 
7I(6):1 149-1 153. 

151.  Winston  SJ.  Gravelyn  TR.  Sitrin  RG.  Prevention  of  bradycardic 
responses  to  endotracheal  suctioning  by  prior  administration  of  neb- 
ulized atropine.  Crit  Care  Med  1987:15(1 1):I009-101 1. 


152.  Walsh  JM.  Van  Derwarf  C.  Hoscheit  D.  Fahey  PJ.  Unsuspected 
hemodynamic  alterations  during  endotracheal  suctioning.  Chest 
1989;95(I):I62-165. 

153.  Anthony  JS.  Sieniewicz  DJ.  Suctioning  of  the  left  bronchial  tree  in 
critically  ill  patients.  Crit  Care  Med  1977;5(3):16l-162. 

154.  Kubota  Y.  Toyoda  Y.  Kubola  H.  Sawada  S.  Ishida  H.  Murakawa 
M.  el  al.  Selective  left  bronchial  suctioning  in  infants  and  children. 
Crit  Care  Med  1986;14(10):902-903. 

155.  Kubota  Y.  Toyoda  Y,  Kubota  H.  Asada  A.  Sugiyama  K.  Treatment 
of  atelectasis  with  selective  bronchial  suctioning:  use  of  a  curved- 
lipped  catheter  with  a  guide  mark.  Chest  I991;99(2):510-512. 

156.  Kubota  Y.  Magaribuchi  T.  Toyoda  Y.  Murakawa  M.  Urabe  N. 
Asada  A.  el  al.  Selective  bronchial  suctioning  in  the  adult  using  a 
curve-lipped  catheter  with  a  guide  mark.  Crit  Care  Med  1982: 
10(10:767-769. 

1 57.  Kubota  Y,  Magaribuchi  T,  Ohara  M,  Fujita  M.  Toyoda  Y.  Asada  A. 
HariokaT.  Evaluation  of  selective  bronchial  suctioning  in  Ihe  adult. 
Crit  Care  Med  1980:8(1 2|:748-749. 

158.  Freedman  AP.  Goodman  L.  Suctioning  the  left  bronchial  tree  in  the 
intubated  adult.  Crit  Care  Med  1 982;  10(0:4.3-^5. 

159.  Panacek  EA.  Albertson  TE,  Rutheri^^ord  WF.  Fisher  CJ.  Fouike  GE. 
Selective  left  endobronchial  suctioning  in  the  intubated  patient. 
Chest  1989:95(4):885-887. 

160.  Haberman  PB.  Green  JP.  Archibald  C.  Dunn  DL.  Hurwitz  SR, 
Ashburn  WL.  Moser  KM.  Determinants  of  successful  selective  tra- 
cheobronchial suctioning.  N  Engl  J  Med  1973:289(20):  1060- 1063. 

161.  Salem  MR.  Wong  AY,  Malhrubhutham  M.  Ramilio  J.  Jacobs  HK. 
Bennett  EJ.  Evaluation  of  selective  bronchial  suctioning  techniques 
used  for  infants  and  children.  Anesthesiology  1978;48(5):379-380. 

162.  Rudy  EB.  Baun  M.  Stone  K.  Turner  B.  The  relationship  between 
endotracheal  suctioning  and  changes  in  intracranial  pressure:  a  re- 
view of  the  literature.  Heart  Lung  1986;15(5):488-494. 

163.  Fisher  DM.  Frewen  T.  Swedlow  DB.  Increase  in  intracranial  pres- 
sure during  suctioning-stimulation  vs.  rise  in  P.,co,.  Anesthesiol- 
ogy I982;57(5):416-417. 

164.  Durand  M.  Sangha  B.  Cabal  LA.  Hoppenbrouwers  T.  Hodgman  JE. 
Cardiopulmonary  and  intracranial  pressure  changes  related  to  en- 
dotracheal suctioning  in  preterm  infants.  Crit  Care  Med  1989:17(6): 
506-510. 

Shah  AR.  Kurth  CD.  Gwiazdowski  SG.  Chance  B.  Delivoria-Pap- 
adopoulos  M.  Fluctuations  in  cerebral  oxygenation  and  blood  vol- 
ume during  endotracheal  suctioning  in  premature  infants.  J  Pediatr 
1991  ;1 20(5  ):769-774. 

Brucia  J.  Rudy  E.  The  effect  of  suction  catheter  insertion  and  tra- 
cheal stimulation  in  adults  with  severe  brain  injury.  Heart  Lung 
l996;25(4):29.5-,-?03. 

167.  Wainwright  SP.  Gould  D.  Endotracheal  suctioning  in  adults  with 
severe  head  injury:  a  literature  review.  Intensive  Crit  Care  Nurs 
l996;12(5):.30.3-308. 

168.  Dohi  S.  Gold  I.  Pulmonary  mechanics  during  general  anesthesia: 
the  influence  of  mechanical  irritation  of  the  airway.  Br  J  Anaesth 
1979;51(3):20.5-214. 

169.  Guglielminotti  J.  Desmonts  J.  Durcuil  B.  Effects  of  tracheal  suc- 
tioning on  respiratory  resistances  in  mechanically  ventilated  pa- 
tients. Chest  1998;1I3(5):L335-I.338. 

170.  Carroll  P.  Closing  in  on  safer  suctioning  (review).  RN  I998;61(5): 
22-27. 

171.  Monaco  FJ.  Meredith  KS.  A  bench  test  evaluation  of  a  neonatal  closed 
tracheal  suction  .system.  Pediatr  Pulmonol  1992;13{2):121-123. 

172.  Wright  J.  Closed-suctioning  procedure  in  neonates  (review).  Neo- 
natal Network  1996;  15(61:87-90. 

173.  Hart  TP.  Mahutte  CK.  Evaluation  of  a  closed-system,  directional- 
lip  suction  catheter.  Respir  Care  1992:37(1  0:1260-1265. 


165 


166. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


771 


Managing  the  Artificial  Airway 


174.  Witmer  MT,  Hess  D,  Simmons  M.  An  evaluation  of  the  effective- 
ness of  secretion  removal  with  the  Ballard  closed-circuit  suction 
catheter.  Respir  Care  1991;36(8):844-848. 

175.  Craig  KC,  Benson  MS,  Pierson  DJ.  Prevention  of  arterial  oxygen 
desaturation  during  closed-airway  endotracheal  suction:  effect  of 
ventilator  mode.  Respir  Care  1984;29(10):1013-!018. 

176.  Taggart  JA,  Dorinsky  NL,  Sheahan  JS.  Airway  pressures  during 
closed  system  suctioning.  Heart  Lung  1988;I7(5):536-542. 

177.  Carlon  GC,  Fox  SJ,  Ackerman  NJ.  Evaluation  of  a  closed-tracheal 
suction  system.  Crit  Care  Med  1987;15(5):522-525. 

178.  Clark  AP,  Winslow  EH,  Tyler  DO,  White  KM.  Effects  of  endotra- 
cheal suctioning  on  mixed  venous  oxygen  saturation  and  heart  rate 
in  critically  ill  adults.  Heart  Lung  1990;19(5  Pt  2):552-557. 

179.  Mattar  JA,  Sprosser  AJ,  Gomes  MV.  A  comparative  study  of  ox- 
ygen transport  during  open  and  closed  methods  of  tracheal  suction- 
ing. Intensive  Crit  Care  Dig  1992;1 1:57-58. 

180.  Johnson  KL,  Kearney  PA,  Johnson  SB,  Niblett  JB.  MacMillan  NL, 
McClain  RE.  Closed  versus  open  endotracheal  suctioning:  costs 
and  physiologic  consequences.  Crit  Care  Med  1994;22(4):658-666. 

181.  Harshbarger  SA,  Hoffman  LA,  Zullo  TG,  Pinsky  MR.  Effects  of  a 
closed  tracheal  suction  system  on  ventilatory  and  cardiovascular 
parameters.  Am  J  Crit  Care  1992;1(3):57-61. 

182.  Deppe  SA,  Kelly  JW,  Thoi  LL,  Chudy  JH,  Longfield  RN,  Ducey 
JP,  et  al.  Incidence  of  colonization,  nosocomial  pneumonia,  and 
mortality  in  critically  ill  patients  using  a  Trach  Care  closed-suction 
system  versus  an  open-suction  system:  prospective,  randomized 
study.  Crit  Care  Med  1990;  18(1 2):  1389-1 393. 

183.  Cobley  M,  Atkins  M,  Jones  PL.  Environmental  contamination  dur- 
ing tracheal  suction:  a  comparison  of  disposable  conventional  cath- 
eters with  a  multiple-use  closed  system  device.  Anaesthesia  1991; 
46(ll):957-96l. 

184.  Ritz  R,  Scott  LR,  Coyle  MB,  Pierson  DJ.  Contamination  of  a  mul- 
tiple-use suction  catheter  in  a  closed-circuit  system  compared  to 


187 


contamination  of  a  disposable,  single-use  suction  catheter.  Respir 
Care  1986(1 1);31:1086-1091. 

185.  Hamori  CA,  O'Connell  JM.  Improperly  positioned  closed-system 
suction  catheter  causes  elevated  peak  inspiratory  airway  pressures 
(letter).  Respir  Care  1991;36(12):I441-1442. 

186.  DePew  CL,  Moseley  MJ,  Clark  EG,  Morales  CC.  Open  vs  closed- 
system  endotracheal  suctioning:  a  cost  comparison.  Crit  Care  Nurse 
1994;14(1):94-I00. 

KoUef  MH,  Prentice  S,  Shapiro  SD,  Eraser  VJ,  Silver  P,  Trovillion 
E,  et  al.  Mechanical  ventilation  with  or  without  daily  changes  of 
in-line  suction  catheters.  Am  J  Respir  Crit  Care  Med  1997;156(2  Pt 
l):466-472. 

Hess  D,  Ciano  BA,  Lemon  T,  et  al.  An  evaluation  of  weekly  changes 
of  in-line  suction  catheters  (abstract).  Am  J  Respir  Crit  Care  Med 
1998;157:A751. 

Hess  D,  Bums  E,  Romagnoli  D,  Kacmarek  RM.  Weekly  ventilator 
circuit  changes:  a  strategy  to  reduce  costs  without  affecting  pneu- 
monia rates.  Anesthesiology  1995;82(4):903-91 1. 
Shorten  DR,  Byrne  PJ,  Jones  RL.  Infant  responses  to  saline  instil- 
lations and  endotracheal  suctioning.  J  Obstet  Gynecol  Neonatal 
Nurs  1991;20(6):464^69. 

Gray  JE,  Maclntyre  NR,  Kronenberger  WG.  The  effects  of  bolus 
normal-saline  instillation  in  conjunction  with  endotracheal  suction- 
ing. Respir  Care  1990;35(8):785-790. 

Ackerman  MH,  Ecklund  MM,  Abu-Jumah  M.  A  review  of  normal 
saline  in.stillation:  implications  for  practice.  Dimens  Crit  Care  Nurs 
1996;15(l):31-38. 

Ackerman  MH.  The  effect  of  saline  lavage  prior  to  suctioning. 
Am  J  Crit  Care  1993;2(4):326-330. 

1 94.  Hagler  DA,  Traver  GA.  Endotracheal  saline  and  suction  catheters: 
sources  of  lower  airway  contamination.  Am  J  Crit  Care  1994;3(6): 
444-447. 


189. 


190. 


191 


192. 


193. 


Discussion 

Heffner:  Nice  presentation.  Dean. 
Let  me  ask  you  about  measuring  cuff 
pressures.  There's  a  lot  of  controversy 
around  the  country  as  to  whether  we 
should  measure  cuff  pressures  and 
what  we  should  do  with  the  informa- 
tion. When  patients  are  running  very 
high  cuff  pressures,  are  we  docu- 
menting potential  difficulties  from 
medical  and  legal  standpoints?  I 
agree  with  all  of  your  comments,  but 
others  don't  necessarily  agree.  What 
do  you  do  in  the  ICU  when  you  have 
a  patient  whom  you're  rounding  on 
and  you  realize  that  to  maintain  a 
seal  you  have  to  tolerate  high  cuff 
pressures? 

Hess:  We  would  have  our  respira- 
tory therapist  discuss  that  with  the  team 


caring  for  that  patient.  Then  the  issue 
is  how  comfortable  does  the  team  feel 
about  reintubating  the  patient,  if  the 
problem  might  be  that  the  tube  is  too 
small.  Or,  we  may  try  to  determine 
whether  this  is  an  issue  with  some  air- 
way anomaly,  and  maybe  the  tube 
needs  to  be  repositioned  so  that  we 
can  get  a  seal  with  a  lower  cuff  pres- 
sure. I  think  that,  typically,  the  issue 
that  would  come  up  is  whether  a  pa- 
tient needs  to  be  reintubated  with  a 
larger  tube  so  that  we  can  achieve  a 
seal  with  a  lower  pressure,  and  then, 
how  comfortable  does  everyone  feel 
about  reintubating  that  patient  with  a 
minimum  of  risk.  How  do  you  address 
the  issue? 

Heffner:  Some  physicians  have  told 
me  that  they'd  rather  not  document 
cuff  pressures,  preferring  to  use  min- 


imal leak  technique  or  just  go  ahead 
and  inflate  until  they  have  a  good  seal 
so  that  they  don't  discover  the  prob- 
lem and  then  have  to  document  it.  To 
me,  it's  really  a  spurious  logic.  Med- 
ically and  legally  it  is  better  to  docu- 
ment a  problem  and  then  justify  the 
existence  of  that  problem  and  why  it's 
still  best  practice  to  maintain  a  high 
cuff  pressure  in  a  specific  patient.  I 
counsel  people  to  do  the  same  thing 
you  do,  which  is  to  determine  why  the 
cuff  pressure  is  elevated  and  why  that 
might  be  necessary,  or  what  they  can 
do  about  it.  Sometimes  putting  a  larger 
tube  in  is  important — sometimes  put- 
ting a  smaller  tube  is  important  if  the 
cuff  can't  inflate  to  its  full  capacity 
and  function  the  way  it's  supposed  to 
in  the  airway.  Occasionally,  we  have 
to  reposition  a  tube  at  a  different  level. 
Also,  it  might  be  all  right  with  some 


772 


Respiratory  Care  •  July  1 999  Vol  44  No  7 


Managing  the  Artificial  Airway 


patients  to  tolerate  a  leak  that  may  not 
cause  a  problem  if  they  are  intubated 
primarily  for  ventilatory  respiratory 
failure  rather  than  hypoxic  respiratory 
failure. 

Hess:  I  think  you  bring  up  another 
important  issue.  The  important  thing 
is  the  pressure  the  cuff  actually  ap- 
plies to  the  tracheal  wall.  If  you  have 
a  very  high  cuff  pressure  but  there  is 
still  a  leak,  the  question  is  whether  the 
cuff  is  producing  any  injury  to  the  tra- 
cheal wall,  since,  even  though  pres- 
sure inside  the  cuff  may  be  very  high, 
if  there  is  a  leak,  that  indicates  that  the 
cuff  is  not  in  full  contact  with  the  tra- 
cheal wall,  so,  how  could  it  injure  the 
tracheal  wall?  That's  actually  a  dis- 
cussion I  get  into  sometimes  with  our 
respiratory  therapists,  who,  appropri- 
ately, get  concerned  if  the  cuff  pres- 
sure is  high.  But  if  there's  still  a  leak, 
how  could  high  cuff  pressure  be  caus- 
ing a  problem? 

Heffner:  So,  it's  really  the  cuff  ten- 
sion against  the  wall  rather  than  the 
intracuff  pressure  that's  important. 

Ritz:  John,  another  important  thing 
to  realize  regarding  the  routine  mon- 
itoring of  cuff  pressure  is  that  there 
are  some  indications  that  clinicians 
who  don't  have  cuff  manometers  and 
are  more  concerned  about  leaks  around 
the  endotracheal  tube  may  inadver- 
tently overpressurize  cuffs,  and  that 
routine  monitoring  and  limiting  the 
number  of  people  with  access  to  the 
cuff  lowers  the  incidence  of  tracheal 
injury.  I  think  routine  monitoring  is 
probably  a  good  idea.  My  read  on  the 
situation  is  similar  to  Dean's;  I  think 
we  should  use  routine  monitoring  to 
prevent  high  cuff  pressures.  The  high 
cuff  pressures  aren't  because  some- 
one has  indiscriminately  overin- 
flated  it,  but  because  of  some  other 
anomaly. 

Heffner:     I  agree. 


Thompson:  In  my  hospital  we're  in 
the  midst  of  a  discussion  about  the 
right  way  to  conduct  suctioning.  Spe- 
cifically, do  you  pass  the  catheter  be- 
yond the  end  of  the  endotracheal  tube? 
I'm  interested  in  other  people's  expe- 
rience and  opinion  about  the  impor- 
tance of  shielding  the  tracheal  mucosa 
from  the  catheter  vs  improved  clear- 
ance of  secretions  after  deep  suction- 
ing. 

Hess:  1  think  the  common  teaching, 
and  what  I  have  taught  over  the  years, 
is  that  for  adults  the  suction  catheter  is 
passed  until  it  meets  resistance,  and 
then  is  pulled  back  a  centimeter  and 
suction  conducted  from  that  point.  I 
do  know  of  literature  that  suggests  that 
is  not  a  good  practice. '""^  In  fact,  in 
the  neonatal  and  pediatric  literature 
there  have  been  reports  of  pneumo- 
thoraces  associated  with  the  passage 
of  suction  catheters  past  the  tip  of  the 
endotracheal  tube.  Ray  (Ritz)  can  cor- 
rect me  if  I'm  wrong,  but  I  think  that 
at  Massachusetts  General  Hospital  our 
practice  in  the  neonatal  ICU  is  that  the 
tip  of  the  suction  catheter  is  not  passed 
beyond  the  tip  of  the  endotracheal  tube. 


REFERENCES 

1.  Bailey  C.  Kattwinkel  J,  Teja  K,  Buckley 
T  .  Shallow  versus  deep  endotracheal  suc- 
tioning in  young  rabbits:  pathologic  ef- 
fects on  the  tracheobronchial  wall.  Pedi- 
atrics 1988;82(5):746-751. 

2.  Anderson  KD,  Chandra  R.  Pneumothorax 
secondary  to  perforation  of  sequential 
bronchi  by  suction  catheters.  J  Pediatr 
Surg  1976;ll(5):687-693. 

3.  Grosfeld  JL,  Lemons  JL,  Ballantine  TV, 
Schreiner  RL  .  Emergency  thoracotomy 
for  acquired  bronchopleural  fistula  in  the 
premature  infant  with  respiratory  distress. 
J  Pediatr  Surg  1980;15(4):416-42l. 

Thompson:  Actually,  I'm  more  con- 
cerned about  older  infants  and  chil- 
dren, but  would  be  interested  in  what 
the  approach  in  adults  is.  Is  your  ap- 
proach widely  accepted  or  is  it  con- 
troversial? It  matches  what  I  was 
taught  to  do,  but  recent  observations 
of  tracheal  injury  by  the  catheter  have 


led  many  people  to  advocate  limiting 
the  passage  of  the  catheter. 

Hess:  The  other  patient  population 
where  that's  a  problem  is  in  Bill  Hur- 
ford's  unit  with  the  pneumonectomies 
and  tracheal  reconstruction  patients 
where  we're  real  careful  about  how 
far  we  pass  the  suction  catheter.  But  I 
think  that,  beyond  that,  the  typical 
practice  is  to  pass  the  catheter  until 
there's  resistance  and  then  pull  back  a 
centimeter  or  so  and  suction  from  that 
point. 

Stauffer:  I  think  that's  a  reasonable 
practice,  considering  that  we're  often 
trying  to  evacuate  secretions  that  are 
deep  in  the  lower  lobe  bronchi.  We 
often  see,  for  example,  left  or  right 
lower  lobe  atelectasis.  In  the  absence 
of  air  bronchograms,  we  presume  that 
mucus  plugging  has  occurred,  so  deep 
suctioning  is  performed.  I  don't  know 
how  effective  it  is. 

Hess:  The  other  issue  about  deep 
suctioning  is  that  the  suction  catheter 
is  only  about  22  inches  long.  It's  not 
very  long.  So  the  suction  catheter  prob- 
ably does  well  to  get  much  past  the 
carina.  I  don't  think  we  do  a  lot  of  real 
deep  suctioning. 

Hurford:  I  would  agree  with  that, 
especially  since  the  advent  of  respira- 
tory therapy-directed  or  -managed 
bronchoscopy  services.  So  we  have 
ready  access  to  bronchoscopic  suction- 
ing. Our  problems  with  deep  suction- 
ing aren't  as  large,  and,  to  echo  your 
point,  we  do  limit  catheter  insertion 
when  there  is  a  bronchial  stump  or  a 
lobectomy  or  an  anastomotic  line  in 
the  tracheobronchial  tree. 

Watson:  I'm  interested  in  this  prob- 
lem of  cuff  leak,  since  this  is  one  of 
those  classic  situations  where  the  ther- 
apists call  us  and  we  come  to  help  out. 
I  think  it  is  the  case  that  many  of  those 
leaking  tubes  (you  cited  a  study  show- 
ing 20%  or  so),  have  perfectly  normal 
cuffs.  The  problem,  really,  is  tube 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


movement,  and  that  poses  a  number 
of  problems.  One  is  the  difficult  ques- 
tion of  whether  you  pharmacologically 
restrain  people,  or  whether  you  tie  their 
heads  down  and  restrain  their  tongues, 
which  is  obviously  absurd.  I've  given 
up  and  accepted  this  as  a  part  of  life, 
but  I  think  we  could  clean  up  our  pro- 
tocol a  bit  since  it's  so  commonly  the 
case  that  the  tube  is  affixed  to  the 
mouth  in  exactly  the  right  place  from 
the  outside,  and  yet  is  moved  inside 
by  the  patient's  tongue  movement. 
Typically,  I'll  get  people  to  periodi- 
cally run  a  suction  catheter  down,  drop 
the  cuff,  shove  the  tube  in  a  little  bit, 
and  then  pull  it  back  until  1  can  pal- 
pate the  cuff  below  the  cricoid  in  an 
adult,  as  a  prophylactic  measure.  It 
used  to  be  that  we  took  daily  chest 
x-rays  and  looked  at  where  the  tube 
was  on  the  chest  film.  That,  of  course, 
became  unaffordable.  I'm  curious  to 
know  what  you  do,  or  whether  you 
just  live  with  it  and  have  people  come 
and  change  the  tube  frequently  and 
find  out  that  the  tube  was  really  okay, 
but  that  the  cuff  was  in  the  mouth  or 
up  in  the  larynx. 

Hess:  Actually.  I  think  it's  very  easy 
to  determine  whether  there's  a  cuff 
rupture.  All  you  need  to  do  is  use  the 
set-up  that  I  showed  on  the  slide  where 
you  have  the  manometer  and  the  sy- 
ringe attached  to  the  cuff.  If  the  sys- 
tem holds  pressure  even  though  there's 
a  leak,  it  cannot  be  a  cuff  rupture.  I 
think  that's  a  simple  thing  that's  often 
overlooked  or  is  not  done  when  there 
is  a  leak  and  somebody  thinks  that  the 
problem  is  that  the  cuff  is  ruptured. 

Bishop:  Dean.  I  think  if  the  cuff 
comes  back  into  the  mouth,  you  actu- 
ally may  have  a  change  in  pressure  on 
your  manometer,  if  you  no  longer  have 
the  tracheal  wall  restricting  it. 

Hess:     But.  even  if  it's  ruptured? 

Bishop:  No,  I'm  saying  that,  in  an 
unruptured  cuff,  you  may  see  a  de- 
cline in  the  pressure.  In  a  chapter  that 


Ray  Ritz  and  I  wrote  for  Dave  Pier- 
son's  respiratory  therapy  textbook'  we 
laid  out  a  protocol  for  dealing  with 
the  question  of  cuff  rupture,  and  went 
through  a  variety  of  steps  to  handle  a 
cuff  that  seems  to  leak. 

REFERENCE 

1.  Bishop  MJ.  Ritz  R.  Airway  managemenl. 
In:  Pierson  DJ.  Kacmarek  RM.  editors. 
Foundations  of  respiratory  care.  New 
Yoric:  Churchill  Livingstone;  1992:82.^- 
842. 

Hess:  If  the  tube  has  moved  ceph- 
alad  so  that  the  cuff  is  inflated  in  the 
pharynx,  that  will  result  in  a  high  cuff 
pressure,  because  it  will  require  a  high 
cuff  volume.  But  that  cuff  will  be  able 
to  hold  pressure,  so  it  should  not  act 
like  a  ruptured  cuff. 

Bishop:  Right.  If  it  stays  in  one 
place,  that's  true.  Jim  (Reibel).  maybe 
you  can  respond  on  this.  One  of  my 
concerns  has  been  seeing  tubes  with 
the  cuffs  too  high,  because  I  under- 
stand from  my  ear-nose-throat  and  tho- 
racic surgery  colleagues  that  tracheal 
injuries  are  repairable,  but  subglottic 
injuries  can  be  much  more  difficult  to 
repair.  A  cuff  inflated  in  the  larynx 
can  certainly  cause  damage.  In  rab- 
bits, inflating  a  cuff  to  exceed  muco- 
sal perfusion  pressure  for  one  hour, 
we  ended  up  with  pretty  significant 
laryngeal  injury.  So  I  worry  about  the 
cuff  being  too  high  and  being  just  im- 
mediately subglottic. 

Reibel:  You're  correct.  The  cricoid 
is  a  complete  circle.  If  you  have  an 
inflated  tube  up  there,  and  the  pres- 
sure if  maintained,  you're  going  to  get 
problems.  As  you  correctly  point  out, 
tracheal  problems  can  be  fixed,  but 
laryngotracheal  problems  are  much 
more  difficult  to  fix.  People  have  tried 
to  adapt  the  anterior  and  posterior  cri- 
coid split  that  they  use  in  pediatric 
patients  to  adults.  In  my  experience 
with  very  few  of  those,  there  is  not  a 
good  extrapolation  of  pediatric  expe- 
rience to  the  adult.  Dr  Grillo  has  a 


very  interesting  technique  wherein  he 
does  a  partial  cricoid  resection  and  de- 
velops a  membranous  tracheal  flap.  He 
does  a  circumferential  subglottic  ex- 
cision and  then  positions  that  mem- 
branous tracheal  flap  on  the  remain- 
der of  the  cricoid,  protecting  the 
cricoarytenoid  joint.  This  technique 
has  been  successful  in  a  great  number 
of  cases  that  otherwise  would  have 
been  doomed  to  failure.  This  work  has 
now  been  adopted  and  successfully  re- 
produced at  other  institutions  around 
the  world. 

Bishop:  I  think  the  key  point, 
though,  is  that  in  terms  of  prevention, 
people  looking  at  chest  films  tend  to 
be  worried  about  the  tube  being  down 
too  far.  but  no  one  seems  to  be  very 
worried  about  the  cuff  being  too  high 
up  in  the  larynx. 

Hess:  A  technique  that  is  sometimes 
described  for  determining  proper  tube 
placement  is  palpation  of  the  cuff  in 
the  suprasternal  notch.  Would  that  im- 
ply that  if  you  can  palpate  the  cuff  in 
the  suprasternal  notch  that  it  may  ac- 
tually be  too  high  in  the  trachea? 

Heffner:  High  positioning  is  a  con- 
cern, particularly  considering  that  the 
cuff  is  going  to  move  up  and  down  in 
the  airway  with  body  position.  Also, 
high  tubes  risk  inadvertent  extubation. 
The  biggest  concern  is  what  Mike 
brought  up — subglottic  injury.  That 
level  of  injury  really  shouldn't  hap- 
pen from  the  cuff.  It  can  happen  from 
the  tube  going  through  the  larynx. 
Dean.  I  think  a  source  of  confusion  in 
monitoring  cuff  pressures  is  that  some 
standard  texts  report  pressures  in  cm 
HjO  while  others  report  it  in  mm  Hg. 
It  is  difficult  for  caregivers  to  remem- 
ber how  to  convert  from  one  to  the 
other. 

Hess:     Multiply  mm  Hg  by  1.36. 

Heffner:  Thank  you.  It  seems  that 
cuff  pressure  units  should  be  standard- 
ized, because  I've  reviewed  medical 


774 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Managing  the  Artificial  Airway 


records  wherein  from  shift  to  shift  dif- 
ferent therapists  have  measured  with 
different  devices  in  different  units,  and 
it  really  gets  very  confusing  for  the 
caretakers. 

Hess:  I  think  that  happened  to  us 
when  the  therapists  had  the  manome- 
ters that  were  in  mm  Hg  and  then  we 
got  them  these  fancy  gadgets  that  were 
in  cm  HnO. 

Stauffer:  Two  questions.  First,  ex- 
actly how  far  should  the  tip  of  the 
endotracheal  tube  rest  above  the  car- 
ina for  a  supine  adult  with  head  in 
neutral  position  in  an  intensive  care 
unit?  Second,  when  a  cuff  leak  is 
present  requiring  inflation  pressures  of 
30-35  mm  Hg  or  higher,  what  if  any, 
are  the  indications  for  a  foam  cuff  en- 
dotracheal tube  placement? 

Hess:  The  chest  radiology  literature 
I  saw  while  putting  together  this  pa- 
per suggested  that  the  tip  of  the  endo- 
tracheal tube  be  5  cm  above  the  car- 
ina. As  for  the  indications  for  the  foam 
cuff,  Charlie  (Durbin)  should  address 
that  question.  To  tell  the  truth,  I've 
never  known  what  to  do  with  foam 
cuffs.  There  are  times  that  we  are  asked 
to  replace  a  trach  tube  with  a  foam 
cuff  trach  tube  because  the  patient  has 
a  dilated  trachea,  and  my  experience 
with  that  is  that  it  doesn't  work  very 
well,  that  the  leak  is  just  as  great  as  it 
was  with  the  conventional  tube,  and 
in  fact  you  end  up  having  to  overpres- 
surize  the  foam  cuff — essentially  hav- 
ing to  convert  it  to  a  conventional  cuff 
in  order  to  get  a  seal.  So  I  have  not 
been  convinced  that  foam  cuffs  really 
add  very  much  for  the  patient  who  has 
a  cuff  leak,  particularly  a  cuff  leak 
secondary  to  a  tracheal  dilation. 

Ritz:  We  don't  use  loads  of  them, 
but  have  found  that  if  it  is  the  first 
tube  you  put  in,  it  works  great.  How- 
ever, if  it  is  not  the  first  tube  used,  the 
foam  cuff  does  not  seem  to  contribute 
much  to  solving  cuff  leak  problems. 


Durbin:  The  foam  cuffed  tube  is 
not  a  rescue  device.  It's  designed  to 
prevent  tracheal  damage.  When  used 
after  tracheomalacia  develops,  just  as 
with  the  Lantz  tube,  it  may  not  form 
an  adequate  seal.  Using  either  of  these 
tubes  after  developing  a  dilated  tra- 
chea does  not  make  much  sense. 

Watson:  I  disagree  about  the  Lantz 
tube.  It  is  possible  to  disarm  the  sys- 
tem, which  I've  done  repeatedly  in 
high  pressure  ventilating  settings  in 
the  burn  units  and  with  bad  ARDS. 
It's  just  a  pain,  and  teaching  every- 
body how  to  do  it  is  very  hard. 

Durbin:  Well,  you  can  overcome 
the  protective  pressure  limitation  with 
a  Bivona  cuff  as  well,  but  the  point  is 
it  doesn't  help  the  patient  by  doing 
that,  and  it  costs  more  money  than  a 
conventional  cuff. 

Campbell:  You  made  a  comment 
and  showed  a  reference  about  closed 
circuit  suction  systems.  And  you  al- 
luded that  the  cost  effectiveness  was 
improved  versus  the  open  technique.  I 
think  we're  a  little  bit  too  quick  to 
accept  that,  especially  in  light  of  the 
fact  that  they  are  maybe  1 0  times  more 
expensive  than  an  open  suction  cath- 
eter. In  the  majority  of  patients,  the 
duration  of  mechanical  ventilation  is 
less  than  24  hours. 

Hess:  We  costed  that  out  in  our 
medical  ICU,  looking  at  the  distri- 
bution of  mechanically  ventilated 
days,  and  looking  at  the  cost  of 
changing  the  inline  suction  catheter 
once  a  day  versus  once  a  week,  and 
changing  the  inline  suction  catheter 
once  a  week  costs  less  to  the  insti- 
tution than  doing  open  suction  pro- 
cedure. 

Campbell:  But  doesn't  that  assume 
the  patient  is  going  to  be  ventilated 
for  a  week? 

Hess:  No  it  doesn't.  What  we  did 
was  look  at  the  distribution  of  me- 


chanically ventilated  patients  and 
costed  it  out  based  upon  the  fact  that 
there  were  a  percentage  of  patients 
ventilated  for  1  day,  2  days,  3  days, 
and  so  forth.  We  took  into  consider- 
ation the  distribution  of  ventilator 
days. 

Campbell:  Bui  the  point  still  re- 
mains that  if  the  patient  is  extubated 
in  less  than  24  hours,  how  could  it  be 
cheaper  to  apply  a  $10  device? 

Hess:  Because  we  have  other  pa- 
tients who  are  ventilated  for  several 
weeks. 

Ritz:  There's  no  price  I  can  place 
on  getting  spit  in  the  face.  Inline  suc- 
tion catheters  prevent  that  from  hap- 
pening so  I  don't  care  how  much  they 
cost. 

Campbell:  My  point  is  that  patient 
selection  is  probably  warranted  with 
that  device — maybe  not  in  your  insti- 
tution, but  in  most  institutions,  I  sus- 
pect. 

Hess:  I  guess  part  of  it,  too,  is  how 
concerned  you  are  about  disconnect- 
ing patients  from  ventilators  to  suc- 
tion them.  When  you  disconnect  a  pa- 
tient from  a  ventilator,  you  spray 
condensate  and  secretions  out  into  the 
environment.  You  can  attach  a  resus- 
citator  bag  to  the  airway  to  bag  the 
patient  during  suctioning  that  may 
have  a  grossly  contaminated  valve  or 
other  kinds  of  issues  that  the  closed 
suction  system  avoids.  Closed  versus 
open  suctioning  is  clearly  an  emotional 
issue,  including  at  our  institution. 

Branson:  You're  talking  about  the 
medical  ICU.  I  don't  have  that  much 
experience  in  the  medical  ICU,  but 
it's  my  experience  from  going  up  there 
that  they  don't  have  a  lot  of  patients 
who  are  on  for  just  a  day.  Do  you 
have  a  lot  of  those  patients,  compared 
to  the  surgical  ICU? 


Respiratory  Care  •  July  1999  Vol  44  No  7 


77:" 


Managing  the  Artificial  Airway 


Hess:  I  can't  tell  you  the  exact  num- 
ber, but  it's  more  than  50%. 

Branson:  Because  what  we  see  in 
the  surgical  ICU  is  that  there's  the 
group  of  patients  who  we  would  prob- 
ably use  closed  circuit  suctioning  on 
because  we  know  they  have  bad  ARDS 
and  they're  going  to  be  on  for  a  long 
time.  And  we  have  that  other  group  of 
patients  who  we  know  are  coming  off 
today,  and  we  wouldn't  use  it,  and 
that  would  probably  save  money. 

Hess:  Yes,  but  the  problem  with  pa- 
tient selection  is  that  it  always  works 
great  in  retrospect,  but  it  never  tells 
you  what  to  do  when  the  patient  gets 
to  the  unit,  at  least  not  in  my  experi- 
ence. 

Stoller:  Dean.  I  think  that,  method- 
ologically, it  comes  down  to  what 
some  would  consider  a  sensitivity 


analysis.  That  is  to  say,  if  the  distri- 
bution of  duration  of  ventilation  were 
to  change  radically  toward  a  shorter 
duration  of  ventilation,  there  must  be 
a  cut  point  at  which  the  cost-effec- 
tiveness no  longer  favors  the  inline 
suction  catheter.  And  so  the  method- 
ologic  question  to  address  this  discus- 
sion gets  to  that.  Did  you  consider  that? 

Hess:     We  did  not  do  ROC  curves. 

Stoller:  Of  course  that  would  be  the 
issue. 

Hess:  We  don't  use  inline  suction 
catheters  in  the  post-anesthesia  care 
unit,  for  example,  nor  in  our  cardiac 
surgery  ICU,  because  those  patients 
are  extubated  in  hours. 

Hurford:  We  use  them  in  the  oper- 
ating room  for  thoracic  operations  on 
cystic  fibrosis  patients.  It's  the  only 


way  you  can  get  enough  suction  cath- 
eters down  there  frequently  enough  to 
complete  the  case. 

Heffner:  I  was  going  to  extend 
Jamie's  (Stoller)  point  that  1  think  we 
have  to  be  careful  with  the  use  of  "cost- 
effective"  or  "cost-effective  analysis." 
We  should  only  use  that  term  if  we've 
done  a  rigorous  cost-effectiveness 
analysis  that  includes  the  societal  per- 
spective of  all  the  costs  and  all  the 
benefits  across  the  health  care  contin- 
uum. Really,  what  we're  talking  about 
is  capital  budget  decisions  in  terms  of 
what's  cost-saving  with  a  reasonable 
short-term  benefit  for  the  patient 
within  the  domain  of  the  hospital,  from 
the  hospital's  perspective.  So  that's 
really  different  than  cost-effective 
analysis. 

Hess:     That  point  is  well  taken. 


776 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation:  Methods  for  Successful  Intubation 

Charles  B  Watson  MD 


Introduction 

Deflnition  of  a  Difficult  Airway 

Conventionally  Trained  Personnel 

Conventional  Training — A  Relative  Concept 

Emergency  Credentials 
Recognition  of  Difficult  Intubation 
Incidence  of  Difficult  Intubation 

Laryngeal  Exposure 

Is  the  Setting  or  the  Airway  Difficult? 

Anatomic  Problems 
Complicating  Conditions 

Medical  Conditions 
The  Difficult  Airway  Algorithm 
Laryngoscopy  Options 

Curved  Laryngoscope  Blade 

Straight  Laryngoscope  Blade 

Tube  Laryngoscope 

Additional  Maneuvers 

Stylets 

Staged  Intubation 
Alternatives  to  Direct  Laryngoscopy 

Blind  Intubation 

Digital  Intubation 

Magnetic  Intubation 

Radiographic  Intubation 

Blind,  Stylet-Guided  Intubation 

Confirming  Blind  Intubation 

Fiberoptic  Systems 
Retrograde  Techniques 

When  to  Discontinue  Direct  Laryngoscopy  Attempts 
Intermediate  Airways 

Evolution  of  the  Esophageal  Obturator  Airway 

Pharyngeal-Tracheal  Lumen  and  Cuffed  Oropharyngeal  Airways 

The  Combitube 

The  Laryngeal  Mask  Airway 
Failed  Intubation  and  Failed  Ventilation 

The  Transtracheal  Airway 

Approach  to  the  Difficult  Airway 

Practical  AppUcation  of  a  Difficult  Airway  Algorithm  for  Respiratory  Care 
Summary 

[Respir  Care  1999:44(7):777-796]  Key  words:  difficult  intubation,  difficult  la- 
ryngoscopy, difficult  airway,  emergency  intubation,  staged  intubation,  airway 
screening,  intubation,  algorithm. 


Respiratory  Care  •  July  1999  Vol  44  No  7  777 


Prediction  of  a  Difficult  Intubation 


Introduction 


Deflnition  of  a  Difficult  Airway 


Both  translaryngeal  and  transtracheal  intubation  have 
long  and  interesting  histories  as  medical  procedures.  They 
began  as  medical  curiosities,  performed  by  medical  spe- 
cialists— rarely  skilled — when  infectious  diseases  of  the 
upper  airway  like  diphtheria  and  quinsy  were  commonly 
fatal.  Now  they  are  commonplace  in  the  hands  of  acute 
care  physicians,  physicians'  assistants,  advanced  practice 
registered  nurses,  and  respiratory  therapists.  Despite  in- 
creased use  of  noninvasive  modes  of  ventilatory  support 
and  the  recent  introduction  of  newer,  "intermediate"  emer- 
gency airways,  intubation  of  the  trachea  with  a  cuffed 
translaryngeal  or  transtracheal  tube  remains  essential  for 
continuous  mechanical  ventilation,  effective  secretion  man- 
agement, and  bypassing  upper  airway  pathology. 

Since  the  promulgation  of  basic  and  advanced  life  sup- 
port (ALS)  skills  protocols  over  30  years  ago  by  the  Amer- 
ican College  of  Cardiology,  direct  laryngoscopy  for  place- 
ment of  a  translaryngeal  airway  has  become  essential  to 
acute  respiratory  practice.  Numerous  articles  and  chapters 
in  basic  respiratory  and  emergency  texts  have  described 
the  procedure.'"^  Intubation  is  widely  taught  in  ALS,  ad- 
vanced trauma  life  support,  pediatric  ALS,  neonatal  ALS, 
obstetric  ALS,  fundamentals  of  critical  care  support,  para- 
medic, and  emergency  medical  technician-intubation  train- 
ing curricula.  Hands-on  experience  is  commonly  gained 
in  the  operating  room,  where  a  number  of  individuals 
are  electively  intubated  as  part  of  routine  surgical  anes- 
thesia care. 

Mounting  experience  with  difficult  tracheal  intubation 
in  the  anesthesia  setting^-^  argues  for  a  more  methodical 
approach  to  individuals  with  anatomic  and  medical  prob- 
lems that  might  complicate  direct  laryngoscopy.'"  Conse- 
quently, the  American  Society  of  Anesthesiologists  (ASA) 
published  and  updated  clinical  guidelines  for  dealing  with 
patients  who  present  a  difficult  airway  and,  in  particular, 
an  intubation  challenge."  Now  modified  guidelines  from 
this  source  have  been  translated  into  other  fields,  including 
emergency  medicine.'-  It  appears  likely  that  difficult  air- 
way management  and  difficult  tracheal  intubation  will  be- 
come routinely-promulgated  ALS  algorithms  during  the 
next  decade'^ — a  respiratory  standard  of  care  for  acute 
care  practitioners. 


Charles  B  Watson  MD  is  affiliated  with  the  Department  of  Anesthesia, 
Bridgeport  Hospital,  Bridgeport,  Connecticut. 

Correspondence:  Charles  B  Watson  MD,  Department  of  Anesthesia, 
Bridgeport  Hospital.  Bridgeport  CT  06610-3801.  E-mail: 
pcwats  (3>  bpthosp.org. 


The  ASA  task  force"  described  the  difficult  airway  as 
one  that  a  "conventionally  trained"  anesthesiologist  can 
not  manage  without  systemic  oxygen  desaturation  despite 
increased  inspired  oxygen  tension  and  without  signs  of 
hypercapnia,  including  hypertension,  tachycardia,  and  other 
secondary  evidence  of  ventilatory  inadequacy.  Procedural 
expertise  is  defined  by  a  trained  individual  who  is  rela- 
tively experienced  with  airway  management  and  intuba- 
tion. The  conventionally  trained  individual  possesses  av- 
erage skills  for  his  or  her  specialty,  which  implies  that  he 
or  she  is  not  a  regional  expert.  Regional  experts  from  any 
specialty  who  participate  in  airway  management  are  rarely 
available  on  a  continuous  basis  in  any  institution. 

Conventionally  Trained  Personnel 

A  conventionally  trained  anesthesiologist  is  recognized 
as  proficient  in  direct  laryngoscopy  (DL),  by  virtue  of 
having  performed  hundreds  of  tracheal  intubations  for  op- 
erative anesthesia  care.  The  experience  is  implicit  in  clin- 
ical training,  although  procedural  numbers  are  not  reported 
for  certification  by  the  American  Board  of  Anesthesiolo- 
gists. Similarly,  the  Council  on  Accreditation  of  the  Amer- 
ican Association  of  Nurse  Anesthetists  has  no  procedural 
guidelines  for  certification  in  DL.  In  our  institution,  a  stu- 
dent nurse  performs  more  than  1 50  DLs  and  demonstrates 
other  proficiencies  before  he  or  she  can  join  the  code  team 
that  responds  to  ALS  and  intubation  calls.  In  contrast, 
paramedics  who  train  in  our  region  perform  supervised  DL 
for  operative  intubation  a  handful  of  times  prior  to  their 
certification  and  6  times  per  year  thereafter  in  order  to 
maintain  certification  for  field  intubation  procedures.  Sim- 
ilarly, the  average  resident  in  the  Yale/Bridgeport  Hospital 
emergency  medicine  program  performs  20-30  DLs  as  part 
of  clinical  training  in  the  procedure.  Contrast  this  with  the 
basic  experience  for  training  in  fiberoptic  bronchoscopy 
suggested  by  the  American  College  of  Chest  Physicians 
(50  procedures)  and  with  the  40  transesophageal  echocar- 
diography probe  placements  required  for  a  cardiologist's 
certification  in  this  procedure  at  the  Mayo  Clinic.''* 

Conventional  Training — A  Relative  Concept 

Clearly,  as  with  electrical  cardioversion  in  the  ALS  set- 
ting, there  must  be  a  distinction  between  the  expert  and 
performance  of  the  minimally-trained  individual  who  re- 
trains periodically.  The  qualifications  of  technicians  who 
perform  tracheal  intubation  have  been  the  subject  of  active 
debate. '5  Credentials  for  practitioners  who  work  in  the 
United  States  are  controlled  on  a  local  level,  either  by  state 
or  regional  requirements,  as  in  the  case  of  paramedics  who 
work  in  regional  ALS  systems,  or  by  a  hospital's  medical 


778 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


staff  rules.  Consequently,  there  is  considerable  variation  in 
minimal  requirements  for  the  performance  of  tracheal  in- 
tubation and  other  life-saving  procedures,  so  "convention- 
al training"  is  a  poorly  defined  concept. 

Emergency  Credentials 

In  our  department,  we  distinguish  between  emergency 
procedures,  which  we  would  not  frequently  perform,  and 
routine  procedures  that  are  performed  on  a  day-to-day  ba- 
sis. Someone  with  emergency  credentials  meets  minimal 
training  criteria  and  might  perform  the  procedure  only 
several  times  a  year.  Routine  credentials,  on  the  other 
hand,  imply  day-to-day  practice  of  the  procedure  or  skill  in 
question.  In  effect,  we  have  a  two-tiered  provider  system 
for  some  emergency  procedures  at  our  institution.  If  there 
is  time,  we  consult  a  conventionally  trained  specialist  or  a 
local  expert.  If  there  is  not  time,  an  individual  with  emer- 
gency credentials  performs  as  best  he  or  she  can. 

Recognition  of  Diflicult  Intubation 

As  a  practical  matter,  difficult  intubation  is  recognized 
in  one  of  3  ways:  first,  as  an  obvious  anatomic  challenge; 
second,  by  association  with  complicating  medical  disease; 
and.  third,  after  poor  or  failed  visualization  of  the  larynx 
and  supraglottic  structures  during  DL.'-  Some  anatomic 
and  medical  obstacles  to  DL  are  obvious,  including  severe 
mandibular  hypoplasia,  distorting  neck  masses,  external 
surgical  fixation  of  the  head  and  neck  or  mandible,  crip- 
pling cervical  arthritis,  cervical  flexion  deformities  due  to 
burn  scars,  trauma  fixation  devices,  and  disfiguring  facial 
trauma.  However,  other  less  obvious  systemic  conditions 
and  anatomic  variations  can  also  complicate  laryngoscopy. 
Whether  an  effort  to  predict  successful  DL  is  justifiable 
has  been  argued. '^'^  Adverse  effects  of  hypoxia  injury, 
cardiovascular  insult,  or  intubation  trauma  incurred  during 
difficult  or  failed  DL  justify  an  airway  assessment  screen- 
ing history  and  physical  exam  for  all  but  the  most  imme- 
diate emergency  procedures.""*'^  The  airway  assessment 
items  should  include:  ( 1 )  airway  history,  (2)  record  re- 
view, (3)  examination  of  mouth,  teeth,  tongue,  and  neck, 
(4)  submental  distances,  (5)  neck  mobility,  (6)  view  from 
the  side,  (7)  nasopharyngeal  patency,  and  (8)  systemic 
disease. 

Incidence  of  Difficult  Intubation 

The  incidence  of  difficult  DL  and  intubation  is  reported 
as  1.5-15%.'"-"  --  Impossible  intubation  during  anesthe- 
sia has  been  reported  in  fewer  than  1%  of  patients  stud- 
ied.'" Frequency  data  are  complicated  by  the  use  of  con- 
flicting terminology  and  clinical  variation  in  risk  scoring.-' 
Also,  the  incidence  of  difficult  and  impossible  intubation 


Table  I .       Grades  of  Visualization  on  Direct  Laryngoscopy 


Visualization 

Structures  Visible  on  Direct 

Class 

Laryngo.scopy 

1 

•  Supraglottic  structures 

•  Laryngeal  inlet 

•  Vocal  cords 

2 

•  Epiglottis 

•  Laryngeal  inlet 

•  Posterior  aryepiglottic  folds 

3 

•  Epiglottis  only 

4 

•  Cannot  see  epiglottis 

(Adapted  from  Reference  24,) 

associated  with  anesthesia  may  be  under-reported  because 
clinicians  often  use  alternative  anesthetic  techniques  in 
order  to  avoid  DL  when  they  anticipate  difficulty. 

Laryngeal  Exposure 

The  most  widely  accepted  method  of  grading  difficulty 
of  DL  is  based  on  the  quality  of  laryngeal  view  obtained.-'* 
Intubation  following  a  grade  3  or  4  view,  where  the  larynx 
is  not  visualized,  must  be  considered  blind.  Table  1  shows 
the  criteria  for  the  grades  of  visualization  in  laryngoscopy. 
Both  blind  and  difficult  DL  are  more  likely  to  be  compli- 
cated by  tissue  trauma,  failed  attempts,  esophageal  intu- 
bation, cardiovascular  and  respiratory  instability,  and  as- 
piration of  gastric  or  pharyngeal  contents.-'' 

Is  the  Setting  or  the  Airway  Difficult? 

While  it  stands  to  reason  that  DL  in  the  emergency 
setting  should  be  more  stressful  than  in  the  operating  room, 
most  studies  published  from  the  emergency  department, 
respiratory  care,  or  pulmonary  standpoint  emphasize  the 
success  (rather  than  complications  and  difficulty)  of  DL 
for  intubation  in  these  settings. -''-'*  Several  research  groups 
have  compared  intubation  difficulty,  outcome,  and  tech- 
niques employed  in  the  field,  emergency  department,  in- 
tensive care  unit,  and  the  operating  room.''-'^  -''-  First-time 
success  rates  are  lower,  while  complication  rates  are  high- 
er, ■^'"■*  and  a  number  of  equipment  and  support  personnel- 
related  complaints  are  experienced  in  acute  settings.-'*''' 
One  rarely  has  time  to  obtain  a  complete  history  and  per- 
form an  optimal  physical  assessment.  The  incidence  of 
active  and  passive  gastrointestinal  reflux  is  higher.'" 
Acutely  decompensating  patients  in  the  special  care  units 
have  a  low  margin  of  safety  for  hypoxemia,  hypertension, 
hypotension,  or  other  stresses.'"'^  These  patients  may  re- 
quire intubation  in  suboptimal  circumstances  and  loca- 
tions, and  might  be  immobilized  so  that  the  intubator  can- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


779 


Prediction  of  a  Difficult  Intubation 


Table  2.      Anatomic  Causes  and  Mechanisms  of  Difficult  Laryngoscopy 


Cause 


Example 


Major  Problem 


Disproportionate  soft  tissues 


Distorted  anatomy 


Lingual  hypertrophy 
Down  syndrome 
Lingual  tonsillar  hypertrophy 
Marked  obesity 
Supraglottic  inflammation 
Prior  neck  dissection 
Expanding  neck  hematoma 

Peritonsillar  abscess 

Pharyngeal  mass  and  branchial  cleft  cyst 

Thyroid  tumor/goiter 

Developmental  craniofacial  anomalies 

Spinal  subluxation/osteophytes 

Maxillofacial  trauma 


•  Oversized  tongue 

•  Mass  effect 

•  Redundant  soft  tissue 

•  Swelling 

•  Torsion 

•  Deviation 

•  Obstructive  edema 

•  Lateral  compression  and  risk 
of  rupture 

•  Deviated  larynx/trachea 

•  Bony  incongruity  and 
disproportionate  anatomy 

•  Extrinsic  mass  effect 

•  Displacement  and/or  bleeding 


Inadequate  jaw  mobility 


Inadequate  neck  mobility 


Temporomandibular  dysfunction 

Short  mandibular  ramus 

Trauma 

Malignant  hyperthermia 

Myotonic  crisis 

Neurolept-malignant  syndrome 

Drug  intoxication 

Infections 

Degenerative  cervical  arthritis 

Morbid  obesity 

Facial  or  neck  bum  scarring 

Dwarfism 

Hydrocephalus 

Cranial  dysplasia 

Cervical  meningomyelocele 

Cervical  trauma 

Fractures 

Thoracic  kyphosis 


Fixed  or  limited  motion 
Inadequate  hinge  length 
Trismus  and/or  locked  jaw 
Masseter  tetanus  and 
generalized  rigidity 
Rigidity,  trismus,  tetanus 


Fused  or  irregular 
intervertebral  joints 
Tissue  limits  movement 
Fusion  and  contractures 
Short,  thick  neck 
Limited  neck  extension 
Inadequate  space 
External  fixation 
Fractures 
Hematoma 
Discontinuity 
Cervical  extension  limited 


not  effectively  extend  and  flex  the  neck  for  direct 
laryngoscopy.  Clearly,  the  setting  is  a  significant  factor. 

Anatomic  Problems 

DL  for  translaryngeal  intubation  requires  displacement 
of  the  tongue  and  tissues  at  the  floor  of  the  mouth  for 
alignment  of  pharyngeal  and  tracheal  axes  so  that  the  lar- 
ynx can  be  seen.^**  The  body  mechanics  required  for  DL 
are  adequate  mouth  opening,  mobile  soft  tissues,  a  flexible 
neck,  and  a  normally  placed  larynx.  Numerous  publica- 
tions document  difficult  laryngoscopy  in  patients  with  ab- 
normalities or  variants  in  laryngeal  position,  soft  tissue 
dimensions  and  mobility,  jaw  shape  and  function,  neck 
flexibility,  and  cervical  spine  joint  function.*'^-'*^  Predic- 


tive assessment  for  ease  of  DL  and  intubation  begins  with 
identification  and  recognition  of  typical  settings.  Table  2 
details  the  anatomic  causes  and  mechanisms  of  difficult 
laryngoscopy,  and  Table  3  summarizes  mechanical  factors 
that  predict  difficult  intubation. 

Interdental  Distance.  Prominent  upper  incisors  can  pose 
a  problem  because  they  limit  laryngoscope  blade  place- 
ment that,  together  with  marginal  mandibular  and  lingual 
mobility,  may  render  DL  impossible.  Unusual  problems 
such  as  calcification  of  the  stylo-hyoid  ligament,"*''  can  fix 
the  base  of  the  tongue  so  that  it  cannot  be  displaced  for 
laryngoscopy.  Jaw  abnormalities  such  as  mandibular  coro- 
noid  hyperplasia"*  and  cherubism,-*^  and  temporomandib- 
ular joint  (TMJ)  disease  can  limit  mouth  opening.  In  ad- 


780 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


Table  3.      Mechanical  Factors  that  Predict  Difficult  Intubation 

Interdental  space  less  than  6-7  cm 
Limited  mouth  opening  (less  than  6-7  cm) 
Limited  temporomandibular  joint  mobility 
Disproportionate  tongue 
Disproportionate  mandibular  ramus 
Disproportionate  hypopharyngeal  tissues 
Limited  flexion  of  lower  cervical  spine 
Immobile  CI -2  vertebral  joint,  limited  flexion 
Short  mandibulo-hyoid  distance  (less  than  6-7  cm) 
Short  mandibulo-thyroid  distance  (less  than  6-7  cm) 
Short  thyro-sternal  distance  (less  than  6-7  cm) 
Anteriorly  tilted  or  laterally  deviated  larynx 


dition,  facial  scarring  due  to  traumatic  bums  or  systemic 
disease  (eg,  pemphigus,  epidermolysis  bullosa,  graft-vs- 
host  disease)  can  restrict  access  to  the  oropharyngeal  and 
nasopharyngeal  airways,  and  limit  neck  extension.  Inter- 
dental distances  with  mouth  opening  should  average  4  cm 
in  the  adult  and,  with  maximal  effort,  6  cm  or  more. 

Temporomandibular  Joint  Function.  The  TMJ' s  func- 
tions as  both  a  gliding  and  hinge  joint  should  be  individ- 
ually tested,  because  each  component  can  be  significantly 
impaired  and  affect  DL.  In  addition,  one  movement  can  be 
abnormal  without  affecting  the  other.  The  examiner  places 
fingers  over  both  TMJs  and  asks  the  patient  to  slide  the 
jaw  forward  and  then  slide  it  from  side  to  side.  Palpable 
clicks,  anterior  dislocation,  or  grinding  sensations,  with  or 
without  pain,  imply  TMJ  disease.  Then  the  patient  should 
be  assessed  for  ability  to  open  the  mouth.  Anterior  dislo- 
cation may  not  be  important — a  significant  percentage  of 
the  population  can  spontaneously  dislocate  and  relocate 
the  mandible  anteriorly  with  a  vigorous  yawn.  Indeed, 
easy  dislocation  may  be  helpful,  because  it  can  improve 
both  the  mask  airway  and  laryngeal  visualization  during 
DL.  Painful  or  significantly  limited  TMJ  movement  and  a 
history  of  recurrent,  long-lasting,  painful  TMJ  dislocations 
are  relative  contraindications  for  orotracheal  intubation. 
Patients  with  TMJ  disease  are  often  highly  motivated  to 
discuss  intubation,  because  pain  and  limited  movement 
interfere  with  their  daily  lives.  The  inflamed,  arthritic, 
fused,  or  traumatized  TMJ  can  markedly  limit  TMJ  move- 
ment, even  after  muscle  relaxants  have  been  administered. 
Joint  mobility,  not  muscle  tone  or  masseter  spasm,  is  the 
issue.^s*" 

Intubation  Difficulty  Scores.  There  is  an  ongoing  de- 
bate between  the  proponents  of  simple  physical  screens  for 
intubation  difficulty  and  those  who  argue  on  behalf  of 
measured  and  derived  indices  of  predictability.  A  number 
of  radiographic  studies  have  been  performed  that  mea- 
sured bony  distances  as  predictors  of  DL.^""  Dynamic 


Table  4.      Modified  Mallampati  Visualization  Scale 


Oropharyngeal 
Grade 


Structures  Visible  on 
Oropharyngeal  Exam 


III 


IV 


Tongue 

Hard  palate 

Soft  palate 

Uvula 

Posterior  pharynx 

Tongue 

Hard  palate 

Soft  palate 

Partial  uvula  and  posterior 

pharynx 

Tongue 

Hard  palate 

Soft  palate 

No  posterior  pharynx 

Anterior  tongue 
Hard  palate 


Adapted  from  Samsoon  GLT.  Young  JRB.  Difficult  tracheal  intubation:  a  retrospective  study. 
Anaesthesia  1987;42:487-190. 


radiographic  studies  have  good  predictive  ability,  but  are 
not  likely  to  be  helpful  in  the  clinical  setting  because  of  the 
cost  and  time  involved.-*^  In  1985  Mallampati  et  al''-  val- 
idated a  predictive  index  of  DL  difficulty  by  visual  inspec- 
tion and  grading  of  tongue  and  pharyngeal  proportions 
with  maximal  mouth  opening.  In  1987  Samsoon  and  Young 
modified  Mallampati's  3-level  descriptive  scale  by  adding 
a  fourth  level  (Table  4).  Around  the  same  time,  Bellhouse 
and  Dore'^  correlated  measured  jaw  dimensions  and  cer- 
vical distances  with  anticipated  ability  to  move  the  neck 
and  displace  the  jaw  and  soft  tissues  for  DL.  Wilson  et  al-° 
measured  several  distances  in  633  patients  and  derived  a 
complex,  6-point  "risk  score"  for  DL,  which  they  tested  in 
778  patients.  These  variables  predicted  that  1.5%  of  pa- 
tients in  Wilson's  second  group  would  be  difficult  to  in- 
tubate; however,  the  predictive  value  of  the  tests,  in  ag- 
gregate, was  only  75%. 

Multifactorial  Intubation  Difficulty  Scores.  Frerk  et  al 
combined  the  modified  Mallampati  scoring  system  with 
the  measured  distance  between  the  anterior  point  of  the 
jaw  and  the  thyroid  cartilage  (thyromental  distance)  in  a 
series  of  patients.-'''*  They  used  radiographic  correlation  to 
show  that  thyromental  distance  correlates  with  the  gap 
between  the  first  and  second  cervical  vertebrae  and,  pre- 
sumably, the  ability  to  extend  the  neck  at  this  joint. ""^  Patil 
et  al  also  measured  thyromental  distances,  and  found  that 
tracheal  intubation  is  more  difficult  for  patients  with  less 
than  6  cm  space.-'"''  Recently,  Randell  reviewed  studies  of 
predictive  indices  and  noted  that  the  sensitivity  of  the  Mal- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


lampati  scale  has  been  reported  to  be  42-81%,  while  that 
of  the  thyromental  distance  has  been  reported  to  be  62- 
91%,  with  a  similarly  wide  range  for  specificity.-^''  Con- 
sequently, he  argued  that  the  best  predictive  system  should 
involve  multifactorial  indices.  However,  a  physician's  po- 
sition on  the  measurement-versus-clinical-assessment  de- 
bate may  be  more  a  matter  of  preference  than  measure- 
ment validity.''*' 

Observer  Inconsistency.  One  of  the  confounding  fac- 
tors that  accounts  for  the  wide  range  of  predictive  sensi- 
tivity reported  for  these  tests  is  examiner  variability.  If  the 
Mallampati  screen  is  performed  with  the  neck  fully  ex- 
tended, this  exam  combines  neck  mobility  with  an  esti- 
mate of  oropharyngeal  space  and  tongue  size,  instead  of 
estimating  the  oropharyngeal  space  and  tongue  dimensions 
alone. ""''  Additionally,  when  thyromental  or hyomental  mea- 
surements are  performed  with  the  neck  extended,  the  cor- 
relation may  differ  considerably  from  measurement  with 
the  neck  in  neutral  position.  Indeed,  some  authors  have 
argued  that  the  poor  sensitivity  and  specificity  of  intuba- 
tion screens,  because  of  observer  variability,  invalidate 
predictive  efforts  altogether.''""' 

Mandibular  Dimensions.  Another  problem  with  the  pre- 
dictive sensitivity  of  both  the  measured  indices  reported 
and  the  descriptive  scoring  system  is  that  jaw  dimensions 
also  play  an  essential  role.  Traditional  predictive  measure- 
ment has  focused  on  tongue  size,  neck  length,  and  neck 
mobility,  with  the  thought  that  the  larynx  is  commonly  too 
■'high"  or  too  "anterior"  for  adequate  DL.  Chou  and  Wu 
recently  identified  a  group  of  patients  with  long  necks, 
good  Mallampati  grades,  and  more  than  adequate  thyro- 
mental distances,  but  who  were  difficult  to  intubate  be- 
cause of  relatively  disproportionate  mandibular  dimen- 
sions."*^ They  argue  that  tongue  mobility  is  more  a 
function  of  mandibulo-hyoid  distance,  since  the  hyoid  bone 
plays  a  key  role  in  lingual  suspension,  and  that  relative  jaw 
opening  is  a  function  of  the  length  of  the  mandibular 
ramus. "^ 

Laryngeal  Tilt.  Roberts  raised  the  question  of  laryngeal 
inclination,  and  designed  and  promoted  a  laryngeal  bubble 
inclinometer  that,  like  a  modified  carpenter's  level,  mea- 
sures laryngeal  angulation. ^  An  anterior  laryngeal  tilt  makes 
it  harder  for  the  laryngoscopist  to  see  the  laryngeal  inlet. 
Cricoid  pressure,  applied  to  prevent  gastrointestinal  reflux 
and  aspiration  during  intubation  under  sedation  or  paral- 
ysis, actually  reduces  the  quality  of  visualization  during 
DL  by  accentuating  anterior  laryngeal  angulation.  Recently, 
several  groups  have  demonstrated  that  cricoid  pressure 
administered  simultaneously  with  cephalad  and  posterior 
pressure  facilitates  successful  intubation  of  both  pediatric 
and  adult  patients.  Posterior  pressure  on  the  upper  thyroid 


tends  to  correct  the  tilt  caused  by  pressure  on  the  cricoid, 
while  rightward  pressure  directs  the  laryngeal  inlet  toward 
the  laryngoscopist' s  line  of  sight.  This  has  been  called 
optimal  external  laryngeal  manipulation''  and  backward, 
upward,  rightward  laryngeal  pressure.''^ "'^ 

Value  of  Predictive  Tests.  A  reasonable  conclusion  af- 
ter review  of  the  airway  literature  is  that  predictive  tests 
can  be  useful.  Intubation  screening  test  sensitivity  may 
predict  75%  or  more  of  difficult  DLs.  However,  the  vari- 
ability in  sensitivity  and  specificity  reported  does  not  jus- 
tify elaborate  or  costly  screening  tests.  Most  clinicians 
conduct  a  modified  Mallampati  exam,  assess  interdental 
space,  comment  on  range  of  cervical  motion,  and  perform 
a  rough  screen  of  jaw  to  hyoid,  thyroid,  and  sternal  dis- 
tances. Many  combine  several  of  these  in  one  multifacto- 
rial screening  maneuver.  If  the  patient  opens  his  or  her 
mouth  widely,  protrudes  the  tongue,  phonates,  and  simul- 
taneously extends  the  neck,  one  can  get  a  general  impres- 
sion of  jaw  mobility,  oropharyngeal  space,  lingual  size, 
and  neck  mobility.  Another  variant  on  this  quick  screen 
has  been  widely  promulgated  as  the  "Rule  of  Threes."  If 
the  examiner  can  place  3  fingers  (approximately  6-7  cm) 
in  the  interdental  space,  between  the  anterior  jaw  and  hy- 
oid bone,  and  between  the  thyroid  cartilage  and  the  sternal 
notch  with  the  neck  in  neutral  position,  there  is  probably 
adequate  "room"  for  DL.  Significant  difficulty  with  2  or 
more  of  these  components  of  the  exam  justifies  a  more 
detailed  assessment,  because  the  probability  of  difficult 
DL  increases  by  3-fold.  Failed  predictors  indicate  a  need 
to  plan  an  alternative  airway  management  technique, 
whether  as  a  primary  approach  or  as  a  backup.''^  Time 
permitting,  a  more  detailed  assessment  can  direct  the  in- 
tubator  to  the  most  appropriate  intubation  technique  when 
difficult  DL  is  anticipated. 

Complicating  Conditions 

Medical  Conditions 

Table  5  lists  congenital,  developmental  and,  acquired 
systemic  diseases  that  can  complicate  DL  and  intubation. 
Those  that  are  associated  with  soft  tissue  and  skeletal  anom- 
alies have  an  obvious  potential.  Rheumatoid  arthritis,  for 
example,  can  present  with  laryngeal,  cervical,  TMJ,  pul- 
monary, and  other  system  involvement.'''*'''^  In  general, 
patients  with  rheumatoid  arthritis  and  ankylosing  spondy- 
litis who  have  progressed  to  the  stage  of  a  fixed  neck  are 
quite  difficult  to  intubate  and  have  a  high  probability  of 
TMJ  involvement.  By  the  time  a  patient  with  the.se  mul- 
tisystem disorders  develops  cervical  rigidity,  other  airway 
components  are  involved  as  well.'"'-^'  Patients  with  rheu- 
matoid and  other  degenerative  arthritides  can  also  develop 
cervical  instability  because  of  pathologic  fractures,  brittle 


782 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


Table  5.      Congenital  and  Acquired  Conditions  Associated  with  Difficult  Intubation 


Condition 


Description 


Problem 


Acrocephalosyndactyly 
Acromegaly 

Anderson's  syndrome 
Angioneurotic  edema 

Anhydrotic  ectodermal 

dysplasia 
Arthrogryposis 
Behfet's  syndrome 
Cerebral  gigantism 
Cherubism 
Chondro-ectodermal 

dysplasia 
Chubby  puffer 
Coagulopathy 
Collagen-vascular 

diseases  and 

syndromes 
Cretinism 

Cri-du-chat  syndrome 

Crouzon"s  disease 
Down  syndrome 

Epidermolysis  bullosa 
Erythema  multiforme 
Fetal  alcohol  syndrome 

Glycogen  storage 

disease 
Goiter 


Goldenhar's  syndrome 
Goltz  syndrome 
Gorlin-Chaudhry-Moss 

syndrome 
Hal  lervorden-Spatz 

syndrome 
Histiocytosis  X 

Hurler's  syndrome 

Infantile  gigantism 
Klippel-Feil  syndrome 
Larsen's  syndrome 

Leopard  syndrome 

Meckel  syndrome 
Median  cleft  face 

Miibius's  syndrome 


Hypoplastic  mandible,  exophthalmos,  craniosynostosis,  retardation 
Growth  hormone  excess,  overgrowth  of  bones,  cartilage,  and  soft  tissues 

with  disproportion 
Mid-face  hypoplasia,  retrognathia,  kyphoscoliosis,  triangular  facies 
Hereditary  or  acquired  C 1 ,  C4  esterase  deficiency.  Episodic  face  and 

laryngeal  edema 
Heat  intolerance,  abnormal  mucous,  hypoplastic  mandible,  respiratory 

infections 
Multiple  contractures,  congenital  and  progressive 
Ulceration  airway,  scarring,  vasculitis 
Acromegalic  features 

Fibrous  dysplasia,  mandibular  abnormality 
Abnormal  maxilla,  cleft  lip  and  palate,  hepatosplenomegaly,  skeletal 

abnormalities,  atrial  and  ventricular  septal  defects 
Obesity,  sleep  apnea,  cor  pulmonale 
Bruising,  hemorrhage,  airway  bleeding 
Multiple  acquired  and  inherited  autoimmune  syndromes  include: 

rheumatoid  arthritis,  polyarteritis  nodosa,  systemic  lupus 

erythematosus,  dermatomyositis 
Goiter,  hypothyroidism,  macroglossia,  abnormal  respiratory  drive, 

hypometabolism 
Retardation,  microcephaly,  micrognathia,  small  larynx,  cat-like  cry  in 

infancy 
Craniosynostosis,  hypoplastic  mandible 
Macroglossia,  small  pharynx,  retardation,  hypotonia,  associated 

abnormalities 
Erosions  and  blisters,  oral  lesions,  and  tongue  adhesion 
Urticaria,  ulcerations,  cardiac  arrhythmias,  coagulopathy,  pleural  blebs 
Multiple  malformations,  including  microcephaly,  microglossia,  cardiac 

lesions 
Muscle  deposits  of  glycogen,  weakness,  macroglossia,  cardiomegaly, 

and  failure 
Unilateral  or  bilateral  mass  effect,  deviated  trachea/larynx,  obstruction, 

retrosternal  tracheal  compression,  vascular  compression,  supraglottic 

edema 
Unilateral  maxillary  and  mandibular  hypoplasia 
Multiple  papillomatosis  membranes  and  skin 
Craniofacial  dysostosis,  dental  and  eye  abnormalities,  skull  asymmetry 

Basal  ganglia  disorder,  dementia  and  dystonia  with  torticollis,  trismus, 

and  scoliosis 
Bone  and  visceral  lesions,  laryngeal  fibrosis,  coagulopathy  and  anemia, 

pulmonary  and  hepatic  lesions 
Mucopolysaccharidosis,  joint  fusion,  abnormal  facies  and  gargoylism. 

deafness,  dwarfism,  and  retardation 
Macrosomia,  macroglossia,  and  exophthalmos 
Fused  cervical  vertebrae  and  neck  rigidity 
Hydrocephalus,  multiple  dislocations,  cleft  palate  and  lip.  abnormal 

laryngeal  cartilages 
Freckles,  95%  have  pulmonic  stenosis,  growth  retardation,  pectus 

carinatum.  kyphosis,  genito-urinary  anomalies 
Microcephaly,  micrognathia,  cleft  epiglottis,  renal  dysplasia 
Multiple  dysraphism.  lipomas  and  dermoid  tumors — especially  over 

frontal  bones 
Paralysis  6th  and  7th  cranial  nerves,  micrognathia,  feeding  difficulties 


Difficult  intubation 
Airway  and  intubation 

Airway  and  intubation 

Airway  obstruction  and  intubation 

Difficult  intubation 

Intubation 

Scar  contractures 

Airway  and  intubation 

Direct  laryngoscopy  quite  difficult 

Airway  and  intubation 

Airway  obstruction 

Obstruction,  aspiration,  mass  effect 

Temporomandibular  joint, 

cricoarytenoid  arthritis,  fixed  neck 

Sensitivity  to  drugs,  intubation, 

obstruction 
Difficult  airway  and  intubation 

Intubation  and  direct  laryngoscopy 
Airway  and  intubation 

Intubation  and  post-intubation  lesions 
Airway  and  post-intubation 
Intubation 

Airway  obstruction 

Obstruction,  intubation 


Airway  and  intubation 
Airway  papillomas 
Airway  and  intubation 

Airway  and  intubation,  spastic 

contractures 
Airway,  bleeding,  intubation 

Airway  and  intubation 

Large  tongue,  direct  laryngoscopy 

Intubation 

Intubation 

Intubation  and  ventilation 

Intubation 

Intubation  and  laryngoscopy 

Aspiration  and  intubation 


Respiratory  Care  •  July  1999  Vol  44  No  7 


7S'i 


Table  5  Continued 


Prediction  of  a  Difficult  Intubation 


Mucolipidosis 

Myositis  ossificans 

Myotonia 

Oral-facial-digital 

syndrome 
Osteogenesis  imperfecta 

Pierre-Robin  syndrome 

Pyle's  disease 

Rieger's  syndrome 

Sleep  apnea  syndromes 

Superior  sulcus  tumor 

Superior  vena  cava 

syndrome 
Tangier  syndrome 

Treacher-Collins's 

syndrome 
Trisomy  13 

Turner's  syndrome 

Vascular  ring 

Velocardiofacial 

syndrome 
Zenker's  diverticulum 


Bone  changes,  joint  limitations,  pulmonary  disease,  cardiac  valve 

insufficiency,  retardation 
Bony  infiltration  of  tendons,  muscle,  fascia,  and  spine  with  cervical 

rigidity 
Progressive  weakness,  myotonic  spasms,  cardiac  lesions,  conduction 

abnormalities,  respiratory  failure,  baldness,  cataracts 
Cleft  lip,  palate,  and  tongue;  hypoplastic  maxilla  and  mandible; 

hydrocephalus;  renal  cysts;  abnormal  fingers 
Pathologic  fractures,  kyphoscoliosis,  dental  weakness,  vascular  fragility, 

deafness 
Cleft  palate,  micrognathia,  macroglossia,  airway  obstruction,  and  cor 

pulmonale 
Craniofacial  abnormalities,  cranial  neuropathy,  and  disproportionate 

mandible 
Hypodontia,  myotonia,  and  maxillary  hypoplasia 

Large  tonsils  and  adenoids,  central  respiratory  unresponsiveness, 

redundant  soft  tissue,  macroglossia,  cranial  nerve  dysfunction,  cor 

pulmonale,  obesity 
Pain,  thoracic  outlet  and  arteriovenous  obstruction,  and  recurrent  nerve 

paralysis 
Vascular  obstruction  due  to  mass  or  clot  causes  upper  airway  edema  and 

may  obstruct  trachea  at  subglottic  level,  compress  heart 
Abnormal  lipid  metabolism,  enlarged  tonsils  and  adenoids,  platelet 

dysfunction  and  hypersplenism,  neuropathy,  coronary  disease 
Mandibulofacial  dysostosis  with  micrognathia,  aplastic  zygomatic 

arches,  choanal  atresia 
Retardation,  microcephaly,  micrognathia,  cleft  lip  and  palate,  ventricular 

septal  defect,  and  dextrocardia 
Webbed  neck,  hypogonadism,  micrognathia,  renal  anomalies,  aortic  and 

pulmonic  anomalies 
Tracheal,  vascular,  and  esophageal  compression  causes  edema  and 

obstruction 
Palatal  and  pharyngeal  anomalies,  congenital  heart  disease,  vertical  face, 

posterior  mandible 
Acquired  pharyngeal  hernia  or  pouch 


Airway  and  intubation 

Intubation  and  airway 

Ventilation,  arrhythmias,  spastic 

contractures 
Intubation  and  airway 

Immobile  neck,  intubation,  loose 

teeth,  bleeding 
Airway  and  intubation 

Intubation  and  airway  obstruction 

Spastic  contractures,  airway 

obstruction 
Drug  sensitivity,  airway  obstruction, 

intubation 

Airway  obstruction  and  intubation 

Airway  obstruction,  deviation, 

intubation 
Airway  obstruction,  coagulopathy 

Airway  obstruction,  intubation 

Intubation 

Intubation 

Obstruction  and  difficult  intubation 

Airway  obstruction  and  intubation 

Aspiration 


osseous  structures,  and  multiple  subluxations.^-  When  the 
neck  is  fixed  or  unstable,  significant  neurologic  injury  to 
the  spinal  cord  is  a  possible  complication  of  DL.  Ad- 
vanced scleroderma  is  associated  with  failed  esophageal 
contractility  and  soft  tissue  rigidity  in  the  neck,  as  in  other 
places.  Neurofibromatosis  can  cause  retropharyngeal  le- 
sions that  obstruct  and  distort  the  airway, ^^  similar  to  the 
irregular,  protruding  retropharyngeal  osteophytes  occasion- 
ally seen  with  degenerative  osteoarthritis,  ankylosing  spon- 
dylitis, or  idiopathic  skeletal  hyperostosis.'"-^'*  Marked  obe- 
sity is  a  condition  that  increases  difficulty  with  both  airway 
management  and  DL.''^  Obstructive  and  mixed  central/ 
obstructive  sleep  apnea  syndromes  present  a  significant 
medical  and  surgical  challenge,  whether  due  to  morbid 
obesity  or  to  inherited  disorders  (eg,  Prader-Willi  syn- 
drome,^■''  cranoisynostosis,^''  Marfan' s  syndrome, ^^  acro- 
megaly,'"* Down  syndrome,^'^  or  Hecht  syndrome**")-  Al- 
though individuals  with  sleep  apnea  commonly  have  very 
poor  airways  and  periodic  breathing  when  they  are  ob- 


tunded  or  sedated,  they  may  also  be  difficult  to  intubate 
because  of  anatomic  problems  that  contribute  to  their  ob- 
struction. Sleep  apnea  patients  with  a  developmental  syn- 
drome or  multisystem  disease  (eg,  acromegaly)  may  also 
be  challenging. 

Neurologic  Injuries.  Localizing  neurologic  signs,  de- 
creased consciousness,  dilated  pupil(s),  posturing,  and  other 
evidence  of  increased  intracranial  pressure  can  present  as 
a  medical  emergency  with  or  without  immediate  airway 
compromise,  as  can  sustained,  uncontrolled  seizures,  or 
status  epilepticus.  Abnormal  muscle  activity  with  clenched 
teeth  and  stertorous  or  periodic  breathing  can  make  DL 
quite  difficult,  as  well  as  raise  intracranial  pressure  to 
more  dangerous  levels.  Alternative  techniques  may  be  re- 
quired because  anticonvulsant  and  sedative  administration 
rarely  decreases  muscle  activity  enough  to  allow  DL.  As 
with  intoxicated  patients,  such  patients  may  require  "phar- 
macologic restraint"  to  allow  effective  evaluation  and 


784 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


care.*"  The  newer  nondepolarizing  muscle  relaxants  like 
rocuronium  (Zemuron)  and  vecuronium  (Norcuron)  induce 
rapid  paralysis  for  DL**-  and  intubation  without  causing 
muscle  contracture,  hypotension,  tachycardia,  or  bradycar- 
dia. When  used  properly  with  sedatives  and  narcotics,^^ 
they  allow  effective  ventilation,  control  of  muscle  metab- 
olism, and  acute  management  of  intracranial  hypertension. 
A  combination  of  anesthetic  and  relaxant  agents  titrated  by 
an  airway  management  expert  will  control  cerebral  metab- 
olism and  blood  flow,  effectively  eliminating  secondary 
cerebral  insults  caused  by  straining,  coughing,  or  hyper- 
tension. The  implications  of  cervical  spine  fracture  and/or 
dislocation  are  similar,  except  that  flexion  and  extension  dur- 
ing DL  can  induce  or  worsen  spinal  cord  injury.  For  this 
reason,  trauma  airway  paradigms  include  use  of  cervical  fix- 
ation collars  and  manual  in-line  traction  on  the  neck. 

Ophthalmologic  Injuries.  Patients  with  open  ophthal- 
mologic injuries  present  unique  problems.  Straining, 
coughing,  and  intubation  maneuvers  can  cause  extrusion 
of  vitreous  or  aqueous  humor,  as  well  as  other  delicate  eye 
structures,  that  may  be  difficult  to  replace  at  surgery.  Mus- 
cle contractions  caused  by  succinylcholine  paralysis  can 
contribute  to  this  process.  The  open  eye,  like  multisystem 
trauma,  requires  advanced  airway  management  skills  and 
pharmacologic  support. 

Coagulopathy  and/or  Anticoagulant  Therapy.  Spe- 
cial care  in  intubation  must  be  taken  with  patients  on  an- 
ticoagulants and  those  with  medical  conditions  that  impair 
clotting  function.  These  conditions  increase  the  risk  of 
airway  bleeding  and  expanding  airway  hematoma  during 
DL.  A  bloody  field  or  the  mass  effect  of  an  expanding 
hematoma  may  obstruct  the  laryngoscopist's  view  at  DL, 
raise  intracranial  pressure,  cause  life-threatening  airway 
obstruction,'"'  and/or  predispose  to  blood  aspiration.  Co- 
agulation problems  may  be  self-evident  because  of  ongo- 
ing bleeding,  or  they  may  be  occult.  In  both  situations, 
progressive  bleeding  after  airway  management  maneuvers 
or  DL  can  make  subsequent  attempts  quite  difficult.  Typ- 
ically, the  endoscopist  begins  with  a  stable  situation  that 
progressively  deteriorates  as  intubation  attempts  or  other 
traumatic  airway  maneuvers  continue.  Known  or  suspected 
coagulopathy  requires  a  very  cautious  approach,  including 
consideration  of  advanced,  atraumatic  techniques  such  as 
fiberoptic  intubation. 

Chronic  anticoagulant  therapy  is  routine  for  patients  with 
artificial  heart  valves  or  a  history  of  significant  deep  ve- 
nous thrombosis,  with  or  without  pulmonary  embolism. 
Platelet  inhibitors  and  heparin  are  commonly  used  in  res- 
cue therapy  for  acute  or  impending  coronary  or  carotid 
occlusion  and  acute  coronary  interventions.  Patients  with 
impending  peripheral  vascular  occlusion  or  recent  vascu- 
lar surgery  are  often  anticoagulated.  Many  patients  under- 


going abdominal  or  orthopedic  procedures  and  who  are 
considered  high  risk  for  deep  venous  thrombosis  received 
low  dose  heparin  perioperatively.  Newer,  more  homoge- 
nous heparin  compounds  and  heparinoids  that  have  a  greater 
potency  and  are  more  consistently  effective  have  been 
introduced  recently  in  the  United  States  and  abroad.  Oc- 
casionally, prophylactic  drug  regimens  are  associated  with 
remarkably  prolonged  clotting  times. 

Systemic  conditions  that  impair  the  microvascular  cir- 
culation can  be  associated  with  an  evolving  coagulopathy 
combined  with  the  consumption  of  clotting  factors  and  the 
release  of  endogenous  circulating  anti-coagulants.  This  is 
most  common  in  sepsis,  but  overwhelming  infection  by 
the  Rocky  Mountain  spotted  fever  bacillus  or  epidemic 
meningitis  caused  by  the  meningococcus  are  well  known 
for  inducing  coagulopathy  and  platelet  dysfunction.  Also, 
severe  pre-eclampsia  and  a  variant  condition  known  in 
obstetrics  as  the  HELLP  syndrome  (hepatitis,  elevated  liver 
function  tests,  low  platelets)  are  commonly  associated  with 
consumption  of  clotting  factors,  platelet  dysfunction,  and 
an  increased  risk  of  bleeding.  Patients  with  severe  hepa- 
titis, whether  chronic  or  infectious,  may  present  with  sig- 
nificant clotting  disorders  due  to  impaired  hepatic  produc- 
tion of  essential  coagulation  factors.  Autoimmune  diseases 
that  are  associated  with  dangerously  low  platelet  levels 
and  spontaneous  or  traumatic  bleeding,  like  idiopathic 
thrombocytopenic  purpura,  can  increase  difficulty.  Clini- 
cal signs  such  as  subcutaneous  bleeding,  prolonged  bleed- 
ing after  needle  punctures,  and  expanding  tissue  hemato- 
mas after  trauma  suggest  active  coagulopathy.  Bleeding 
after  minimal  airway  trauma  can  rapidly  become  a  critical 
airway  management  problem. 

The  Difficult  Airway  Algorithm 

A  growing  consensus  of  acute  care  practitioners  identi- 
fied the  difficult  airway  as  a  recurrent  problem  for  life 
support  and  anesthesia.  It  has  two  presentations:  unpre- 
dictably difficult  intubation,  and  recognizably  difficult  in- 
tubation. Isolated  efforts  toward  a  goal-oriented  approach 
led  to  disease-specific  (eg,  advanced  trauma  life  support), 
regional,  and  organization-specific  protocols.  In  the  early 
1990s,  an  ASA  task  force  took  an  evidence-based  ap- 
proach to  the  issue  by  conducting  a  two-step  meta-analy- 
sis— review  of  literature  from  1 973  through  1 99 1 ,  and  by 
drawing  on  the  experience  of  50  recognized  airway  man- 
agement experts."  Decision  pathways  were  based  on  crit- 
ical linkages  between  the  views  and  data  identified  by  the 
process.  In  brief,  recommendations  were:  ( 1 )  preintubation 
assessment  should  be  used  as  a  guide  for  planning  intu- 
bation, (2)  awake  techniques  should  be  chosen  if  DL  is 
likely  to  be  difficult  (Fig.  1),  (3)  alternative  airways  and 
techniques  should  be  chosen  in  a  methodical  fashion  when 
unexpected  difficulty  with  DL  is  encountered  (Fig.  2),  and 


Respiratory  Care  •  July  1999  Vol  44  No  7 


785 


Prediction  of  a  Difficult  Intubation 


Awake  intubation  attempt 


z\ 


Success 


Failure 


■  Verify  position 

■  Capnography 

•  Oximetry 

•  Clinical  exam 


Consider  alternative 
technologies 

Consider 
tracheostomy  or 
cricothyrotomy 


Fig.  1.  Awake  Intubation  Decision  Algorithm. 

(4)  an  airway  management  algorithm  will  improve  out- 
come. The  ASA  task  force  refrained  from  endorsing  spe- 
cific techniques  in  various  settings  because  the  skills  and 
options  in  each  facility  or  system  may  vary  somewhat. 
Subsequent  experience  led  to  the  incorporation  of  newer 
"intermediate"  airways  (eg,  the  laryngeal  mask  airway)  as 
potentially  life-saving  options  when  ventilation  is  difficult 
and  DL  for  tracheal  intubation  is  impossible.  For  instance, 
the  laryngeal  mask  airway  often  achieves  ventilation  in 
nonintubatable  patients,  and  can  act  as  an  intubation  guide. 
It  is  recommended  that  equipment  and  supplies  be  or- 
ganized in  a  central  location  for  dealing  with  difficult  in- 
tubation procedures  and  that  personnel  be  aware  of  insti- 
tutional protocols  and  related  equipment.  If  the  patient  was 
initially  difficult  to  intubate  or  ventilate,  the  extubation 
plan  should  take  those  problems  into  account.  As  with 
other  advanced  life  support  skills,  DL  and  alternative  tech- 
niques that  are  part  of  the  difficult  airway  algorithm  should 
be  refreshed  through  retraining  in  simulation  and  practice. 


laryngoscope),  reviewed  briefly  below.  Since  the  prob- 
lems presented  by  the  difficult  DL  vary,  an  example  of 
each  type  should  be  available  on  the  difficult  airway  cart. 
Most  laryngoscopes  are  now  available  with  fiberoptic  light- 
ing systems  that  are  more  reliable  and  brighter.  Battery 
bulbs  that  screw  into  the  blade  tend  to  become  loose  or 
corroded  and  flicker  after  repeated  cleaning.' 

Curved  Laryngoscope  Blade 

The  curved  blade,  exemplified  by  the  Macintosh  laryn- 
goscope blade,  slides  down  the  tongue  and  seats  in  the 
vallecula.  It  tends  to  provide  greater  mouth  opening  and 
affords  a  greater  interdental  aperture.  It  is  thought  to  be 
easier  for  beginners  and  is  most  often  the  first  choice  for 
those  with  basic  intubation  skills. **■*  The  McCoy**''**'^  and 
Corazzelli  modifications  provide  a  flexible  tip  for  the  curved 
blade  that  lifts  the  base  of  the  tongue  and  epiglottis  further 
out  of  the  endoscopist's  view,  facilitating  intubation  in 
some  cases. 

Straight  Laryngoscope  Blade 

The  straight  blade,  as  exemplified  by  the  widely-used 
Miller  blade,  gives  a  more  complete  view  of  the  larynx  as 
the  operator  lifts  the  epiglottis  out  of  the  way.  The  straight 
blade  is  more  appropriate  with  anterior  laryngeal  angula- 
tion, limited  interdental  aperture,  or  limited  neck  mobili- 
ty.^^  A  helpful  modification  of  the  Miller  blade  places  the 
light  on  the  left  side,  so  that  it  is  less  likely  to  be  blocked 
by  the  tracheal  tube  as  the  tube  is  advanced  through  the 
field  of  view  into  the  larynx. 

Tube  Laryngoscope 


Laryngoscopy  Options 

There  are  numerous  variations  on  the  3  basic  designs  of 
laryngoscope  blade  (curved  blade,  straight  blade,  and  tube 


Intubation  attempt  on  patient  under  general  anesthesia 

> 

^X 

Success 

Failure 

Ventilation  inadequate 

\ 

\ 

. 

' 

■  Verify  position 

■  Capnography 

Ventilation  adequate 

•  Awaken 
Spontaneous 

ventilation 
■  Call  for  help 

•  Emergency 

pathway 

' 

f 

Employ  intermediate 
techniques 

Fig.  2.  Decision  Algorithm  with  Anesthesia/Paralysis. 


The  tube  laryngoscope,  as  seen  in  half-round  or  3-quarter- 
round  configuration  (eg,  Flagg,  Wis-Hipple,  Wis-Foreg- 
ger)  or  in  closed  tube  configuration  (eg,  Jackson  or  ante- 
rior commissure  laryngoscope),  is  a  straight  blade  with  a 
curved  shield  that  keeps  soft  tissue  out  of  the  field  of  view. 
The  tube  laryngoscope  is  most  helpful  in  patients  with 
prominent  teeth,  limited  neck  motion,  or  disproportionate 
soft  tissues  or  tongue. 

Additional  Maneuvers 

Additional  maneuvers  that  improve  the  quality  of  the 
view  during  DL  include  optimal  head  and  neck  position- 
ing**'* and  optimal  external  laryngeal  pressure.*^  '■'*'*  All  de- 
scriptions of  DL  emphasize  the  need  to  optimally  extend 
the  upper  cervical  vertebrae  while  flexing  the  lower  cer- 
vical spine.  In  most  patients,  the  work  of  lifting  and  po- 
sitioning the  head  and  neck  can  be  reduced  by  placing  a 
pillow  under  the  occiput  while  extending  the  neck  for 


786 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


laryngoscopy.  Since  the  best  maneuver  for  mask  ventila- 
tion is  marked  extension  of  the  neck,  it  may  be  helpful  to 
use  a  small  pillow  or  rolled  sheets  under  the  neck  or  shoul- 
ders for  this  purpose.  These  can  be  shifted  from  under  the 
neck  and  shoulders,  where  the  mask  airway  is  optimal,  to 
the  occiput  for  the  "sniffing"  position  and  laryngoscopy, 
and  back  again  for  mask  ventilation.  A  patient  with  a 
relatively  large  head  or  thin  torso  may  have  considerable 
anterior  flexion  of  the  lower  cervical  spine  to  begin  with, 
and  thus  only  require  upper  neck  extension.  Patients  in 
cervical  traction,  or  who  have  truncal  obesity,  may  require 
forceful  anterior  lift  during  suspension  laryngoscopy  or 
laryngeal  pressure.  As  noted  earlier,  cricoid  pressure  or  an 
anteriorly  tilted  larynx  displaces  the  laryngeal  inlet  ante- 
rior to  the  laryngoscope  tip.  Optimal  external  laryngeal 
pressure,  together  with  adjusting  head  and  neck  position, 
may  increase  the  quality  of  laryngeal  view  by  one  Cor- 
mack  grade.^**  Optimal  external  laryngeal  manipulation 
should  be  considered  if  a  first  DL  attempt  is  difficult.  No 
single  maneuver  works  for  all  patients,  so  the  laryngosco- 
pist  should  seek  the  best  view  both  by  adjusting  head  and 
neck  position  and  by  recruiting  an  experienced  person  to 
provide  optimal  external  laryngeal  manipulation  or  sup- 
port the  head  and  neck.****  If  the  patient  is  lying  on  the  floor, 
it  may  be  easier  to  manage  intubation  with  the  operator 
lying  on  his/her  side  rather  than  kneeling  or  squatting  over 
the  patient.^- 

Stylets 

Under  emergency  circumstances,  one  should  always  use 
a  stylet,  whether  rigid,  malleable,  or  flexible.  Viewing  the 
larynx  clearly  during  DL  is  only  the  first  step  in  tracheal 
intubation.  Directing  the  tube  through  the  mouth  and  lar- 
ynx and  into  the  trachea  may  be  almost  as  difficult.  First- 
time  success  rates  are  higher  when  the  tracheal  tube  is 
stiffened  and  can  be  directed  more  accurately.  As  the  tra- 
cheal tube  is  passed  through  the  laryngeal  inlet,  it  may 
need  to  be  rotated  so  that  the  anteriorly  curved  tip  won't 
catch  in  the  larynx.  Forceful  anterior  pressure  by  a  stylet- 
ted  tube  can  traumatize  the  trachea.  On  the  other  hand,  a 
flexible  tube  without  a  stylet  may  bend  back  into  the  phar- 
ynx and  pass  into  the  esophagus.  By  convention,  the  tra- 
cheal tube  tip  is  beveled  left  to  right  so  that  the  tip  will  not 
catch  on  the  left  vocal  apparatus  as  it  is  passed  into  the 
larynx  from  the  right  side  of  the  mouth.  A  stylet  enables 
the  operator  to  direct  and  rotate  the  tube  so  that  this  bevel 
turns  anteriorly  and  slides  into  the  trachea  after  it  passes 
the  level  of  the  cords.  A  malleable  stylet  allows  the  intu- 
bator  maximum  flexibility  of  shape  to  achieve  the  ideal 
curve  and  angle  for  oral  intubation.  A  flexible  stylet  such 
as  the  FlexGuide  (Mallinckrodt  Inc,  Pleasanton,  Califor- 
nia) can  be  redirected  in  use  so  that  the  tip  of  the  tube  can 


be  passed  into  and  below  the  larynx  without  withdrawing 
and  reshaping  the  stylet. 

Staged  Intubation 

Staged  intubation  has  been  widely  used  in  the  United 
States  and  abroad  for  difficult  intubations  or  when  the 
view  of  the  larynx  is  imperfect.  Staged  intubation  tech- 
niques employ  a  guide  wire,  gum  rubber  elastic  bougie, 
controlled  stylet,  or  angled  ventilating  stylet.  With  this 
approach,  a  stylet  is  passed  into  the  larynx  and  trachea  as 
the  first  stage,  either  under  direct  vision  or  blindly.  In  the 
second  stage,  the  stylet  provides  the  guide  over  which  an 
endotracheal  tube  is  passed  through  the  larynx.**'^  '^'  The 
gum  rubber  bougie  is  a  common  surgical  item,  found  in 
many  operating  rooms,  and  has  been  most  widely  used  as 
an  intubation  guide  in  this  setting.  A  modified  tracheal 
tube  that  facilitates  staged  intubation  has  been  introduced 
in  the  United  Kingdom,'^-  but  is  not  yet  available  in  the 
United  States.  A  translaryngeal  guide  wire  can  be  used  as 
the  first  of  3  steps  for  passage  of  a  tapered  stylet  or  a 
hollow  ventilating  stylet  over  which  intubation  can  be 
achieved.  Insufflating  or  ventilating  stylets  allow  oxygen 
tlow,  jet  ventilation,^'  or  assisted  breaths  as  an  endotra- 
cheal tube  is  advanced  over  them  through  the  larynx  and 
into  the  trachea.'"''^  In  cases  where  the  patient  is  breathing 
spontaneously  and  DL  is  difficult  or  impossible,  accuracy 
of  blind  intubation  over  an  insufflating  stylet  can  be  en- 
hanced. The  Airway  Exchange  Catheter  (Cook  Interna- 
tional Inc,  Bloomington,  Indiana)  is  a  2-ended,  hollow 
stylette  with  side  air  holes  and  depth  markings.  It  is  avail- 
able with  2  types  of  ventilating  adapters.  One  is  a  Luer 
lock  fitting  for  insufflation  and  the  other  is  a  15  mm  adapter 
for  bag  ventilation.  Each  is  easily  detached  .so  that  insuf- 
flation can  be  interrupted  for  passage  of  a  tracheal  tube. 
This  useful  device  comes  in  pediatric  and  adult  sizes,  with 
both  straight  and  angled  versions,  for  intubation  and  as  a 
guide  for  tracheal  tube  change.  Sonic  devices  that  amplify 
breath  sounds'*^  or  capnometers'"  '''*  that  confirm  phasic 
carbon  dioxide  exhalation  through  an  insufflation  stylet 
add  a  measure  of  security  to  staged  procedures. 

Alternatives  to  Direct  Laryngoscopy 

Blind  Intubation 

Blind  intubation  can  be  performed  both  nasally  and 
orally.  Many  blind  intubations  are  performed  during  at- 
tempted DL  when  the  view  is  inadequate.  The  tracheal 
tube  or  an  intubating  stylet  is  blindly  directed  toward  the 
operator's  best  guess  of  laryngeal  location.  Note  that  in  the 
trauma  setting,  there  is  a  significant  risk  of  foreign  body 
dislocation  from  the  damaged  airway  and  into  the  trachea 
as  the  endotracheal  tube  is  passed." 


Respiratory  Care  •  July  1999  Vol  44  No  7 


787 


Prediction  of  a  Difficult  Intubation 


One  disadvantage  of  blind  intubation  is  that  even  sev- 
eral confirmatory  tests  do  not  absolutely  assure  that  the 
tracheal  tube  is  correctly  seated  below  the  glottic  aperture 
(and  not  within  the  glottic  aperture). '*'*  Various  types  of 
tube  benders  and  guides'""  have  also  been  used  to  facili- 
tate blind  techniques.'"' 

The  nasal  approach,  while  complicated  by  an  increased 
risk  of  bleeding,  nasal  bone  fracture,  and  sinusitis.'"-  has 
been  widely  utilized  over  the  years  for  blind  intubation. 
This  is  partly  because  a  tube  that  makes  the  nasopharyn- 
geal curve  into  the  posterior  pharynx  is  angled  so  that  it  is 
more  likely  to  pass  anteriorly  into  the  larynx  than  an  oral 
tube.  Several  techniques  can  enhance  success  of  blind  na- 
sotracheal intubation;  these  include  head  and  neck  reposi- 
tioning, inflation  of  the  tracheal  tube  cuff,'""*  use  of  a  tube 
(eg,  the  Endotrol  tube  [Mallinckrodt  Inc,  Pleasanton,  Cal- 
ifornia]) or  stylet  that  can  be  directed  into  line  with  the 
larynx,  and  passage  over  a  nasotracheal  suction  catheter. 

Digital  Intubation 

Digital  intubation,  in  which  the  tracheal  tube  is  guided 
manually  into  the  larynx,  is  most  useful  in  a  resuscitation 
setting,  with  a  flaccid  patient,  when  intubation  equipment 
is  faulty,  or  when  large  quantities  of  vomitus  or  blood 
obscure  the  airway.  One  of  the  operator's  hands  is  inserted 
deeply  into  the  mouth  so  that  one  or  two  middle  fingers  lift 
the  epiglottis  as  others  palpate  the  posterior  larynx.  The 
tracheal  tube  is  advanced  between  these  guiding  fingers 
into  the  larynx  with  the  other  hand.  Obviously  one  must  be 
able  to  open  the  mouth  and  have  a  hand  that  fits  in  the 
mouth.  Blind  digital  intubation  is  easier  if  the  patient  is 
edentulous  and  the  operator  has  long,  slender  fingers. 

Magnetic  Intubation 

Another  variant  of  the  staged  intubation  technique 
employs  a  magnetic  stylet  that  is  directed  by  a  powerful 
magnet  over  the  larynx  or  the  sternal  notch.'""*  Blind  place- 
ment can  be  confirmed  using  any  of  the  methods  described 
below. 

Radiographic  Intubation 

There  are  some  case  reports  of  difficult  airway  intuba- 
tion conducted  under  fluoroscopic  guidance  in  an  elective 
situation.'"''  Computed  tomography  has  been  used  at  least 
once,'"''  and  it  seems  likely  that  magnetic  resonance  im- 
aging will  be  put  to  this  use  as  well. 

Blind,  Stylet-Guided  Intubation 

A  curved  stylet,  rigid  or  malleable,  can  be  employed  as 
a  guide  for  blind  orotracheal  intubation.  This  is  usually  a 


2-handed  technique.  A  stylet  carrying  an  endotracheal  tube 
is  directed  by  one  hand  while  the  other  hand  palpates  the 
neck  as  the  stylet  is  directed  behind  the  tongue  toward  the 
larynx.  The  sensing  hand  determines  whether  the  tube  and 
stylet  successfully  enter  the  larynx.  Most  clinicians  don't 
use  this  technique  in  day-to-day  practice  because  of  the 
risk  of  blind  trauma  to  the  oropharynx  and  airway.  How- 
ever, an  expert  can  use  this  technique  without  complica- 
tions in  most  patients  with  normal  upper  airways. 

Confirming  Blind  Intubation 

Spontaneous  ventilation  through  the  tube  may  be  evi- 
dent upon  direct  inspection'"^  or  auscultation  of  amplified 
breath  sounds.  After  blind  intubation,  whether  ventilation 
is  spontaneous  or  controlled,  confirmatory  techniques  like 
capnometry''**'"**  and  physical  examination  are  needed,  be- 
cause the  tracheal  tube  was  not  visualized  as  it  passed  into 
the  trachea.'"'^""  One  effective  technique  for  confirming 
intubation  involves  bulb  reinflation.'"  Since  the  esopha- 
gus does  not  contain  air,  neither  a  (non-self-inflating)  ven- 
tilating bag  nor  a  large  rubber  bulb  will  inflate  if  the  tube 
is  in  the  esophagus. "- 

Fiberoptic  Systems 

Other  modifications  of  the  staged  technique  are  helpful 
as  alternatives  to  DL  when  difficulty  is  anticipated.  Rigid, 
malleable,  and  flexible  fiberoptic  systems  are  widely  used. 

Flexible  Systems.  Several  models  of  flexible  fiberoptic 
bronchoscope  (FFB)  are  used  for  a  number  of  airway  in- 
terventions in  critical  care  and  anesthesia  practice."-'"*' 
In  most  cases,  the  FFB  functions  as  a  visually  guided  stylet 
over  which  the  endotracheal  tube  is  passed."^""  Most 
fiberoptic  approaches  are.  therefore,  not  blind  tech- 
niques.'^''"'' The  experienced  operator  can  guide  a  FFB 
through  the  nose  or  mouth  and  into  the  trachea  in  one  pass. 
Alternatively,  the  FFB  can  be  passed  through  an  intubating 
guide  or  an  intermediate  airway  that  serves  as  a  guide, 
such  as  the  laryngeal  mask  or  the  pharyngeal-tracheal  lu- 
men airway  (discussed  below)."-*  When  the  FFB  cannot 
be  pas.sed  directly  into  the  airway  as  an  intubation  guide, 
it  may  serve  to  direct  a  guide  wire  or  other  stylet,  over 
which  staged  intubation  can  be  performed. '  ''*  Alternatively, 
an  FFB  can  serve  as  an  indirect  laryngoscope  that  provides 
guidance  for  a  stylet  or  tube  passed  from  the  side.'-"  Short, 
flexible  instruments  designed  for  indirect  laryngo.scopy 
have  also  been  popular  for  nasal  and  oral  intubation:  how- 
ever, the  operator  has  no  ability  to  evaluate  the  lower 
airways  or  perform  endobronchial  intubation  with  these 
systems.  Other  FFBs,  such  as  the  choledochoscope  and 
cystoscope,  have  also  been  used  for  fiberoptic  intubation. 


788 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


Alternative  Fiberoptic  Instruments.     Rigid  and  mallea- 
ble fiberoptic  systems  are  used  as  intubation  guides  and 
for  indirect  laryngoscopy.  Straight,  rigid  instruments  mod- 
eled on  the  Hopkins  telescope  are  used  for  direct  laryngo- 
scopic  examination  and  as  intubating  stylets.  The  mallea- 
ble fiberoptic  system  is  more  versatile.  It  can  be  shaped  for 
the  airway  and  inserted  orally,  either  directly  or  with  other 
I    adjuvants  such  as  a  direct  laryngoscope  or  tongue  depres- 
j    sor.  Malleable  systems  come  in  2  types.  The  earliest  was 
I   an  intubating  laryngoscope-stylet  that  carries  an  endotra- 
;   cheal  tube  over  it  (American  Optical  and  other  manufac- 
turers). More  recently,  a  malleable  video  stylet  has  been 
developed  that  can  be  placed  into  the  trachea,  orally  or 
nasally,  as  the  first  step  in  staged  intubation.  Another  in- 
novative variant  on  this  idea  is  the  fiberoptic  endotracheal 
tube,  which  can  be  used  as  an  indirect  fiberoptic  laryngo- 
scope for  intubation  and  for  periodic  assessment  of  the 
trachea  and  tube  position  afterwards. 

The  Bullard,  Wu,  and  Upshur  Scopes.  The  Bullard 
laryngoscope  (Circon  Corporation,  Santa  Barbara,  Califor- 
nia) is  a  rigid  fiberoptic  blade  with  an  external  light  source 
that  carries  an  angled  stylet.  Minimal  mouth  opening  is 
required  for  a  laryngeal  view,  so  this  device  can  be  used 
when  neck  and  jaw  mobility  are  inadequate.*""-'  Using 
this  system,  the  larynx  is  kept  under  direct  vision  while  a 
tracheal  tube  is  passed  from  the  side.  A  single-  or  double- 
lumen  endotracheal  tube  can  be  passed  over  the  laryngo- 
scope's integral  stylet  and  into  the  larynx  under  direct 
vision.  The  WuScope  (Achi  Corporation,  Fremont,  Cali- 
fornia) is  a  tube  laryngoscope  that  incorporates  an  FFB  as 
its  guide.  It  must  be  passed  through  the  mouth,  but  it 
provides  an  excellent  view  of  the  larynx  through  a  narrow 
aperture  and  allows  intubation  with  either  a  single-  or 
double-lumen  endotracheal  tube  over  a  stylet.  Neither  the 
Bullard  scope  nor  the  WuScope  require  as  much  jaw  mo- 
bility or  neck  flexion  and  extension  as  do  conventional 
DL.  The  Upshur  scope  (Meditron,  Keighley,  United  King- 
dom) is  another  fiberoptic  variant,  and  has  advocates, 
though  some  feel  that  it  is  more  cumbersome  than  con- 
ventional laryngoscopy.'--  None  of  these  instruments  al- 
lows a  view  of  the  trachea  very  far  below  the  larynx. 

Video  Laryngoscopy.  Most  fiberoptic  systems  can  be 
connected  to  a  video  monitor  so  that  more  than  one  clini- 
cian can  observe  the  pathology  so  as  to  allow  video  re- 
cording of  the  procedure.'-"  An  additional  advantage  is 
removal  of  the  operator' s  eye  from  the  potential  path  of 
oral  secretions  or  vomitus. 

Light  Wand  Intubation.  Blind,  light-wand  intubation 
employs  a  fiberoptic  stylet  that  is  guided  into  the  larynx 
by  way  of  external  determination  of  the  stylet's  location 


Respiratory  Care  •  July  1999  Vol  44  No  7 


in  the  neck,  based  on  transillumination  through  the 
neck. '23-1 26  Proponents  of  the  light  wand  argue  that  it  is  as 
effective  as  DL,  but  less  traumatic. '^^  The  Augustine  Guide 
(Augustine  Medical  Inc,  Eden  Prairie,  Minnesota)  pro- 
vides a  manipulator  and  lighted  stylet  for  blind  intuba- 
tion.'"-'29  From  time  to  time  the  FFB  has  been  used  as  a 
fiberoptic  light  wand. 

Fiberoptic  Systems:  Summary.  Fiberoptic  devices  pro- 
vide a  number  of  options  for  laryngoscopy  and  intubation. 
Full  length  instruments  such  as  the  FFB  can  be  used  through 
the  mouth,  nose,  or  tracheostomy,  and  they  allow  the  op- 
erator to  see  around  corners  and  obstacles  in  the  airway. "'^ 
The  FFB  offers  versatility,  because  it  can  be  used  for 
bronchial  work,  including  tracheostomy,'''"  as  well  as  in 
the  upper  airway.  Fiberoptic  techniques  are  highly  suc- 
cessful and  less  traumatic  in  a  number  of  difficult  intuba- 
tion settings,*^  but  they  require  time '-3'  and  special  exper- 
tise that  may  not  be  available  in  the  acute  setting. ''"■^'^■"^ 
Since  they  are  not  always  successful,  other  options  must 
be  available.''-3'33.'34 

Retrograde  Techniques 

Retrograde  intubation  employs  a  transtracheally  directed 
guide  wire  or  catheter  that  is  passed  into  the  pharynx  from 
the  cricothyroid  membrane.  The  retrograde  wire  will  sup- 
port a  stylet  or  FFB  that  ultimately  guides  a  translaryngeal 
tube  into  place.  The  retrograde  technique  has  been  useful 
for  difficult  pediatric  and  adult  airways.  It  is  an  old  ap- 
proach that  has  seen  increased  popularity  since  the 
introduction  of  a  new  kit  that  includes  a  tapered  stylet 
for  passage  over  an  atraumatic  guide  wire  for  use  as  an 
intubation  guide  (Cook  Critical  Care  Inc,  Bloomington, 
Indiana). 

When  to  Discontinue  Direct  Laryngoscopy  Attempts 

As  noted  previously,  the  ASA  task  force  supported  a 
systematic,  protocol-driven  approach  to  the  difficult  air- 
way.'^  Representatives  of  other  medical  specialties,  in- 
cluding trauma  surgeons  and  emergency  medicine  practi- 
tioners,'"  have  implemented  algorithms  for  difficult  airway 
management  as  well.  Key  elements  of  these  protocols  in- 
clude recognition  of  problems  that  would  preclude  intu- 
bation by  rigid  laryngoscopy  and  recognition  of  difficulty 
when  direct  laryngoscopy  fails.  When  intubation  difficulty 
is  predicted,  alternative  equipment  and  individuals  with 
special  skills  can  be  assembled  prior  to  attempting  DL. 
When  difficult  DL  is  encountered  unexpectedly,  direct  in- 
tubation attempts  should  be  limited  to  2  or  3  at  most,  and 
the  duration  of  intubation  attempts  should  be  limited  as 
well.  After  the  first  failed  attempt,  pause  to  rethink  the 


789 


Prediction  of  a  Difficult  Intubation 


situation,  reconsider  patient  and  operator  positioning,  and 
possibly  choose  an  alternative  blade.  The  most  skilled  in- 
dividual available  should  attempt  the  DL.  Consider  alter- 
native methods  if  the  second  DL  attempt  fails.  Early  aban- 
donment of  DL  and  use  of  intermediate  airways  for  rescue 
ventilation,  together  with  alternative  intubation  techniques, 
may  be  lifesaving.  Difficult  airway  algorithms  emphasize 
the  prompt  use  of  alternatives,  which  may  include  a  sur- 
gical airway  or  percutaneous  transtracheal  airway,  to  avoid 
the  possible  adverse  effects  of  interrupted  ventilation  or 
laryngoscopic  airway  trauma.  Appropriate  equipment  for 
management  of  the  difficult  airway  must  be  available.  Since 
advance  recognition  of  the  problem  is  not  guaranteed  and 
the  setting  may  be  life-threatening,  difficult  airway  man- 
agement supplies  must  be  available  to  all  of  the  acute  care 
areas  of  a  hospital  and  the  emergency  department. 3' 

Intermediate  Airways 

Evolution  of  the  Esophageal  Obturator  Airway 

Artificial  airways  other  than  the  endotracheal  tube  were 
once  limited  to  oropharyngeal  and  nasopharyngeal  airways 
employed  with  conventional  ventilating  bag/valve/mask 
systems.  Cuffed  endotracheal  tubes  inadvertently  placed  in 
the  esophagus  during  blind  or  failed  intubation  attempts 
have  been  used  to  vent  esophageal  contents  during  mask 
ventilation.  In  effect,  a  misplaced  tracheal  tube  can  serve 
as  an  esophageal  obturator.  An  esophageally-placed  tube 
commonly  diverts  gastrointestinal  contents  from  the  phar- 
ynx, and  its  balloon,  when  inflated,  blocks  refluxed  con- 
tents from  the  lower  airway.  This  principle  was  adapted  to 
rescue  airways.  A  blunt  double-lumen  esophageal  obtura- 
tor blocks  the  esophagus  and  provides  an  oropharyngeal 
airway  that  mates  with  a  mask  or  standard  15  mm  tracheal 
tube  connector.  The  more  sophisticated,  esophagogastric 
tracheal  obturator  (EGTO)  system  employed  a  hollow  dis- 
tal obturator  tube.  It  was  also  used  with  a  specially  de- 
signed mask  for  ventilation.  Because  the  EGTO's  distal 
tube  might  blindly  pass  orally  into  the  larynx  during  in- 
sertion, it  was  designed  to  allow  tracheal  ventilation,  if 
translaryngeal  intubation  were  recognized.  The  esophageal 
obturator  concept  works  in  the  acute  setting,  although  the 
esophageal  obturator  airway  and  EGTO  are  inferior  to 
translaryngeal  intubation.  For  this  reason,  they  have  largely 
been  abandoned  by  hospitals  and  emergency  medical  ser- 
vices in  the  United  States. '^''■''^ 


by  Benumof  as  supraglottic  airways,  because  they  all  ter- 
minate in  the  pharynx  and  use  a  ventilating  pathway  that 
includes  the  larynx.^  The  pharyngeal-tracheal  lumen  air- 
way (PTL)  (Mallinckrodt  Inc,  Pleasanton,  California)  and 
the  cuffed  oropharyngeal  airway  (COPA)  (Mallinckrodt 
Inc,  Pleasanton,  California)  displace  pharyngeal  tissues 
with  a  pharyngeal  balloon  to  facilitate  ventilation.  De- 
scriptions of  use  of  the  PTL  have  been  published  for  field 
resuscitation  and  emergency  department  applications.'^* 
The  PTL  has  a  unique  role  when  upper  airway  bleeding 
obstructs  the  intubator's  view  of  the  larynx."**  The  COPA, 
a  modified  oropharyngeal  airway  with  a  low  pharyngeal 
balloon,  must  be  sized  appropriately  and  has  been  more 
widely  used  in  the  anesthesia  setting.''*'^  Like  the  PTL, 
the  COPA  has  a  15  mm  ventilating  adapter  so  that  a  bag/ 
valve  system  can  be  directly  attached  for  ventilation.  In 
addition,  the  COPA  can  be  used  as  a  route  for  tracheal 
intubation. ''♦"The  appropriate  COPA  tends  to  be  a  size 
larger  than  the  comparable  Guedel  oropharyngeal  air- 
way that  would  ordinarily  be  employed  with  mask  venti- 
lation. Just  as  an  inappropriately  placed  oral  airway  can 
obstruct  by  forcing  the  epiglottis  and/or  base  of  the  tongue 
into  the  lower  pharynx,  an  oversized  COPA  can  seal  the 
airway.'-" 


The  Combitube 

The  esophago-tracheal  Combitube  (Kendall  Healthcare, 
Mansfield,  Massachusetts)  was  designed  by  Dr  Frass  et  al 
as  an  improved  esophageal  obturator  airway. '^^  It  is  a 
double  tube  with  upper  oropharyngeal  and  esophageal  bal- 
loons. It  functions  like  an  EGTO  but  has  a  ventilating 
adapter  for  the  pharyngeal  airway  tube,  and  a  pharyngeal 
balloon.  The  Combitube  replaces  the  confusing  mask  con- 
nection of  the  EGTO  with  a  standard  ventilating  adapter, 
and  opens  the  pharyngeal  airway  with  its  oropharyngeal 
balloon.  If  a  Combitube  is  passed  too  far  into  the  airway, 
the  pharyngeal  balloon  can  obstruct  the  glottis. '''■'  It  has 
been  used  in  the  field,'-'-  in  critical  care  settings  for  long- 
term  ventilatory  support,''*^  and  as  an  intermediary  for 
FEB  intubation  and  tracheostomy.'**'-*-''  There  is  some  ev- 
idence that  the  Combitube  is  easier  for  emergency  medical 
technicians  to  place  and  use  in  the  field  than  the  PTL,  the 
oral  airway  and  bag/valve/mask  system,  or  the  laryngeal 
mask  airway  (LMA).'** 


Pharyngeal-Tracheal  Lumen  and  Cuffed 
Oropharyngeal  Airways 

Recently,  other  airways  have  been  introduced  in  anes- 
thesia practice  and  field  resuscitation.  These  are  described 


The  Laryngeal  Mask  Airway 

The  LMA  is  used  as  a  primary  airway  during  anesthesia 
when  esophageal  reflux  is  not  a  potential  problem  and 
high  ventilatory  pressures  are  not  required.  The  LMA  was 


790 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


invented  about  20  years  ago  by  Dr  Archibald  Brain.  It  is 
awkward  looking,  but  effectively  bypasses  the  upper  air- 
way and  places  a  ventilating  mask  around  the  larynx,  using 
a  special  cuff  design  that,  because  of  its  unique  shape, 
seats  in  the  hypopharynx.  A  grid  over  the  distal  end  of  the 
ventilating  tube  prevents  soft  tissue  or  the  epiglottis  from 
protruding  into  the  airway  and  obstructing  it.  The  LMA 
comes  in  7  sizes,  one  for  each  age  range.  No  matter  how 
the  LMA  is  sized,  the  pharyngeal  cuff  can  only  provide  a 
low-pressure  seal.  If  the  LMA  is  sized  properly,  peak  air- 
way pressures  required  for  a  leak  should  be  20-25  cm 
HjO.  Since  cuff  inflation  increases  the  posterior  pharyn- 
geal space,  it  prevents  supraglottic  soft  tissue  obstruction 
unless  the  cuff  itself  is  inflated  over  the  pharynx,  which 
rarely  occurs.''*''  There  is  evidence  that  during  clinical  an- 
esthesia the  LMA  is  more  reliable  than  the  COPA.'""*  More 
recently,  it  was  recognized  by  anesthesia  personnel  as  a 
rescue  airway  through  which  tracheal  intubation  can  be 
performed  when  mask  ventilation  is  difficult  and  direct 
laryngoscopy  is  unsuccessful.'''''*'"''^''  Fiberoptic  technique 
increases  the  success  rate  of  intubation  through  an  LMA 
for  adults  and  children,''''''55-i57  and  retrograde  technique 
has  been  employed  as  well.'°'  Lately,  it  has  been  sug- 
gested as  a  primary  airway  for  resuscitation."*  One  short- 
coming of  the  LMA  as  a  bridge  to  tracheal  intubation  is 
the  length  and  diameter  of  the  insertion  tube.  A  tracheal 
tube  larger  than  6  mm  internal  diameter  cannot  pass  through 
the  conventional  LMA.  In  addition,  since  smaller  tracheal 
tubes  are  also  shorter  in  length,  a  6  mm  tracheal  tube  is 
more  likely  to  have  its  cuff  inflated  within  the  larynx  of 
taller  patients.  A  number  of  techniques  have  been  designed 
for  staged  tube  change  for  a  size  that  is  more  convenient 
for  long-term  ventilatory  support. 

A  newer  modification  of  the  LMA,  the  intubating  LMA 
(iLMA)  has  been  specifically  designed  for  blind  tracheal 
intubation."'*  The  iLMA  functions  as  an  airway  in  the 
same  fashion  as  the  LMA.  A  shorter,  wider  ventilating 
tube  makes  it  easy  to  pass  or  withdraw  an  iLMA  from  over 
a  translaryngeal  tube.  A  redesigned,  tapered  tracheal  tube 
is  passed  blindly  through  the  vendlating  airway.  The  oro- 
tracheal tube  can  be  as  large  as  8  mm.  Consequently,  it  is 
not  necessary  to  change  the  tracheal  tube  from  a  6  mm  to 
a  larger  size  for  adults  after  intubation,  as  with  a  conven- 
tional LMA.  The  iLMA  has  a  flat  metal  handle  that  projects 
posteriorly.  This  allows  the  intubator  to  stand  above  the 
head  of  a  supine  patient  and  reposition  the  iLMA  for  blind 
attempts  to  pass  the  tracheal  tube.  Early  field  trials  indi- 
cated that  the  iLMA  design  increases  the  success  of  blind 
intubation  to  90-100%  for  patients  without  laryngeal 
pathology  (compared  to  from  20-40%  with  the 
LMA).'""-""*  The  iLMA  can  be  used  for  both  staged 
intubation  and  extubation. 


Failed  Intubation  and  Failed  Ventilation 

The  Transtracheal  Airway 

When  alternative  intubation  techniques  and  intermedi- 
ate airways  are  inappropriate  or  fail,  the  transtracheal  air- 
way is  the  definitive  option.'' "  Transtracheal  airway  op- 
dons  include  transtracheal  jet  catheter,  percutaneous 
cricothyrotomy  and  tracheotomy  kits,  and  surgical  crico- 
thyrotomy  or  tracheotomy.  Cardiopulmonary  bypass  has 
been  used  from  time  to  dme"''*  but  is  limited  in  availability 
and  most  commonly  reserved  as  a  standby  option  in  the 
operadng  room.  In  recent  years,  a  broad  range  of  percu- 
taneous transtracheal  airway  kits  has  come  on  the  mar- 
l^^gf  166,167  Percutaneous  needle-catheter  systems  are  easily 
inserted  when  the  trachea  can  be  palpated  and  allow  ox- 
ygen insufflation  and  jet  ventilation.-^  They  may  also  fa- 
cilitate translaryngeal  intubation.  "'**  Most  percutaneous  sys- 
tems utilize  a  modified  Seldinger  technique,  derived  from 
methods  used  to  place  percutaneous  vascular  catheters.  A 
guide  wire  passed  through  a  needle  or  catheter,  followed 
by  a  dilator,  allows  passage  of  large-diameter  catheters  or 
tracheal  tubes  into  the  trachea.  Surgical  cricothyrotomy  or 
tracheotomy  has  an  important  place  in  the  difficult  airway 
algorithm.  A  surgical  airway  may  be  an  initial  option  in 
the  patient  with  anticipated  difficulty,  or  a  choice  when  the 
airway  is  lost  and  no  other  approach  will  produce  rapid 
results.  Clinicians  who  use  the  Seldinger  technique  in  day- 
to-day  pracdce  are  more  comfortable  with  its  applications, 
while  surgery-trained  individuals  with  up-to-date  skills  may 
produce  faster  results  with  direct  tracheotomy  or  cricothy- 
rotomy. Both  surgical  and  percutaneous  techniques  are 
problemadc  when  the  neck  is  fixed  or  scarred  in  flexion  or 
when  masses  distort  the  anatomy. 

Approach  to  the  Difficult  Airway 

Many  Alternatives.  The  list  of  choices  for  difficult  air- 
way management  is  long.  Institutions  that  have  attempted 
to  provide  equipment  and  technical  support  for  most  of 
these  options  incur  logistical  difficulty  with  equipment 
provision  and  replacement,  staff  readiness,  and  the  delin- 
eation of  systematic  approaches.  When  almost  every  op- 
tion is  present  at  a  difficult  airway  station  or  on  a  desig- 
nated cart,  pracdtioners  have  difficulty  finding  the 
equipment  needed  for  a  particular  approach.  The  cost  of 
equipping  each  potential  location  with  a  multitude  of  in- 
tubation equipment  items  could  easily  exceed  the  cost  of 
setting  up  a  standard  ALS  cart,  including  defibrillator. 
Teaching  personnel  and  maintaining  their  expertise  with 
numerous  intermediate  and  surgical  airway  options  present 
a  daundng  challenge  to  insdtutional  or  departmental  edu- 
cation programs.  Increasing  complexity  presents  increased 
risk  of  error,  confusion,  and  failure. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


79  i 


Prediction  of  a  Difficult  Intubation 


Table  6.        Difficult  Airway  Cart  Equipment  and  Supplies 

•  Routine  intubation  kit  with  blades,  airways,  tubes,  oxygen  source, 
suction  and  bag/valve/mask  system 

Flagg,  Foregger,  Wisconsin  or  other  tube  laryngoscope  blades 
Malleable  intubating  stylets 
Angled  insufflating  stylets 
Tube  changers  in  3  sizes 

Magill  forceps  for  directing  nasotracheal  intubation 
Intubating  laryngeal  mask  airway  kit  (multiple  sizes  with  special 
tracheal  tubes) 

Retrograde  tracheal  intubation  kit  (adult  and  pediatric) 
8  French  rapid  infusion  device/percutaneous  cricothyrotomy  kit 
High  pressure  oxygen  insufflation  system  with  manual  trigger 
Fiberoptic  intubation  airways 
Malleable  fiberoptic  stylette  laryngoscope 

Flexible  intubating  fiberoptic  bronchoscope  with  battery  light  source 
Surgical  tracheotomy  kit 
Percutaneous  dilatational  tracheotomy  kit 
Portable  chemical  or  infrared  capnometer 
Portable  pulse  oximeter 


Keep  It  Simple.  Experience  with  ALS  and  other  tech- 
nical medical  systems  corroborates  the  idea  that  practitio- 
ners should  employ  techniques  they  are  familiar  with — 
"keep  it  simple."  These  observations,  together  with 
considerable  regional  variation  in  personnel  availability, 
financial  resources,  and  technical  expertise,  argue  for  the 
creation  of  institution-specific  or  region-specific  protocols 
for  management  of  the  difficult  airway.'-'^  Surgical  op- 
tions will,  of  course,  be  less  comfortable  for  nonsurgical 
respiratory  therapists,  while  surgeons  and  others  who  prac- 
tice in  high-volume  trauma  centers  with  ample  surgical 
back-up  may  wish  to  promote  surgical  airway  interven- 
tions to  their  first  option  when  translaryngeal  intubation 
fails  or  is  impossible.  It  is  probably  best  to  limit  the  equip- 
ment options  in  order  to  reduce  maintenance  and  training 
requirements.  Table  6  lists  the  equipment  in  a  more  re- 
stricted difficult  airway  cart. 

Practical  Application  of  a  Diillcult  Airway  Algorithm 
for  Respiratory  Care 

The  difficult  airway  algorithm  fits  into  a  continuum  of 
airway  management  in  acute  respiratory  care.  In  each  in- 
stitution, equipment,  airway  management  protocols,  and 
training  should  be  well  defined.  Patients  who  are  obtunded 
or  unconscious  should  be  approached  "awake."  An  alter- 
native approach  is  necessary  when  the  experienced  respi- 
ratory therapist  or  first-tier  responder  is  unable  to  intubate 
the  patient  after  2  attempts,  using  a  logical  sequence  of 
intubation  maneuvers  including  repositioning  the  head  and 
neck  and  backward,  upward,  rightward  laryngeal  pressure. 
If  ventilation  can  be  managed,  effort  can  be  directed  to- 
ward finding  a  more  experienced  individual.  During  this 


time,  alternative  equipment  and  drugs  can  be  accessed. 
When  ventilation  is  inadequate,  another  option  must  be 
selected.  Consideration  should  be  given  to  rescue  airway 
insertion  as  a  temporizing  measure.  Definitive  transtra- 
cheal intubation  is  an  appropriate  choice.  Although  very 
active  patients  may  require  pharmacologic  restraint  with 
paralytic  drugs,  these  should  not  be  employed  without 
access  to  alternative  emergency  equipment  and  the  ability 
to  place  a  transtracheal  airway,  should  ventilation  and  trans- 
laryngeal intubation  prove  impossible  after  paralysis.  With 
patients  who  present  obvious  anatomic  or  medical  con- 
traindications to  DL,  the  practitioner  should  entertain 
alternative  techniques  for  intubation  as  the  initial  option 
and  assemble  the  appropriate  personnel  and  equipment. 

Summary 

In  recent  years,  a  proliferation  of  choices  has  evolved 
for  intubation  and  management  of  the  difficult  airway. 
Almost  a  decade  of  guideline  promulgation  has  set  the 
stage  for  evolution  of  respiratory  care  standards  that  man- 
date an  organized  approach  to  management  of  the  difficult 
intubation.  Awake  intubation  and  other  alternative  intuba- 
tion approaches  are  recommended  when  direct  laryngos- 
copy is  likely  to  be  more  risky  or  more  difficult  than  usual. 
When  direct  laryngoscopy  is  attempted  and  is  difficult, 
only  a  limited  number  of  attempts  should  be  made  before 
alternative  options  are  selected.  Practitioners  should  be- 
come skilled  with  the  use  of  intermediate  airways  that  can 
rescue  them  from  a  difficult  airway  situation.  The  unex- 
pectedly difficult  laryngoscopy,  together  with  a  difficult 
mask  airway,  requires  immediate  action — not  persistent 
attempts  to  intubate  by  DL.  Monitors  of  ventilation  and 
oxygenation  improve  the  practitioner's  ability  to  recognize 
difficult  ventilation  and/or  the  success  of  intubation. 

No  single  group  that  provides  acute  respiratory  care  has 
total  responsibility  for  airway  management:  therefore,  dif- 
ficult intubation  guidelines  will  be  applied  to  each  group 
or  department  involved.  All  respiratory  therapists,  regard- 
less of  training  background,  will  be  held  to  the  same  stan- 
dard of  care  for  difficult  airway  management. 

Along  with  the  need  for  individual  institutions  and  prac- 
titioners to  join  in  formulation  of  internal  standards  that  fit 
national  guidelines  comes  a  need  for  equipment  mainte- 
nance and  an  ongoing  program  of  training.  Training  and 
equipment  policies  should  be  modeled  after  those  required 
for  compliance  with  national  ALS  or  advanced  trauma  life 
support  protocols.  Tracheal  intubation  is  required  in  the 
field,  the  emergency  department,  the  operating  room,  the 
special  care  units,  and  on  the  wards  of  our  medical  insti- 
tutions. This  establishes  a  burden  of  organization  and  train- 
ing that  is  shared  by  all  areas  and  staff  who  participate  in 
cardiopulmonary  critical  care. 


792 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


REFERENCES 

1.  Finucane  BT.  Santora  AH.  Techniques  of  intubation.  In:  Finucane 
B,  Santora  A.  editors.  Principles  of  airway  management.  Philadel- 
phia: F  A  Davis;  1988:124-144. 

2.  Roberts  JT.  Fundamentals  of  tracheal  intubation.  New  York:  Grune 
&  Stratton.  Inc;  1983. 

3.  Bedford  RF.  Circulatory  responses  to  tracheal  intubation.  In:  Bishop 
MJ.  editor.  Physiology  and  consequences  of  tracheal  intubation. 
Philadelphia:  J  B  Lippincott;  1988:201-210. 

4.  Benumof  JL.  Conventional  (laryngoscopic)  orotracheal  and  naso- 
tracheal intubation  (single-lumen  tube).  In:  Benumof  JL,  editor. 
Clinical  procedures  in  anesthesia  and  intensive  care.  Philadelphia: 
J  B  Lippincott;  1992:115-148. 

5.  Benumof  JL.  Airway  manageinent:  principles  and  practice.  St  Lou- 
is: Mosby;  1996. 

6.  Florette  OG.  Kirby  RR.  Airway  management.  In:  Civelta  JM,  Tay- 
lor RW.  Kirby  RR.  editors.  Critical  care.  Philadelphia:  Lippincott- 
Raven;  1997:2263. 

7.  Rocke  DA.  Murray  WB.  Rout  CC.  Gouws  E.  Relative  risk  analysis 
of  factors  associated  with  difficult  intubation  in  obstetric  anesthe- 
sia. Anesthesiology  1992;77(l):67-73. 

8.  Mark  LJ,  Beattie  C,  Ferrell  CL,  Trempy  G,  Dorman  T,  Schauble  JF. 
The  difficult  airway:  mechanisms  for  effective  dissemination  of 
critical  information.  J  Clin  Anesth  1992;4(3):247-2S1. 

9.  Benumof  JL.  Manageinent  of  the  difficult  adult  airway:  with  special 
emphasis  on  awake  tracheal  intubation  Anesthesiology  1991:75(6): 
1087-1110.  Piihlislu'il  enalum  appears  in  Aneslhcsiology  1993: 
78(J):224. 

10.  Williamson  JA.  Webb  RK.  Szekely  S.  Gillies  ER.  Dreosti  AV.  The 
Australian  Incident  Monitoring  Study.  Difficult  intubation:  an  anal- 
ysis of  2000  incident  reports.  Anaesth  Intensive  Care  I993;2I(5): 
602-607. 

1 1 .  Practice  guidelines  for  management  of  the  difficult  airway.  A  report 
by  the  American  Society  of  Anesthesiologists  Task  Force  on  Man- 
agement of  the  Difficult  Airway.  Anesthesiology  1 993:78(3  ):597- 
602. 

12.  Watson  CB.  Difficult  airway:  the  ASA  algorithm.  In:  Marks  L, 
editor.  Difficult  airway:  challenges  for  the  millenium.  Cambridge 
MA:  Society  for  Airway  Management;  1998. 

13.  Crosby  ET.  Cooper  RM.  Douglas  MJ.  Doyle  DJ.  Hung  OR.  La- 
brecque  P.  et  al.  The  unanticipated  difficult  airway  with  recom- 
mendations for  management.  Can  J  Anaesthesia  1998;5(8):757- 
776. 

14.  Seward  J.  Khandheria  B.  Oh  JK.  Abel  MD.  Hughes  RW  Jr.  Ed- 
wards WJ.  et  al.  Transesophageal  echocardiography:  technique,  an- 
atomic correlations,  implementation,  and  clinical  applications.  Mayo 
Clin  Proc  1988;63(7):649-680. 

15.  Sayre  MR,  Sakles  JC.  Mistier  AF.  Evans  JL.  Kramer  AT.  Pancioli 
AM.  Field  trial  of  endotracheal  intubation  by  basic  EMTs.  Ann 
Emerg  Med  1998;31(2):228-233. 

16.  Calder  I.  The  pre-induction  airway  examination  prevents  catastro- 
phes: arguments  to  the  contrary.  Am  J  Anesthesiol  1998:25:184— 
185. 

17.  Bergler  W.  Maleck  W,  Bakcr-Schreyer  A.  Petroianu  G.  Hermann 
K.  Difficult  intubation  in  otorhinolaryngologic  laser  surgery.  Is 
there  a  predictive  parameter?  HNO  1997:45(1 1):923-926. 

18.  Mallampati  S.  Rao  S.  The  pre-induction  airway  examination  pre- 
vents catastrophes:  arguments  in  favor.  Am  J  Anesthesiol  1998:25: 
183-184. 

19.  Egan  TD.  Wong  KC.  Predicting  difficult  laryngoscopy  for  tracheal 
intubation:  an  approach  to  airway  assessment.  Ma  Tsui  Hsueh  Tsa 
Chi  I993;3I(3):165-I78. 

20.  Wilson  ME.  Spiegelhalter  D.  Robert.son  JA.  Lesser  P.  Predicting 
difficult  intubation.  Br  J  Anae.sth  1988;61(2):2I  I-2I6. 


21.  Wat.son  C.  Smith  D.  Unexpected  difficulty  with  tracheal  intubation. 
Anesthesiology  News  1987:10. 

22.  Nath  G,  Sekar  M.  Predicting  difficult  intubation-a  comprehensive 
scoring  .system.  Anaesth  Intensive  Care  I997;25(5):482^86. 

23.  Rose  DK.  Cohen  MM.  The  incidence  of  airway  problems  depends 
on  the  definition  used.  Can  J  Anaesth  l996;43(I):30-34. 

24.  Cormack  RS.  Lehane  J.  Difficult  tracheal  intubation  in  obstetrics. 
Anaesthesia  1984:39(1  l):l  105-1 1 1 1. 

25.  Benumof  JL.  Management  of  the  difficult  airway.  Ann  Acad  Med 
Singapore  1994;23(4):589-591. 

26.  Harrison  T,  Thomas  SH,  Wedel  SK.  In-flight  oral  endotracheal 
intubation.  Am  J  Emerg  Med  I997:15(6):558-561. 

27.  Larmon  B,  Schriger  DL.  Snelling  R,  Morgan  MT.  Results  of  a 
4-hour  endotracheal  intubation  class  for  EMT-basics.  Ann  Emerg 
Med  l998:3l(2):224-227. 

28.  Sakles  JC.  Laurin  EG,  Rantapaa  AA,  Panacek  EA.  Airway  man- 
agement in  the  emergency  department:  a  one-year  study  of  610 
tracheal  intubations.  Ann  Emerg  Med  1998;31(3):325-332. 

29.  Mackie  A,  Watson  CB.  A  survey  of  intubation  procedures  at  the 
North  Carolina  Memorial  Hospital.  In:  Reines  HD,  editor.  Third 
symposium:  Carolina-Virginia  Society  of  Critical  Care  Medicine. 
Charleston  SC:  Carolina-Virginia  Society  of  Critical  Care  Medi- 
cine; 1984:14. 

30.  Watson  CB.  Tracheal  intubation  in  the  emergency  setting.  Respir 
Ther  1986;16:20-26. 

31.  Deem  S.  Bishop  MJ.  Evaluation  and  management  of  the  difficult 
airway.  Crit  Care  Clin  I995;l  l(l):l-27. 

32.  Adnet  F.  Cydulka  RK.  Lapandry  C.  Emergency  tracheal  intubation 
of  patients  lying  supine  on  the  ground:  influence  of  operator  body 
position.  Can  J  Anaesth  1998;45(3):266-269. 

33.  Cunitz  G.  Early  management  of  head  injury.  Acta  Anae.sthesiol 
Scand  Suppl  1997;111:46-47. 

34.  Schwartz  DE.  Matthay  MA,  Cohen  NH.  Death  and  other  compli- 
cations of  emergency  airway  management  in  critically  ill  adults.  A 
prospective  investigation  of  297  tracheal  intubations.  Anesthesiol- 
ogy 1995;82(2):367-376. 

35.  Walls  RM.  Management  of  the  difficult  airway  in  the  trauma  pa- 
tient. Emerg  Med  Clin  North  Am  1998;16(l):45-61. 

36.  Thibodeau  LG.  Verdile  VP.  Bartfield  JM.  Incidence  of  aspiration 
after  urgent  intubation.  Am  J  Emerg  Med  1997;l5(6):562-565. 

37.  Grande  CM.  Stene  JK,  Bernhard  WN.  Airway  management:  con- 
siderations in  the  trauma  patient.  Crit  Care  Clin  1990;6(l):37-59. 

38.  Watson  CB.  Lumb  PD.  Intubation  of  the  trachea  in  the  critical  care 
setting  (letter).  JAMA  I985;254(22):3I79-3180. 

39.  Cantillo  J.  Cypel  D,  Schaffer  SR.  Goldberg  ME.  Difficult  intuba- 
tion from  gastroesophageal  reflux  disease  in  adults.  J  Clin  Anesth 
l998;I0(3):235-237. 

40.  O'Donnell  JJ,  Birkinshaw  R,  Harte  B.  Mechanical  airway  obstruc- 
tion secondary  to  retropharyngeal  haematoma.  Eur  J  Emerg  Med 
1997,4(3):  166-168. 

41.  Crosby  ET,  Grahovac  S.  Diffuse  idiopathic  skeletal  hyperostosis: 
an  unusual  cause  of  difficult  intubation.  Can  J  Anaesth  I993;40(l ): 
54-58. 

42.  Appleby  JN,  Bingham  RM.  Craniodiaphyseal  dysplasia;  another 
cause  of  difficult  intubation.  Paediatr  Anaesth  l996;6(3);225-229. 

43.  Goldenberg  D.  Golz  A,  Flax-Goldenberg  R,  Joachims  HZ.  Severe 
laryngeal  injury  caused  by  blunt  trauma  to  the  neck:  a  case  report. 
J  Laryngol  Otol  1997:1 1 1(12):1 174-1 176. 

44.  Koay  CK.  Difficult  tracheal  intubation-analysis  and  management 
in  37  ca.ses.  Singapore  Med  J  1 998:39(3):  1 12-1 14. 

45.  Sharwood-Smith  GH.  DilTiculty  in  intubation:  calcified  stylohyoid 
ligment.  Anaesthesia  I976;31(4):508-510. 

46.  Latto  IP,  Vaughan  RS.  Difficulties  in  tracheal  intubation,  2nd  edi- 
tion. London;  W  B  Saunders;  1997. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


79.'^ 


Prediction  of  a  Difficult  Intubation 


47.  Maydew  RP,  Berry  FA.  Cherubism  with  difficult  laryngoscopy  and 
traclieal  intubation.  Anesthesiology  1985;62(6):810-812. 
Redicl<  LF.  The  temperomandibular  joint  and  tracheal  intubation. 
Anaesth  Analg  1987;66(7):675-676. 

Coonan  TJ,  Hope  CE,  Howes  BJ,  Holness  O,  Maclnnis  EL.  Anky- 
losis of  the  temporo-mandibular  joint  after  temporal  craniotomy-a 
cause  of  difficult  intubation.  Can  Anaesth  Soc  J  1985;32(2):158- 
160. 

White  A,  Kander  PL.  Anatomical  factors  in  difficult  direct  laryn- 
goscopy. Br  J  Anaesth  1975;47(4):468^74. 
Horton  WA.  Fahy  L,  Charters  P.  Disposition  of  cervical  vertebrae, 
atlanto-axial  joint,  hyoid  and  mandible  during  X-ray  laryngoscopy. 
Br  J  Anaesth  I989;63(4):435^38. 

Mallampati  S,  Gatt  S,  Gugino  LD,  Desai  SP,  Waraksa  B,  Freiberger 
D,  Liu  PL.  A  clinical  sign  to  predict  difficult  tracheal  intubation:  a 
prospective  study.  Can  Anaesth  Soc  J  I985;32(4):429^34. 
Bellhouse  CP,  Dore  C.  Criteria  for  estimating  likelihood  of  diffi- 
culty of  endotracheal  intubation  with  the  Macintosh  laryngoscope. 
Anaesth  Intensive  Care  1988;16(3):329-337. 
Frerk  C.  Predicting  difficult  intubation.  Anaesthesia  1991;46(12): 
1005-1008. 

Frerk  CM,  Till  CB,  Bradley  AJ.  Difficult  intubation:  thyromental 
distance  and  the  atlanto-occipital  gap.  Anaesthesia  1996;51(8):738- 
740. 

Patil  V,  Stehling  L,  Zauder  H.  Fiberoptic  endoscopy  in  anesthesia. 
Chicago:  Year  Book  Medical  Publishers;  1983. 
Randell  T.  Prediction  of  difficult  intubation.  Acta  Anaesthesiol 
Scand  1996;40(8  Pt  2):  1016-1023. 

Gates  JD,  Macleod  AD,  Dates  PD,  Pearsall  FJ,  Howie  JC,  Murray 
GD.  Comparison  of  two  methods  for  predicting  difficult  intubation. 
Br  J  Anaesth  1991;66(3):305-309. 

Tham  EJ,  Gildersleve  CD,  Sanders  LD,  Mapleson  WW,  Vaughan 
RS.  Effects  of  posture,  phonation  and  observer  on  Mallampati  clas- 
sification. Br  J  Anaesth  1992:68(1  ):32-38. 

Tse  JC.  Rimm  EB,  Hussain  A.  Predicting  difficult  endotracheal 
intubation  in  surgical  patients  scheduled  for  general  anesthesia:  a 
prospective  blind  study.  Anesth  Analg  1995;8l(2):254-258. 
Karkouti  K.  Rose  DK,  Ferris  LE,  Wigglesworth  DF,  Meisami-Fard 
T,  Lee  H.  Inter-observer  reliability  of  ten  tests  used  for  predicting 
difficult  tracheal  intubation.  Can  J  Anaesth  1996;43(6):554-559. 
Chou  HC,  Wu  TL.  Mandibulohyoid  distance  in  difficult  laryngos- 
copy. Br  J  Anaesth  !993;71(3):335-339. 

63.  Chou  HC,  Wu  TL.  Thyromental  distance-shouldn't  we  redefine  its 
role  in  the  prediction  of  difficult  laryngoscopy?  (letter).  Acta  An- 
aesthesiol Scand  1998;42(1):  136-1 37. 

Wu  TL.  WuScope  System  Newsletter.  Fremont  CA:  Achi  Co  1998; 
12:5. 

Ulrich  B,  Listyo  R,  Gerig  HJ,  Gabi  K,  Kreienbuhl  G.  The  difficult 
intubation:  the  value  of  BURP  and  3  predictive  tests  of  difficult 
intubation.  Anaesthesist  l998;47(l):45-50. 
Knill  RL.  Difficult  laryngoscopy  made  easy  with  a  "BURP".  Can  J 
Anaesth  l993;40(3):279-282. 

67.  Rose  DK,  Cohen  MM.  The  airway:  problems  and  predictions  in 
18.500  patients.  Can  J  Anaesth  1994:41(5  Pt  l):372-383. 
Hakala  P,  Randell  T.  Intubation  difficulties  in  patients  with  rheu- 
matoid arthritis:  a  retrospective  analysis.  Acta  Anaesthesiol  Scand 
1998:42(2):195-I98. 

Mashio  H,  Kojima  T,  Goda  Y,  Kawahigashi  H,  Ito  Y.  Kato  M. 
(Intubation  of  a  patient  with  rheumatoid  arthritis  with  a  7.5-mm-ID 
armored  endotracheal  tube  using  a  laryngeal  mask  airwayl.  Masui 
I997;46(I2):1639-1643. 

70.  Pepin  J.  Delia  Negra  E,  Grosclaude  S,  Billon  C,  Levy  P.  Sleep 
apnoea  syndrome  secondary  to  rheumatoid  arthritis.  Thorax  1995; 
5()(6):692-697. 


48 


49, 


50 


51 


52 


53 


54, 


55 


56, 


57 


58 


59 


60, 


61 


62 


64 


65 


66 


68 


69 


71.  D'Arcy  EJ,  Fell  RH,  Ansell  B,  Arden  G.  Ketamine  and  juvenile 
chronic  polyarthritis:  anaesthetic  problems  in  Still's  disease  and 
allied  disorders.  Anaesthesia  1976;31(5):624-632. 

72.  Crosby  ET,  Liu  A.  The  adult  cervical  spine:  implications  for  airway 
management.  Anaesth  I990;37(l):77-93. 

73.  Watson  C.  Upper  airway  obstruction  caused  by  neurofibromatosis. 
Anesthesiology  News  1993;  16-20. 

74.  Ranasinghe  DN,  Calder  I.  Large  cervical  osteophyte-another  cause 
of  difficult  flexible  fibreoptic  intubation.  Anaesthesia  1994;49(6): 
512-514. 

75.  Kaplan  J,  Fredrickson  PA,  Richardson  JW.  Sleep  and  breathing  in 
patients  with  the  Prader-Willi  syndrome.  Mayo  Clin  Proc  1991; 
66(1 1):1 124-1126. 

76.  Edwards  TJ,  David  DJ,  Martin  J.  Aggressive  surgical  management 
of  sleep  apnea  syndrome  in  the  syndrome  craniosynostoses.  J  Cranio- 
fac  Surg  1992;3(I):8-1I. 

77.  Cistulli  PA,  Wilcox  I,  Jeremy  R,  Sullivan  CE.  Aortic  root  dilatation 
in  Marfan's  syndrome:  a  contribution  from  obstructive  sleep  apnea? 
(review)  Chest  1997;l  1 1(6):1763-1766. 

78.  Mickelson  SA,  Rosenthal  LD,  Rock  JP,  Senior  BA,  Friduss  ME. 
Obstructive  sleep  apnea  syndrome  and  acromegaly.  1994:111(1): 
25-30. 

79.  Lefaivre  JF,  Cohen  SR,  Burstein  FD,  Simms  C,  Scott  PH,  Mont- 
gomery GL,  et  al.  Down  syndrome:  identification  and  surgical  man- 
agement of  obstructive  sleep  apnea.  Plast  Reconstr  Surg  1997;99(3): 
629-637. 

80.  Lano  CF  Jr,  Werkhaven  J.  Airway  management  in  a  patient  with 
Hecht's  syndrome.  South  Med  J  1997;90(12):1241-1243. 

8 1 .  Stene  JK,  Grande  CM.  General  anesthesia:  management  consider- 
ations in  the  trauma  patient.  Crit  Care  Clin  1990;6(l):73-84. 

82.  Sieber  TJ,  Zbinden  AM,  Curatolo  M,  Shorten  GD.  Tracheal  intu- 
bation with  rocuronium  using  the  "timing  principle."  Anesth  Analg 
1998;86(5):1 137-1 140. 

83.  Sivilotti  ML,  Ducharme  J.  Randomized,  double-blind  study  on  sed- 
atives and  hemodynamics  during  rapid-sequence  intubation  in  the 
emergency  department:  The  SHRED  Study.  Ann  Emerg  Med  1998; 
31(3):313-324. 

84.  Higashizawa  T,  Bito  H,  Nishiyama  T,  Sakai  T,  Konishi  A:  [As- 
sessment of  the  practice  of  endotracheal  intubation  by  levering 
Laryngoscope  in  teaching  of  undergraduate  medical  students].  Ma- 
sui 1997;46(9):1255-I258. 

85.  Benham  SW,  Gale  L.  A  new  hinged  tip  laryngoscope.  Anaesthesia 
I997;52(9):869-871. 

86.  Chisholm  DG,  Calder  I.  Experience  with  the  McCoy  laryngoscope 
in  difficult  laryngoscopy.  Anaesthesia  1997;52(9):906-908. 

87.  Henderson  JJ.  The  use  of  paraglossal  straight  blade  laryngoscopy  in 
difficult  tracheal  intubation.  Anaesthesia  l997;52(6):552-560. 

88.  Vanner  RG,  Clarke  P,  Moore  WJ,  Raftery  S.  The  effect  of  cricoid 
pressure  and  neck  support  on  the  view  at  laryngoscopy.  Anaesthesia 
1997;52(9):896-900. 

89.  Dogra  S,  Falconer  R,  Latto  IP.  Successful  difficult  intubation:  tra- 
cheal tube  placement  over  a  gum-elastic  bougie.  Anaesthesia  1990; 
45(9);774-776. 

90.  Weller  RM.  Gum  elastic  bougie  for  difficult  double-lumen  intuba- 
tion (letter).  Anaesthesia  1998;53(3):31 1. 

91 .  Nocera  A.  A  flexible  solution  for  emergency  intubation  difficulties. 
Ann  Emerg  Med  1996;27(5):665-667. 

92.  West  MR,  Jonas  MM,  Adams  AP,  Carli  F.  A  new  tracheal  tube  for 
difficult  intubation.  Br  J  Anaesth  1996;76(5);673-679. 

93.  Spencer  RF,  Rathmell  JP,  Viscomi  CM.  A  new  method  for  difficult 
endotracheal  intubation:  the  use  of  a  jet  stylet  introducer  and  cap- 
nography.  Anesth  Analg  1995;8I(5):  1079-1083. 


794 


Respiratory  Care  •  July  1 999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


94.  Cooper  RM.  Cohen  DR.  The  use  of  an  endotracheal  ventilation 
catheter  for  jet  ventilation  during  a  difficult  intubation.  Can  J  An- 
aesth  1994;41(12):II96-II99. 

95.  Wolf  C.  LeJeune  FE  Jr.  Douglas  JR  Jr.  A  technique  for  intubation 
of  the  difficult  airway.  Otolaryngol  Head  Neck  Surg  1987:96(3): 
278-281. 

96.  Cook  RT  Jr.  Stene  JK  Jr.  The  BAAM  and  endotrol  endotracheal 
tube  for  blind  oral  intubation.  Beck  Airway  Air  Flow  Monitor. 
J  Clin  Anesth  I993;5(5):43l^32. 

97.  Bheiide  MS.  Thompson  AE.  Orr  RA.  Utility  of  an  end-tidal  carbon 
dioxide  detector  during  stabilization  and  transport  of  critically  ill 
children.  Pediatrics  1992:89(6  Pt  I ):  1042-1044. 

98.  Harris  RD.  Gillett  MJ.  Joseph  AP.  Vinen  JD.  An  aid  to  blind  nasal 
intubation.  J  Emerg  Med  I998:l6(l):9.3-9.'i. 

99.  Werman  HA.  Falcone  RE.  Glottic  positioning  of  the  endotracheal 
tube  tip:  a  diagnostic  dilemma.  Ann  Emerg  Med  1998;31(.')):643- 
646. 

100.  Watanabe  S.  Yaguchi  Y.  Suga  A.  Asakura  N.  A  "bubble-tip"  (Air- 
guide)  tracheal  tube  sy.stem:  its  effects  on  incidence  of  epistaxis  and 
ease  of  tube  advancement  in  the  subglottic  region  during  nasotra- 
cheal intubation.  Anesth  Analg  1994:78(6):  1140-1 143. 

101.  Arndt  GA.  Topp  J.  Hannah  J.  McDowell  TS,  Lesko  A.  Intubation 
via  the  LMA  using  a  Cook  retrograde  intubation  kit.  Can  J  Anaesth 
l998;4.'i(3):2.57-260. 

102.  Pedersen  J.  Schurizek  BA.  Melsen  NC.  Juhl  B.  The  effect  of  na- 
sotracheal intubation  on  the  paranasal  sinu.ses:  a  prospective  study 
of  434  intensive  care  patients.  Acta  Anaesthesiol  Scand  1991 :3.')(  I ): 
11-13. 

103.  Casals-Caus  P.  Mayoral-Rojals  V.  Canales  MA.  Ruiz-Tamarit  V, 
Casals-Castells  A.  Cochs-Cristia  J.  [Inflation  of  the  endotracheal 
tube  cuff  as  an  aid  for  blind  nasotracheal  intubation  in  patients  with 
predicted  difficult  laryngoscopy].  Rev  Esp  Anestesiol  Reanim  1997; 
44(8):302-.304. 

104.  Patil  VU.  Buckingham  T.  Willoughby  P.  Szeverenyi  NM.  Magnetic 
orotracheal  intubation:  a  new  technique.  Anesth  Analg  1994:78(4): 
749-752. 

105.  Sato  N.  Yuge  O.  Endotracheal  intubation  under  image  guidance  for 
a  child  with  tracheal  stenosis.  Hiroshima  J  Med  Sci  1995:44(2): 
53-54. 

106.  Kawana  S.  Nakabayashi  K.  Kawashiina  F.  Watanabe  H.  Namiki  A. 
Hirano  T.  Difficult  intubation  assisted  by  three-dimensional  com- 
puted tomography  imaging  of  the  pharynx  and  the  larynx.  Anes- 
thesiology I995:83(2):4I6-4I9. 

107.  Kelly  JJ.  Eynon  CA.  Kaplan  JL,  de  Garavilla  L.  Dalsey  WC.  Use 
of  tube  condensation  as  an  indicator  of  endotracheal  tube  place- 
ment. Ann  Emerg  Med  1998;3l(5):57.5-578. 

108.  Ward  KR.  Yealy  DM.  End-tidal  carbon  dioxide  monitoring  in  emer- 
gency medicine.  Part  2:  clinical  applications.  Acad  Emerg  Med 
l998;5(6):637-646. 

109.  Cardoso  MM.  Banner  MJ.  Melker  RJ.  Bjoraker  DG.  Portable  de- 
vices used  to  detect  endotracheal  intubation  during  emergency  sit- 
uations: a  review.  Crit  Care  Med  l998:26(5):957-964. 

1  10.  Spiller  JD.  Noblett  KE.  Endotracheal  tube  occlusion  following  blind 
oral  intubation  with  the  Endotrol  (trigger)  endotracheal  tube:  a  case 
report.  Am  J  Emerg  Med  1998:16(3):276-278. 

111.  Kasper  CL.  Deem  S.  The  self-inflating  bulb  to  detect  esophageal 
intubation  during  emergency  airway  management.  Anesthesiology 
l998:88(4):898-902. 

1 12.  Knottenbelt  JD.  The  suction  test  for  oesophageal  placement  of  the 
endotracheal  tube  using  an  oesophageal  detector  device:  caution  is 
required  with  inexperienced  operators.  Eur  J  Emerg  Med  1 994: 1  (4): 
17.3-174. 

I  13.  Olopade  CO.  Prakash  UB.  Bronchoscopy  in  the  critical-care  unit. 
Mayo  Clin  Proc  I989:64(I0):I255-1263. 


1 14.  Ovassapian  A.  Randel  GI.  The  role  of  the  fiberscope  in  the  criti- 
cally ill  patient.  Crit  Care  Clin  1995:1 1(  1):29-51. 

1 15.  Watson  CB.  Anesthetic  uses  for  the  pediatric  flexible  fiberoptic 
bronchoscope.  Anesthesiol  Rev  1982:8-21. 

116.  Dellinger  RP,  Bandi  V.  Fiberoptic  bronchoscopy  in  the  intensive 
care  unit.  Crit  Care  Clin  l992:8(4):755-772. 

1 1 7.  Gorback  M.  Watson  C.  Fiberoptic  intubation.  In:  Emergency  air- 
way management.  Philadelphia:  B  C  Decker:  1990. 

1 18.  Guzman  JL.  Use  of  a  short  flexible  fiberoptic  endoscope  for  diffi- 
cult intubations.  Anesthesiology  1997:87(6):  1563-1564. 

119.  Scherlitz  A.  Peters  J  [A  guidewire  as  a  reintubation  aid:  transla- 
ryngeal  fiberoptic  insertion  of  a  guidewire  into  the  trachea  to  assist 
fiberoptic  reintubation  in  patients  difficult  to  intubate].  Anaesthe- 
sist  1994.43(9):618-620. 

120.  Aoyama  K.  Takenaka  I.  Sata  T.  Shigematsu  A.  Use  of  the  fibre- 
scope-video  camera  system  for  difficult  tracheal  intubation.  Br  J 
Anaesth  1996:77(5):662-664. 

121.  Watts  AD.  Gelb  AW,  Bach  DB.  Pelz  DM.  Comparison  of  the 
Billiard  and  Macintosh  laryngoscopes  for  endotracheal  intubation 
of  patients  with  a  potential  cervical  spine  injury.  Anesthesiology 
l997:87(6):l,335-l-342. 

122.  Weiss  M.  Video-intuboscopy:  a  new  aid  to  routine  and  difficult 
tracheal  intubation.  Br  J  Anaesth  1998:8()(4):525-527. 

123.  Weiss  M.  Management  of  difficult  tracheal  intubation  with  a  video- 
optically  modified  schroeder  intubation  stylet  (letter).  Anesth  Analg 
1997;85(5):1 181-1 182. 

1 24.  Midtlun  M.  Laerkholm  Hansen  C.  Jen.sen  K.  Pedersen  T.  The  Bul- 
lard  laryngoscope:  reports  of  two  cases  of  difficult  intubation.  Acta 
Anaesthesiol  Scand  I994:38(3):-3(XK302. 

125.  Fridrich  P.  Frass  M.  Krenn  CG.  Weinstabl  C.  Benumof  JL.  Krafft 
P.  The  UpsherScope  in  routine  and  difficult  airway  management:  a 
randomized,  controlled  clinical  trial.  Anesth  Analg  1997:85(6): 
1377-1381. 

126.  Friedman  PG.  Rosenberg  MK.  Lebenbom-Mansour  M.  A  compar- 
ison of  light  wand  and  suspension  laryngoscopic  intubation  tech- 
niques in  outpatients.  Anesth  Analg  l997:85(3):578-582. 

127.  Cook-Sather  SD.  Schreiner  MS.  A  simple  hoinemade  lighted  stylet 
for  neonates  and  infants:  a  description  and  case  report  of  its  use  in 
an  infant  with  the  Pierre  Robin  anomalad.  Paediatr  Anaesth  1997: 
7(3):233-2.35. 

128.  Hung  OR.  Pytka  S.  Morris  I.  Murphy  M.  Stewart  RD.  Lightwand 
intubation:  Il-Clinicai  trial  of  a  new  lightwand  for  tracheal  intuba- 
tion in  patients  with  difficult  airways.  Can  J  Anaesth  1995:42(9): 
826-830. 

129.  Hung  OR.  Light-guided  tracheal  intubation  through  the  laryngeal 
mask  airway  (letter).  Anesth  Analg  1997:85(6):  1415. 

1.30.  Carr  R.  Reyford  H.  Belani  K.  Bouffiers  E.  Krivosic-Horbcr  R. 
Palahniuk  R.  Evaluation  of  the  Augustine  Guide  for  difficult  tra- 
cheal intubation.  Can  J  Anaesth  1995:42(12):)  171-1 175. 

131.  Krafft  P.  Fitzgerald  R.  Pernerstorfer  T.  Kapral  S.  Weinstabl  C.  A 
new  device  for  blind  oral  intubation  in  routine  and  difficult  airway 
management.  Eur  J  Anaesthesiol  1994:1 1(3):207-212. 

132.  Kovac  AL.  Use  of  the  Augustine  stylet  anticipating  difficult  tra- 
cheal intubation  in  Treacher-Collins  syndrome.  J  Clin  Anesth  1992: 
4(5):409^12. 

133.  Rosenblatt  WH.  Wang  A.  Oliver  RH.  The  fibre-optic  bronchoscope 
as  an  aid  to  difficult  tracheostomy.  J  Otolaryngol  1997:26(5):322- 
324. 

134.  Hakala  P.  Randell  T.  Meretoja  OA.  Rintala  R.  Orotracheal  fibre- 
optic  intubation  in  children  under  general  anaesthesia.  Paediatr  An- 
aesth 1997:7(5):37 1-374. 

135.  Watson  CB.  Learning  fiberoptic  intubation.  J  Cardiothorac  Anesth 
I990;4(3):419. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


T}5 


Prediction  of  a  Difficult  Intubation 


141. 


142. 


136.  Hakala  P,  Randell  T.  Valli  H.  Laryngoscopy  and  fibreoptic  intu- 
bation in  acromegalic  patients.  Br  J  Anaesth  1998;80(3):345- 
347. 

137.  Wulf  H.  Brinkmann  G.  Rautenberg  M.  Management  of  the  difficult 
airway.  A  case  of  failed  fiberoptic  intubation.  Acta  Anaesthesiol 
Scand  1997;41(8):1080-1082. 

138.  Murphy  M.  The  difficult  airway:  emergency  medicine  view.  In: 
Marks  L,  editor.  Difficult  airway:  challenges  for  the  millenium. 
Cambridge  MA:  Society  for  Airway  Management;  1998. 

139.  Cicala  R.  The  traumatized  airway.  In:  Benumof  J.  editor.  Airway 
management:  principles  and  practice.  St  Louis:  Mosby-Year  Book: 
1996:736-762. 

140.  Frass  M.  The  Combitube:  esophageal/tracheal  double  lumen  air- 
way. In:  Benumof  J,  editor.  Airway  management:  principles  and 
practice.  St  Louis:  Mosby-Year  Book,  Inc;  1996:444-454. 
Watson  C.  Case  examples  and  analysis.  In:  Benumof  J.  editor. 
Airway  management:  principles  and  practice.  St  Louis:  Mosby- 
Year  Book,  Inc;  1996:561-585. 

Boufflers  E,  Maslowski  D,  Menu  H.  Guermouche  T.  Theeten  G, 
Beague  D,  et  al.  [The  clinical  use  of  the  cuffed  oropharyngeal 
airway  (COPA).]  Ann  Fr  Anesth  Reanim  1998;17(3):206-209. 

143.  Pigott  DW.  Kay  NH,  Greenberg  RS.  The  cuffed  oropharyngeal 
airway  as  an  aid  to  fibreoptic  intubation.  Anaesthesia  1998;53{5): 
480-483. 

144.  Kawana  S,  Matsuno  A,  Nakabayashi  K,  Yamamoto  S,  Iwasaki  H, 
Watanabe  H,  et  al.  A  high,  large  epiglottis  disturbs  proper  posi- 
tioning of  the  laryngeal  mask  and  cuffed  oropharyngeal  airway. 
Anesth  Analg  1998:87(2):489^90. 

145.  Hoak  S,  Koestner  A.  Esophageal  tracheal  Combitube  in  the  emer- 
gency department.  J  Emerg  Nurs  1997;23(4):347-350. 

146.  Hofbauer  R,  Roggla  M,  Staudinger  T.  Wiltschke  C,  Kornek  GV, 
Sterz  F,  et  al.  [Emergency  intubation  with  the  Combitube  in  a 
patient  with  persistent  vomiting|.  Anasthesiol  Intensivmed  Not- 
fallmed  Schmerzther  1994;29(5):306-308. 

147.  Blostein  PA,  Koestner  AJ,  Hoak  S.  Failed  rapid  sequence  intuba- 
tion in  trauma  patients:  esophageal  tracheal  combitube  is  a  useful 
adjunct.  J  Trauma  1998.44(3):534-537. 

148.  Mallick  A,  Quinn  AC,  Bodenham  AR,  Vucevic  M.  Use  of  the 
Combitube  for  airway  maintenance  during  percutaneous  dilatational 
tracheostomy.  Anaesthesia  1998;53(3):249-255. 

149.  Rumball,  CJ,  MacDonald  D.  The  PTL,  Combitube.  laryngeal  ma.sk, 
and  oral  airway:  a  randomized  prehospital  comparative  study 
of  ventilatory  device  effectiveness  and  cost-effectiveness  in  470 
cases  of  cardiorespiratory  arrest.  Prehosp  Emerg  Care  I997;l(l): 
1-10. 

150.  Watson  C.  LMA-assisted  tracheal  intubation.  Anesthesiol  News 
1995:3:20-24. 

151.  Brimacombe  JR,  Brimacombe  JC.  Berry  AM,  Morris  R,  Mecklem 
D,  Clarke  G,  et  al.  A  comparison  of  the  laryngeal  mask  airway  and 
cuffed  oropharyngeal  airway  in  anesthetized  adult  patients.  Anesth 
Analg  1998;87(1):147-I52. 


152.  Parmet  JL,  Colonna-Romano  P,  Horrow  JC,  Miller  F,  Gonzales  J, 
Rosenberg  H.  The  laryngeal  mask  airway  reliably  provides  rescue 
ventilation  in  cases  of  unanticipated  difficult  tracheal  intubation 
along  with  difficult  mask  ventilation.  Anesth  Analg  1998;87(3): 
661-665. 

153.  Brimacombe  J,  Berry  A,  Verghese  C.  The  laryngeal  mask  airway  in 
critical  care  medicine  (review).  Intensive  Care  Med  1995;21(4): 
361-364. 

154.  Rabb  MF,  Minkowitz  HS,  Hagberg  CA.  Blind  intubation  through 
the  laryngeal  mask  airway  for  management  of  the  difficult  airway 
in  infants.  Anesthesiology  1996;84(6):15I0-151 1. 

155.  Benumof  JL.  Laryngeal  mask  airway  and  the  ASA  difficult  airway 
algorithm  (review).  Anesthesiology  l996;84(3):686-699. 

156.  Luk'ianov  MV.  Zolicheva  N:  [The  use  of  the  laryngeal  mask  in  a 
female  patient  with  an  unpredictable  difficult  intubation].  Anes- 
teziol  Reanimatol  1997:Jul-Aug(4):69-71. 

157.  Preis  CA,  Hartmann  T,  Zimpfer  M.  Laryngeal  mask  airway  facil- 
itates awake  fiberoptic  intubation  in  a  patient  with  severe  oropha- 
ryngeal bleeding.  Anesth  Analg  1998;87(3):728-729. 

158.  Ofer  R,  Dworzak  H:  [The  laryngeal  mask:  a  valuable  instrument  for 
cases  of  difficult  intubation  in  children.  Anesthesiologic  manage- 
ment in  the  presence  of  Pierre-Robin  syndrome  |.  Anaesthesist 
1996;45(3):268-270. 

159.  Mizikov  VM,  Variushina  TV.  Kirimov  II:  [Fiberoptic  bronchos- 
copy via  laryngeal  mask  in  children],  Anesteziol  Reanimatol  1997; 
Sept-Oct(5):78-80. 

160.  Patel  A,  Venn  PJ,  Barham  CJ.  Fiberoptic  intubation  through  a 
laryngeal  mask  airway  in  an  infant  with  Robin  sequence.  Eur  J 
Anaesthesiol  1998;15(2):237-239. 

161.  Bryden  DC,  Gwinnutt  CL.  Tracheal  intubation  via  the  laryngeal 
mask  airway:  a  viable  alternative  to  direct  laryngoscopy  for  nursing 
staff  during  cardiopulmonary  resuscitation.  Resuscitation  1998; 
36(1):  1 9-22. 

162.  Brain  Al,  Verghese  C,  Addy  EV,  Kapila  A.  The  intubating  laryn- 
geal mask.  I:  Development  of  a  new  device  for  intubation  of  the 
trachea.  Br  J  Anaesth  1997;79(6):699-703. 

163.  Langenstein  H.  The  laryngeal  mask  airway  in  the  difficult  intuba- 
tion. The  results  of  a  prospective  study.  Anaesthesist  1995;44(10): 
712-718. 

164.  Brain  Al,  Verghese  C,  Addy  EV,  Kapila  A,  Brimacombe  J.  The 
intubating  laryngeal  mask.  II:  A  preliminary  clinical  report  of  a  new 
means  of  intubating  the  trachea.  Br  J  Anaesth  1997;79(6):704-709. 

165.  Brimacombe  JR.  Difficult  airway  management  with  the  intubating 
laryngeal  ma.sk.  Anesth  Analg  1997:85(5):  1 173-1 175. 

166.  Langenstein  H,  Moller  F:  [First  experience  with  laryngeal  intuba- 
tion mask.]  Anaesthesist  1998;47(4):31 1-319. 

167.  Parr  MJ,  Gregory  M,  Baskett  PJ.  The  intubating  laryngeal  mask.  Use 
in  failed  and  difficult  intubation.  Anaesthesia  1998;53(4):343-348. 

168.  Belmont  MJ,  WaxMK.  De  Souza  FN:  The  difficult  airway:  cardio- 
pulmonary bypass-the  ultimate  solution.  Head  Neck  1998;20(3): 
266-269. 


Discussion 

Durbin:  Did  you  say  that  the  abihty 
to  provide  a  surgical  airway  is  an  ap- 
propriate and  essential  component  of 
the  management  of  the  difficult  air- 
way? Is  it  necessary  to  be  able  to  pro- 
vide this  airway? 


Watson:  I  believe  it  is.  We  haven't 
done  an  emergency  tracheostomy  in 
our  operating  room  in  some  time,  be- 
cause we  have  highly  expert  individ- 
uals who  use  alternative  modes  of  rec- 
ognizing and  approaching  difficult 
airways.  However,  the  fact  that  the 
emergency  medicine  and  trauma  com- 


munity has  adopted  this  makes  it  in- 
evitable. There  is  no  reason  why  per- 
cutaneous or  direct  transtracheal 
airway  insertion  must  be  fraught  with 
the  kinds  of  difficulties  that  were  re- 
ported out  of  the  Korean  War  experi- 
ence or  that  are  reported  in  the  epi- 
sodic experience  of  poorly   trained 


796 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Prediction  of  a  Difficult  Intubation 


individuals.  Tiiis  procedure  is  like  any 
other  emergency  medical  procedure, 
and  if  it's  taught  and  supervised  ap- 
propriately, it  will  have  a  high  prob- 
ability of  successful  outcome  and  a 
lower  complication  rate  than  in  the 
random,  sporadic,  poorly  monitored 
setting  that  we're  used  to  hearing 
about. 


Durbin:  I  agree  with  you  in  princi- 
ple, but  the  development  of  expertise 
is  a  problem.  The  needle  cricothyroid- 
otomy  is  a  way  to  make  people  feel 
like  they're  doing  a  surgical  airway 
without  incurring  as  much  risk.  But 
this  airway  approach  has  many  prob- 
lems. With  the  high  pressures  in- 
volved, dissection  of  gas  into  soft  tis- 
sues can  occur  even  if  the  catheter  is 
in  the  tracheal  lumen.  It  doesn't  really 
work  very  well.  But  it  does  give  peo- 
ple something  to  do  when  they  reach 
the  point  of  "can't  intubate/can't  ven- 
tilate" in  a  patient  who  might  die.  Our 
emergency  medical  technologists  are 
capable  of  doing  a  surgical  cricothy- 
roidotomy.  They  are  experienced  in 
intubating,  so  when  they  reach  the 
point  of  "can't  intubate/can't  venti- 
late," there  really  is  nothing  else  for 
them  to  do.  I  worry,  though,  that  few 
people  will  get  enough  experience  to 
do  a  cricothyroidotomy  or  emergency 
tracheostomy  and  will  not  be  able  to 
do  it  well  when  it's  needed.  How  can 
anyone  practice  this  procedure  in  a 
realistic  setting?  How  can  one  actu- 
ally be  good  at  it  when  the  time  comes? 
We  can't  have  an  ear-nose-throat  sur- 
geon sitting  there  ready  to  do  it  in 
every  hospital  24  hours  a  day.  But 
that's  probably  what  it  takes  to  guar- 
antee quality  and  safety  with  a  surgi- 
cal approach. 

Reibel:  You  really  can't  practice  that 
operation.  I've  done  maybe  2  or  3  in 
18  years,  and  it  makes  me  shudder  to 
think  about  it.  It  always  takes  longer 
than  you  think.  There's  no  way  one 
can  really  be  facile  at  that  operation. 
You  just  do  the  best  you  can. 


Watson:  I  appreciate  that  point.  You 
know  it  was  not  long  ago  that  we  were 
doing  cricothyroidotomy  for  tracheal 
ticklers  and  other  therapeutic  proce- 
dures—  cricothyroid  aspirations  for  di- 
agnostic purposes.  Cricothyroidotomy 
is  not  an  inherently  dangerous  proce- 
dure. Though  it's  inconceivable  that  a 
community  hospital  emergency  room 
could  afford  to  have  someone  regu- 
larly available  who  can  do  a  2-minute 
surgical  tracheostomy  with  great  reli- 
ability, emergency  skills  can  be  prac- 
ticed on  animals. 

Reibel:  I  would  contend  that  a  cri- 
cothyroid insertion  that  you  just  al- 
luded to  is  not  in  the  emergency  pa- 
tient whom  you  can't  intubate  or 
ventilate.  Those  little  procedures  that 
can  be  done  expeditiously  are  in  thin- 
necked  individuals  who  you  can  po- 
sition appropriately.  The  situation  of  a 
big  burly  guy  with  obstructive  sleep 
apnea  and  a  big  tongue,  who  is  bleed- 
ing after  an  elective  tonsillectomy,  is 
where  I  would  defy  you  to  insert  that 
tube  expeditiously. 

Hurford:  These  were  the  consider- 
ations that  we  had  when  we  made  our 
recommendation  for  our  hospitals 
where  we  have  trauma  surgeons,  or 
senior  surgeons  available  24  hours  a 
day,  7  days  a  week.  When  these  rare 
situations  occur,  the  last  thing  you 
want  is  an  inexperienced  individual 
with  no  prior  experience  in  neck  sur- 
gery to  do  the  procedure  and  start  in- 
sufflating high  pressure  air  into  the 
neck.  This  cuts  off  any  possibility  that 
when  the  trauma  surgeon  arrives  the 
procedure  can  be  performed  success- 
fully. The  recommendation  for  our 
programs  was  for  our  programs  be- 
cause these  are  Level  One  trauma  cen- 
ters and  there '  s  plenty  of  people  around 
who  have  a  great  deal  of  expertise  in 
managing  the  surgical  airway.  I  didn't 
see  the  point  of  having  anesthesia  res- 
idents who  would  be  inadequately 
trained  under  the  best  of  conditions 
and  who  would  use  it  under  the  worst 


of  condition.s — maybe  once  or  twice 
in  their  entire  careers — doing  that  pro- 
cedure. Needle  cricothyroidotomy  has 
a  significant  complication  rate  when 
you're  combining  it  with  high  pres- 
sure ventilation — and  that  complica- 
tion rate  then  prevents  the  proper  sur- 
geon from  doing  the  proper  procedure 
and  saving  the  patient's  life  under  the 
worst  of  conditions.  It  seems  that 
you're  ending  up  taking  the  most 
poorly  trained  individual  and  putting 
them  in  that  position. 

Watson:  With  due  respect,  I  don't 
believe  I  said  that.  What  I  said  was 
that  each  institution  needs  to  have  a 
protocol  that  incorporates  an  approach 
to  the  difficult  airway  and  an  approach 
to  the  "can't  intubate/can't  ventilate" 
situation.  I  could  produce  precisely 
analogous  situations  with  tracheal  in- 
tubation or  any  other  emergency  thing 
that  we  do.  I  appreciate  the  fact  that 
inexperienced  people  can't  do  certain 
things,  but  1  would  ask  who  or  what 
approach  we're  going  to  take  to  the 
"can't  intubate/can't  ventilate"  situa- 
tion when  you  have  someone  with  the 
credentials  that  you've  defined  as  be- 
ing adequate  for  translaryngeal  intu- 
bation, and  when  other  alternative  air- 
ways are  not  working?  We  know  those 
situations  exist. 

Hurford:  The  problem  we  have 
right  now  is  not  below  the  airway.  The 
problem  right  now  is  that  the  laryn- 
geal mask  airway,  while  it's  in  the 
ASA  algorithms,  hasn't  made  it  to  the 
emergency  rooms  in  the  country, 
hasn't  made  it  to  the  ambulance  crews 
and  paramedics,  other  than  in  a  few 
places.  The  promulgation  of  an  ade- 
quate alternative  to  a  bag  and  mask 
airway  will  solve  many  of  the  prob- 
lems for  which  cricothyroidotomies 
are  now  being  performed.  I've  re- 
viewed cases  where  emergency  crico- 
thyroidotomies were  performed  by 
people  with  no  prior  experience  on  a 
patient  who  is  spontaneously  breath- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


7':" 


Prediction  of  a  Difficult  Intubation 


ing.  I  can't  see  why  something  hke 
that  should  have  been  done. 

Watson:  It  would  be  interesting  to 
hear  others"  views  about  this  issue. 
Clearly  you  feel  very  strongly  about 
that,  but  I  know  of  people  who've 
muffed  LMA  insertions,  too.  I  would 
submit  to  you  that  this  is  a  dynamic, 
changing  environment.  The  emer- 
gency medicine  people  1  know  are 
teaching  use  of  the  LMA.  There  are 
also  segments  that  are  teaching  the  use 
of  the  PTL  airway.  There's  quite  an 
argument  over  what  should  be.  We  all 
saw  people  u.se  the  esophageal  obtu- 
rator airways  for  years,  and  they  were 
banished  because  of  the  same  kinds  of 
condemnation  that  you're  citing  with 
respect  to  cricothyroidotomy,  so  I'm 
not  prepared  to  accept  any  argument 
about  which  is  the  best  airway  inter- 
vention. However,  I  strongly  believe 
that  the  data  support  the  notion  of  an 
organized  approach  to  the  difficult  air- 
way, which  should  include  alternative 
airways  and  rescue  therapies,  and 
should  probably  include  some  type  of 
transtracheal  airway.  But  I'd  be  curi- 
ous to  hear  what  others  have  to  say. 

Bishop:  Bill  (Hurford),  I've  listened 
to  you  repeatedly  condemn  cricothy- 
roidotomy, and  while  I  agree  it's  not 
something  you  want  to  see  happening 
too  much,  I  know  there  is  the  occa- 
sional situation  where  it  can  be  life- 
saving.  I  remember  a  very  thin  patient 
with  osteogenesis  imperfecta  who  had 
started  to  seize  from  hypoxia,  could 
not  be  intubated  from  above,  couldn't 
be  ventilated,  and  his  life  was  saved 
by  a  cricothyroidotomy.  It  was  the  first 
one  I'd  done,  but  I'd  studied  the  anat- 
omy, I'd  done  a  lot  of  cricothyroid 


punctures,  and  I  have  no  regrets.  In 
fact,  it  was  absolutely  the  right  thing 
to  do.  So,  I  appreciate  what  you're 
saying,  because  I've  also  seen  crico- 
thyroidotomy done  in  the  field  on  pa- 
tients in  whom  it  probably  shouldn't 
have  been  done,  where  patients  may 
have  been  paralyzed  too  soon  or  in- 
appropriately. But,  I  don't  think  we 
should  say  "never."  I  think  there  may 
be  indications  for  it.  I've  also  seen  jet 
ventilation  via  cricothyroid  puncture 
be  life-saving  in  a  patient  who  bled 
into  an  epiglottic  tumor.  So,  there  are 
the  occasional  cases,  and  I  don't  think 
we  should  condemn  it  absolutely. 


Watson:  I  think  this  is  a  quality  as- 
surance issue  that  you're  raising.  You 
have  individuals  who  are  inadequately 
trained,  inadequately  supervised,  and 
where  the  follow-up  is  inadequate, 
who  are  trying  to  do  a  procedure  that 
they  don't  know  the  indications  for  or 
have  the  ability  to  perform.  The  bur- 
den on  us  is  within  our  systems — that 
quality  assurance  be  a  living  process 
that  we  continue  to  follow.  You  can't 
have  respiratory  therapists  doing  intu- 
bations and  recognizing  the  difficult 
ones  and  calling  for  help  if  you  don't 
review  the  ones  that  they  call  for  help 
with  and  the  ones  that  they  don't  call 
for  help  with.  You  can't  have  anes- 
thesia residents  doing  that.  You  can't 
have  pulmonary  physicians  doing  that. 
This  is  a  requirement  in  our  institu- 
tions. And  in  the  region,  in  our  EMS 
system,  it's  a  requirement.  Every  one 
of  those  events  is  reviewed  by  a  qual- 
ity assurance  council.  The  solution  is 
adequate  follow-up  and  quality  assur- 
ance of  an  appropriate  protocol — not 
condemnation  of  a  piece  of  the  proto- 


col out  of  proportion  to  the  rest  of  the 
data.  And,  clearly  we  do  need  more 
data  because  we  don't  have  real  infor- 
mation about  what  the  absolute  safest 
approach  is. 

Hurford:  Agreed.  We  don't  have 
any  sort  of  substantial  data  on  the 
safety,  efficacy,  and  complication  rates 
of  the  emergency  cricothyroidotomy 
or  the  needle  cricothyroidotomy  with 
jet  ventilation  under  the  conditions  that 
we're  discussing.  I  also  agree  that  there 
are  situations  where  needle  cricothy- 
roidotomy is  appropriate,  but  I  would 
condemn  the  algorithmic  approach, 
where  there  is  an  enthusiasm  to  move 
very  quickly  to  a  surgical  airway  with- 
out adequate  consideration  of  the  al- 
ternatives, including  calling  for  con- 
sultation. While  the  algorithms  that 
have  been  discussed  here  are  very  rea- 
soned and  academic,  unfortunately, 
what  I  have  seen  out  in  some  places  is 
an  approach  that  doesn't  follow  the 
same  rigorous  thought  processes. 
That's  what  I'm  condemning. 

Watson:  I  concur.  I  think  the  model 
of  advanced  cardiac  life  support  should 
be  reviewed.  In  most  institutions,  ev- 
ery code  is  reviewed  in  some  detail, 
and  senior  medicine  residents  who  fail 
to  treat  algorithms  appropriately  get 
beat  up.  The  anesthesia  component  of 
the  response  and  the  respiratory  ther- 
apy component  of  the  response  is  dealt 
with  when  it  fails  to  meet  those  needs. 
I  think  this  will  happen  with  airway 
management.  And  I  think  a  two-tiered 
system  is  inevitable  because  you  sim- 
ply cannot  provide  the  most  expert  in- 
dividual on  the  scene  on  every  occa- 
sion. It's  not  feasible  in  today's  world. 


798 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Extubation  and  the  Consequences  of  Reintubation 


Robert  S  Campbell  RRT 


Introduction 

Separation  of  Weaning  and  Extubation  Criteria 
Standard  Extubation  Criteria 
Extubation  Failure 
Significance  of  Extubation  Failure 
Summary 

[Respir  Care  I999:44(7):799-8031  Key  words:  intubation,  extubation,  reintu- 
bation, extubation  failure,  ventilator  weaning. 


Introduction 


Separation  of  Weaning  and  Extubation  Criteria 


Clinical  use  of  artificial  airways  is  similar  to,  and  often 
necessitated  by  the  need  for  mechanical  ventilation.  Sim- 
ilar to  initiation  of  mechanical  ventilation,  the  primary 
goal  from  the  moment  of  placement  of  the  artificial  airway 
is  to  prepare  and  evaluate  the  patient  for  its  removal.  In  the 
majority  of  cases,  use  of  an  invasive  artificial  airway  is 
intended  as  a  temporizing  therapy  that  should  be  discon- 
tinued at  the  earliest  appropriate  time,  but  clinical  and 
philosophical  arguments  are  commonplace  about  what  is 
the  earliest  appropriate  time.  A  review  of  current  literature 
on  this  topic  suggests  that  there  are  serious  risks  related  to 
the  duration  of  invasive  artificial  airways.'-^  Our  primary 
goal  should  be  to  minimize  these  risks  as  soon  as  possible. 
We  should  attempt  to  identify  and  employ  well-detmed, 
reliable  measures  and  tests  for  predicting  successful  extu- 
bation, while  recognizing  that  some  patients  will  fail  ex- 
tubation despite  the  best  prediction  efforts  of  highly  knowl- 
edgeable and  experienced  clinicians.  This  paper  discusses 
the  predictors  and  measures  that  may  be  helpful  in  reduc- 
ing the  incidence  of  extubation  failure,  with  an  emphasis 
on  information  that  may  be  confusing  or  misleading  in 
predicting  successful  extubation.  The  etiology  of  extuba- 
tion failure,  treatment  options,  and  clinical  ramifications 
of  reintubation  are  also  reviewed. 


Robert  S  Campbell  RRT  is  affiliated  with  the  Department  of  Surgery, 
Divi.sion  of  Trauma/Critical  Care,  University  of  Cincinnati  College  of 
Medicine,  Cincinnati,  Ohio. 

Correspondence:  Robert  S  Campbell  RRT.  Department  of  Surgery,  Di- 
vision of  Trauma/Critical  Care.  University  of  Cincinnati  College  of  Med- 
icine. 2.^1  Bethesda  Avenue.  Cincinnati  OH  4.'5267-0.';.'iX.  E-mail: 
robert.campbell@UC.edu. 


Before  assessing  a  patient's  readiness  for  extubation, 
the  indications  for  use  of  invasive  artificial  airways  should 
be  reviewed,  with  specific  attention  to  the  indications  that 
necessitated  intubation  for  each  particular  patient.  Hess 
has  described  in  detail  the  accepted  indications  for  use  of 
invasive  artificial  airways.**  Accepted  indications  for  place- 
ment of  invasive  artificial  airways  include:  ( 1 )  mainte- 
nance of  the  upper  airway,  (2)  protection  of  the  lower 
airway,  (3)  application  of  positive  pressure  to  the  lower 
airway  or  need  of  high  oxygen  concentrations,  and  (4) 
facilitation  of  pulmonary  toilet.  The  indications  for  intu- 
bation and  mechanical  ventilation  should  be  clearly  delin- 
eated in  the  clinician's  mind.  Currently  accepted  indica- 
tions for  the  use  of  positive  pressure  mechanical  ventilation 
include:  (1)  apnea,  (2)  acute  ventilatory  failure,  (3)  im- 
pending ventilatory  failure,  (4)  intentional  respiratory  al- 
kalosis (closed  head  injury),  and  (5)  refractory  hypoxemia. 
Although  facilitation  for  mechanical  ventilation  appears 
on  the  list  of  indications  for  invasive  airways,  it  is  well 
accepted  that  in  certain  circumstances  noninvasive  posi- 
tive pressure  ventilation  is  a  valid  alternative  to  intubation 
and  may  offer  better  patient  comfort  and  improved  out- 
come.■*■"'  A  common  misconception  is  that  the  need  for  an 
invasive  airway  is  a  valid  indication  for  mechanical  ven- 
tilation. Many  patients  have  the  ability  and  cardiopulmo- 
nary reserves  to  maintain  a  normal  breathing  pattern  and 
acceptable  gas  exchange  but  at  the  same  time  do  not  have 
the  reflexes  necessary  to  control  the  upper  airway.  If  neu- 
romuscular blockade  and/or  sedation  are  used  as  part  of 
the  intubation  procedure,  a  short  course  of  mechanical 
ventilation  will  ensue.  Determining  the  continued  need  for 
and  benefit  from  mechanical  ventilation  and  invasive  air- 
ways independent  of  each  other  is  essential.  Successful 


Respiratory  Care  •  July  1999  Vol  44  No  7 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


removal  of  the  artificial  airway  is  an  inappropriate  end- 
point  for  the  weaning  and  discontinuance  of  mechanical 
ventilation. 

There  are  4  accepted  techniques  to  wean  mechanical 
ventilation:  (1)  unassisted  spontaneous  breathing  periods 
(T-piece  trials)  interposed  with  periods  of  full  ventilatory 
support;  (2)  intermittent  mandatory  ventilation  (with  or 
without  pressure  support)  to  partition  a  percentage  of  the 
necessary  work  of  breathing  (WOB)  between  the  ventila- 
tor and  patient;  (3)  pressure  support  ventilation  to  partition 
the  breath-by-breath  WOB  between  the  ventilator  and  the 
patient;  and  (4)  abrupt  discontinuation  of  ventilatory  sup- 
port. To  date,  no  study  has  shown  a  significant  advantage 
of  any  one  technique.  In  terms  of  evaluating  the  patient's 
ability  to  sustain  spontaneous  ventilation,  unassisted  spon- 
taneous breathing  trials  appear  to  be  the  most  predictive 
and  efficient  method.  A  state-of-the-art  weaning  protocol 
would  include  an  initial  assessment  of  the  patient's  breath- 
ing ability  and  mechanics  by  measuring  the  standard  pre- 
diction factors  and  criteria  of  weaning  success:  respiratory 
rate,  tidal  volume,  minute  volume,  and  maximum  inspira- 


tory pressure.  If  the  patient  displays  the  ability  to  breathe 
spontaneously,  a  daily  20-minute  unassisted  breathing  trial 
should  be  done  to  determine  the  patient's  breathing  pat- 
tern, mechanics,  and  gas  exchange  in  the  absence  of  ven- 
tilatory assistance.  Patients  who  pass  the  initial  unassisted 
spontaneous  breathing  trial  should  not  be  returned  to  the 
mechanical  ventilator,  and  would  be  abruptly  discontinued 
from  ventilator  assistance.  Patients  who  fail  the  initial  un- 
assisted spontaneous  breathing  trial  require  weaning  with 
one  of  the  aforementioned  techniques.  Weaning  in  this 
case  involves  the  titration  of  ventilatory  support  in  the 
period  between  the  daily  unassisted  spontaneous  breathing 
trials.  Independent  of  the  technique  chosen,  the  goal  should 
be  to  provide  a  level  of  ventilatory  assistance  that  avoids 
fatigue  of  the  respiratory  muscles,  results  in  an  acceptable 
breathing  pattern  and  gas  exchange,  and  maintains  patient 
comfort  and  general  well-being.  Mechanical  ventilation 
weaning  and  titration  of  ventilatory  support  are  best  ac- 
complished with  an  accepted  weaning  protocol."'-  There 
are  several  reports  that  weaning  protocols  tend  to  reduce 
the  duration  of  mechanical  ventilation  without  increasing 


Table  1 .      Extubation  Criteria  to  Evaluate  for  Continued  Need  of  Invasive  Airway 


General  Criteria 


Specific  Tests,  Values,  and  Conditions 


Adequate  gas  exchange  during  unassisted  spontaneous 
breathing  trial 

Adequate  respiratory  muscle  strength 


Acceptable  pulmonary  mechanics 


Adequate  airway  protective  reflexes 


Normal,  improving,  or  manageable  pulmonary  secretions 


Stable  hemodynamic  function 


Presence  of  a  gas  leak  around  the  deflated  cuff  upon 
delivery  of  a  positive  pressure  breath 

No  anticipation  for  the  need  for  reintubation  in  the 
near  future 

Absence  of  previously  identified  difficulties  with  intubation 


Ratio  of  arterial  oxygen  tension  to  fraction  of  inspired  oxygen  (PaOj/Flo,)  >  250 

Appropriate  pH  and  PacOj 

Ratio  of  ventilatory  dead  space  to  tidal  volume  (V,7V.|^)  <  0.6 

Maximum  inspiratory  pressure  <  -30  cm  H,0 

Vital  capacity  >  15  mL/Kg 

Transdiaphragmatic  pressure  during  spontaneous  breathing  <  15%  of  maximum 

Respiratory  rate  <  35  breaths  per  minute 

Tidal  volume  >  4  mL/Kg 

Ratio  of  respiratory  rate  to  tidal  volume  (f/V^.)  <  105  during  spontaneous  breathing 

Respiratory  system  compliance  >  25  mL/cm  H,  O 

Work  of  breathing  <  0.8  J/L 

Oxygen  cost  of  breathing  <  15%  of  total  oxygen  consumption 

Tracheal  occlusion  pressure  in  the  first  100  ms  >  -6  cm  H,0 

Gag  reflex  intact 
Acceptable  cough 
Ability  to  swallow 
Appropriate  mental  status 

Secretion  volume 
Secretion  consistency 

Acceptable  blood  pressure  during  spontaneous  breathing  trial 
Acceptable  heart  rate  during  spontaneous  breathing  trial 
No  evidence  of  cardiogenic  pulmonary  edema 


800 


Respiratory  Care  •  July  1999  Vol  44  No  7 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


the  complication  or  reintubation  rate.  Once  the  patient 
passes  an  unassisted  spontaneous  breathing  trial,  he  or  she 
should  be  considered  "weaned."  At  that  point,  criteria  for 
the  removal  of  the  artificial  airway  should  be  assessed. 

Standard  Extubation  Criteria 

Standard  extubation  criteria  are  designed  to  evaluate  the 
patient's  ability  to  maintain  the  upper  airway,  protect  the 
lower  airway,  and  maintain  adequate  pulmonary  toilet.  Ba- 
sic evaluation  involves  determination  of  adequate  gag,  swal- 
low, and  cough  reflexes  and  abilities.  The  patient's  mental 
status  should  also  be  evaluated  to  determine  his  or  her 
ability  to  protect  the  lower  airway,  follow  basic  instruc- 
tions, and  perform  common  postextubation  respiratory  ma- 
neuvers such  as  incentive  spirometry,  cough,  and  deep 
breathing.  The  amount  and  consistency  of  pulmonary  se- 
cretions should  also  be  evaluated.  Table  I  lists  standard 
extubation  criteria,  each  of  which  has  some  predictive  value. 
Evaluation  of  these  criteria  is  more  an  art  than  a  science, 
since  most  of  the  criteria  are  not  simple  pass/fail  tests.  The 
decision  whether  to  risk  removal  of  the  artificial  airway  is 
largely  based  on  the  practitioner's  experience  and  on  his  or 
her  interpretation  of  the  patient's  history  and  clinical  course. 
Occasionally,  additional  testing,  such  as  evaluation  of  the 
patient's  ability  to  breathe  around  the  occluded  artificial 
airway  with  the  cuff  deflated,'^''*  and  measurement  of  the 
percentage  of  tidal  volume  leaked  around  the  tube  with  the 
cuff  deflated,"'^  can  aid  in  the  decision-making  process. 
Bronchoscopy  and/or  direct  laryngoscopy  may  be  useful 
in  certain  patients  with  upper  airway  deformities  or  edema. 

Extubation  Failure 

No  matter  how  diligent  the  clinician  is  in  performing  the 
extubation  assessment,  successful  extubation  will  never  be 
100%  predictable.  Reported  failure  rates  for  planned  ex- 
tubation range  from  4%-23%. '''--''  This  range  is  primarily 
the  result  of  the  aggressiveness  and  general  philosophy  of 
the  individual  clinician  or  clinician  group,  and  to  a  lesser 
degree  may  reflect  the  patient  population  studied  or  indi- 
vidual patient  characteristics.  The  risks  of  the  continued 
presence  of  the  artificial  airway  must  be  weighed  against 
the  risks  of  extubation  and  potential  extubation  failure.  An 
extubation  failure  rate  of  10-19%  seems  to  be  clinically 
acceptable.  This  will  obviously  depend  on  the  patient  pop- 
ulation and  the  duration  of  intubation  and  mechanical  ven- 
tilation. Patients  in  the  post-anesthesia  recovery  unit  or  the 
cardiac  intensive  care  unit  (ICU),  who  are  intubated  and 
mechanically  ventilated  for  short  periods  of  time  should 
have  an  extubation  failure  rate  of  less  than  6%.'^  Patients 
requiring  mechanical  ventilation  for  more  than  48  hours 
because  of  underlying  lung  pathophysiology  or  decondi- 
tioning  of  the  respiratory  muscles,  or  who  require  pro- 


longed weaning  of  ventilatory  support,  would  be  expected 
to  have  higher  extubation  failure  rates,  approaching  20%.'*^ 
Lower  extubation  failure  rates  suggest  that  some  patients 
may  be  undergoing  inappropriately  prolonged  intubation 
and/or  mechanical  ventilation.  Higher  failure  rates  may 
suggest  that  some  patients  are  being  extubated  prematurely 
and  exposed  to  additional  risks  following  extubation  and 
related  to  the  replacement  of  the  artificial  airway.  Tracking 
extubation  failure  rates  is  a  classic  quality  assurance  index 
that  can  lead  to  a  better  understanding  of  the  factors  in- 
fluencing success,  improvement  of  care  management,  and, 
possibly,  improvement  of  patient  outcomes. 

Many  studies  have  retrospectively  reported  the  incidence, 
timing,  and  reason  for  extubation  failure,  but  without  con- 
trolling for  independent  variables.  Usually  the  reasons  for 
extubation  failure  are  divided  into  2  categories:  airway 
related  and  nonairway  related.  The  timing  of  extubation 
failure  is  correlated  most  closely  with  the  etiology  of  fail- 
ure, with  airway  related  failures  typically  occurring  ear- 
ly— less  than  8  hours  after  extubation.  Airway-related  ex- 
tubation failure  is  usually  associated  with  upper  airway 
obstruction,  resulting  from  laryngospasm,  laryngeal  edema, 
supraglottic  obstruction,  or  aspiration  of  upper  airway  or 
gastric  secretions.  Nonairway-related  failures  can  occur  up 
to  72  hours  post-extubation,  and  are  usually  associated 
with  impaired  gas  exchange  (hypoxemia,  hypercarbia)  or 
excessive  WOB  from  worsening  pulmonary  mechanics. 

Dojat  et  aP"*  recently  evaluated  a  knowledge-based  sys- 
tem for  deciding  when  to  wean  and  extubate  their  patients. 
The  knowledge-based  system  predicted  failure  in  all  10 
patients  who  had  also  failed  traditional  predictors  collected 
during  and  following  an  unassisted  spontaneous  breathing 
trial.  In  28  patients  who  were  considered  to  have  passed  all 
of  the  traditional  predictors,  the  knowledge-based  system 
disagreed  in  9  patients.  Extubation  failure  rate  was  8% 
when  there  was  agreement  between  the  knowledge-based 
system  and  traditional  predictors,  and  23%  when  there  was 
disagreement.  This  study  suggests  that  collection  and  eval- 
uation of  additional  information  over  traditional  simple 
predictors  may  provide  better  prediction  of  negative  out- 
come after  patients  have  passed  the  spontaneous-breathing 
trial. 

It  is  a  commonly  held  belief  that  the  WOB  will  be 
reduced  following  removal  of  the  artificial  airway.  Recent 
studies  have  shown  that  post-extubation  WOB  actually 
increases  in  many  patients,  most  likely  because  of  incom- 
plete control  of  the  upper  airway. ™-^^ 

It  is  important  to  track  the  incidence  of  extubation  fail- 
ure and  complications  in  patients  who  experience  unplanned 
extubations.  Unplanned  extubations  should  be  .separated 
into  intentional  self-extubation  and  accidental  extuba- 
tion.^"^"'-'' Risk  factors  for  predicting  intentional  self-extu- 
bation include  lack  of  adequate  sedation,  inappropriate 
ventilator  settings,  noncircumferential  stabilization  of  the 


Respiratory  Care  •  July  1999  Vol  44  No  7 


S^M 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


airway,  and  lack  of  proper  hand  restraints.  Note,  however, 
that  up  to  80%  of  patients  who  intentionally  self-extubate 
do  not  require  replacement  of  the  artificial  airway.  This 
high  number  of  successful  self-extubations  suggests  that 
more  aggressive  evaluation  and  weaning  are  appropriate. 
Risk  factors  for  the  prediction  of  accidental  extubation  in- 
clude mode  of  ventilation,  noncircumferential  stabilization  of 
the  airway,  rotational  therapy,  and  frequent  bedside  proce- 
dures or  interventions  that  require  patient  movement.  Not 
surprisingly,  the  reintubation  rate  in  this  patient  population  is 
much  higher,  approaching  85%.  However,  this  still  means 
that  15%  of  the  patients  believed  not  to  be  extubation  candi- 
dates could  in  fact  be  successfully  extubated. 

Significance  of  Extubation  Failure 

As  noted  earlier,  extubation  failure  rates  of  10-19%  are 
currently  clinically  acceptable.  In  order  to  accept  these 
numbers,  evaluation  of  outcome  measures  and  other  com- 
plication rates  are  necessary,  with  appropriate  comparison 
to  successfully  extubated  patients.  Torres  et  al,"*''  in  a  study 
of  40  medical  patients  requiring  reintubation,  were  among 
the  first  to  quantify  the  relationship  between  reintubation, 
mortality,  ICU  days,  and  incidence  of  pneumonia.  Mor- 
tality (35%  vs  20%),  ICU  length  of  stay  (19.4  vs  13.9),  and 
incidence  of  pneumonia  (47%  vs  10%)  were  all  higher  in 
patients  requiring  reintubation,  compared  to  a  matched 
group  of  control  subjects  who  were  successfully  extubated. 
Epstein  et  al'**  recently  reported  on  289  consecutive  extu- 
bations  of  medical  patients.  They  reported  a  15%  reintu- 
bation rate,  and  the  mortality  among  patients  failing  extu- 
bation was  more  than  3  times  greater  (43%  vs  12%)  than 
those  successfully  extubated.  In  addition,  ICU  length  of 
stay  (21  days  vs  5  days)  was  longer  in  the  group  that  failed 
extubation,  as  were  hospital  days  (31  days  vs  16  days). 

In  a  study  that  included  484  patients,  Esteban  et  aP" 
reported  an  overall  reintubation  rate  of  19%.  ICU  mortal- 
ity was  significantly  higher  in  the  group  requiring  reintu- 
bation (27%  vs  3%).  More  recently,  Epstein  et  al'^  at- 
tempted to  determine  the  factors  associated  with 
reintubation  and  mortality.  Of  74  patients  requiring  rein- 
tubation, 69%  were  associated  with  nonairway-related  fail- 
ure. Overall  mortality  was  42%,  but  mortality  was  much 
higher  when  the  etiology  of  extubation  failure  was  non- 
airway  related  (53%  vs  17%).  There  was  also  an  associa- 
tion between  mortality  and  time  to  reintubation.  Mortality 
was  24%  in  patients  reintubated  within  12  hours  and  51% 
when  reintubation  occurred  more  than  12  hours  after  ex- 
tubation. Another  interesting  finding  in  this  study  was  that 
the  time  to  reintubation  was,  on  average,  10  hours  earlier 
if  failure  was  related  to  the  airway,  as  compared  to  non- 
airway  failures.  This  study  illustrates  the  problems  asso- 
ciated with  correlating  mortality  and  other  outcome  mea- 
sures to  the  need  for  reintubation  alone.  Obviously,  airway 


related  extubation  failure  is  easier  to  identify  and  treat 
clinically.  Patients  who  fail  extubation  for  nonairway  re- 
lated reasons  are  commonly  treated  with  other  modalities 
before  the  decision  to  reintubate  is  made.  This  study  in- 
dicates that  the  increased  mortality  is  not  associated  with 
the  reintubation  procedure.  But  is  the  mortality  associated 
with  the  time  period  and  therapy  administered  between 
extubation  and  reintubation?  Is  it  associated  with  other 
factors  such  as  the  underlying  disease  state  and  other  co- 
morbid  conditions?  Or  is  it  associated  with  the  subsequent 
prolongation  of  intubation  and  mechanical  ventilation? 
Certainly,  more  prompt  identification  of  nonairway-related 
failure,  and  timely  intervention  (possibly  including  a  trial 
of  noninvasive  positive  pressure  ventilation)  and  earlier 
reintubation  would  be  associated  with  lower  complication 
and  mortality  rates.  It  is  well  accepted  that  the  duration  of 
mechanical  ventilation  alone  is  related  to  mortality.  Tro- 
che and  Moine^^  reported  a  mortality  rate  of  24%  when  the 
requirement  for  mechanical  ventilation  was  less  than  4 
days,  compared  to  a  mortality  of  56%  if  more  than  4  days 
of  mechanical  ventilation  were  required.  The  reintubation 
rate  in  this  study  was  only  4%,  and  reflected  a  predominantly 
surgical  patient  population.  Daley  et  aH'  also  correlated  mor- 
tality and  reintubation  in  a  group  of  405  trauma  patients,  and 
found  that  the  overall  reintubation  rate  was  low  (7%),  and 
that  there  was  no  difference  in  mortality  between  patients 
requiring  reintubation  and  those  successfully  extubated. 

Summary 

Removal  of  the  artificial  airway  is  the  goal  of  therapy 
beginning  at  the  time  of  initial  placement,  and  should  be 
done  at  the  earliest  appropriate  time.  However,  determi- 
nation of  patient  readiness  for  extubation  is  difficult  be- 
cause some  of  the  extubation  criteria  are  subject  to  inter- 
pretation. The  extubation  procedure  itself  is  associated  with 
few  complications,  but  the  need  for  reintubation  is  asso- 
ciated with  many  reported  complications  and  increased 
mortality  and  morbidity.  Although  the  relationship  between 
reintubation  and  increased  mortality  and  morbidity  remains 
unclear,  clinicians  should  diligently  monitor  patients  in  the 
postextubation  period  and  promptly  provide  appropriate 
care  and  procedures  to  improve  patient  comfort,  safety, 
and  outcome.  Reintubation  rates  should  be  monitored  in 
each  institution  and  within  different  care  areas  in  order  to 
improve  the  quality  of  care  and  aid  decision  makers  in 
augmenting  and  improving  their  clinical  practice. 

REFERENCES 

1.  Colice  GL,  Stukel  TA,  Dain  B.  Laryngeal  complications  of  pro- 
longed intubation.  Chest  1989;96(4):877-884. 

2.  Torres  A,  Aznar  R,  Gatell  JM,  Jimenez  P,  Gonzalez  J,  Ferrer  A,  et  al. 
Incidence,  risk,  and  prognosis  factors  of  nosocomial  pneumonia  in  me- 
chanically ventilated  patients.  Am  Rev  RespirDis  1990;142(3):523-528. 


802 


Respiratory  Care  •  July  1999  Vol  44  No  7 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


3.  Stauffer  JL.  Olson  DE,  Petty  TL.  Complications  and  consequences 
of  endotracheal  intubation  and  tracheotomy:  a  prospective  study  of 
150  critically  ill  adult  patients.  Am  J  Med  1981:70(l):65-76. 

4.  Santos  PM.  Afrassiabi  A.  Weymuller  EA  Jr.  Risk  factors  associated 
with  prolonged  intubation  and  laryngeal  injury.  Otolaryngol  Head 
Neck  Surg  1994;1 1  l(4):4.'i3^59. 

5.  Kastanos  N.  Estopa  Miro  R.  Marin  Perez  A.  Xaubet  Mir  A.  Agusti- 
Vidal  A.  Laryngotracheal  injury  due  to  endotracheal  intubation:  in- 
cidence, evolution,  and  predisposing  factors.  A  prospective,  long- 
term  study.  Crit  Care  Med  1983:1 1(.')):362-367. 

6.  Hozapfel  L.  Chevret  S.  Madinier  G.  Ohen  F.  Demingeon  G.  Coupry  A. 
Chaudet  M.  Influence  of  long-term,  oro-  or  nasotracheal  intubation  on 
nosocomial  maxillary  sinusitis  and  pneumonia:  results  of  a  prospective, 
randomized,  clinical  trial.  Cnt  Care  Med  1993:21(8):  1 132-1 138. 

7.  Stauffer  JL,  Silvestri  RC.  Complications  of  endotracheal  intubation, 
tfacheostomy  and  artificial  airways.  Respir  Care  1982;27(4):4 17^.34. 

8.  Hess  D.  Indications  for  translaryngeal  intubation.  Respir  Care  1999; 
44(6):759-772. 

9.  Meduri  GU.  Turner  RE.  Abou-Shala  N.  Wunderink  R.  Tolley  E. 
Noninvasive  positive  pressure  ventilation  via  face  mask:  first  line 
intervention  in  patients  with  acute  hypercapnic  and  hypoxemic  re- 
spiratory failure.  Chest  1996;109(1):179-193. 

10.  Hess  D.  Noninvasive  positive  pressure  ventilation:  predictors  of  suc- 
cess and  failure  for  adult  acute  care  applications.  Respir  Care  1997; 
42(4):424-43 1 . 

1 1 .  Kollef  MH.  Shapiro  SD.  Silver  P.  St  John  RE.  Prentice  D.  Sauer  S. 
et  al.  A  randomized,  controlled  trial  of  protocol-directed  versus  phy- 
sician-directed weaning  from  mechanical  ventilation.  Crit  Care  Med 
1997;25{4):567-.574. 

12.  Saura  P.  Blanch  L.  Mestre  J.  Valles  J,  Artigas  A.  Fernandez  R. 
Clinical  consequences  of  the  implementation  of  a  weaning  protocol. 
Intensive  Care  Med  1996;22(10):1052-1056. 

13.  Bach  JR.  Saporito  LR.  Criteria  for  extubation  and  tracheostomy  tube 
removal  for  patients  with  ventilatory  failure:  a  different  approach  to 
weaning.  Chest  1 996;  1 10(6):  1566- 1571. 

14.  Ho  LI.  Ham  HJ.  Lien  TC.  Hu  PY.  Wang  JH.  Postextubation  laryn- 
geal edema  in  adults:  risk  factor  evaluation  and  prevention  by  hy- 
drocortisone. Intensive  Care  Med  1996;22(9):933-936. 

15.  Miller  RL.  Cole  RP.  Association  between  reduced  cuff  leak  volume 
and  postextubation  stridor.  Chest  1 996;  1 10(4):  1035-1040. 

16.  Fisher  MM.  Raper  RF.  The  "cuff-leak"  test  for  extubation.  Anaes- 
thesia 1992:47(1):  10- 12. 

1 7.  Epstein  SK.  Ciubotaru  RL.  Independent  effects  of  etiology  of  failure 
and  time  to  reintubation  on  outcome  for  patients  failing  extubation. 
Am  J  Respir  Crit  Care  Med  1998;158(2):489-493. 

18.  Reyes  A.  Vega  G.  Blancas  R,  Morato  B.  Moreno  JL.  Torrecilla  C. 
Cereijo  E.  Early  vs  conventional  extubation  after  cardiac  surgery 
with  cardiopulmonary  bypass.  Chest  1997:1 12(l):193-201. 

19.  Epstein  SK.  Ciubotaru  RL.  Wong  JB.  Effect  of  failed  extubation  on 
the  outcome  of  mechanical  ventilation.  Chest  1997:1 12(0:186-192. 

20.  Esteban  A.  Alia  I.  Gordo  F.  Fernandez  R.  Solsona  JF.  Vallverdu  I.  et 
al.  Extubation  outcome  after  spontaneous  breathing  trials  with  T- 
tube  or  pressure  support  ventilation.  The  Spanish  Lung  Failure  Col- 
laborative Group.  Am  J  Respir  Crit  Care  Med  1 997;  1 56(2  Pt  1  ):459- 
465.  Published  erratum  Am  J  Respir  Crit  Care  Med  1997.156(6): 
2028. 

21.  Kollef  MH.  O'Brien  JD.  Silver  P.  The  impact  of  gender  on  outcome 
from  mechanical  ventilation.  Chest  1997;1 1 1(2):434-441. 

22.  Troche  G.  Moine  P.  Is  the  duration  of  mechanical  ventilation  pre- 
dictable? Chest  1997:1 12(3):745-751. 

23.  Doering  LV.  Relationship  of  age.  sex.  and  procedure  type  to  extu- 
bation outcome  after  heart  surgery.  Heart  Lung  1997;26(6):439^147. 

24.  Ely  EW.  Baker  AM.  Dunagan  DP.  Burke  HL.  Smith  AC.  Kelly  PT. 
et  al.  Effect  on  the  duration  of  mechanical  ventilation  of  identifying 


25 


26, 


27 


28 


30 


31 


33 


34 


patients  capable  of  breathing  spontaneously.  New  Engl  J  Med  1996; 
335(25):  1864-1 869. 

Dojal  M.  Harf  A.  Touchard  D.  Laforest  M.  Lemaire  F.  Brochard  L. 
Evaluation  of  a  knowledge-based  systein  providing  ventilatory  man- 
agement and  decision  for  extubation.  Am  J  Respir  Crit  Care  Med 
1996;I53(3):997-1004. 

Epstein  SK.  Etiology  of  extubation  failure  and  the  predictive  value  of 
the  rapid  shallow  breathing  index.  Am  J  Respir  Crit  Care  Med  1995; 
152(2):545-549. 

DeHaven  CB  Jr.  Hurst  JM.  Branson  RD.  Evaluation  of  two  different 
extubation  criteria:  attributes  contributing  to  success.  Crit  Care  Med 
l986;14(2):92-94. 

Shackford  SR.  Virgilio  RW.  Peters  RM.  Early  extubation  versus 
prophylactive  ventilation  in  the  high  risk  patient:  a  comparison  of 
postoperative  management  in  the  prevention  of  respiratory  compli- 
cations. Anesth  Analg  1981  ;60(2):76-80. 

29.  Gillespie  DJ.  Marsh  HM.  Divertie  MB.  Meadows  JA  3rd.  Clinical 
outcome  of  respiratory  failure  in  patients  requiring  prolonged  (>  24 
hours)  mechanical  ventilation.  Chest  1986;90(3):364-369. 
Ishaaya  AM.  Nathan  SD.  Belman  MJ.  Work  of  breathing  after  ex- 
tubation. Chest  1995:107(1  ):204-209. 

Nathan  SD.  Ishaaya  AM.  Koemer  SK.  Belman  MJ.  Prediction  of 
minimal  pressure  support  during  weaning  from  mechanical  ventila- 
tion. Chest  1993;103(4);1215-I219. 

32.  Davis  K  Jr.  Campbell  RS.  Johannigman  JA.  Valente  JF.  Branson 
RD.  Changes  in  respiratory  mechanics  after  tracheostomy.  Arch  Surg 
1999:134(1  ):59-62. 

Straus  C.  Louis  B.  Isabey  D.  Lemaire  F.  Harf  A.  Brochard  L.  Con- 
tribution of  the  endotracheal  tube  and  the  upper  airway  to  breathing 
workload.  Am  J  Respir  Crit  Care  Med  1998;157(  I  ):23-30. 
Betbese  AJ.  Perez  M.  Bak  E.  Rialp  G.  Mancebo  J.  A  prospective 
study  of  unplanned  endotracheal  extubation  in  intensive  care  unit 
patients.  Crit  Care  Med  I998;26(7):l  180-1 186. 

35.  Boulain  T.  Unplanned  extubation  in  the  adult  intensive  care  unit:  a 
prospective  multicenter  study.  Association  des  Reanimateurs  du  Cen- 
tre-Ouest.  Am  J  Respir  Crit  Care  Med  1998;157(4Pt  1  ):1 131-1 137. 
Mort  TC.  Unplanned  tracheal  extubation  outside  the  operating  room: 
a  quality  improvement  audit  of  hemixlynamic  and  tracheal  airway 
complications  associated  with  emergency  tracheal  reintubation. 
Anesth  Analg  1998.86(6):  1 171-1 176. 

Chevron  V.  Menard  JF.  Richard  JC.  Girault  C.  Leroy  J.  Bonmarchand 
G.  Unplanned  extubation:  risk  factors  of  development  and  predictive 
criteria  for  reintubation.  Crit  Care  Med  1998:26(6):  1049-1053. 
Atkins  PM.  Mion  LC.  Mendelson  W.  Palmer  RM.  Slomka  J.  Franko  T. 
Characteristics  and  outcomes  of  patients  who  self-extubate  from  venti- 
latory support:  a  case-control  study.  Chest  1997:1  I2(5):I3I7-1323. 

39.  Vas.sal  T.  Anh  NG.  Gabillet  JM.  Guidet  B.  Staikowsky  F.  Offenstadl 
G.  Prospective  evaluation  of  self-extubations  in  a  medical  intensive 
care  unit.  Intensive  Care  Med  1993:19(6):340-.342. 
Coppolo  DP.  May  JJ.  Self-extubations:  a  1 2-month  experience.  Chest 
1990:98(1):  165- 169. 

Whelan  J.  Simpson  SQ.  Levy  H.  Unplanned  extubation:  predictors  of 
successful  termination  of  mechanical  ventilatory  support.  Chest  1994; 
105(6):1808-1812. 

Listello  D.  SesslerCN.  Unplanned  extubation:  clinical  predictors  for 
reintubation.  Chest  1994:105(5):  1496-1503. 
Tindol  GA  Jr.  DiBenedetto  RJ.  Kosciuk  L.  Unplanned  extubations. 
Chest  1994;  1 05(6):  1804- 1807. 

Torres  A.  Gatell  JM.  Aznar  E,  el-Ebiary  M,  Puig  de  la  Bellacasa  J, 
Gonzalez  J.  et  al.  Re-intubation  increases  the  risk  of  nosocomial 
pneumonia  in  patients  needing  mechanical  ventilation.  Am  J  Re.spir 
Crit  Care  Med  1995:152(1):137-141. 

Daley  BJ.  Garcia-Perez  F,  Ross  SE.  Reintubation  as  an  outcome 
predictor  in  trauma  patients.  Chest  1996:1 10(6):1577-1580. 


.36 


37 


.38, 


40 


41 


42. 


43 


44. 


45. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


8(i  < 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


Discussion 

Bishop:  About  15  years  ago,  Hen- 
ning  Pontoppiden  came  as  a  visiting 
professor  at  Harborview  and  made 
rounds  with  our  chief  of  surgery.  Pon- 
toppiden said  in  a  discussion  about 
patients,  "Why  don't  we  just  take  out 
the  tube  and  see  how  the  patient  does? 
No  problem  if  we  have  to  reintubate, 
is  it?"  Our  chief  of  surgery  said,  "I 
think  it's  a  very  big  problem  if  we 
have  to  reintubate."  So  here  we  had  2 
critical  care  experts  who  very  much 
disagreed  on  it.  I'm  not  sure  we  have 
the  evidence,  as  you  point  out.  My 
personal  feeling  is:  when  in  doubt,  take 
it  out.  Suppose  we  have  a  30%  rein- 
tubation  rate?  We  don't  have  evidence 
that  that  has  adverse  effects,  and  yet, 
keeping  a  patient  intubated  is  at  least 
costly,  and  we  think  probably  has  risks. 
So  where  does  the  17%  come  from? 

Campbell:  Well,  that' s  a  good  ques- 
tion. I  thought  about  rounding  that 
number  up,  and  perhaps  I  should  have 
rounded  it  up,  but  it's  more  of  a  per- 
sonal thing,  yet  based  on  most  of  the 
literature,  which  indicates  that  there  is 
a  less  than  20%  failure  rate. 

Bishop:  I  would  submit  that  a  lot  of 
it  has  to  do  with  how  comfortable  peo- 
ple feel  in  reintubating  and  reintubat- 
ing  safely,  and  I  think  that's  where 
some  of  the  difference  comes  from. 

Campbell:  1  would  agree  with  that 
as  well,  and  I  also  think  that  you  have 
to  look  at  the  patient  population  that 
you're  dealing  with.  If  you're  looking 
at  a  surgical  ICU,  then  I  believe  that 
the  "when  in  doubt,  take  it  out"  policy 
will  probably  be  successful  the  major- 
ity of  the  time.  But  in  the  medical 
ICU,  that  probably  would  not  be  the 
case.  1  think  there  is  evidence  to  sug- 
gest that  there  might  be  an  altered  out- 
come with  reintubation  in  that  patient 
population. 

Hess:  1  would  refer  you  to  the  study 
by  Esteban,  published  in  the  blue  jour- 


nal (AJRCCM)  about  a  year  ago, 
where  they  compared  7  cm  HjO  of 
pressure  support  to  a  T-piece  for  a 
2-hour  spontaneous  breathing  trial, 
and  I  think  had  a  reintubation  rate  of 
around  18-20%  in  both  groups.' 

REFERENCE 

1.  Esteban  A,  Alia  I,  Gordo  F,  Fernandez  R, 
Solsona  JF,  et  al.  Extubation  outcome  after 
spontaneous  breathing  trials  with  t-tube  or 
pressure  support  ventilation.  The  Spanish 
Lung  Failure  Collaborative  Group.  Am  J  Re- 
spir  Crit  Care  Med  1997;  156(2  Pt  1):459- 
465. 

Campbell:     It  was  19%. 

Hess:  But  one  of  the  issues  that  was 
brought  out  in  that  paper  was  that  the 
patients  who  were  reintubated  in  ei- 
ther group  had  a  significantly  higher 
mortality  than  those  who  were  not  re- 
intubated. 

Durbin:  The  crux  of  the  issue  is 
whether  those  patients  have  a  worse 
outcome  because  they  were  reintu- 
bated or  because  they  were  sicker  and 
therefore  needed  reintubation.  The 
question  is  whether  the  process  of  re- 
intubation or  the  period  of  inappropri- 
ate extubation  is  the  cause  of  the  poorer 
outcome.  There's  really  no  way  that  I 
can  analyze  the  data  any  better  than 
you  did  in  your  presentation.  I  don't 
think  that  it  is  the  process  of  intuba- 
tion that  causes  the  trouble,  but  we 
really  don't  know.  I  believe  it's  some- 
thing else  about  the  patient.  I  don't 
think  we  know  the  answer,  because  1 
don't  think  we  collect  or  present  the 
data  in  a  way  that's  very  meaningful. 
We  don't  know  yet  whether  it's  some- 
thing about  reintubation,  or  being  ex- 
tubated  for  a  short  period  of  time,  or 
whether  these  are  just  sicker  patients. 
I  challenge  you  all  to  think  about  this 
problem,  because  I  believe  we  need 
that  answer  in  order  to  know  what  to 
do  differently  and  better. 

Hurford:  I  agree  there  are  no  real 
data.  But,  it  would  be  very  odd  for 
someone  in  a  post-anesthesia  care  unit 


or  someone  in  an  operating  room  man- 
agement position  to  think  that  it's  OK  if 
20%  of  the  patients  in  the  post-anesthe- 
sia care  unit  have  to  be  reintubated  after 
general  anesthesia,  going  on  the  assump- 
tion that  there's  no  harm  or  additional 
risk  with  reintubation.  Charlie  (Durbin), 
I'd  like  your  comment. 

Durbin:  The  post-anesthesia  care 
unit  is  an  interesting  environment  to 
study,  because  it  looks  like  patients 
who  require  reintubation  in  a  post-an- 
esthesia care  unit  (which  you  would 
think  would  be  a  healthier  group  of 
patients)  might  be  a  good  model  to 
look  at  to  see  if  the  reintubation  process 
is  a  problem,  and  it  turns  out  it  is.  The 
patients  who  require  reintubation  in  the 
post-anesthesia  care  unit  have  a  higher 
incidence  of  pneumonia  and  have  longer 
hospital  stays.  These  data  are  not  cor- 
rected for  severity  of  disease. '"'^ 

REFERENCES 

1.  Mathew  JP,  Rosenbaum  SH,  O'Connor  T, 
Barash  PG.  Emergency  tracheal  intubation 
in  the  post-anesthesia  care  unit:  physician 
error  or  patient  disease?  Anesth  Analg  1 990; 
71(6):691-697. 

2.  Miller  KA,  Harkin  CP,  Bailey  PL.  Postop- 
erative tracheal  extubation.  Anesth  Analg 
1995;80(1):149-172. 

3.  Berg  H,  Roed  J,  Viby-Mogensen  J, 
Mortensen  CR,  Engbaek  J.  Skovgaard  LT, 
Krintel  JJ  .  Residual  neuromu.scular  block  is 
a  risk  factor  for  postoperative  pulmonary 
complications:  a  prospective,  randomized, 
and  blinded  study  of  postoperative  pulmo- 
nary complications  after  atracurium,  vecu- 
ronium and  pancuronium.  Acta  Anaesthe- 
siol  Scand  1997:41:109.5-1103. 

Hurford:  Then  why  should  the 
ICU's  environment  be  any  different? 

Durbin:  I  don't  know  that  it  is.  But 
I  still  don't  know  the  answer  to  the 
question. 

Hurford:  But  it's  OK  to  have  a  20% 
reintubation  rate  in  the  ICU  on  the 
basis  of  the  data  that  we  currently  don't 
have. 

Durbin:  If  you  ventilate  patients  for 
extended  periods,  a  20%  reintubation 


804 


Respiratory  Care  •  July  1999  Vol  44  No  7 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


rate  may  be  reasonable.  In  fact,  we 
may  be  performing  an  extubation  trial. 
I've  used  that  term  in  the  extubation 
clinical  practice  guideline.'  During  its 
review,  a  lot  of  people  did  not  like 
that.  They  thought  that  an  extubation 
trial  was  not  something  we  should  dis- 
cuss. But  the  words  "extubation  trial" 
are  present,  because  I  think  that  is 
something  anesthesiologists  describe. 
It  is  a  successful  method  for  making 
the  final  determination  of  extubation 
readiness — fully  expecting  that  some 
patients  will  need  reintubating. 

REFERENCE 

1 .  AARC  Clinical  Practice  Guideline.  Removal 
of  the  endotracheal  tube.  Re.spir  Care  1999; 
44(0:85-90. 

Thompson:  I  would  argue  that  the 
post-anesthesia  care  unit  and  ICU  are 
very  different  settings.  In  the  post-an- 
esthesia care  unit  patients  required  air- 
way management  for  a  surgical  pro- 
cedure. The  vast  majority  are  fairly 
healthy — few  have  multiorgan  system 
failure.  They  were  breathing  indepen- 
dently prior  to  surgery.  One  expects 
that  the  vast  majority  will  breathe  well 
after  surgery;  so,  a  failure  rate  of  20% 
would  be  extraordinary.  ICU  patients 
have  many  reasons  for  intubation  and 
are  in  a  recovery  period  that  can  be 
difficult  to  judge.  I  agree  with  Charlie 
that  sometimes  the  only  way  to  know 
with  certainty  if  they  can  breathe  is  to 
allow  them  to  try.  The  other  point  is 
that  we  shouldn't  delude  ourselves  to 
think  that  we  are  always  "protecting" 
our  ICU  patients.  Sometimes  doing 
something  longer  only  adds  risk,  rather 
than  providing  benefit.  It  may  be  en- 
tirely reasonable  to  allow  a  failed  extu- 
bation rate  of  1  in  5,  because  that  means 
that  4  of  5  have  successfully  made  the 
transition  back  to  spontaneous  breath- 
ing and  are  not  at  risk  for  the  multiple 
complications  associated  with  intuba- 
tion and  mechanical  ventilation. 

Hurford:  An  excellent  point.  Take, 
for  example,  a  patient  who  has  under- 
gone lung  volume  reduction  surgery. 
In  those  cases,  you  really  want  to  get 


them  extubated  and  off  the  ventilator, 
because  they  can't  be  mechanically 
ventilated  well,  and  a  mechanical  ven- 
tilation is  terrible  for  them.  So  there 
you  really  want  to  err  in  the  absolute 
other  direction.  It's  very  interesting:  dif- 
ferent patients  respond  differently  to  in- 
tubation and  mechanical  ventilation. 

Watson:      The  risk  of  ventilator-as- 
sociated pneumonia  and  a  whole  host 
of  things  that  are  associated  with 
chronic  ventilation  that  we've  had  ups 
and  downs  in  believing  about — things 
like  ventilator  "brain"  that  the  neuro- 
surgeons used  to  believe  in — these 
things  have  to  be  weighed  against  the 
other  side.  (And  in  this  world  of  in- 
creasing examination  of  quality  assur- 
ance thresholds,  there's  a  widely  pro- 
mulgated notion  that  a  reintubation 
rate  is  some  number  beyond  which 
you  should  not  go.)  But  I  would  say 
that  the  difference  between  the  ICU 
and  the  recovery  room  is  that  people 
in  recovery  rooms  are  waking  up,  and 
they've  got  leftover  drug  effects  that 
we're  waiting  to  wear  off.  Increasingly 
now,  we're  finding  the  2  populations 
merging.  We  often  attempt  the  trial  of 
extubation,  the  trial  of  therapy  with- 
out the  pulmonary  artery  catheter,  the 
trial  of  whatever  kind  of  critical  ther- 
apy is  conducted  in  the  recovery  room 
in  hopes  of  keeping  the  patient  out  of 
the  ICU  or  of  being  able  to  stage  the 
patient  into  intermediate  care.  So, 
we're  going  to  have  to  accept  higher 
reintubation  rates  than  1-2%.  I  think 
it's  very  much  an  institutional  issue. 
We  don't  do  lung  reduction  therapy, 
but  in  places  that  do,  that's  a  concern. 
Somebody  who  has  his  trachea  re- 
sected— we'd  like  to  get  the  tube  out 
pretty  soon  if  we  could.  There  are  a 
number  of  settings  where  a  trial  of 
therapy  is  totally  appropriate.  And 
there's  a  risk  management  issue  asso- 
ciated with  whom  you  subject  to  that 
trial  of  extubation.  I  think  they  have 
to  be  evaluated.  The  other  subset  is 
the  subset  of  people  who  were  diffi- 
cult to  intubate,  and  who  are  now  dif- 
ficult to  extubate,  and  how  do  you  man- 


age those  people?  I  think  we  have 
newer  ways  to  deal  with  them  that 
enable  us  to  be  more  comfortable  than 
we  used  to  be,  while  in  the  old  days, 
if  someone  was  hard  to  intubate,  he 
was  left  with  a  breathing  tube  for  3 
months,  and  then  trached  because  no- 
body wanted  to  take  it  on. 

Campbell:  I  want  to  discuss  the  pa- 
tients who  have  scheduled  returns  to 
the  operating  room,  maybe  every  48 
hours,  every  72  hours,  maybe  weekly. 
How  do  you  manage  that?  That's  very 
controversial  in  our  institution.  A  lot 
of  people  want  to  keep  the  patient  in- 
tubated for  the  period  they  are  in  the 
intensive  care  unit  between  operations. 
I've  seen  patients  who  get  extubated 
12  hours  after  surgery  and  reintubated 
4  or  5  more  times  in  the  next  2-week 
period.  We  don't  realize  an  increase 
in  mortality,  or  ventilator-associated 
pneumonia,  or  tube-associated  pneu- 
monia in  that  patient  population.  I 
think  it's  the  fact  that  the  patient  has 
failed  extubation  that's  important,  and 
it's  not  the  reintubation  procedure  or 
the  replacement  of  the  endotracheal 
tube;  it's  the  fact  that  the  patient  had 
something  underlying  that  made  them 
fail,  and  I  think  now  we  need  to  look 
at  the  timing  to  intervention,  and  rec- 
ognition of  that  failure.  One  thing,  by 
the  way,  that  makes  me  nervous  about 
noninvasive  positive  pressure  ventila- 
tion is  that  in  the  patients  who  fail 
extubation,  they  are  likely  also  to  fail 
noninvasive  positive  pressure  ventila- 
tion, and  that  may  very  well  be  a  de- 
lay into  definitive  treatment.  So, 
there's  still  a  lot  we  need  to  learn  about 
this  patient  group. 

Pierson:*  A  final  comment.  One  of 
the  issues  that's  emerged  from  your 
presentation  and  this  discussion  is  how 
much  we  are  in  need  of  objective  data 


*  David  J  Pierson  MD.  Division  of  Pulmonary 
Critical  Care  Medicine.  Department  of  Medi- 
cine, University  of  Washington,  Seattle,  Wash- 
ington. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


8':- 


EXTUBATION  AND  THE  CONSEQUENCES  OF  ReINTUBATION 


about  the  ability  to  remove  the  endo- 
tracheal tube  as  opposed  to  the  pa- 
tient's ability  to  breathe  spontaneous- 
ly; that  is,  the  separation  of  weaning 
and  extubation,  which  much  of  the  lit- 
erature has  failed  to  do.  Studies  by 
Coplin  et  al'  looked  at  a  large  number 
of  head-injury  patients  who  remained 
comatose  to  various  degrees  but  who 
met  their  predetermined  weaning  cri- 
teria, and  observed  what  the  manag- 
ing physicians  did  with  respect  to  tak- 
ing out  the  tube.'  It  was  found  that 
patients  who  were  extubated  sooner 
did  better,  had  fewer  pneumonias,  had 
shorter  ICU  stays,  and  lower  costs — 
not  too  surprising.  But,  as  part  of  that 


study,  an  attempt  was  made  to  develop 
a  set  of  extubation  criteria  analogous 
to  the  weaning  criteria.  In  addition  to 
the  Glasgow  Coma  Scale  score  and 
general  condition,  they  looked  at  6  dif- 
ferent factors  in  an  airway  care  score^ — 
amount  and  quality  of  secretions,  spon- 
taneous cough  and  gag,  and  so  forth. 
That  score  didn't  have  any  correlation 
with  the  need  for  reintubation.  The 
only  2  factors  that  did,  statistically, 
were  whether  the  patient  had  needed 
suctioning  3  times  or  more  in  the  pre- 
ceding 8-hour  shift,  and  whether  the 
patient  had  a  spontaneous  cough.  So, 
in  a  deliberate  attempt  to  try  to  find 
associations  with  the  need  for  reintu- 


bation once  people  met  weaning  cri- 
teria, it  was  disappointing.  And  it 
would  be  intuitive,  I  would  think,  that 
people  who  don't  cough  and  who  have 
a  lot  of  secretions  are  going  to  have  to 
be  reintubated,  and  that's,  in  fact,  what 
that  study  found. 

REFERENCES 

1.  Coplin  WM.  Rubenf'eld  CD.  Cooley  KD. 
Newell  DW.  Pierson  DJ.  When  should  brain 
injured  patients  be  exiubaled?  (abstract) 
Chest  19%;  110;  1 85s. 

2.  Coplin  WM.  Cooley  KD.  Rubenfeld  CD, 
Pierson  DJ.  An  airway  care  score  to  aid  ex- 
tubation after  acute  brain  injury  (abstract). 
RcspirCare  19%;41(  10);950. 


45^"    International 


Respiratory    Congress 


D  E  C  E  M  B  E  R     1  3  -  Ife  ,_jr-^  9  9 

Las   Vegas^    Nevada 


806 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


John  E  Heffner  MD 


Introduction 

The  Risks  of  Different  Modes  of  Airway  Support 

Acute  Complications  of  Airway  Intubation 

Long-term  Complications  of  Airway  Intubation 
Benefits  of  Different  Modes  of  Airway  Approach 
Economic  Analysis 
A  Decision  Analysis  Approach 
Future  Investigation 

[Respir  Care  1999;44(7):807-815]  Key  words:  tracheotomy,  complications  of 
airway  intubation,  complications  of  tracheotomy,  advantages  of  tracheotomy, 
timing  of  tracheotomy. 


Introduction 

During  the  last  30  years,  tracheotomy  has  become  one 
of  the  most  commonly  performed  surgical  procedures  in 
critical  care  medicine.  Despite  this  widespread  use,  patient 
selection  and  procedure  timing  remains  controversial  in 
ventilator-dependent  patients. '  Some  experts  emphasize  the 
surgical  risks  and  costs  of  tracheotomy  and  caution  against 
its  implementation  until  a  patient  remains  ventilator  de- 
pendent for  2-3  weeks. 2  -*  Advocates  of  the  procedure 
argue  for  earlier  tracheotomy,  emphasizing  the  benefits  of 
a  surgical  airway  and  the  acceptable  risks  of  tracheotomy 
compared  to  prolonged  translaryngeal  intubation.-''  These 
differing  viewpoints  have  spawned  numerous  observational 
studies  and  a  few  randomized,  comparative  studies  that 
seek  to  establish  the  "holy  grail"  of  airway  management: 
when  is  the  ideal  time  to  perform  a  tracheotomy?^ 

This  review  departs  from  the  usual  assumption  that  there 
is  an  ideal  time  for  tracheotomy,  universally  applicable  to 
all  critically  ill  patients,  and  maintains  that  patient  selec- 
tion for  tracheotomy  and  the  timing  of  the  procedure  are 
complex  decisions  that  have  no  simple,  universal  solution. 
Decisions  regarding  tracheotomy  have  been  overly  influ- 
enced by  analyses  of  the  comparative  risks  of  tracheotomy 
compared  to  translaryngeal  intubation,  and  insufficient  at- 


John  E  Heffner  MD  is  affiliated  with  the  Department  of  Medicine.  Med- 
ical University  of  South  Carolina,  Charleston.  South  Carolina. 

Correspondence;  John  E  Heffner  MD,  Department  of  Medicine,  Medical 
University  of  South  Carolina,  Charleston  SC  29425.  E-mail: 
heffnerj@musc.edu 


tention  has  been  directed  to  their  relative  benefits.  This 
review  emphasizes  the  importance  of  incorporating  the 
patient's  perspective  and  unique  clinical  circumstances  into 
the  decision  of  whether  to  perform  a  tracheotomy,  leading 
to  the  conclusion  that  different  patients  become  appropri- 
ate candidates  for  tracheotomy  at  varying  times  in  their 
clinical  course,  and  that  some  patients  cannot  be  expected 
to  benefit  from  the  procedure. 

The  Risks  of  Different  Modes  of  Airway  Support 

Most  discussions  of  tracheotomy  timing  have  framed 
the  argument  for  delaying  tracheotomy  in  ventilator-de- 
pendent patients  in  terms  of  the  risks  of  the  procedure 
compared  with  the  risks  of  prolonged  translaryngeal  intu- 
bation. Although  this  approach  ignores  the  relative  bene- 
fits of  different  routes  of  airway  support,  procedure-related 
risk  is  an  important  component  of  the  decision  for  airway 
selection.  Two  categories  of  risk  have  been  assessed:  the 
acute  complications  and  the  delayed  or  long-term  compli- 
cations of  differing  modes  of  airway  support.' 

Acute  Complications  of  Airway  Intubation 

Quantification  of  the  early  risks  of  tracheotomy  has  var- 
ied among  reports.  Case  series  performed  during  the  first 
decade  of  widespread  use  of  "floppy,"  low-pressure  endo- 
tracheal tube  cuffs  reported  a  high  morbidity  from  trache- 
otomy."*  Between  4%  and  36%  of  patients  experienced 
airway  obstruction,  bleeding  from  the  stomal  incision. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


Table  I .       Early  Complications  of  Standard  Surgical  Tracheotomy 


Displaced 

Moderate 

Obstruction 

Subcutaneous 

Pneumothorax 

Aspiration 

Total 

Tube  (%) 

Bleeding  (%) 

{%) 

Air  (%) 

(%) 

(%) 

Morbidity  (%) 

Stauffer' 

51 

- 

36 

4 

9 

4 

8 

66 

Stock" 

81 

0 

2 

0 

0 

2 

0 

6 

Goldstein'' 

124 

2 

0 

0 

0 

2 

0 

6 

Astrachan'" 

52 

0 

0 

- 

0 

0 

0 

14 

Pogue" 

102 

0 

2 

0 

0 

0 

0 

6  ; 

Wease'- 

204 

<  1 

1 

<  1 

0 

<  1 

0 

3 

Upadhyay" 

536 

2 

4 

0 

0 

1 

0 

9 

n  =  number. 

overly  large  or  misplaced  stomal  incisions,  or  stomal  wound 
infections,  with  an  overall  morbidity  of  66%  (Table  1).-^ 

Other  clinical  centers  subsequently  reported  lower  com- 
plication rates  from  standard  tracheotomy,  with  total  mor- 
bidity ranging  from  3%  to  14%  (see  Table  1  ).*-"  Analysis 
of  the  pooled  data  from  these  later  studies  estimates  the 
overall  morbidity  from  standard  tracheotomy  to  be  7%.'*  '^ 
Because  the  research  groups  did  not  employ  the  same 
definitions  to  identify  procedural  complications,  it  is  dif- 
ficult to  compare  the  morbidity  data  from  these  studies. 
However,  reexamination  of  earlier  reports  indicates  that 
the  high  incidence  of  tracheotomy  complications  reported 
in  these  studies  may  relate  to  the  performance  of  the  pro- 
cedure by  trainees  from  multiple  surgical  services,  often 
with  limited  supervision  by  senior  physicians.^  Centers 
that  reserve  tracheotomy  to  experienced  teams  report  lower 
rates  of  complications.  It  appears  from  available  data  that 
clinically  important,  early  complications  from  tracheot- 
omy range  from  1%  to  7%. 

The  acute  complications  of  percutaneous  dilation  tra- 
cheotomy (PDT)  are  still  undergoing  evaluation.  Performed 
by  Seldinger  technique,  PDT  avoids  surgical  incision  of 
cervical  tissue  planes  and  the  anterior  tracheal  wall.  Using 
varying  definitions  to  identify  complications,  recent  stud- 
ies report  an  overall  morbidity  range  between  8%  and  23% 
(Table  2).  A  recent  review  of  the  pre- 1995  PDT  literature 
(which  standardized  the  definitions  of  acute  complications) 


Table  2.      Early  Complications  of  Percutaneous  Dilatational  Tracheotomy 


reported  an  overall  morbidity  from  PDT  of  7.6%,'''  which 
is  similar  to  the  incidence  of  acute  complication  from  stan- 
dard tracheotomy.  It  appears  that  PDT,  like  standard  tra- 
cheotomy, can  be  performed  in  ventilator-dependent  pa- 
tients with  an  acceptable  incidence  of  morbidity  due  to 
early  complications.'''  All  contemporary  studies  support 
the  conclusion  that  mortality  from  tracheotomy  in  criti- 
cally ill  patients  is  less  than  1%.** 

Other  early  complications  of  tracheotomy,  such  as  the 
risk  for  nosocomial  pneumonia,  patient  discomfort,  noso- 
comial sinusitis,  and  encumbered  patient  mobility,  will  be 
discussed  as  they  compare  to  similar  complications  from 
translaryngeal  intubation. 

The  acceptability  of  risks  for  acute  complications  from 
tracheotomy  depends  on  the  comparable  risks  anticipated 
from  maintaining  the  endotracheal  intubation.  Risks  from 
translaryngeal  intubation  are  usually  reported  as  the  con- 
sequences of  the  intubation  procedure  itself.  However,  the 
acute  complications  from  translaryngeal  intubation  that 
should  be  compared  to  tracheotomy  are  the  ongoing  risks 
of  maintaining  the  endotracheal  intubation  (Table  3). 

Unplanned  extubation  is  an  important  complication  of 
translaryngeal  intubation;  it  occurs  in  8-13%  of  ventila- 
tor-dependent patients,  and  results  in  cardiopulmonary 
complications  in  6-31%  of  instances.'''^'''  Nosocomial 
pneumonia,  which  occurs  more  commonly  in  ventilated 
patients  who  undergo  extubation  but  require  reintubation,"* 


Displaced 

Moderate 

Obstruction 

Subcutaneous 

Pneumothorax 

Aspiration 

Total 

Tube  (%) 

Bleeding  (%) 

(%) 

Air  (%) 

(%) 

(%) 

Morbidity  (%) 

Ciaglia''- 

15 

0 

2 

0 

1 

0 

0 

8 

Toursarkisslan"' 

141 

0 

2 

0 

- 

<1 

0 

8 

Bause"" 

151 

0 

1 

0 

0 

<1 

0 

8 

Graham'''' 

31 

6 

6 

0 

3 

3 

0 

23 

Hill"' 

356 

1 

0 

0 

1 

0 

19 

Petros'"" 

137 

0 

3 

2 

0 

3 

11 

n  =  number. 

808 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


Table  3.      Ongoing  Risks  from  Prolonged  Translaryngeal  Intubation 


Inadvertent  decannulation 
Inability  to  communicate 
Oversedation 
Poor  oral  care 
Nosocomial  pneumonia 
Epistaxis  during  nasal  intubation 
Orthostasis  and  limited  ability  to 
mobilize 


Anxiety 

Airway  discomfort 
Prolonged  ICU  stay 
Nosocomial  sinusitis 
Compromised  nutrition 


represents  one  of  the  more  serious  but  difficult  to  docu- 
ment consequences  of  unplanned  extubation.  Stauffer  et  al 
reported  a  lower  incidence  of  self-extubation  when  venti- 
lator-dependent patients  were  converted  to  a  tracheoto- 
my.' 

Many  of  the  clinically  important  ongoing  complications 
of  prolonged  intubation  relate  to  the  discomfort  that  pa- 
tients experience  from  the  translaryngeal  endotracheal  tube. 
Ventilator-dependent  patients  report  that  frequent  airway 
suctioning,  appliances  designed  to  maintain  endotracheal 
tube  position,  and  restraints  to  prevent  self-extubation  are 
major  sources  of  discomfort  and  anxiety.''^  Several  studies 
indicate  that  the  inability  to  speak  because  of  the  presence 
of  an  endotracheal  tube  represents  one  of  the  most  dis- 
tressing aspects  of  ventilator  dep>endence,  and  invokes  anx- 
iety, frustration,  fear,  and  depression. "-21  Both  nasotra- 
cheal and  orotracheal  endotracheal  tubes  hinder  meaningful 
communication  between  patients  and  their  families  and 
caregivers.  Also,  prolonged  translaryngeal  intubation  de- 
lays transfer  from  intensive  care  unit  (ICU)  settings  to 
step-down  or  intermediate  care  units  where  patients  can 
have  more  frequent  interactions  with  their  families  and 
lower  levels  of  resource  utilization.  Translaryngeal  intu- 
bation limits  patient  mobility,  such  as  to  transfer  to  a  bed- 
side chair,  compared  to  tracheostomized  patients. 

The  clinical  consequences  of  patient  discomfort,  anxi- 
ety, and  immobility  associated  with  translaryngeal  intuba- 
tion are  potentially  serious  but  not  well  documented.  Ag- 
itated, critically-ill  patients  run  a  risk  that  they  will  be 
oversedated  in  an  effort  to  manage  their  motor  activities, 
sleeplessness,  and  apparent  psychic  discomfort.  Overseda- 
tion of  ventilator-dependent  patients  delays  successful 
weaning  from  mechanical  ventilation  and  increases  the 
risk  of  nosocomial  pneumonia.--  The  pathogenesis  of  an 
increased  risk  of  pulmonary  infection  from  oversedation 
remains  uncertain,  but  may  relate  to  poor  clearance  of 
airway  secretions  because  of  static  body  positioning.  Con- 
cern regarding  the  increased  incidence  of  and  consequences 
related  to  heavy  sedation  in  ventilated  patients  has  been 
the  subject  of  recent  editorial  comment.-' 

Prolonged  translaryngeal  intubation  also  presents  a  risk 
for  nosocomial  sinusitis. -''--^  A  recent  prospective,  obser- 
vational study  by  Rouby  et  al  found  that  95%  of  critically 


ill  patients  ventilated  for  7  days  through  a  nasotracheal 
tube  develop  radiographic  evidence  of  maxillary  sinusitis, 
as  demonstrated  by  complete  sinus  opacification  or  intra- 
cavitary air-fluid  levels.-^  Thirty-eight  percent  of  patients 
with  radiographic  sinusitis  were  found  to  have  infectious 
sinusitis  when  evaluated  by  sinus  aspiration  and  quantita- 
tive culture  techniques.  The  organisms  isolated  from  in- 
fected sinuses  represent  the  typical  Gram-positive  and 
Gram-negative  bacterial  and  fungal  pathogens  that  pro- 
duce life-threatening  infections  in  the  ICU.  Although  the 
study  by  Rouby  et  al  was  not  designed  to  establish  noso- 
comial sinusitis  as  a  source  of  systemic  infection,  patients 
with  sinusitis  had  a  70%  risk  of  developing  nosocomial 
pneumonia,  compared  to  a  43%  risk  for  patients  with  nor- 
mal sinus  computed  tomography  examinations.-''  More- 
over, 38%  of  patients  with  ventilator-associated  pneumo- 
nia had  the  same  pathogens  isolated  from  their  sinuses  and 
lower  airways.  Sinus  lavage  (without  the  addition  of  an- 
tibiotics) resolved  clinical  manifestations  of  sepsis  in  the 
majority  of  patients. 

Several  studies  indicate  that  translaryngeal  intubation 
through  the  oral  route  does  not  eliminate  the  risk  of  nos- 
ocomial sinusitis.2'*2''.28  Rouby  et  al  observed  radiographic 
sinusitis  in  23%  of  orally-intubated  patients.-''  These  pa- 
tients did  not  have  other  nasal  catheters,  such  as  sump  or 
feeding  tubes,  that  could  have  been  the  etiology  of  sinus- 
itis. It  appears  that  some  undefined  factors  promote  nos- 
ocomial sinusitis  in  intubated  patients,  in  addition  to  direct 
obstruction  of  sinus  ostia  by  nasotracheal  tubes. 

The  incidence  of  nosocomial  sinusitis  as  a  consequence 
of  tracheotomy  has  not  been  studied.  However,  in  our  ICU 
we  have  rarely  identified  sinusitis  as  a  cause  of  fever  for 
ventilator-dependent  patients  managed  with  a  tracheotomy. 

Translaryngeal  intubation  allows  aspiration-'^"  and  pre- 
sents a  major  risk  for  nosocomial  pneumonia.'- '''*  Place- 
ment of  an  endotracheal  tube  through  the  larynx  interferes 
with  glottic  function  and  promotes  pooling  of  oral  secre- 
tions within  the  trachea,  above  the  endotracheal  tube  cuff. 
This  reservoir  for  respiratory  pathogens  appears  to  be  an 
important  source  of  ventilator-associated  pneumonia,  as 
indicated  by  the  lower  incidence  of  pneumonia  observed 
in  patients  treated  with  specialized  endotracheal  tubes  that 
remove  fluid  above  the  cuff.^'--"  Several  studies  indicate 
that  tracheotomy  tubes  similarly  interfere  with  glottic  func- 
tion.'** Maintenance  of  normal  glottic  closure  appears  to 
depend  on  preservation  of  cyclic  respiratory  air  flow  across 
the  vocal  cords. '*  Diversion  of  air  flow  away  from  the 
larynx  after  placement  of  a  tracheostomy  removes  this 
stimulus  to  normal  glottic  closure.  This  may  explain  the 
observation  that  microaspiration  persists  despite  placement 
of  a  tracheotomy  tube.'"-''''-''' 

Though  both  translaryngeal  endotracheal  tubes  and  tra- 
cheostomy tubes  interfere  with  normal  glottic  function,  no 
studies  have  been  published  that  compare  the  degree  of 


Respiratory  Care  •  July  1999  Vol  44  No  7 


80' 


Tracheotomy:  Indications  and  Timing 


aspiration  of  bacteria-laden,  upper  airway  secretions  with 
these  2  modes  of  airway  support.  It  is  suspected  that  trans- 
laryngeal  intubation  would  result  in  a  greater  degree  of 
aspiration,  because  endotracheal  tubes  pass  through  the 
vocal  cords,  resulting  in  wide-open  glottic  incompetence. 
This  hypothesis  agrees  with  recent  observations  that  the 
incidence  of  ventilator-associated  pneumonia  is  lower  in 
trauma  victims  with  respiratory  failure  who  are  managed 
with  early  tracheotomy  compared  to  prolonged  ventilation 
with  translaryngeal  endotracheal  tubes. ' 

Prolonged  translaryngeal  intubation  also  complicates 
oral  nutrition,  which  necessitates  feeding  tube  or  paren- 
teral nutrition,  with  their  associated  risks.  Poor  oral  hy- 
giene is  an  additional  difficulty  with  prolonged  oral  intu- 
bation. 

Long-Term  Complications  of  Airway  Intubation 

Tracheotomy  presents  risks  for  tracheal  stenosis,  both  at 
the  segment  of  the  trachea  adjacent  to  the  tracheostomy 
tube  cuff,  and  at  the  tracheal  stoma  site."""''*  The  incidence 
of  cuff-related  tracheal  stenosis  has  decreased  markedly 
with  the  advent  of  the  high- volume  low-pressure  tube  cuff."" 
Although  tracheotomy  tube  cuffs  are  slightly  lower  in  vol- 
ume than  most  similarly-sized  endotracheal  tubes,  no  pub- 
lished data  disagree  with  the  impression  that  tracheotomy 
tubes  and  translaryngeal  endotracheal  tubes  present  a  sim- 
ilar risk  for  tracheal  stenosis. 

Tracheotomy  presents  a  more  clinically  important  risk 
for  tracheal  stenosis  at  the  stoma  site."*  Standard  surgical 
tracheotomy  entails  an  incision  through  the  anterior  tra- 
cheal wall,  which  results  in  healing  by  cicatrization  and 
the  potential  for  tracheal  stenosis  1-6  months  after  airway 
decannulation.  It  is  difficult  to  estimate  the  incidence  of 
tracheal  stenosis  after  tracheotomy,  because  of  the  limited 
number  of  studies  that  have  conducted  careful  imaging  or 
endoscopic  evaluations  of  the  airway  on  long-term  patient 
follow-up  after  decannulation."**  Also,  the  available  obser- 
vational studies  vary  in  their  definitions  of  tracheal  steno- 
sis, with  airway  narrowings  &  10-40%  qualifying  as  ste- 
notic lesions.  These  degrees  of  stenosis  usually  do  not 
compromise  ventilatory  function,  which  develops  most  of- 
ten in  patients  who  experience  more  than  50%  loss  of 
tracheal  caliber.  Also,  the  advent  of  PDT  appears  to  have 
decreased  the  incidence  of  tracheal  stenosis  after  decan- 

Table  4  lists  the  recent  studies  that  examined  the  risks  of 
tracheal  stenosis  in  critically  ill  patients  who  have  under- 
gone a  tracheotomy.  It  appears  that  contemporary  tech- 
niques of  tracheotomy  and  airway  management  in  the  ICU 
result  in  complication  rates  between  0%  and  16%  for  tra- 
cheal stenosis  from  tracheotomy.'*^-'^  The  incidence  of 
high  grade  stenosis  that  requires  corrective  interventions  is 
uncertain,  but  available  data  suggest  that  this  complication 


Table  4.      Long-Term  Risks  for  Tracheal  Stenosis  after  Tracheotomy 


Reference 

Tracheotomy 
technique 

Tracheal 
stenosis  (%) 

Visualization 
technique 

Law'"' 

Rosenbower'" 
van  Heum''* 
Callanan™ 
Law'*' 

Open              81               16* 
PDT/open          55                0 
PDT              150              <1 
PDT               9                 0 
PDT              41                7t 

s  dilatational  tracheotomy:  MRI  ^  magnetic  resonance 
clieotomy.  *Deftnition  of  tracheal  stenosis  was  greater 
ost  <  40%  airway  caliber. 

Tracheoscopy 

Tracheoscopy 

Symptoms 

MRI 

Tracheoscopy 

PDT  =  percutaneou 
standard  surgical  tra 
narrowing.  iGroup 

imaging;  Open  = 
than  20%  tracheal 

occurs  uncommonly  in  survivors  of  respiratory  failure  who 
undergo  tracheotomy. 

Although  symptomatic  tracheal  stenosis  after  tracheot- 
omy decannulation  represents  an  important  source  of  mor- 
bidity, the  available  corrective  surgical  interventions  for 
tracheal  stenosis  provide  good  results  in  most  patients. 
Resection  of  stenotic  segments  of  the  trachea,  with  pri- 
mary end-to-end  anastomoses,  can  be  applied  to  patients 
with  stenotic  lesions  that  extend  across  as  much  as  50%  of 
the  tracheal  length.'*3'*"53 

Other  long-term  complications  of  tracheotomy  include 
swallowing  dysfunction,  tracheocutaneous  fistulae,  tra- 
cheo-esophageal  fistulae,  and  neck  scars.''"**  Only  a  small 
minority  of  patients  who  undergo  tracheotomy  experience 
any  of  these  complications  to  a  degree  that  represents  a 
major  clinical  problem. 

The  long-term  complications  of  prolonged  translaryn- 
geal intubation  derive  from  the  impact  of  endotracheal 
tubes  on  subglottic  structures.  The  endolaryngeal  segment 
of  endotracheal  tubes  flexes  toward  the  posterior  endola- 
rynx  in  the  region  of  the  arytenoids  and  cricoid  cartilage 
where  the  native  airway  curves  anteriorly  from  the  poste- 
rior pharynx  (Figure  1).-^"*  The  endotracheal  tube  applies 
high  wall  tensions  against  these  posterior  glottic  and  sub- 
glottic structures.  Animal  studies  indicate  that  measured 
wall  tensions  can  exceed  200-400  mm  Hg^'-'*  in  these 
regions  of  the  airway.  Most  of  this  tension  focuses  on  the 
posterior  aspect  of  the  cricoid  cartilage,  the  arytenoid  car- 
tilages, and  the  posterior  segments  of  the  vocal  cords. ■''^ 

Endotracheal  tube  wall  tension  against  the  posterior  as- 
pect of  the  cricoid  cartilage  is  problematic  because  the 
cricoid  ring  forms  the  structural  foundation  of  the  larynx. 
Injury  to  the  cricoid  ring  can  result  in  involution  of  laryn- 
geal structures  and  postextubation  subglottic  stenosis.  In- 
jury to  the  arytenoid  cartilages  and  posterior  segments  of 
the  vocal  cords  produces  interarytenoid  fibrous  bands  that 
can  result  in  glottic  stenosis,  glottic  incompetence,  and 
long-term  alterations  in  voice.  Endotracheal  tubes  can  also 
cause  vocal  cord  paralysis.'*-^' 


810 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


Arytenoid 
cartilages 


Cricoid 
cartilage 


Fig.  1 .  Anatomic  position  of  an  endotracheal  tube  in  the  upper 
airway.  The  curvature  of  the  tube  creates  pressure  points  on  pos- 
terior laryngeal  structures.  The  arrows  denote  contact  points  that 
can  cause  damage  to  the  arytenoid  cartilages  and  the  postehor 
aspect  of  the  cricoid  ring. 


Reports  differ  on  the  incidence  of  complications  to  glot- 
tic and  subglottic  structures  after  translaryngeal  intubation. 
Few  studies  have  provided  long-term  follow-up  with  care- 
I'ul  airway  examinations  of  patients  who  have  recovered 
from  critical  illness.  However,  several  reports  provide  some 
insights  into  the  risks  for  this  complication  from  transla- 
ryngeal intubation.  Elliott  et  al  noted  in  30  survivors  of 
acute  respiratory  distress  syndrome  (ARDS)  that  3  patients 
required  laryngotracheal  reconstruction  for  subglottic  ste- 
nosis, which  persisted  in  2  patients  after  surgery.''"  A  pro- 
spective observational  study  by  Whited  is  frequently 
quoted,  because  it  meticulously  assessed  patients  for  air- 
way complications  after  extubation.'''  Whited's  results  sup- 
port the  concept  that  long-term  airway  injury  commonly 
occurs  after  translaryngeal  intubation  and  that  the  inci- 
dence and  severity  of  airway  injury  correlate  with  the  du- 
ration of  intubation.  Patients  intubated  for  2-5  days  had  a 
6%  incidence  of  transient  laryngeal  injury.  Patients  intu- 
bated for  6-10  days  had  a  5%  incidence  of  chronic  laryn- 
geal stenosis.  Patients  intubated  for  11-24  days  had  an 
1 1%  incidence  of  extensive  laryngeal  stenosis. 

More  recently,  Thomas  et  al  reported  on  150  consecu- 
tive critically  ill  adult  and  pediatric  patients  who  required 
intubation  for  more  than  24  hours  for  various  indications 
and  observed  that  8.6%  had  long-term  laryngeal  sequel- 
ae.''- These  sequelae  included  subglottic  stenosis  (3.3%), 
vocal  cord  palsy  (2%),  tracheomalacia  (2%),  and  bilateral 


vocal  cord  paralysis  (1%).  Laryngeal  complications  were 
especially  common  in  patients  with  seizures  (25%)  and 
patients  with  head  trauma  (19%).  Another  prospective 
study,  performed  by  Vukanovic  et  al,  examined  87  pa- 
tients intubated  for  less  than  1  day  to  as  long  as  82  days.**^ 
They  noted  a  34%  incidence  of  subglottic  and  tracheal 
lesions,  which  were  severe  stenoses  in  3.4%  of  the  study 
cohort.  They  noted  a  significant  correlation  between  du- 
ration of  intubation  and  the  severity  of  tracheal  lesions. 
The  majority  of  airway  lesions  resulted  from  the  endotra- 
cheal tube  cuff,  the  tip  of  the  endotracheal  tube,  or  the 
suction  cannulae. 

Holdgaard  et  al  evaluated  379  critically  ill,  nasotrache- 
ally-intubated  patients,  of  whom  28 1  were  available  for 
long-term  follow  up  1-2  years  after  recovery.''^  Of  these 
281  patients,  35%  had  long-term  symptoms  from  the  nose, 
24%  had  symptoms  related  to  the  ears,  20%  had  maxillary 
sinus  problems,  29%  had  chronic  voice  problems,  and  32% 
had  throat  complaints.  The  duration  of  intubation  corre- 
lated with  the  duration  of  laryngeal  symptoms. 

Other  prospective  studies  have  not  observed  a  high  risk 
for  long-term  laryngeal  injury  in  critically  ill  patients  ven- 
tilated through  a  translaryngeal  route,  or  an  association 
between  the  duration  of  intubation  and  the  risk  of  airway 
damage.  Colice  et  al  found  that  in  their  cohorts  of  critically 
ill  patients,  superficial  mucosal  ulcerations  were  commonly 
present  after  extubation,  but  resolution  of  airway  injury 
occurred  during  follow-up.'''*  '*''  The  severity  of  observed 
airway  lesions  did  not  con-elate  with  the  duration  of  intu- 
bation. Dunham  et  al  examined  trauma  patients  and  did  not 
identify  a  correlation  between  the  duration  of  intubation 
and  the  incidence  of  subglottic  stenosis." 

It  is  difficult  to  reconcile  the  varying  observations  from 
these  investigations  of  airway  injury  from  translaryngeal 
intubation.  Multiple  factors  can  alter  the  progression  of 
superficial  ulcers  to  deep-seated  endolaryngeal  lesions,^*'' 
including  airway  suppuration,  systemic  hypotension,  co- 
morbid  conditions,  ventilator-induced  airway  pressure,  and 
patient  mobility.  Therefore,  spectrum  bias,  varying  ap- 
proaches to  respiratory  care,  and  management  of  other 
acute  conditions  may  affect  the  observed  outcomes  from 
these  studies.  Also,  in  contrast  to  the  other  reported  stud- 
ies,"'-''^ patients  reported  by  Colice  et  al'''* '"'  and  Dunham 
et  aH  did  not  experience  fixed  airway  stenoses.  Thus,  it  is 
not  possible  for  the  latter  studies  to  find  a  correlation 
between  fixed  airway  lesions  and  duration  of  intubation. 
The  available  patient  series  indicate  that  clinically  impor- 
tant laryngeal  injury  occurs  in  0-l97f  of  translaryngeally 
intubated  patients.'''''''*-^-  Translaryngeal  intubation  is  the 
most  common  cause  of  laryngeal  stenosis  referred  to  oto- 
laryngologists.^^ 

It  is  generally  accepted  that  surgical  correction  of  sub- 
glottic stenosis  is  more  difficult  than  surgical  correction  of 
tracheal  stenosis  caused  by  a  tracheotomy  tube.^''  For  this 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


Table  5.      Potential  Advantages  of  Tracheotomy  Compared  to 
Prolonged  Translaryngeal  Intubation 

Increased  patient  mobility 

Increased  comfort 

Improved  airway  suctioning 

Early  transfer  of  ventilator-dependent  patients  from  the  ICU 

Less  direct  endolaryngeal  injury 

Enhanced  oral  nutrition 

Enhanced  phonation  and  communication 

Decreased  airway  resistance  for  promoting  weaning  from 

mechanical  ventilation 

Decreased  risk  of  nosocomial  pneumonia  in  patient  subgroups 


reason,  some  experts  favor  conversion  to  tracheostomy  to 
avoid  the  subglottic  lesions  associated  with  prolonged  trans- 
laryngeal intubation. 

BeneHts  of  Different  Modes  of  Airway  Support 

As  previously  discussed,  tracheotomy  offers  several  po- 
tential benefits  to  patient  care  (Table  5).  Patient  comfort  is 
the  major  advantage  of  tracheotomy. '°  Patients  interviewed 
after  recovery  from  ventilator  dependence  indicate  im- 
proved comfort  with  tracheotomy  intubation.  Improved 
comfort  may  decrease  the  need  for  sedation  in  critically  ill 
patients,  which  has  been  associated  with  an  increased  risk 
of  nosocomial  pneumonia. ^^  Patient  mobility  is  enhanced 
with  tracheotomy.  Hemodynamically  stable  patients  can 
move  to  a  chair  with  less  risk  of  accidental  extubation. 
Also,  transfer  from  the  ICU  is  facilitated  before  weaning 
from  mechanical  ventilation.^ 

The  psychological  stress  experienced  by  critically  ill 
patients  because  of  inability  to  communicate  has  been  well 
documented."''-''"^''  Tracheotomy  allows  articulated 
speech,  which  enhances  a  patient's  sense  of  well-being 
and  control. ^o-^S'^" 

A  tracheostomy  tube  presents  opportunities  for  oral  nu- 
trition in  the  ventilator-dependent  patient,''*  which  de- 
creases the  risk  of  complications  from  parenteral  nutrition. 
Airway  resistance  is  expected  to  be  lower  with  a  trache- 
ostomy tube  than  a  translaryngeal  endotracheal  tube,  which 
often  has  increased  resistance  in  vivo  because  of  inspis- 
sated secretions  and  turbulent  air  flow.**"**'  This  advantage 
may  explain  the  observation  that  trauma  patients  who  un- 
dergo early  tracheotomy  have  shorter  periods  of  mechan- 
ical ventilation  and  shorter  ICU  stays  than  patients  with 
prolonged  translaryngeal  intubation.-'' 

One  of  the  most  important  potential  advantages  of  a 
surgical  airway  is  that  of  decreasing  the  incidence  of  nos- 
ocomial pneumonia.  Rodiguez  et  al  randomized  107  trauma 
patients  to  early  tracheotomy  (7  days  or  less  of  mechanical 
ventilation)  or  delayed  tracheotomy  (greater  than  7  days  of 
mechanical  ventilation),  and  observed  the  incidence  of  nos- 


ocomial pneumonia  as  diagnosed  by  clinical  criteria.''  They 
noted  that  78%  of  the  early  tracheotomy  patients  experi- 
enced pneumonia,  compared  to  96%  of  the  delayed  tra- 
cheotomy patients.  Similarly,  a  retrospective  study  by 
Kluger  et  al  detected  a  lower  incidence  of  pneumonia  in 
1 1 8  trauma  patients  converted  to  a  tracheotomy  during  the 
first  week  of  mechanical  ventilation,  as  compared  to  at  a 
later  time  in  the  hospital  stay.*- 

The  benefits  of  translaryngeal  intubation  derive  primar- 
ily from  the  effectiveness  of  the  procedure  in  providing 
reliable  airway  access  for  patients  with  respiratory  failure. 
However,  recent  advances  in  respiratory  care  have  empha- 
sized the  advantages  of  noninvasive  ventilation**-''  **''  as  an 
alternative  method  for  providing  an  interface  with  venti- 
lator support  in  patient  subgroups,  and  avoiding  the  risks 
of  an  endolaryngeal  tube.  There  are  no  ongoing  benefits  of 
prolonged  translaryngeal  intubation  beyond  the  provision 
of  airway  access  until  patients  can  undergo  successful  ex- 
tubation. Most  of  the  management  efforts  directed  toward 
patients  with  respiratory  failure  focus  on  accelerating  suc- 
cessful weaning  and  the  removal  of  endotracheal  tubes  as 
soon  as  possible  so  as  to  avoid  the  attendant  risks. 

Economic  Analysis 

Both  tracheotomy  and  prolonged  translaryngeal  intuba- 
tion have  been  claimed  to  provide  cost-effective  benefits. 
These  differing  impressions  depend  on  the  perspective 
taken  when  the  relative  cost-effectiveness  of  these  inter- 
ventions are  considered.  For  instance,  prolonged  transla- 
ryngeal intubation  saves  the  cost  of  tracheotomy,  which 
ranges  between  $1,370  and  $2,832  for  standard  tracheot- 
omy, and  between  $742  and  $1,370  for  PDT.^^-gQ  How- 
ever, tracheotomy  can  promote  earlier  transfer  out  of  ICU, 
thereby  decreasing  critical  care  costs  that  can  exceed  $  1 ,000 
a  day.  Also  important  is  the  patient's  viewpoint  in  terms  of 
comfort  and  quality-adjusted  analyses.  Recently  published 
standards  for  cost-effectiveness  research  caution  against 
concluding  that  one  intervention  is  more  cost-effective  than 
another  unless  rigorous  cost-effectiveness  evaluations  have 
been  performed  with  explicit  assumptions  and  sensitivity 
analyses.'"  Such  studies  have  not  been  conducted  for  air- 
way management,  so  no  conclusions  can  yet  be  made  re- 
garding the  relative  cost  advantages  of  different  modes  of 
airway  support  for  ventilator-dependent  patients. 

A  Decision  Analysis  Approach 

The  foregoing  review  emphasizes  the  gaps  in  our  clin- 
ical knowledge  regarding  determining  the  ideal  time  to 
perform  a  tracheotomy  in  ventilator-dependent  patients. 
Existing  studies  on  the  relative  advantages  of  different 
modes  of  airway  support  have  various  designs  and  diverse 
patient  populations  with  small  sample  sizes  and  conflict- 


812 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


ing  conclusions.''  Moreover,  hardly  any  data  are  available 
regarding  patients'  and  patients'  families'  perceptions  of 
the  relative  desirability  of  different  modes  of  airway  sup- 
port. Clinicians  are  faced  with  a  difficult  task  when  mak- 
ing airway  decisions;  these  decisions  require  consideration 
of  the  disparate  functional  and  anatomic  complications 
associated  with  tracheotomy  (tracheal  injury)  compared  to 
translaryngeal  intubation  (laryngeal  injury),  and  the  dif- 
fering benefits  anticipated  from  each  mode  of  airway 
support. ''I 

To  appropriately  time  tracheotomy  in  ventilator-depen- 
dent patients,  clinicians  are  left  with  a  need  to  individual- 
ize care.' ''- "^^  Multiple  factors  determine  the  possible  ben- 
efits of  tracheotomy  in  a  given  patient.  Trauma  patients 
(who  are  at  high  risk  for  nosocomial  pneumonia)  may 
benefit  from  an  earlier  conversion  to  tracheotomy  than 
patients  with  acute  exacerbations  of  chronic  obstructive 
pulmonary  disease.  Patients  requiring  heavy  sedation  to 
manage  hypoxic  respiratory  failure  are  less  likely  to  ben- 
efit from  the  comfort  advantages  of  tracheotomy  than  are 
mentally  alert  patients  with  respiratory  failure  due  to  neu- 
romuscular disease.  Patients  with  bleeding  diatheses  or 
abnormalities  of  cervical  structures  may  have  a  greater 
surgical  risk  from  tracheotomy,  justifying  a  delay  of  the 
procedure.  Because  each  patient's  clinical  circumstances 
are  unique,  it  is  not  possible  to  determine  a  standardized 
time,  applicable  to  all  critically  ill  patients,  for  performing 
tracheotomy.  Flexibility  in  decision-making  is  necessary 
to  address  the  individual  patient's  needs  and  preferences. 
This  decision-making  approach  avoids  overly  simplistic 
rules  that,  for  instance,  promote  translaryngeal  intubation 
for  2-3  weeks,  after  which  tracheotomy  becomes  indi- 
cated. No  data  establish  that  2-3  weeks  is  the  outer  limit 
of  safety  for  translaryngeal  intubation  or.  conversely,  that 
some  patients  might  not  benefit  from  earlier  conversion  to 
a  tracheostomy. 

The  conversion  to  a  tracheostomy  should  be  anticipated 
early  in  the  clinical  course  of  every  ventilator-dependent 
patient.'-'^'''''*  Patients  who  appear  likely  to  recover  from 
respiratory  failure  and  achieve  successful  extubation  within 
a  reasonable  period  of  mechanical  ventilation  can  be  main- 
tained with  a  translaryngeal  endotracheal  tube  and  reeval- 
uated after  a  week  of  care.  Patients  who  demonstrate  re- 
spiratory deterioration  or  failure  to  improve  after  7  days  of 
ventilation  are  unlikely  to  undergo  extubation  within  the 
next  several  days.  Such  patients  can  be  examined  to  de- 
termine if  the  benefits  of  tracheotomy  outweigh  the  risks 
and  expense  of  the  procedure.  This  evaluation  should  in- 
clude a  patient-centered  perspective  and  consider  the  com- 
fort advantages  of  the  procedure. 
I  Some  patients  may  appear  to  be  obvious  candidates  for 
tracheotomy  within  the  first  days  of  ventilation  if  the  se- 
verity of  their  critical  illness  makes  recovery  unlikely  within 
the  next  2  weeks.  Other  patients  may  never  become  can- 


didates for  tracheotomy  because  of  a  grave  prognosis  for 
survival  or  recovery  of  meaningful  neurologic  function. 

The  anticipatory  approach  of  selecting  patients  for  tra- 
cheotomy benefits  from  the  ability  of  physicians  to  antic- 
ipate or  predict  the  clinical  course  of  a  patient's  respiratory 
failure,  and  prediction  models  can  assist  clinicians  in  iden- 
tifying patients  who  are  unlikely  to  undergo  eariy  extuba- 
tion. A  report  by  Heffner  et  al  confirmed  the  validity  of  a 
prediction  rule  (comprised  of  radiographic  findings  and 
markers  of  oxygenation)  for  identifying  patients  who  were 
unlikely  to  achieve  early  extubation  after  one  week  of 
ventilation.^'"'  A  similar  model  predicted  mechanical  ven- 
tilation for  more  than  14  days  in  trauma  patients  as  deter- 
mined by  clinical  predictors  available  on  the  second  day  of 
ICU  care.'^ 

Future  Investigation 

Future  investigations  should  examine  the  benefits  of 
tracheotomy  performed  at  varying  times  during  the  course 
of  critically  ill  patients  with  different  underiying  condi- 
tions to  determine  the  relative  benefits  of  tracheotomy  vs 
prolonged  translaryngeal  intubation.  Such  studies  will  need 
to  examine  outcomes  from  patients'  and  patient  families' 
perspectives,  and  provide  long-term  observations  of  de- 
layed complications  from  the  different  modes  of  airway 
support. 

REFERENCES 

1 .  Heffner  JE.  Timing  of  tracheotomy  in  mechanically  ventilated  pa- 
tients. Am  Rev  Respir  Dis  1993;147(3):768-77l. 

2.  Marsh  HM.  Gillespie  DJ,  Baumgartner  AE.  Timing  of  tracheos- 
tomy in  the  critically  ill  patient.  Chest  1989;96(1):I90-I93. 

3.  Stauffer  JL,  Olson  DE,  Petty  TL.  Complications  and  consequences 
of  endotracheal  intubation  and  tracheotomy:  a  prospective  study  of 
1.50  critically  ill  adult  patients.  Am  J  Med  1981;70(l):65-76. 

4.  Dunham  MC.  LaMonica  C.  Prolonged  tracheal  intubation  in  the 
trauma  patient.  J  Trauma  1 984:24(2):  120- 124. 

5.  Rodriguez  JL.  Steinberg  SM,  Luchetti  FA,  Gibbons  KJ,  Taheri  PA, 
Flint  LM.  Early  tracheostomy  for  primary  airway  management  in 
the  surgical  critical  care  setting.  Surgery  1990;l08(4):655-659. 

6.  Maziak  DE,  Meade  MO.  Todd  TR.  The  timing  of  tracheotomy:  a 
systematic  review.  Chest  1998;1 14(2):60.S-609. 

7.  Heffner  JE,  Miller  KS,  Sahn  SA.  Tracheostomy  in  the  intensive 
care  unit.  Part  2:  complications.  Chest  1986:90(3):430-436. 

8.  Stock  MC,  Woodward  CG.  Shapiro  BA,  Cane  RD,  Lewis  V.  Pecaro 
B.  Perioperative  complications  of  elective  tracheostomy  in  criti- 
cally ill  patients.  Crit  Care  Med  1986;l4(10):861-863. 

9.  Goldstein  SI.  Breda  SD.  Schneider  KL.  Surgical  complications  of 
bedside  tracheotomy  in  an  otolaryngology  residency  program.  La- 
ryngoscope 1987;97(12):1407-1409. 

10.  Astrachan  DI,  Kirchner  JC.  Goodwin  WJ  Jr.  Prolonged  intubation 
vs.  tracheotomy:  complications,  practical  and  psychological  con- 
siderations. Laryngoscope  1988:98(1 1):  1 16.'i-l  169. 

1 1 .  Pogue  MD.  Pecaro  BC.  Safety  and  efficiency  of  elective  tracheos- 
tomy performed  in  the  intensive  care  unit.  J  Oral  Maxillofac  Surg 
l995:53(8):895-897. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


813 


Tracheotomy:  Indications  and  Timing 


12.  Wease  GL,  Frikker  M,  Villalba  M,  Glover  J.  Bedside  tracheostomy 
in  the  intensive  care  unit.  Arch  Surg  1996;13l(5):552-555. 

13.  Upadhyay  A,  Maurer  J.  Turner  J,  Tiszenkel  H,  Rosengart  T.  Elec- 
tive bedside  tracheostomy  in  the  intensive  care  unit.  J  Am  Coll  Surg 
1996;183{l):51-55. 

14.  Powell  DM,  Price  PD,  Forrest  LA.  Review  of  percutaneous  trache- 
ostomy. Laryngoscope  1998;108(2):  170-177. 

15.  Friedman  Y,  Fildes  J,  Mizock  B,  Samuel  J,  Patel  S,  Appavu  S, 
Roberts  R.  Comparison  of  percutaneous  and  surgical  tracheosto- 
mies. Chest  1996;110(12):480-485. 

16.  Listello  D,  Sessler  CN.  Unplanned  extubation:  clinical  predictors 
for  reintubation.  Chest  1994;105(5):1496-1503. 

17.  Coppoio  DP,  May  JJ.  Self-extubations:  a  12-month  experience. 
Chest  1990:98(1):165-169. 

18.  Torres  A,  Gatell  JM,  Aznar  E,  el-Ebiary  M,  Puig  de  la  Bellacasa  J, 
Gonzalez  J,  et  al.  Re-intubation  increases  the  risk  of  nosocomial 
pneumonia  in  patients  needing  mechanical  ventilation.  Am  J  Respir 
Crit  Care  Med  1995;152(1):I37-14I. 

19.  Johnson  MM,  Sexton  DL.  Distress  during  mechanical  ventilation: 
patients'  perceptions.  Crit  Care  Nurse  1990;  10(7):48-57.  Published 
erratum  in  Crit  Care  Nurse  I990:I0(8):72. 

20.  Heffner  JE,  Casey  K,  Hoffman  C.  Care  of  the  mechanically  venti- 
lated patient  with  a  tracheotomy.  In:  Tobin  MJ,  editor.  Principles 
and  practice  of  mechanical  ventilation.  New  York:  McGraw  Hill; 
1994:749-774. 

21.  Fitch  M.  Patient  perceptions:  being  unable  to  speak  on  a  ventilator. 
RRT  1987;23:21-23. 

22.  Kollef  MH,  Levy  NT,  Ahrens  TS,  Schaiff  R,  Prentice  D,  Sherman 
G.  The  use  of  continuous  i.v.  sedation  is  associated  with  prolon- 
gation of  mechanical  ventilation.  Chest  1998;1 14(2):541-548. 

23.  Petty  TL.  Suspended  life  or  extending  death?  (editorial)  Chest  1 998; 
114(2):360-361. 

24.  Holzapfel  L.  Nosocomial  maxillary  sinusitis  during  mechanical  ven- 
tilation: comparison  of  orotracheal  versus  the  nasotracheal  route  for 
intubation  (letter).  Intensive  Care  Med  199l;17(2):125-126. 

25.  Heffner  JE.  Nosocomial  sinusitis:  den  of  multiresistant  thieves? 
(editorial)  Am  J  Respir  Crit  Care  Med  1994;l50(3);608-609. 

26.  Rouby  JJ,  Laurent  P,  Gosnach  M,  Cambau  E,  Lamas  G,  Zouaoui  A, 
et  al.  Risk  factors  and  clinical  relevance  of  nosocomial  maxillary 
sinusitis  in  the  critically  ill.  Am  J  Respir  Crit  Care  Med  1994; 
150(3):776-783. 

27.  Bert  F,  Lambert-Zechovsky  N.  Sinusitis  in  mechanically  ventilated 
patients  and  its  role  in  the  pathogenesis  of  nosocomial  pneumonia. 
Eur  J  Clin  Microbiol  Infect  Dis  1996;l5(7):533-544. 

28.  Spapen  H,  Deron  P,  Hamels  K,  Dilloer  M,  Ramet  J,  Huyghens  L. 
Nosocomial  pansinusitis  in  orotracheally  intubated  critically  ill  pa- 
tients. Acta  Otorhinolaryngol  Belg  1995;49(3):251-255. 

29.  Spray  SB,  Zuidema  GD,  Cameron  JL.  Aspiration  pneumonia:  in- 
cidence of  a.spiration  with  endotracheal  tubes.  Am  J  Surg  1976; 
131(6):70l-703. 

30.  Elpern  EH,  Jacobs  ER,  Bone  RC.  Incidence  of  aspiration  in  trache- 
ally  intubated  adults.  Heart  Lung  1987;16(5):527-53l. 

31.  Torres  A,  Serra-Batlles  J,  Ros  E,  Piera  C,  Puig  de  la  Bellacasa  J, 
Cobos  A,  et  al.  Pulmonary  a.spiration  of  gastric  contents  in  patients 
receiving  mechanical  ventilation:  the  effect  of  body  position.  Ann 
Intern  Med  1992;1 16(7):540-543. 

32.  Valles  J,  Rello  J.  [Prevention  of  respiratory  infections  in  the  intu- 
bated patient]  (editorial).  Enferm  Infecc  Microbiol  Clin  I994;I2(5): 
231-2.34. 

33.  Hamer  DH,  Barza  M.  Prevention  of  hospital-acquired  pneumonia  in 
critically  ill  patients  (review).  Antimicrob  Agents  Chemother  1993; 
37(5):931-938. 


34.  Craven  DE,  Steger  KA,  Barber  TW.  Preventing  nosocomial  pneu- 
monia: state  of  the  art  and  perspectives  for  the  1990s.  Am  J  Med 
1991;91(3B):44S-53S. 

35.  Mahul  P,  Auboyer  C,  Jospe  R,  Ros  A,  Guerin  C,  el  Khouri  Z,  et  al. 
Prevention  of  nosocomial  pneumonia  in  intubated  patients:  respec- 
tive role  of  mechanical  subglottic  .secretions  drainage  and  stress 
ulcer  prophylaxis.  Intensive  Care  Med  1992;18(l):20-25. 

36.  Valles  J,  Artigas  A,  Rello  J,  Bonsoms  N,  Fontanals  D,  Blanch  L,  et 
al.  Continuous  aspiration  of  subglottic  secretions  in  preventing  ven- 
tilator-associated pneumonia.  Ann  Intern  Med  I995;I22(3):I79- 
186. 

37.  Greene  R,  Thompson  S,  Jantsch  HS,  Teplick  R,  Cullen  DJ,  Greene 
EM,  et  al.  Detection  of  pooled  secretions  above  endotracheal-tube 
cuffs:  value  of  plain  radiographs  in  sheep  cadavers  and  patients. 
AJR  Am  J  Roentgenol  1994;163(6):  1333-1337. 

38.  Sasaki  CT,  Suzuki  M,  Horiuchi  M,  Kirchner  JA.  The  effect  of 
tracheostomy  on  the  laryngeal  closure  reflex.  Laryngoscope  1977; 
87(9  Pt  1):  1428-1433. 

39.  Bemhard  WN,  Cottrell  JE.  Sivakumaran  C,  Patel  K.  Yost  L,  Tum- 
dorf  H.  Adjustment  of  intracuff  pressure  to  prevent  aspiration.  An- 
esthesiology 1979;50(4);363-366. 

40.  Cameron  JL,  Reynolds  J,  Zuidema  GD.  Aspiration  in  patients  with 
tracheostomies.  Surg  Gynecol  Obstet  l973;136(l);68-70. 

41.  Arola  MK,  Puhakka  H,  Makela  P.  Healing  of  lesions  caused  by 
cuffed  tracheostomy  tubes  and  their  late  sequelae:  a  follow  up 
study.  Acta  Anaesthesiol  Scand  1980;24(3):169-I77. 

42.  Arola  MK,  Inberg  MV,  Puhakka  H.  Tracheal  stenosis  after  trache- 
ostomy and  after  orotracheal  cuffed  intubation.  Acta  Chir  Scand 
1981;147(3):183-192. 

43.  Grillo  HC,  Donahue  DM.  Poslintubation  tracheal  stenosis  (review). 
Chest  Surg  Clin  N  Am  1996;6(4):725-731. 

44.  Grillo  HC,  Donahue  DM,  Mathisen  DJ,  Wain  JC,  Wright  CD. 
Postintubalion  tracheal  stenosis;  treatment  and  results.  J  Thorac 
Cardiova.sc  Surg  1995;109(3):486-493. 

45.  Brooks  R,  Barllett  RH.  Gazzaniga  AB.  Management  of  acute  and 
chronic  disorders  of  the  trachea  and  subglottis.  Am  J  Surg  1985; 
150(1):24-31. 

46.  Heffner  JE.  Upper  airway  dysfunction.  In:  Marini  JJ,  Slutsky  AS, 
editors.  Physiological  basis  of  ventilatory  support.  New  York:  Mar- 
cel Dekker;  1998:533-574. 

47.  Rosenbower  TJ,  Morris  JA  Jr,  Eddy  VA,  Ries  WR.  The  long-term 
complications  of  percutaneous  dilatational  tracheostomy.  Am  Surg 
1998:64(1  ):82-87. 

48.  van  Heurn  LW,  Goci  R.  de  Ploeg  1,  Ramsay  G,  Brink  PR.  Late 
complications  of  percutaneous  dilatational  tracheotomy.  Chest  1996; 
1 10(6);  1572-1576. 

49.  van  Heurn  LW,  van  Geffen  GJ,  Brink  PR.  Clinical  experience  with 
percutaneous  dilatational  tracheostomy:  report  of  150  cases.  Eur 
J  Surg  l996;162(7):531-535. 

50.  Callanan  V.  Gillmore  K,  Field  S,  Beaumont  A.  The  use  of  magnetic 
resonance  imaging  to  assess  tracheal  stenosis  following  percutaneous 
dilatational  tracheostomy.  J  Laryngol  Otol  1 997; 1 1  l(IO):953-957. 

51.  Law  RC,  Carney  AS,  Manara  AR.  Long-term  outcome  after  per- 
cutaneous dilational  tracheostomy:  endoscopic  and  spirometry  find- 
ings. Anaesthesia  l997;52(l):5l-56. 

52.  Ciaglia  P,  Graniero  KD.  Percutaneous  dilatational  tracheostomy; 
results  and  long-term  follow-up.  Chest  1992:101(2):464-467. 

53.  Grillo  HC.  Surgery  of  the  trachea  (review).  Curr  ProbI  Surg  1970; 
July:3-59. 

54.  Quartararo  C,  Bishop  MJ.  Complications  of  tracheal  intubation: 
prevention  and  treatment.  Semin  Aneslh  I990;9:l  19-127. 

55.  Steen  JA,  Lindholm  CE,  Brdlik  GC,  Foster  CA.  Tracheal  tube 
forces  on  the  posterior  larynx:  index  of  laryngeal  loading.  Crit  Care 
Med  1982;10(3);I86-I89. 


814 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


57 


58 


56.  Weymuller  EA  Jr.  Bishop  MJ.  Fink  BR,  Hibbard  AW,  Spelman  FA. 
Quantification  of  intralaryngeal  pressure  exerted  by  endotracheal 
tubes.  Ann  Otol  Rhinol  Laryngol  1983;92{5  Pt  l):444-447. 
Benjamin  B.  Prolonged  intubation  injuries  of  the  larynx:  endo- 
scopic diagnosis,  classification,  and  treatment.  Ann  Otol  Rhinol 
Laryngol  SuppI  l99.3;160(Apr):l-l5. 

Cavo  JW  Jr.  True  vocal  cord  paralysis  following  intubation.  La- 
ryngoscope 1985:95(1 1):l.352-I3.59. 

59.  Cheong  KF.  Chan  MY,  Sin-Fai-Lam  KN.  Bilateral  vocal  cord  pa- 
ralysis following  endotracheal  intubation.  Anaesth  Intensive  Care 
l994:22(2):206-208. 

Elliott  CG,  Rasmusson  BY,  Crapo  RO.  Upper  airway  obstruction 
following  adult  respiratory  distress  syndrome:  an  analysis  of  30 
survivors.  Chest  l988;94(3):526-530. 

Whited  RE.  A  prospective  study  of  laryngotracheal  sequelae  in 
long-term  intubation.  Laryngoscope  1984:94(3):367-377. 
Thomas  R,  Kumar  EV.  Kameswaran  M.  Shamim  A,  al  Ghamdi  S, 
Mummigatty  AP.  Okafor  BC.  Post  intubation  laryngeal  sequelae  in 
an  intensive  care  unit.  J  Laryngol  Otol  1995;I09(4):3I3-316. 
Vukanovic  S.  Sidani  AH,  Ducommun  JC,  Suter  P,  Wettstein  P. 
Tracheal  and  subglottic  lesions  following  long-standing  intubation: 
a  radiological  and  clinical  study.  Diagn  Imaging  1 982:5 1(5):224- 
233. 

Holdgaard  HO,  Pedersen  J,  Schurizek  BA,  Melsen  NC,  Juhl  B. 
Complications  and  late  sequelae  following  nasotracheal  intubation. 
Acta  Anaesthesiol  Scand  I993:37(5):475^80. 
Colice  GL.  Resolution  of  laryngeal  injury  following  translaryngeal 
intubation.  Am  Rev  Respir  Dis  1992:145(2  Pt  l):36l-364. 
Colice  GL,  Stukel  TA,  Dain  B,  Laryngeal  complications  of  pro- 
longed intubation.  Chest  l989;96(4):877-884. 
Heffner  JE.  Tracheal  intubation  in  mechanically  ventilated  patients 
(review).  Clin  Chest  Med  1988:9(0:2,3-35. 
McCulloch  TM.  Bishop  MJ.  Complications  of  translaryngeal  intu- 
bation. Clin  Chest  Med  I99l:i2(3):507-52l. 
Bishop  MJ.  Weymuller  EA  Jr,  Fink  BR.  Laryngeal  effects  of  pro- 
longed intubation  (review).  Ancsth  Analg  l984:63(3):335-342. 
Deane  RS,  Shinozaki  T,  Morgan  JG.  An  evalulaon  of  the  cuff 
characteristics  and  incidence  of  laryngeal  complications  using  a 
new  nasotracheal  tube  in  prolonged  intubations.  J  Trauma  1977; 
I7(4):3I1-3I4. 

Kastanos  N.  Estopa  Miro  R,  Marin  Perez  A,  Xaubet  Mir  A.  Agusti- 
Vidal  A.  Laryngotracheal  injury  due  to  endotracheal  intubation 
incidence:  evolution,  and  predisposing  factors:  a  prospective  long- 
term  study.  Crit  Care  Med  1983:1 1(5):362-367. 
Rashkin  MC,  Davis  T.  Acute  complications  of  endotracheal  intu- 
bation. Relationship  to  reintubation.  route,  urgency,  and  duration. 
Chest  1986.89(2):  165-167. 

Weymuller  EA  Jr.  Bishop  MJ.  Santos  PM.  Problems  associated 
with  prolonged  intubation  in  the  geriatric  patient.  Otolaryngol  Clin 
North  Am  1990:23(6):  1057-1074.  Published  errutiim  in  Otolaryn- 
gol Clin  North  Am  I99l:24(6):xi. 

Wood  DE,  Mathisen  DJ.  Late  complications  of  tracheotomy.  Clin 
Chest  Med  l991:l2(3):597-609. 

Obier  K,  Haywood  LJ.  Enhancing  therapeutic  communications  with 
acutely  ill  patients.  Heart  Lung  1973:2(1  ):49-53. 
Bergbom-Engbert  I.  Haljamae  H.  Assessment  of  patients'  experi- 
ence of  discomforts  during  respirator  therapy.  Crit  Care  Med  1989; 
1 7(10):  1 068- 1072. 

Leder  SB.  Importance  of  verbal  communication  for  the  ventilator- 
dependent  patient  (editorial).  Chest  1990;98(4);792-793. 

78.  Godwin  JE.  Heffner  JE.  Special  critical  care  considerations  in  tra- 
cheostomy management.  Clin  Chest  Med  l99l:l2(3):573-583. 

79.  Lawless  CA.  Helping  patients  with  endotracheal  and  tracheostomy 
tubes  communicate.  Am  J  Nurs  1975:75(12):2I5I-2153. 


60, 


61 


62 


63 


64 


65 


66, 


67 


68 


69, 


70, 


71 


72 


73 


74 


75 


76 


77 


80.  Banner  MJ,  Blanch  PB,  Kirby  RR.  Imposed  work  of  breathing  and 
methods  of  triggering  a  demand-flow,  continuous  positive  airway 
pres,sure  system.  Crit  Care  Med  1993;2I(2):I83-I90. 

8 1 .  Wright  PE.  Marini  JJ,  Bernard  GR.  In  vitro  versus  in  vivo  com- 
parison of  endotracheal  tube  airflow  resistance.  Am  Rev  Respir  Dis 
1989;I40(I):I0-16. 

82.  Kluger  Y.  Paul  DB,  Lucke  J,  Cox  P,  Colella  JJ,  Townsend  RN,  et 
al.  Early  tracheostomy  in  trauma  patients.  Eur  J  Emerg  Med  1996; 
3(2):9.5-10l. 

83.  Kramer  N,  Meyer  TJ.  Meharg  J,  Cece  RD,  Hill  NS.  Randomized, 
prospective  trial  of  noninvasive  positive  pressure  ventilation  in  acute 
respiratory  failure.  Am  J  Respir  Crit  Care  Med  I995:I5I(6):I799- 
1806. 

84.  Confalonieri  M.  Parigi  P,  Scartabellati  A.  Aiolfi  S,  Scor.setti  S. 
Nava  S.  Gandola  L.  Noninvasive  mechanical  ventilation  improves 
the  immediate  and  long-term  outcome  of  COPD  patients  with  acute 
respiratory  failure.  Eur  Respir  J  1 996:9(3  ):422^30. 

85.  Nava  S.  Ambrosino  N.  Clini  E.  Prato  M.  Orlando  G.  Vitacca  M.  et 
al.  Noninvasive  mechanical  ventilation  in  the  weaning  of  patients 
with  respiratory  failure  due  to  chronic  obstructive  pulmonary  dis- 
ease: a  randomized,  controlled  trial.  Ann  Intern  Med  1 998;  1 28(9): 
721-728. 

86.  Hill  BB,  Zweng  TN,  Maley  RH.  Charash  WE.  Toursarkissian  B. 
Kearney  PA.  Percutaneous  dilational  tracheostomy:  report  of  356 
cases.  J  Trauma  l996;4l(2):238-244. 

87.  Toursarkissian  B.  Zweng  TN.  Kearney  PA.  Pofahl  WE.  Johnson 
SB.  Barker  DE.  Percutaneous  dilational  tracheostomy:  report  of 
141  cases.  Ann  Thorac  Surg  l994;57(4):862-867. 

88.  McHenry  CR.  Raebum  CD.  Lange  RL.  Priebe  PP.  Percutaneous 
tracheostomy:  a  cost-effective  alternative  to  standard  open  trache- 
ostomy. Am  Surg  1997;63(7):646-652. 

89.  Cobean  R.  Beals  M.  Moss  C.  Bredenberg  CE.  Percutaneous  dila- 
tational  tracheostomy:  a  safe,  cost-effective  bedside  procedure.  Arch 
Surg  1996:13 1(3):26.5-27 1. 

90.  Gold  MR.  Siegel  JE.  Russell  LB.  Weinstein  MC.  Cost-effectiveness  in 
health  and  medicine.  New  York:  Oxford  University  Press:  1996. 

91.  Heffner  JE.  Timing  tracheotomy:  calendar  watching  or  individual- 
ization of  care?  (editorial)  Chest  1998;!  l4(2):36l-363. 

92.  Heffner  JE.  Timing  of  tracheotomy  in  ventilator-dependent  patients 
(review).  Clin  Chest  Med  I99I:I2(3):61 1-625. 

93.  Heffner  JE.  Medical  indications  for  tracheotomy  (review).  Chest 
1989:96(1):  1 86- 1 90. 

94.  Plummer  AL,  Gracey  DR.  Consensus  conference  on  artificial  air- 
ways in  patients  receiving  mechanical  ventilation  (review).  Chest 
1989:96(1):I78-I80. 

95.  Heffner  JE,  Brown  LK,  Barbieri  CA,  Harpel  KS.  DeLeo  J.  Prospective 
validation  of  an  acute  respiratory  distress  syndrome  predictive  score. 
Am  J  Respir  Crit  Care  Med  1995:162(5  Pt  I):I5I8-I526. 

96.  Heffner  JE,  Zamora  CA.  Clinical  predictors  of  prolonged  transla- 
ryngeal intubation  in  patients  with  the  adult  respiratory  distress 
syndrome.  Chest  I990;97(2):447^52. 

97.  John.son  SB,  Kearney  PA.  Barker  DE.  Early  criteria  predictive  of 
prolonged  mechanical  ventilation.  J  Trauma  1992;33(  l):95-100. 

98.  Bause  H.  Prause  A,  Schulte  am  Esch  J.  [Indications  and  technique  of 
percutaneous  dilatation  tracheotomy  for  intensive  care  patients.)  Anas- 
thesiol  Intensivmed  Notfallmed  Schmerzther  1995;30(8):492^96. 

99.  Graham  JS.  Mulloy  RH,  Sutherland  FR,  Rose  S.  Percutaneous  ver- 
sus open  tracheostomy:  a  retrospective  cohort  outcome  study. 
J  Trauma  1 996:4 1(2):245-250. 

100.  Petros  S,  Engelmann  L.  Percutaneous  dilatational  tracheostomy  in 
a  medical  ICU.  Intensive  Care  Med  1997;23(6):6.30-634. 

101.  Law  JH,  Barnhart  K,  Rowlett  W,  de  la  Rocha  O,  Lowenberg  S. 
Increased  frequency  of  obstructive  airway  abnormalities  with  long- 
term  tracheostomy.  Chest  1993:I04(I):I36-I38. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


8!^ 


Tracheotomy:  Indications  and  Timing 


Discussion 

Pierson:*  In  my  experience,  trache- 
otomy facilitates  weaning  from  me- 
chanical ventilation,  although  this  may 
be  as  much  because  of  effects  on  cli- 
nician behavior  as  any  physiologic 
changes.  We  have  a  tendency  to  get 
weaning  and  extubation  so  tangled  up 
in  our  minds  that  we  prolong  the  pro- 
cess of  discontinuing  ventilatory  sup- 
port because  we  automatically  include 
extubation  in  our  thinking,  and  in  mar- 
ginal cases  we  delay  because  we're 
afraid  that  if  the  patient  isn't  ready, 
we  will  have  to  put  the  endotracheal 
tube  back  in.  Once  the  patient  has  a 
tracheostomy,  weaning  becomes  a 
simple  matter  of  switching  the  patient 
onto  a  T-piece,  and  if  they're  not  ready 
you  just  hook  the  ventilator  up  again. 

Heffner:  I  think  that's  true,  and 
maybe  what  we  need  to  do  is  to  take 
a  look  at  the  state  of  the  art  of  how  we 
manage  airway  decisions,  and  what 
drives  our  management  decisions, 
whether  they  be  physician  behavior, 
variable  interpretations  of  clinical 
findings,  or  the  wish  to  decrease  air- 
way resistance.  We  strive  to  provide 
interventions  that  give  the  best  out- 
comes for  our  patients  within  the  lim- 
its of  the  medical  culture  in  which  we 
practice.  You  know,  I  don't  do  many 
tracheotomies  in  the  ICU.  Whenever 
I've  talked  or  written  about  it,  I  think 
some  readers  or  listeners  have  inter- 
preted that  I'm  arguing  for  an  earlier 
induction  of  tracheotomy.  Actually, 
what  I'm  trying  to  argue  for  is  a  dif- 
ferent approach  to  decision-making — 
to  try  to  understand  how  we  make  the 
decision,  on  what  bases  we  make  the 
decision,  which  data  we're  reading, 
following,  and  invoking,  and  then 
monitor  our  clinical  course  and  out- 
comes. I've  got  to  say,  though,  with 
not  doing  many  tracheotomies  and  try- 


*  David  J  Pierson  MD,  Division  of  Pulmonary 
Critical  Care  Medicine,  Department  of  Medi- 
cine, University  of  Washington,  Seattle,  Wash- 
ington. 


ing  real  hard  to  extubate  people  as 
early  as  possible,  we've  had  a  number 
of  patients  we  couldn't  wean,  and  then 
I've  been  impressed  by  the  fact  that 
once  we  did  a  tracheotomy,  they  were 
off  mechanical  ventilation  in  a  couple 
of  days.  I  think  it  might  be  true  that 
some  patients  come  off  the  ventilator 
more  rapidly  if  they  have  a  tracheos- 
tomy in  place.  Whether  it  allows  me 
then  to  cut  the  sedation  or  talk  the 
night  nurses  into  not  sneaking  the  Ati- 
van dose  in  (because  they  perceived 
that  the  patient  was  uncomfortable) — 
whatever  the  magic  of  a  tracheotomy 
is,  I  don't  know.  But  in  the  limits  of 
the  culture  in  which  I  practice,  it  seems 
that  intervention  for  subgroups  of  pa- 
tients does  have  value  for  getting  them 
off  the  ventilator  earlier. 

Pierson:  I'm  sure  that's  true,  and 
that  my  statement  was  a  bit  oversim- 
plified. 

Branson:  David  (Pierson),  we  saw 
the  exact  same  thing  over  and  over 
again,  and  we  actually  designed  a 
study'  to  look  at  the  work  of  breath- 
ing when  patients  were  breathing  just 
through  the  endotracheal  tube,  not  con- 
nected to  the  ventilator,  and  then  we 
would  do  the  same  thing  within  8  hours 
of  their  having  a  tracheotomy.  We 
found  that  there  is  a  tendency  for  tra- 
cheostomized  patients  (matched  for 
the  same  size  internal  diameters)  to 
have  a  lower  respiratory  rate,  lower 
minute  volume,  and  a  slightly  lower 
work  of  breathing  per  minute.  Bro- 
chard's  group  has  done  a  similar  study 
that  showed  very  similar  things.^  We 
found  that  4  patients  ended  up  getting 
extubated  in  between  dose  times  be- 
fore they  could  have  a  tracheotomy, 
and  their  work  of  breathing  was  very 
high — much  higher  than  either  through 
the  trach  or  through  the  endotracheal 
tube.  Maybe  we  should,  as  Dean  (Hess) 
said  earlier,  just  disconnect  some  of 
these  patients  from  the  ventilator  but 
keep  the  orotracheal  tube  in,  because 
the  issue  then  isn't  that  the  patient 
needs  to  be  on  the  ventilator,  it's  that 


they  need  to  have  an  airway.  We've 
kind  of  come  to  the  decision  in  the 
trauma  ICU  that  the  time  to  trach  the 
patient  is  when  they  don't  need  to  be 
on  the  ventilator  anymore,  but  you 
can't  remove  the  endotracheal  tube. 

REFERENCES 

1 .  Davis  K  Jr,  Campbell  RS  Johnannigman  JA, 
Valente  JF,  Branson  RD.  Changes  in  respi- 
ratory mechanics  after  tracheostomy.  Arch 
Surg  1999;134(l):59-62.. 

2.  Diehl  JL,  El  Atrous  S,  Touchard  D,  Lemaire 
F,  Brochard  L.  Changes  in  the  work  of  breath- 
ing induced  by  tracheotomy  in  ventilator- 
dependent  patients.  Am  J  Respir  Crit  Care 
Med  l999;159(2):383-388 

Heffner:  Often  in  clinical  investi- 
gation, we  tend  to  use  intermediary 
end  points,  such  as  airway  resistance, 
and  then  attempt  to  determine  whether 
an  intervention  such  as  tracheotomy 
is  going  to  have  an  impact  on  the  true 
outcome  of  interest,  such  as  getting 
off  the  ventilator.  Sometimes,  despite 
the  u.se  of  good  deductive  reasoning, 
an  intermediary  end-point  may  not  re- 
ally be  a  predictor  of  the  ability  to 
wean.  So,  it's  hard  to  get  around  stud- 
ies that  look  at  early  tracheotomy  in 
homogeneous  groups  of  patients,  such 
as  trauma  patients,  and  observe  a 
shorter  length  of  stay.  We  should  crit- 
ically appraise  those  studies,  and  ask 
who  is  making  the  decision  about 
transfer  from  the  ICU.  Were  these  cli- 
nicians aware  of  the  intent  of  the  study 
and  of  the  tracheotomy?  Generally, 
these  studies  are  not  adequately 
blinded.  We  should  expect  good  ex- 
perimental designs  from  investigators 
who  are  doing  studies  that  adminis- 
trators and  HMOs  (Health  Mainte- 
nance Organizations)  are  going  to  read 
and  use  to  tell  us  how  to  practice  med- 
icine. It's  very  difficult  to  do  those 
investigations,  but  without  those  data, 
I  think  we  have  to  take  a  lot  of  these 
results  with  a  grain  of  salt. 

Bishop:  In  a  hospital  that's  not  a 
Level  One  trauma  facility,  I  might  be 
more  inclined  toward  an  earlier  tra- 
cheotomy. My  recollection  is  that  the 


816 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


general  consensus  at  the  NAMDRC 
(National  Association  for  Medical  Di- 
rectors of  Respiratory  Care)  was  that 
this  was  not  a  procedure  that  should 
be  done  in  acutely  unstable  patients. 
For  the  patient  who  is  on  20  cm  HjO 
of  PEEP  (positive  end-expiratory  pres- 
sure), the  patient  whose  weight  is  up 
25  kilos,  the  patient  who  has  multiple 
chest  tubes,  there  probably  is  no  ur- 
gency for  a  tracheotomy.  It  is  really 
something  for  the  long  haul.  Would 
you  agree  that  the  time  to  do  it  is  not 
just  when  they're  in  for  the  long  haul, 
but  also  when  the  patient  is  stable 
enough  that  they  can  be  taken  very 
safely  to  the  operating  room? 

Heffner:  Yes,  I  would  agree.  1  think 
that,  from  a  decision  analysis  stand- 
point, we  should  emphasize  the  indi- 
vidualization of  care.  Ask  yourself, 
what  are  the  benefits  I'm  hoping  to 
achieve  with  a  tracheotomy?  For  me, 
it's  usually  simplification  of  care,  de- 
crease of  sedatives  for  a  conscious  pa- 
tient, increasing  patient  comfort,  and 
enhancing  patient  mobility.  When  you 
have  someone  in  the  early  phase  of 
ARDS,  receiving  high  PEEP,  you're 
not  going  to  reap  those  benefits  with  a 
tracheotomy.  Early  ARDS  would  max- 
imize the  potential  risks  of  tracheot- 
omy and  limit  the  likelihood  of  ben- 
efit, which  shifts  you  toward  keeping 
the  translaryngeal  tube  in  place  longer. 
Conversely,  if  you've  got  a  conscious 
patient  with  a  neuromuscular  disor- 
der, such  as  myasthenia,  who  has  pneu- 
monia and  worsened  neuromuscular 
capacity,  that  patient  might  benefit 
from  a  tracheostomy  on  the  third  day 
of  hospitalization  if  you  can  predict 
that  they're  going  to  be  on  the  venti- 
lator for  2-3  weeks.  So,  if  that  patient 
can  benefit  from  the  comfort  advan- 
tages of  a  tracheotomy,  you  might  de- 
cide to  do  it  earlier  in  the  course  of 
disease  than  you  would  for  the  unsta- 
ble ARDS  patient,  everything  else  be- 
ing equal. 

Stoller:  John,  you've  done  your 
usual  masterful  job  of  defining  this 


literature,  and  I  think  you've  taken  ev- 
idence-based medicine  about  as  far  as 
it  can  go  in  the  context  of  this  contro- 
versial subject.  You  outlined  the  cri- 
teria of  a  randomized  trial,  and  con- 
cluded that,  given  the  impossibility  of 
conducting  such  a  trial,  we  are  rele- 
gated to  the  next  best  observational 
data  of  meta-analysis  and  evidence- 
based  medicine.  However,  we  also  live 
in  the  era  of  the  NEXT  (The  National 
Emphysema  Treatment  Trial)  trial  and 
the  OBEST  (The  Overholt-Blue  Cross 
Emphysema  Surgery  Trial)  trial, 
which  are  multicenter  and,  atypically, 
funded  by  insurers,  including  HCFA 
(Health  Care  Financing  Administra- 
tion), Blue  Cross/Blue  Shield  of  Mas- 
sachusetts, and  consortia  of  other  in- 
surers who  stand  to  benefit.  Given 
these  novel  funding  strategies  for  im- 
portant randomized  trials,  can  you 
imagine  conducting  a  multicenter  ran- 
domized trial  of  tracheotomy  interven- 
tion at  the  time  intervals  you  outlined? 
We  confront  this  issue  in  so  many  dif- 
ferent arenas,  and  I  think  that  in  the 
era  of  evidence-based  medicine,  we're 
quick  to  conclude  that  randomized  tri- 
als are  impossible  because  they're  hard 
and  expensive.  But  I'  ve  started  to  think 
that  perhaps  the  eggshell  is  breaking  a 
little  bit  about  the  seeming  impossi- 
bility of  randomized  trials.  Maybe 
we're  too  quick  to  conclude  that  these 
things  can't  be  done. 

Heffner:  I'd  like  to  see  such  a  tra- 
cheotomy study  done,  and  even  per- 
haps with  limited  scope  with  3  or  4  of 
those  patient  subgroups  that  we  have 
listed  up  there  in  high-volume  centers 
that  are  known  for  the  excellence  of 
their  respiratory  therapy  in  their  ICUs 
and  the  excellence  of  their  surgical 
technique,  so  we  can  control  for  co- 
variants.  I  think  that  certainly  is  pos- 
sible, but  so  far  there  hasn't  been  a  lot 
of  energy  surfacing  to  rigorously  in- 
vestigate tracheotomy.  I  worry  that 
when  we  do  rigorous  studies  we  will 
come  up  with  the  "efficacy"  of  the 
intervention.  "Efficacy"  describes 
what  works  in  a  research  setting.  In 


these  best  practice  centers,  we  can 
learn  the  correct  decision-making,  but 
what  we  talked  about  in  this  confer- 
ence is  the  "effectiveness"  of  what  we 
do.  "Effectiveness"  pertains  to  what 
works  in  real  world  settings.  We  need 
to  ask  if  the  research  results  from  best 
practices  centers  are  applicable  to  the 
community  hospitals,  where  most  pa- 
tient care  occurs  in  this  country.  I  agree 
that  multicenter,  randomized,  con- 
trolled trials  are  best,  and  if  we  can 
get  the  energy  and  support  to  do  such 
studies,  then  we  should,  but  we're  still 
challenged  to  determine  how  general- 
izable  the  results  are  going  to  be. 

Stauffer:  I  would  echo  that  com- 
ment. I  think  such  a  study  is  feasible 
and  certainly  desirable.  The  question 
is  whether  the  findings  would  be 
widely  applicable.  What  we  are  fac- 
ing is  a  vastly  different  tracheotomy 
complication  rate  between  trainees  in 
fairly  unsupervised  settings  and  expe- 
rienced surgeons  who  have  done  this 
operation  many  times  and  take  a  per- 
sonal interest  in  the  outcome  of  the 
patient.  The  complication  rate  of  tra- 
cheotomy is  so  variable  from  report  to 
report  and  institution  to  institution  that 
it  may  reflect  the  personal  interest  and 
the  skill  of  the  surgeon.  When  this 
operation  is  done  by  second-year  res- 
idents who  are  pretty  much  on  their 
own,  I  think  you're  going  to  see  high 
complication  rates,  such  as  we  ob- 
served 20  years  ago.'  I  have  another 
comment  in  regard  to  an  earlier  sub- 
ject— the  issue  of  removing  a  trache- 
ostomy tube  once  it's  in.  I  think  phy- 
sicians, by  nature,  are  eager  to  extubate 
patients  as  soon  as  possible.  I  don't 
find  everyone  interested  in  decannu- 
lating  patients  as  soon  as  possible. 
There  .seems  to  be  some  inertia  to  leave 
tracheostomy  tubes  in  place. 

REFERENCE 

1 .  Stauffer  JL.  Olson  DE,  Petty  TL.  Compli- 
cations and  con.sequences  of  endotracheal 
intubation  and  tracheotomy:  a  prospective 
study  of  150  critically  ill  adult  patients. 
Am  J  Med  l981;70(l):6.S-76. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


817 


Tracheotomy:  Indications  and  Timing 


Heffner:  I  think  that's  a  good  point. 
I've  learned  a  lot  from  respiratory  ther- 
apists in  my  career,  and  one  of  the 
things  I  learned  in  a  stint  in  private 
practice  with  a  superb  group  of  respi- 
ratory therapists  in  Colorado  Springs 
was  their  approach  to  getting  the  trach 
tube  out  as  early  as  possible.  They 
were  very  aggressive.  They  used  a  lot 
of  tracheostomy  buttons,  to  be  able  to 
accelerate  weaning.  Trach  buttons  al- 
low airway  decannulation  while  re- 
taining the  option  of  putting  the  trach 
tube  back  in.  This  approach  acceler- 
ates getting  the  tube  out  quickly. 
There's  pretty  good  literature  on  how 
to  do  that,  but  it  doesn't  exist  in  our 
usual  academic,  high-end  journals. 

Bishop:  John,  as  you've  gone  over 
the  literature,  what  do  you  think  about 
the  conjecture  that  tracheotomy  fol- 
lowing prolonged  intubation  actually 
increases  the  risk  of  laryngeal  steno- 
sis? That' s  a  criticism  that' s  been  made 
of  Whited's  cases  of  stenosis.'  Per- 
haps what  he  actually  demonstrated  is 
that  a  tracheostomy  following  pro- 
longed intubation  results  in  stenosis. 

REFERENCE 

1 .  Whited  R.  A  prospective  study  of  laryn- 
gotracheal sequelae  in  long-term  intuba- 
tion. Laryngoscope  1984;94(3);367-377. 

Heffner:  There's  a  concern  that  the 
longer  you  leave  the  translaryngeal 
tube  in,  the  more  you  damage  the  lar- 
ynx, which  is  the  first  insult  to  the 
airway,  and  then  if  you  put  the  trach 
tube  in,  you  may  allow  suppuration  of 
the  airway  to  reflux  proximally  into 
this  denuded  mucosa,  which  represents 
the  second  insult.  That  argument  cuts 
both  ways.  It  could  be  an  argument 
against  doing  the  tracheotomy,  or  it 
could  be  an  argument  to  do  the  tra- 
cheotomy earlier,  before  that  first  in- 
jury occurs.  Clarence  Sasaki  used  an 
animal  model  to  study  contamination 
of  the  laryngeal  region  of  the  airway 
caused  by  tracheotomy,  and  found  that 
there  was  increased  colonization  and 


damage  to  the  mucosa.'  As  far  as  I 
know,  this  finding  has  never  been  dem- 
onstrated in  humans.  We  did  a  study 
that  we  haven't  published  yet,  where 
we  bronchoscoped  intubated  patients 
and  sampled  the  endolarynx,  pre-trach 
and  then  post-trach,  with  quantitative 
culture  techniques.  We  were  unable  to 
find  any  contamination  of  the  subglot- 
tic region  after  tracheotomy,  or  in- 
crease in  colonization.  The  subglottic 
regions  are  already  so  colonized  and 
contaminated  that  we  couldn't  iden- 
tify any  increase  in  concentration  of 
bacteria. 


REFERENCE 

1.  Sasaki  CT.  Horiuchi  M.  Koss  N.  Trache- 
ostomy-related  subglottic  stenosis:  bacte- 
riologic  pathogens.  Laryngoscope  1979; 
89(6  Pt  l):857-865. 


Bishop:  I  thought  Gene  Colice' s  pa- 
per' suggested  that  patients  who  had  a 
tracheotomy  after  intubation  ended  up 
with  more  laryngeal  problems. 

REFERENCE 

1.  Colice  GL.  Resolution  of  laryngeal  injury 
following  translaryngeal  intubation.  Am 
RevRespirDis  l992;145(2Pt  l):.%l-364. 

Heffner:  Yes,  but  again,  it  wasn't 
randomized.  It  was  an  observational 
study,  which  tends  to  bias  the  sicker 
patients  into  the  tracheotomy  arm.  This 
issue  is  a  causation  question,  and  we 
can't  answer  causation  questions  by 
observational  studies. 


Reibel:  This  concern  has  been 
around  a  long  time,  and  1  don't  see  it 
substantiated.  I  think  the  thing  that's 
underappreciated  is  the  importance  of 
reflux  of  acid  peptic  .secretions  up  onto 
this  denuded  mucosa.  Gastroesphageal 
reflux  and  laryngopharyngeal  reflux 
is  a  hot  topic  now.  We  haven't  really 
done  a  good  job  of  looking  at  that,  but 
1  think  that  when  we  do,  it  will  start  to 
be  a  significant  predictor  of  posterior 


glottic  pathology.  It's  difficult  to  use 
proton  pump  inhibition,  because  you 
can't  give  it  intravenously  in  an  easily 
accessible  form,  and  it's  tough  to  put 
down  a  tube.  Hj  blockade  and  promo- 
tility  agents  don't  achieve  the  same 
efficacy. 

Heffner:  So,  that  may  be  another 
reason  to  elevate  the  head  in  intubated 
patients,  or  undergo  tracheotomy. 

Watson:  Over  the  years  that  I've 
watched  this  literature,  I've  found  it 
very  depressing,  mostly  because  what 
you  have  is  groups  of  individuals  who 
compare  their  best  practice  with  some- 
body else's  worst  practice  and  then 
draw  emotional  conclusions.  This  is 
largely  because  needed  studies  have 
not  yet  been  done.  It  seems  to  me  that 
this  practice  is  sort  of  a  self-guided 
thing;  that  is,  it  grows  and  changes  by 
itself,  almost  in  isolation  from  the  ac- 
ademic literature,  given  the  flaws  in 
the  academic  literature.  I'm  curious  to 
know  what  the  implication  of  percu- 
taneous tracheostomy  would  be.  I've 
certainly  seen  that  in  the  region  where 
I  work,  laryngologists  are  almost  never 
doing  tracheostomies  anymore.  It's  ex- 
traordinary to  go  to  the  operating  room. 
This  is  a  very  low  morbidity  picture. 
I'm  curious  to  know  whether  you  have 
any  thoughts  about  where  we're  go- 
ing with  that.  Will  we  be  doing  more 
trachs  because  it's  viewed  as  easier 
somehow  and  less  frightening?  Or  will 
we  be  doing  the  same  number?  Will 
we  be  doing  them  sooner? 

Heffner:  I've  been  trying  to  observe 
that  in  ICUs  around  the  country  where 
there  is  a  nonsurgeon  intensivist  re- 
sponsible for  the  patients  who  has 
learned  how  to  do  that  procedure.  And, 
it  seems  like  the  outcomes  are  varied. 
I  made  rounds  in  one  ICU  where  prob- 
ably 80%  of  the  ventilator  patients  had 
a  tracheotomy.  Tracheotomy  was  al- 
ways done  in  the  first  3  days  in  this 
major  academic  institution.  The  inten- 
sivist had  learned  the  procedure  and 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy:  Indications  and  Timing 


made  the  patient-centered  decision, 
"This  is  good  for  my  patients,  I've 
noticed  that  they  do  better  with  a  tra- 
cheotomy, I  don"t  have  to  wait  for  op- 
erating room  time,  and  I  can  do  the 
procedure  myself."  Other  medical  in- 
tensivists  have  learned  how  to  do  the 
procedure,  but  have  not  expanded  their 
use  of  tracheotomy  in  their  ICU.  In 
these  ICUs,  learning  percutaneous  tra- 
cheostomy has  simplified  the  chain  of 
events  to  getting  the  trach  done,  but 
hasn't  changed  physicians'  beliefs  re- 
garding the  value  of  tracheotomy.  Cost 
and  simplicity  of  doing  a  procedure 
do  factor  into  decision-making,  so  tra- 
cheotomy could  be  employed  more  of- 
ten if  we  cut  out  some  of  the  hurdles 
and  expense  of  having  the  procedure 
done. 


Stoller:  I'd  like  to  revisit  the  dis- 
cussion about  randomized  trials  and 
the  distinction  between  efficacy  and 
effectiveness.  I  think  it  is  important 
that  the  need  to  understand  effective- 
ness not  pre-empt  our  interest  in  de- 
termining efficacy.  Perhaps  studies 
that  establish  efficacy  can  be  the 
springboard  for  understanding  varia- 
tions in  practice  that  impact  effective- 
ness. In  fact,  I  think  it  would  prompt 
even  more  interest  in  performing  ef- 
ficacy studies  so  that  we  can  under- 
stand deviations  caused  by  local  prac- 


tice variations  that  would  define  the 
reasons  for  lack  of  effectiveness  when 
the  maneuver  is  efficacious. 

Heffner:  I  agree,  and  would  pro- 
mote randomized,  controlled  trials  in 
every  question  in  medicine.  But  this 
issue  has  been  around  for  a  long  time, 
and  so  far  we  haven't  seen  the  energy 
or  funding  emerge  to  really  get  ran- 
domized trials  done.  I  think  Mike 
Bishop,  Gene  Colice,  and  I  met  10 
years  ago  and  discussed  the  reason- 
ableness of  doing  a  multicenter  trial, 
at  least  between  the  3  of  us,  who  were 
interested  in  airway  management.  We 
didn't  have  the  support  or  resources 
to  get  it  done.  I  think  we  can  now 
possibly  look  to  the  AHCPR  (Agency 
for  Health  Care  Policy  and  Research) 
for  funding,  since  they  are  interested 
in  examining  best  clinical  practices. 
Perhaps  they  can  help  prioritize  im- 
portant topics  in  clinical  medicine  that 
impact  sufficiently  society  to  justify 
funding  of  randomized,  control  trials. 
That's  a  course  we  should  perhaps  ac- 
cept as  a  responsibility  to  follow  after 
this  conference. 


Thompson:  I  would  urge  anyone 
who  conducts  such  a  study  to  exam- 
ine who  does  the  procedure,  what  their 
training  has  been,  and  who's  super- 


vising them.  Outcomes  are  likely  to 
vary  with  the  experience  of  the  oper- 
ator and  the  degree  of  independence 
permitted.  Otherwise,  in  effect,  we 
may  be  comparing  the  results  of  jun- 
ior house  staff  to  those  of  senior  fac- 
ulty, rather  than  the  safety  and  effi- 
cacy of  2  procedures. 

Heffner:  I  think  we  have  sufficient 
understanding  of  the  procedure  and  the 
results  of  timing  at  different  points  of 
care,  the  outcomes  of  interests  we 
should  observe,  and  the  factors  that 
dictate  success  from  a  technical  stand- 
point. For  most  medical  centers  and 
hospitals  (community  or  academic), 
the  most  important  task  is  to  organize 
a  group  of  interested,  multidisciplinary 
people  to  come  up  with  a  guideline  or 
practice  protocol.  The  exact  elements 
of  the  protocol  are  perhaps  less  im- 
portant than  having  a  protocol  in  place 
that  can  then  be  monitored  and  ad- 
justed on  the  basis  of  monitored  re- 
sults. This  allows  development  in  your 
practice  domain  of  best  practices.  Why 
some  centers  have  a  Mike  Bishop  who 
promotes  best  practices  in  airway  man- 
agement and  other  centers  don't  is  un- 
clear. Physicians  and  nonphysician 
champions  emerge  in  some  medical 
centers  to  drive  the  culture  toward  con- 
tinuous improvement. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy  A'racheostomy 


James  F  Reibel  MD 


Introduction 

Surgical  (Open)  Tracheostomy 

Percutaneous  Dilational  Tracheotomy 

Summary 

[Respir  Care  1999;44(7):820-823]  Key  words: 
percutaneous  dilational  tracheotomy. 


tracheotomy,  tracheostomy. 


Introduction 

Tracheotomy  is  a  mainstay  in  the  airway  management 
of  critically  ill  patients,  providing  access  for  mechanical 
ventilation,  clearance  of  secretions,  and  protection  of  the 
airway.  This  procedure  has  often  been  performed  in  the 
operating  room  (OR),  by  preference  of  the  surgical  team. 
Bedside  tracheotomy  has  been  done  reluctantly,  despite 
evidence  that  the  procedure  can  be  done  safely  and  cost- 
efficiently  at  the  bedside,'  eliminating  the  risks  involved 
with  patient  transport. ^  The  development  of  percutane- 
ous dilational  tracheotomy  (PDT)^  has  allowed  trache- 
otomy to  be  safely  conducted  by  both  surgeons  and 
nonsurgeons.  Experience  with  PDT  has  shown  that  many 
patients  can  be  safely  tracheotomized  in  the  intensive 
care  unit  (ICU),  thereby  eliminating  risks  of  transport, 
easing  scheduling  difficulties,  and  providing  significant 
cost  savings.  These  developments  have  catalyzed  dis- 
cussion of  the  "how"  and  "where"  of  performing  tra- 
cheotomy/tracheostomy. 

Surgical  (Open)  Tracheostomy 

Surgical  tracheotomy  or  tracheostomy  can  be  safely  per- 
formed at  the  bedside,'  but  surgeons  prefer  to  perform  the 
procedure  in  the  operating  room,  where  the  lighting  is 
better,  there  is  a  full  complement  of  assistants  available, 
and  the  ergonomics  of  the  operating  table  are  more  favor- 


James  F  Reibel  MD  is  affiliated  with  the  Department  of  Otolaryngology. 
Head  and  Neck  Surgery,  University  of  Virginia  Medical  Center.  Char- 
lottesville. Virginia. 

Correspondence:  James  F  Reibel  MD.  Department  of  Otolaryngology, 
Head  and  Neck  Surgery.  University  of  Virginia  Medical  Center.  Char- 
lottesville VA  22908.  E-mail:  JFR2J@hscmail.mcc.virginia.edu. 


able.  The  lack  of  these  favorable  factors  should  indeed 
lead  to  the  performance  of  a  technically  difficult  open 
procedure  in  the  OR  if  it  is  in  the  patient's  best  interest. 
Nevertheless,  evidence  that  bedside  tracheotomy  or  tra- 
cheostomy can  be  accomplished  at  less  cost,  without  need 
for  patient  transport,  and  with  low  complication  rates  should 
lead  to  an  increase  in  tracheostomies  performed  in  the 
ICU.'  Surgeons  are  slowly  being  persuaded  and  are  seek- 
ing to  improve  the  ergonomics  of  the  ICU  .setting  for  this 
procedure."* 

Tracheotomy  refers  to  an  opening  made  in  the  trachea 
without  connection  to  the  skin  surface.  Tracheostomy 
refers  to  a  tracheal  opening  with  a  surgical  attachment 
to  the  skin.  Patient  safety  is  enhanced  when  tracheos- 
tomy is  performed.  The  attachment  to  the  skin  facili- 
tates identification  of  the  tract  and  prompt  reinsertion  of 
the  tracheal  cannula  if  the  patient  should  accidentally 
become  decannulated.  The  modification  of  the  Bjork 
flap^  (as  advocated  by  Dukes'"  and  Chew^)  provides  a 
secure  attachment  of  trachea  to  skin  (Fig.  1).  Creation 
of  the  tracheal  flap  and  tract  does  not  add  significant 
technical  difficulty  or  increase  the  incidence  of  stenosis, 
and  the  tract  facilitates  transfer  from  endotracheal  tube 
to  tracheostomy  tube.  In  patients  with  short,  thick  necks, 
where  a  tracheal  flap  might  not  reach  the  skin,  a  mod- 
ification of  the  "omega"  skin  flap  technique  might  be 
necessary  to  provide  this  secure  tract.'*  Since  a  selection 
bias  for  use  of  the  open  technique  in  the  more  difficult 
cases  is  already  becoming  apparent,  the  tracheostomy 
procedure  provides  an  extra  measure  of  safety. 

Percutaneous  Dilational  Tracheotomy 

Development  of  the  PDT  technique  in  1985  provided 
surgeons  and  non-surgeons  with  a  significant  new  option 
in  securing  the  airway.^  Numerous  studies  have  indicated 


820 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy/Tracheostomy 


Fig.  1.  A:  Tracheal  exposure  prior  to  flap  creation.  Cricoid  hook  (short  arrow)  holds  cricoid  cartilage  and  elevates  trachea  into  the  wound. 
Second  tracheal  interspace  (long  arrow)  is  superior  limit  of  the  modified  "Bjork"  flap.  B:  Cricoid  hook  continues  to  elevate  trachea  in 
preparation  for  insertion  of  tracheotomy  tube.  Suture  (arrow)  secures  trachea  to  skin  margin. 


that  PDT  is  re-producible  with  complication  rates  usually 
lower  than  open  tracheotomy.''-'-*  These  studies  also  dem- 
onstrate that  PDT  can  be  performed  safely  and  expedi- 
tiously'"'-''' at  the  bedside  without  the  risk  and  cost  of 
transportation  to  the  OR.'"'--'* 

Until  a  physician  has  had  significant  experience  with 
this  technique,  strict  selection  criteria  should  be  utilized 
(Table  1 ).  As  one  becomes  more  experienced  with  PDT, 
it  can  be  applied  in  more  difficult  situations. '"'^  Diffi- 
cult reintubation  if  the  airway  is  lost  during  PDT  should 
prompt  a  decision  for  an  open  procedure. "  • '  -  With  proper 
patient  selection,  PDT  can  be  safely  performed,  and 
the  advantages  of  enhanced  patient  care  at  lower  cost 
accrue. 

The  Seldinger  technique  concept  is  familiar  to  all  who 
work  in  the  ICU  environment.  While  the  technique  is 

Table  1 .      Selection  Criteria  for  Percutaneous  Dilational  Tracheotomy 


PRO 

•  Easy  reintubation  (A) 

•  No  coagulopathy  (R) 

•  Adult  (R) 

•  Favorable  neck  anatomy  (R) 

•  Good  extension 

•  Thin 

•  No  goiter 

•  No  prior  anterior  surgery 


CON 

•  Difficult  reintubation  (A) 

•  Coagulopathy  (A) 

•  Unfavorable  anatomy  (R) 


■  absolute  indication,  R  -  relative  indication. 


Straightforward,  appropriate  attention  to  detail  in  execu- 
tion will  facilitate  an  expeditious  procedure  with  minimal 
complications.  The  patient  is  positioned  with  the  neck  ex- 
tended, and  the  skin  in  the  area  of  puncture  and  incision  is 
infiltrated  with  local  anesthetic  with  epinephrine  from  the 
kit  (Fig.  2).  Some  additional  topical  anesthetic  can  be  in- 
stilled into  the  trachea  via  the  endotracheal  tube  as  well. 
Physiologic  monitors  are  checked  frequently  as  the  patient 
is  appropriately  sedated  and  paralyzed  as  required.  Flex- 
ible fiberoptic  guidance  is  not  required,'"'-  but  its  use 
does  confirm  proper  midline  introduction  of  the  needle 
and  guide  wire  without  cartilaginous  injury  and  helps 
prevent  paratracheal  insertion  of  the  dilators  and  inad- 
vertent injury  of  the  membranous  trachea'""''*  (Fig. 
3).  When  using  bronchoscopic  guidance,  an  end-tidal 
carbon  dioxide  monitor  is  advisable''-''*  to  avoid  hyper- 
carbia,  especially  with  head  injury  patients.  Once  the 
tracheotomy  tube  is  in  place,  it  should  be  sutured  to  the 
skin  and  secured  with  a  twill  tape  tied  snugly  around  the 
neck. 

The  most  significant  perioperative  risk  for  a  patient  un- 
dergoing PDT  is  accidental  decannulation.  This  complica- 
tion must  be  addressed  with  the  ICU  staff  in  advance.  Prior 
to  2  weeks,  a  mature  tract  has  not  formed,  and  attempted 
reinsertion  of  the  tracheotomy  tube  can  lead  to  bleeding, 
tracheal  injury,  and  death.  The  patient  suffering  accidental 
decannulation  should  be  reintubated  orally  and  the  airway 
controlled.  Once  the  airway  is  controlled,  the  tract  can  be 
explored,  allowing  replacement  of  the  guide  wire  and  di- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


82! 


Tracheotomy/Tracheostomy 


SIMS,  Inc. 

Ktt-ric,  NH  a543l  U.S.A. 


Asiiis; 


CAT.  NO.  511070 

TUBE  ID  7.(Wi 

PWPCOMraNCHTS-                    MOCC0IMM.COMKMEKT91 

s  siwwew'PiiCAraB)             i   peittsiiwcoofupf  wntuis     i   w*  cm  won 

3    lOOOnHO'lPVFKtUTION  <0I   1     ?AKn  1 D  MHCUTMKOilS                  1     UF'.INtAlOn 

1    txo'vaiti'wscnm.toi           CWjmwwironcnirtBr                i    '(a«naiN,iNTnoooceni*Ei»,f 

a    G*uraS«»OES                            t     »li™>in.iW«IIC*NMULA                  1     ZSQKiT'JIH  MFtOte 

«IICUI*HEOOS  ISHOT  Jim.                      ■«.  WiHt.'WW*  (1  iW.OOOl  Si* 

1    JO Ff  ootuHtron                        s   nyimcfcrnmBesfOrc  luctsiP) 
1    t  ft  tumma  CAT^nn                 i    sc*iJ>tt 

1     nUDHATOB                                       t     Q*l«t  St-Ndf; 

PER-Fir     J 

PEHCUIANCOUS  OILAnONAL  niACHEOSIOMY  KIT 
wtth  SPECIALTY  TRACHEOSTOMV  TUBE 

TUaE  1.0.         1 

tJ«UTio»                                                                OTtmuty 

-   tCliayrLjWVEP15*i.»>IEfJ,LIION»*fiWFCI=(EriB»        ■   COKieNJS  WlWiMMS  hMa(*li«»BC  STEBnE  ij'VtSS 

■  Wae(lfc,njl*!lA«PlMTfl)CrsTV.lSDe«Ct'Qi»J.t 
BY  OH  CW  niE  OflOHl  Of  A  PMYSiCUW 

■  SEE  iMS»ii  arcti  rnowKQ  'on  ■iMn«n 

Jis—ssrssr.a;™--' — - 

Fig.  2.  One  of  the  commercially  available  PDT  kits.  A:  List  of  in- 
cluded components.  B:  Components  in  package. 


lators,  with  successful  reinsertion  of  the  tracheotomy  tube.* 
This  protocol  should  be  reinforced  frequendy  to  ensure 
that  all  members  of  the  ICU  staff  are  aware  of  the  risks 
inherent  in  the  misguided  attempt  to  reinsert  the  tracheot- 
omy tube. 

Properly  done,  PDT  has  been  shown  to  be  a  safe  and 
cost-effective  procedure.  Pneumothorax  has  been  reported 
in  0-10%  of  surgical/open  procedures,  while  the  incidence 
of  pneumothorax  with  PDT  is  0.4-6.4%.'^'o"'4  Bleeding 
complication  rates  of  1.2-3.2%9"'i  '-'^  with  PDT  compare 
favorably  with  the  widely  varying  bleeding  complication 
rates  of  1-37%  reported  with  open  procedures."''*  Steno- 
sis has  been  acceptably  low  (0.8-2.3%)'''"''*  compared  to 
surgical  tracheostomy  (0.5%).''*  The  cost  savings  of 
$  1 ,300-$l  ,900,'0'2-"*  and  the  significantly  more  rapid  pro- 
cedure time  of  PDT'""''*  would  mean  little  without  such 
evidence  of  safety  and  reproducibility. 

Summary 

Tracheotomy  and  tracheostomy  are  procedures  that  pro- 
vide airway  access  for  continued  mechanical  ventilation 


and  pulmonary  toilet  in  critically  ill  patients.  The  devel- 
opment and  refinement  of  PDT'-'  has  added  a  capability 
that  allows  patients  to  be  treated  safely  and  expeditiously 
at  cost  savings.  While  applicable  to  many,  if  not  most 
patients,  not  all  should  be  considered  for  this  technique. 
Patients  with  difficult  anatomy,  either  at  the  procedure  site 
or  of  the  upper  airway  precluding  expeditious  oral  intuba- 
tion, especially  those  with  upper  airway  obstruction,  should 
have  open  surgical  tracheostomy.  The  open  technique 
should  be  utilized  in  the  ICU  setting  more  frequently, 
thereby  reserving  transportation  to  the  OR  for  those  who 
require  it.  Only  in  an  environment  of  collaboration  and 
cooperation  will  such  an  efficient  approach  flourish;  how- 
ever, improved  patient  outcomes,  reduced  direct  patient 
costs,  and  enhanced  efficiency  of  OR  utilization  are  pow- 
erful incentives. 


REFERENCES 

1.  Wease  GL,  Frikker  M,  Villalba  M,  Glover  J.  Bedside  tra- 
cheostomy in  the  intensive  care  unit.  Arch  Surg  1996;  1.31  (5):552- 
555. 

2.  Indeck  M,  Peterson  S,  Smith  J.  Brotman  S.  Risk,  cost  and  benefit  of 
transporting  ICU  patients  for  special  studies.  J  Trauma  1988:28(7): 
1020-1025. 

3.  Ciaglia  P,  Firsching  R,  Syniec  C.  Elective  percutaneous  dilatational 
tracheotomy.  A  simple  bedside  procedure:  preliminary  report.  Chest 
1985;87(6):715-719. 

4.  Sokolov  M,  Roth  Y,  Harell  M.  Improved  ergonomics  for  bedside 
trachecstomy.  Laryngoscope  l998;108(6):944-945. 

5.  Bjork  VO.  Partial  resection  of  the  only  remaining  lung  with 
the  aid  of  respirator  treatment.  J  Thor  Cardiovasc  Surg  1960; 
39:179. 

6.  Dukes  HM.  Tracheostomy.  Thorax  1970;25(5):573-576. 

7.  Chew  JY,  Cantrell  RW.  Tracheostomy.  Complications  and  their  man- 
agement (review).  Arch  Otolaryngol  1972;96(6):538-545. 

8.  Eliachar  I,  Stegmoyer  RJ,  Levine  HL,  Sivak  ED,  Mehta  AC,  Tucker 
HM.  Planning  and  management  of  long-standing  tracheostomy.  Oto- 
laryngol Head  Neck  Surg  1987;97(4):385-390. 

9.  Marx  WH,  Ciaglia  P,  Graniero  KD.  Some  important  details  in  the 
technique  of  percutaneous  dilatational  tracheostomy  via  the  modified 
Seldinger  technique.  Chest  1996:1 10(3):762-766. 

10.  Hill  BB,  Zweng  TN,  Maley  RH,  Chara.sh  WE,  Toursarkissian  B, 
Kearney  PA.  Percutaneous  dilational  tracheostomy:  report  of  356 
cases.  J  Trauma  1996;41(2):238-243. 

1 1 .  Graham  JS,  Mulloy  RH,  Sutherland  FR,  Rose  S.  Percutaneous  versus 
open  tracheostomy:  a  retrospective  cohort  outcomes  study.  J  Trauma 
1996;4I(2):245-250. 

12.  Cobean  R,  Beals  M,  Moss  C,  Bredenberg  CE.  Percutaneous  dilata- 
tional tracheostomy:  a  safe  cost-effective  bedside  procedure.  Arch 
Surg  I996;131(3):265-27I. 

13.  Fernandez  L,  Norwood  S,  Roettger  R.  Gass  D,  Wilkins  H  3rd.  Bed- 
side percutaneous  tracheostomy  with  bronchoscopic  guidance  in  crit- 
ically ill  patients.  Arch  Surg  1996;131(2):129-132. 

14.  Powell  DM,  Price  PD.  Forrest  LA.  Review  of  percutaneous  trache- 
ostomy. Laryngoscope  1998;108(2):170-177. 


822 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy/Tracheostomy 


..:   Hbt: 
D.O.  EIPTH: 

ii   16  961 
15:42:135 

.-,-1 1 .qo 


C    COttCMT 


Fig.  3.  Percutaneous  dilational  tracheotomy  being  performed  with  bronchoscopic  guidance.  A:  Placement  of  guide  wire  and  dilator.  B: 
Progressive  dilation.  C:  Bronchoscope  view  showing  approphate  placement  and  no  cartilage  injury.  D:  Insertion  of  the  tracheotomy  tube. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


823 


Tracheotomy/Tracheostomy 


Discussion 

Heffner:  One  of  the  problems  with 
doing  a  PDT  is  impaling  the  endotra- 
cheal tube.  Pulling  the  endotracheal 
tube  back  during  a  difficult  procedure 
risks  hypoventilation.  A  neat  innova- 
tion I  saw  presented  from  the  Sloan- 
Kettering  group  was  the  use  of  an  ex- 
tubation  laryngeal  mask  airway 
(LMA)  during  PDT.  I  was  wondering 
if  you've  had  experience  with  that,  or 
can  comment.  Is  that  something  we 
should  do? 

Reibel:  We  do  it  with  a  fiberoptic 
scope  through  the  endotracheal  tube. 
That  way,  we  know  we're  at  the  right 
spot;  we  can  see  where  the  needle  pen- 
etrates the  trachea;  we  can  count  the 
rings.  If  we  happen  to  back  the  tube 
out  too  far,  the  scope  is  in  the  way, 
allowing  easy  reintubation.  When  you 
lose  the  advantage  of  the  broncho- 
scopic  guidance,  you  can't  ensure  that 
you  have  a  sagittal  introduction,  and 
you  can't  ensure  that  you're  not  com- 
ing through  cartilage  in  the  process. 
Avoiding  injury  to  the  cartilage  is 
absolutely  key.  We  think  we  can 
minimize  stenosis  complications  if  we 
take  great  care  to  avoid  injuring  the 
cartilage. 

Durbin:  I  can  comment  on  the  use 
of  the  LMA  in  PDT.  I  presented  an 
abstract  at  the  American  Association 
for  Respiratory  Care  meeting  report- 
ing the  first  7  patients  that  we've  done 
with  an  LMA. '  It' s  a  very  elegant  tech- 
nique in  a  patient  who  is  breathing 
spontaneously.  If  needed,  you  can  give 
positive  pressure  with  the  LMA.  The 
advantage  of  the  LMA  is  that  you  can 
accurately  identify  the  tracheal  rings 
and  avoid  the  cricoid  ring  because  the 
endotracheal  tube  is  no  longer  in  the 
way.  It  works  very  nicely.  The  neu- 
rosurgical patients  are  ideal  because 
they  already  have  diminished  airway 
reflexes.  What  I've  found  is  that  if 
you  have  to  extubate  the  patient  to  use 
the  LMA,  some  of  these  patients  de- 
velop stridor  and  require  reintubation 


for  airway  control.  I've  done  this  4  or 
5  times,  and  it  turns  a  10-minute  pro- 
cedure into  a  1-hour  procedure,  so  I 
am  no  longer  electively  extubating  pa- 
tients at  the  time  I'm  doing  a  PDT.  I'll 
extubate  them  an  hour  ahead,  come 
back,  and  if  they're  okay,  then  use  the 
LMA.  I  do  really  like  using  the  LMA, 
because  it  protects  the  bronchoscope 
from  the  needle.  If  the  needle  dam- 
ages the  bronchoscope,  that's  a  $5,000 
mistake.  After  topical  anesthesia  and 
a  transtracheal  local  injection,  I  place 
the  LMA  with  the  patient  under  light 
sedation.  The  LMA  is  usually  directly 
in  front  of  the  larynx,  so  you  can  eas- 
ily see  the  laryngeal  anatomy  and  as- 
sess how  much  damage  prolonged  in- 
tubation has  caused.  You  can  quickly 
intubate  through  the  LMA  with  the  fi- 
beroptic scope  if  you  have  an  endotra- 
cheal tube  threaded  on  it  ready  to  go. 

REFERENCE 

1.  Durbin  CG  Jr,  Seay  W.  Use  of  the  laryn- 
geal mask  airway  (LMA)  during  perfor- 
mance of  percutaneous,  bedside  tracheot- 
omy (abstract).  Respir  Care  1998;43(10): 
838. 

Watson:  I  would  comment  that  I 
actually  don't  do  percutaneous  trache- 
otomies, though  I  assist  with  them 
from  time  to  time.  We  began  doing 
them  all  bronchoscopically,  and  we 
went  through  this  process  with  how 
far  back  do  you  pull  the  tube  to  get  it 
out  of  the  way  (which  was  problem- 
atic in  our  institution  because  the  habit 
had  been  to  have  the  tube  too  far  down), 
cut  down,  open  the  trachea  over  the 
tube,  and  then  pull  the  tube  back  so 
that  one  would  insert  the  tracheostomy 
tube,  whether  we  did  a  flap  or  not. 
People  do  the  same  technique  in  dif- 
ferent ways.  A  modification  that  I've 
used  on  occasions  when  1 '  ve  been  wor- 
ried about  difficulty  of  reintubation  is 
to  put  a  pediatric  airway  exchange 
catheter  down.  That  leaves  me  with  a 
sense  of  security,  with  oxygen  flow- 
ing into  the  trachea.  Whatever  upper 
airway  maneuver  I  do,  typically  the 
breathing  tube  adjusts  very  far  back  in 


the  larynx,  and  the  scope  is  kept  well 
above  the  puncture  site,  so  that  when 
I  see  the  guide  wire  and  we  start  di- 
lating, I  pull  the  small  airway  exchange 
catheter  out.  I'd  be  surprised  to  see 
that  many  people  were  doing  this  in 
the  patients  who  were  worrisome  from 
the  standpoint  of  intubation. 

Bishop:  We  don't  do  percutaneous 
PDTs  in  our  hospital.  I  see  significant 
political  battles  that  would  arise.  Cer- 
tainly one  potential  pitfall  that  I'd  be 
concerned  about,  and  would  like  to 
hear  your  opinion  on,  is  that  if  you 
have  nonsurgeons  doing  these,  how 
do  surgeons  feel  about  potentially  be- 
ing called  upon  to  take  care  of  some- 
body else's  complications? 

Reibel:  Obviously,  our  residents 
aren't  crazy  about  it,  but  that  has  not 
been  a  problem.  Jon  Truwit  told  me 
that  he's  occasionally  had  a  little  bit 
of  nuisance  bleeding  as  he's  intro- 
duced one  of  the  dilating  catheters. 
He  just  holds  pressure  on  it  to  tam- 
ponade it,  and  he's  never  had  to  abort. 
We  don't  want  to  take  a  case  that  has 
a  precarious  airv/ay  and  lose  that  air- 
way. If  you  have  a  ca.se  that  you  know 
is  a  difficult  reintubation,  and  you  get 
a  little  bit  of  bleeding,  I  would  back 
out  and  not  persist.  Surgeons  are  al- 
ways relatively  quickly  available  to 
come  and  bail  you  out  if  you  get  into 
trouble.  The  issue  of  turf  battles — this 
is  something  we're  going  to  have  to 
be  adult  about  and  work  through. 
We're  going  to  have  to  do  what's  best 
for  both  the  patient  and  the  institution, 
collectively.  If  we  can  have  patients 
get  done  expeditiously  without  in- 
creased complications  and  at  a  cost 
savings,  we're  going  to  have  better 
outcomes.  We're  going  to  have  less  of 
a  headache  for  our  OR  directors  and 
fewer  nurses  quitting  because  of  fre- 
quently having  to  stay  an  extra  2  or  3 
hours  to  get  the  elective  surgery  done. 
So,  admittedly,  there  are  going  to  be 
turf  battles.  But,  at  the  end  of  the  day 
we're  going  to  have  to  be  adults  and 
work  through  it. 


824 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy/Tracheostomy 


Durbin:  I'd  like  to  compliment  Jim 
(Reibel)  on  how  easily  this  has  gone 
in  our  own  institution.  Jon  Truwit  is  a 
pulmonologist,  head  of  the  medical 
ICU.  At  his  first  10  or  so  procedures 
he  had  an  anesthesiologist  and  an  ear- 
nose-throat  surgeon  with  him  when  he 
did  the  procedure.  It  was  a  collabora- 
tive team  learning  the  process.  Now 
it's  being  endorsed  by  all  3  services 
and  general  surgery.  In  fact,  the  ear- 
nose-throat  residents  are  often  doing 
the  procedure  with  me  to  get  their  ex- 
perience as  well.  It's  been  a  collabo- 
rative process  to  introduce  the  right 
technique  for  the  group  of  patients  who 
will  benefit  from  it.  Maybe  there's 
some  competition,  but  it's  minimal.  I 
think  everybody  agrees  that  it's  to  the 
institutional  advantage  to  do  PDTs  on 
appropriate  individuals.  It's  also  ap- 
propriate to  have  backup  from  all  ser- 
vices if  the  need  arises. 

Stauffer:  I  guess  I'm  going  to  be 
somewhat  of  a  skeptic  here,  because, 
at  last  count,  I  think  we  only  had  4 
randomized,  prospective  clinical  trials 
of  PDT  versus  standard  tracheoto- 
my,' -^  and  in  1  of  those  4  trials.  I 
believe,  the  percutaneous  technique 
was  done  in  the  operating  room.'*  In  2 
of  the  studies,--*  it  was  done  under 
general  anesthesia.  Only  1  of  the  stud- 
ies addressed  long-term  complications 
of  PDT.'  One  nonrandomized  study 
did  look  at  some  of  the  long-term  com- 
plications of  PDT.''  I  would  echo  a 
concern  that  John  Heffner  raised  in  an 
editorial''  in  1991,  that  we  need  more 
information  about  PDT  before  we  to- 
tally embrace  it.  Another  comment  is 
that  in  some  of  the  cost  or  charge  anal- 
yses that  have  been  published,  the  au- 
thors did  not  include  the  cost  of  the 
bronchoscopy  procedure  (hospital 
charge  and  professional  charge).  I 
think  when  you  add  that  in.  and  when 
you  consider  that  standard  tracheot- 
omy can  be  done  at  the  bedside,  sav- 
ing the  OR  costs,  the  costs  of  PDT 
and  standard  tracheotomy  are  actually 
somewhat  similar. 


REFERENCES 

1 .  Hazard  P.  Jones  C.  Benitone  J.  Comparative 
clinical  trial  of  standard  operative  tracheos- 
tomy with  percutaneous  tracheostomy.  Crit 
Care  Med  I991;19(8):I018-1024. 

2.  Crofts  SL,  Alzeer  A,  McGuire  GP,  Wong 
DT,  Charles  D.  A  comparison  of  percutane- 
ous and  operative  tracheostomies  in  inten- 
sive care  patients.  Can  J  Anaesth  1 995;42(9): 
115-119. 

3.  Friedman  Y.  Fildes  J,  Mizock  B.  Samuel  J, 
Patel  S.  Appavu  S.  Roberts  R.  Comparison 
of  percutaneous  and  surgical  tracheostomies. 
Chest  1996;110(2):480-485. 

4.  Holdgaard  HO.  Pedersen  J.  Jensen  RH,  Out- 
zen  KE.  Midtgaard  T.  Johansen  LV,  et  al. 
Percutaneous  dilatational  tracheostomy  ver- 
sus conventional  surgical  tracheostomy:  a 
clinical  randomized  study.  Acta  Anaesthe- 
siol  Scand  1998;42(.5);545-550. 

5.  van  Heurn  LW,  Goei  R,  de  Ploeg  I,  Ramsay 
G,  Brink  PR.  Late  complications  of  percu- 
taneous dilatational  tracheotomy.  Chest 
1996;110(6):1572-1576. 

6.  Heffner  JE.  Percutaneous  tracheotomy:  novel 
technique  or  technical  novelty?  (editorial). 
Intensive  Care  Med  1991;17(5):252-253. 

Reibel:  About  the  .second  issue,  I 
agree.  There  is  no  reason  that  we  can't 
do  open  procedures  at  the  bedside.  In 
regard  to  the  cost  issue  for  the  flexible 
scope,  from  time  to  time  we  will  use 
one  of  our  flexible  scopes  and  won't 
charge  the  patient.  If  we  are  under  time 
pressure  occasionally,  we  will  get  the 
bronch  cart,  and  then  the  patient  is 
charged.  I  believe  the  institution  does 
generate  an  extra  charge  for  that.  We  do 
not  charge  for  bronchoscopy,  but  there 
is  an  institutional  charge  for  the  use  of 
the  scope.  The  Olympus  ENFP  scope 
will  fit  in  an  appropriately  trimmed  en- 
dotracheal tube  easily,  and  we've  got 
those  readily  available  in  the  clinic. 

Hurford:  One  of  the  things  to  re- 
member when  you're  looking  at  costs 
is  that  what  the  hospital  can  charge  as 
an  institutional  charge  is,  of  course, 
irrelevant  to  the  actual  cost  of  the  pro- 
cedure to  the  hospital.  What  you  need 
to  look  at  is  the  marginal  costs  of  la- 
bor, personnel,  and  replaceable  equip- 
ment that  the  hospital  incurs  when 
comparing  a  tracheostomy  done  in  the 
OR  with  one  done  in  the  ICU.  We 
have  extremely  limited  experience 


with  PDT  at  our  hospital,  and  the  ex- 
perience that  we  have  is  skewed  in 
that  most  of  the  patients  we  have  seen 
have  been  referred  for  repair  of  tra- 
cheal or  cricoid  damage.  One  of  the 
most  common  things  we've  seen  has 
been  cricoid  injury  from  the  PDT  be- 
ing done  too  high.  It's  not  unusual 
that  the  PDT  has  actually  been  a  cri- 
coidthyrotomy  rather  than  a  tracheos- 
tomy. Is  that  just  a  very  unusual 
skewed  view,  or  does  bronchoscopy 
really  help  compared  to  doing  it  with- 
out bronchoscopy? 

Reibel:  I  think  it  helps.  Everybody 
wants  to  adopt  this  new  technique.  It's 
like  the  situation  after  the  advent  of 
the  CO2  laser:  everybody  wanted  to 
use  it.  It  is  the  same  with  PDT — it  has 
its  place.  You  need  to  have  anatomy 
that  you  can  easily  localize  by  palpa- 
tion. If  you  can  feel  the  cricoid,  you 
shouldn't  impale  it  with  the  introducer 
and  dilators.  If  you  can  feel  it  and  you 
can  have  visual  confirmation  of  the 
sagittal  introduction  into  the  trachea, 
not  injuring  cartilage,  I  think  that's 
the  best  you  can  do  with  this  tech- 
nique. I  think  it's  up  to  us  to  make 
sure  this  technique  is  used  appropri- 
ately and  properly.  I  think  this  venue 
is  appropriate  to  get  the  word  out. 

Thompson:  Yesterday,  you  asked 
me  if  we  were  doing  PDTs  on  the  ad- 
olescents, and  the  answer  was  no.  Do 
you  know  whether  people  have  begun 
to  lower  the  age  threshold  anywhere? 

Reibel:  I  have  no  firsthand  infor- 
mation, but  I'd  bet  on  it.  Because  peo- 
ple want  to  be  the  first  to  push  the 
envelope.  They  are  going  to  want  to 
extend  the  indications  for  this.  I  think 
it's  appropriate  for  us  to  say  do  it  at 
your  own  risk.  I  certainly  don't  think 
it's  appropriate  to  take  it  below  14, 
15,  16.  I've  seen  all  3  of  those  ages  in 
the  literature,  but  we  have  not  done  it 
on  anyone  who  is  not  of  legal  age. 

Durbin:  I've  done  it  on  a  16-year- 
old. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


825 


Tracheotomy/Tracheostomy 


Reibel:     How  was  it? 

Durbin:  It  was  a  big  16-year-old, 
bigger  than  me.  It  went  fine. 

Watson:  PDT  is  not  that  new  a  pro- 
cedure. In  the  mid-  to  late- 1960s,  a 
neurosurgical  group  in  Philadelphia 
did  work  with  the  Seldinger  technique 
for  placing  standard  tracheostomy 
tubes:  they  published  and  actually  mar- 
keted their  stuff.  What's  going  on  at 
this  point  is  that  we  have  a  company 
that  began  selling  bronchoscopy- 
assisted  PDT  and  training  people  all 
over  the  country,  and  now  we're  see- 
ing an  explosion  of  interest.  I  think 
the  reason  the  interest  and  the  sales 
are  coupling  with  growth  of  utiliza- 
tion is  that  it's  just  much  more  con- 
venient and  that  does  play  a  role. 
Sooner  or  later,  even  in  Boston,  how 
much  it  costs  will  become  very  im- 
portant, because  it  will  come  out  of 
the  pockets  of  the  people  in  the  Bos- 
ton system  who  are  supporting  it,  no 
matter  what  the  fixed  rate  may  be.  This 
still  suffers  from  the  problem  that  all 
of  the  airway  literature  has,  which  is 
that  each  paper  looks  at  a  specific  way 
of  doing  something,  and  there's  wide 
variability  around  the  world  in  percu- 
taneous dilatational  tracheotomy; 
many  people  do  a  cut-down  to  the  tra- 
chea, and  then  they  know  where 
they're  putting  the  needle.  There  are 
horrible  complications  published  by 
people  who  are  doing  blind  sticks  at 
the  trachea,  and  then  there  are  the  peo- 
ple who  do  use  the  bronchoscope  and 
those  who  don't.  In  our  institution,  the 
trauma  surgeons  stopped  using  the 
bronchoscope  after  about  30  cases,  and 
we  have  yet  to  have  any  complica- 
tions without  bronchoscopy.  I  think  it 
was  a  reassurance  issue,  but  we  don't 
have  and  probably  won't  get  data  that 
compare  apples  with  apples,  because 
of  this  variability,  because  it's  so  con- 
venient, it's  cheaper,  and  it  .seems  to 
not  be  associated  with  great  compli- 
cation rates  overall. 


Campbell:  This  spring,  we  were  at 
the  Brussels  critical  care  meeting,  and 
there  was  a  great  debate  about  the  dif- 
ferences between  different  manufac- 
turers and  different  techniques.  I'm 
wondering  how  you  or  someone  at 
your  hospital  did  the  evaluation,  and 
have  they  changed  some  of  those?  Are 
there  still  differences  based  on  the 
equipment  that's  available?  And  what 
are  they? 

Reibel:  I  don't  want  to  advocate  any- 
body's equipment.  1  think  people  have 
to  evaluate  the  equipment  on  their  own 
and  find  out  what  works  at  their  insti- 
tution. This  has  to  be  agreed  to  by  the 
intensivists  and  surgeons  who  collab- 
orate on  this,  because  the  hospital  will 
not  stock  different  commercial  kits. 

Durbin:  I  can  comment  on  this  is- 
sue. There  are  basically  2  kits  avail- 
able. There's  a  kit  by  Ciaglia  and  one 
by  Portex.  The  Ciaglia  kit  does  not 
come  with  its  own  tracheostomy  tube. 
You  have  to  add  the  tube  to  the  kit. 
This  is  a  major  disadvantage  because 
the  added  tube  doesn't  fit  on  the  dila- 
tors quite  as  snugly,  so  introducing  it 
is  more  difficult.  The  Shiley-Portex 
device  has  a  snug-fitting  tube  with  a 
small  cuff  that  goes  in  a  lot  easier. 
We've  opted  for  this  kit  in  our  insti- 
tution, although  I  have  to  tell  you  I've 
now  done  50  of  them,  and  I  don't  like 
the  tube  cuff  very  much.  It's  a  thin, 
high-pressure  cuff,  and  it's  gotten  me 
into  trouble  a  couple  of  times.  I've 
had  to  change  several  tubes  early  be- 
cause of  it.  I'm  thinking  now  maybe 
the  Ciaglia  kit  is  the  right  idea,  where 
you  can  use  whatever  tube  you  wish. 

Pierson:  1  would  like  to  discuss  the 
correct  use  of  the  words  tracheotomy 
and  tracheostomy.  I  wonder  if  all  of 
us  here  could  agree  on  definitions  for 
those  words.  1  regard  tracheotomy,  by 
analogy  to  laparotomy,  as  a  surgical 
procedure,  whereas  tracheostomy,  by 
analogy  to  colostomy,  is  the  opening 
that  is  made.  Therefore,  the  tube  you 
put  into  it  is  a  tracheostomy  tube. 


Reibel:  A  tracheotomy  is  an  open- 
ing in  the  trachea.  A  tracheostomy  is 
an  opening  in  the  trachea  with  a  direct 
connection  to  the  skin.  A  PDT  does 
not  initially  create  a  tracheostomy  be- 
cause there  is  no  connection  with  the 
skin.  For  surgical  tracheostomy  to  be 
100%  correct,  we  would  have  to  su- 
ture the  skin  edge  360  degrees  around 
the  tracheal  opening.  For  the  purposes 
of  safety,  a  secure  inferior  attachment, 
as  with  the  Duke's  modification  of  the 
Bjork  flap,  provides  a  secure  connec- 
tion between  skin  and  the  tracheal  mar- 
gin that  will  prevent  loss  of  the  tra- 
cheotomized  airway. 

Pierson:*  Is  that  usage  also  em- 
ployed? In  other  words,  are  there  other 
usages  as  well? 

Reibel:  People  use  it  however  they 
please. 

Pierson:  I've  looked  and  been  un- 
able to  find  the  information  you  just 
gave  me,  but  perhaps  I've  not  looked 
in  the  right  places. 

Reibel:  You  can  think  of  it  in  these 
terms.  A  tracheostomy  is  created  when 
someone  has  a  laryngectomy  and  has 
a  360  degree  tracheal  mucosa  to  skin 
margin.  That  is  a  true  tracheostomy. 

Pierson:  So  you  wouldn't  regard 
what  our  people  in  the  ICU  do  as  tra- 
cheostomies? 

Reibel:  1  would  not,  until  there  is  an 
epithelialized  tract  from  the  skin  down 
to  the  tracheal  margin.  That's  why 
there's  a  problem  with  loss  of  the  can- 
nula for  the  first  2  weeks.  That,  I  think, 
is  one  of  the  risks  inherent  in  the  way 
this  thing  has  been  sold  to  people.  It's 
sold  as  convenient  and  less  costly,  and 


*  David  J  Pierson  MD,  Division  of  Pulmonary 
Critical  Care  Medicine,  Department  of  Medi- 
cine. University  of  Washington,  Seattle,  Wash- 
ington. 


826 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheotomy/Tracheostomy 


that's  all  true.  But  I  think  it's  also 
potentially  more  risky. 

Thompson:  Am  I  correct  in  under- 
standing that  most  of  the  patients  I 
care  for  have  a  tracheotomy  that  be- 
comes a  tracheostomy  about  a  week 
or  2  later? 

Reibel:  When  there  is  a  mature  tract 
from  the  skin  margin  down  to  the  tra- 
cheal opening  the  patient  has  a  trache- 
ostomy. Most  pediatric  surgeons  put  a 
couple  of  retraction  sutures  in  and  tape 
them  to  the  skin  on  either  side  and  if  you 
lose  the  airway,  you  pull  them  up  and 
elevate  the  trachea  and  open  the  lumen. 


Heffner:  I've  tried  to  learn  the 
proper  use  of  these  terms  also.  My 
review  of  the  ear-nose-throat  litera- 
ture, both  textbooks  and  articles,  sup- 
ports the  position  that  the  difference 
between  tracheotomy  and  tracheos- 
tomy is  the  nature  of  the  hole  that  you 
end  up  with.  I'm  a  little  bit  at  a  dis- 
advantage because  I  don't  speak 
Greek,  but  friends  who  do  have  told 
me  that  the  root  words  have  different 
meanings  than  what  you  described. 
■'Otomy"  means  to  cut.  "Ostomy"  is 
the  hole  that  is  produced.  So  I  think 
some  confusion  persists  regarding  use 
of  these  terms. 


Pierson:  I  think  a  lot  of  this  is  Greek. 
Although  I'm  usually  prejudiced 
against  jargon,  I  think  I'm  going  to  go 
home  and  refer  to  them  both  as  a  trach. 

Heffner:  A  review  I  read  within  the 
last  year  (but  have  been  unable  to  lo- 
cate since)  of  the  topic  stated  that  only 
pedagogues  worry  about  the  differ- 
ence. Perhaps  we  should  share  these 
sentiments. 

Branson:  I  want  to  make  sure  that 
everybody  asks  Dave  if  he  could  speak 
Greek,  not  Geek. 

Pierson:     That  goes  in  the  Journal! 


Respiratory  Care  •  July  1999  Vol  44  No  7 


827 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


John  L  Stauffer  MD 


Introduction 

Selected  Complications  of  Endotracheal  Intubation 
Complications  During  the  Intubation  Procedure 
Complications  While  the  Endotracheal  Tube  Is  in  Place 
Complications  During  and  Immediately  After  Extubation 
Late  Complications  After  Extubation 
Selected  Complications  of  Tracheotomy 

Complications  During  the  Tracheotomy  Operation 
Complications  While  the  Tracheostomy  Tube  Is  in  Place 
Complications  During  and  Immediately  After  Decannulation 
Late  Complications  after  Decannulation 
[Respir  Care  1999;44(7):828-843]  Key  words:  intubation,  tracheotomy,  tra- 
cheostomy, endotracheal  tube,  tracheostomy  tube,  artificial  airway,  adverse 
effects,  larynx. 


Introduction 

Concern  about  complications  stemming  from  the  use  of 
artificial  airways  has  been  evident  since  these  devices  were 
first  introduced  into  clinical  practice.  When  MacEwen  suc- 
cessfully performed  transoral  endotracheal  intubation  in 
1878  for  the  relief  of  upper  airway  obstruction,'  he  rec- 
ognized the  potential  for  complications  of  this  procedure. 
His  report  of  4  cases  includes  description  of  adverse  ef- 
fects associated  with  the  use  of  endotracheal  tubes  (ETTs), 
including  patient  discomfort,  cough,  mucosal  congestion, 
and  glottic  edema.  MacEwen' s  first  patient  actually  expe- 
rienced no  complications  from  the  procedure:  "After  the 
operation  was  finished,  . . .  the  tube  was  withdrawn,  it 
having  acted  throughout  without  the  slightest  hitch."'  When 
Jackson  introduced  the  modern  era  of  tracheotomy  with 
his  publication  in  1909,^  he  too  was  concerned  about  se- 
rious complications,  reporting  that  3  of  his  first  100  pa- 
tients died  as  a  result  of  the  tracheotomy  operation  itself. 


While  some  of  the  adverse  events  associated  with  en- 
dotracheal intubation  and  tracheotomy  are  inherent  conse- 
quences of  airway  instrumentation,  rather  than  true  com- 
plications, most  of  the  complications  are  avoidable,  and  a 
great  deal  of  research  has  been  published  on  the  recogni- 
tion, management,  and  avoidance  of  these  problems.  The 
present  discussion  classifies  the  complications  according 
to  a  conventional  scheme, ^'t  and  addresses  only  the  major 
complications  of  translaryngeal  intubation  and  standard 
tracheotomy  that  are  important  in  respiratory  care  and  the 
practice  of  pulmonary  and  critical  care  medicine  (Table  1). 
The  emphasis  is  on  prospective  studies  and  recent  publi- 
cations regarding  adult  patients  suffering  from  critical  ill- 
ness. The  complications  of  percutaneous  dilational  trache- 
otomy, alternative  airways,  and  special  purpose  ETTs  are 
addressed  elsewhere  in  these  conference  proceedings. 

I  will  use  the  common  term  endotracheal  intubation  to 
refer  to  translaryngeal  (transoral  or  transnasal)  intubation 
of  the  trachea  with  an  ETT,  and  the  term  tracheotomy  to 
refer  to  the  surgical  procedure  of  placing  a  tracheostomy 
tube  (TT)  into  the  trachea. 


John  L  Stauffer  MD  is  affiliated  with  the  Section  of  Pulmonary,  Allergy, 
and  Critical  Care  Medicine,  Department  of  Medicine.  The  Milton  S 
Hershey  Medical  Center,  The  Penn  State  Geisinger  Health  System,  Her- 
shey.  Pennsylvania. 

Correspondence:  John  L  Stauffer  MD,  The  Milton  S  Hershey  Medical 
Center,  MC  H04I,  The  Penn  State  Geisinger  Health  System,  PO  Box 
850,  Hershey  PA  1703.1-0850.  E-mail:  jstaLiffe@med.hmc.psghs.edu. 


Selected  Complications  of  Endotracheal  Intubation 

Several  reviews  of  endotracheal  intubation  complica- 
tions have  been  published  during  the  1990s.'*  ■*  The 
present  review  addresses  the  selected  complications 
listed  in  Table  2. 


828 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


Table  1 .      Temporal  Classification  of  Complications  of  Endotracheal 
Intubation  and  Tracheotomy 

Complications  of  endotracheal  intubation 

•  During  the  intubation  procedure 

•  While  the  endotracheal  tube  is  in  place 

•  During  and  immediately  after  extubation 

•  Late  complications  after  extubation 

Complications  of  tracheotomy 

•  During  the  tracheotomy  operation 

•  While  the  tracheostomy  tube  is  in  place 

•  During  and  immediately  after  decannulation 

•  Late  complications  after  decannulation 


Table  2.      Selected  Complications  of  Endotracheal  Intubation 

During  the  intubation  procedure 

•  Cardiac  arrest 

•  Nasal  and  oral  trauma 

•  Pharyngeal  and  hypopharyngeal  trauma 

•  Laryngeal  and  tracheal  trauma 

•  Main  bronchus  intubation 

•  Pulmonary  aspiration 

•  Esophageal  intubation 

While  the  endotracheal  tube  is  in  place 

•  Nasal  and  oral  ulceration;  oral  cellulitis 

•  Sinus  effusions  and  sinusitis 

•  Otitis 

•  Laryngeal  injury 

•  Tracheal  injury 

•  Pulmonary  complications 

•  Self-extubation 

•  Mechanical  problems  with  tube  or  cuff 

•  Patient  discomfort 

During  and  immediately  after  extubation 

•  Sore  throat 

•  Stridor 

•  Hoarseness 

•  Odynophagia 

•  True  vocal  cord  immobility 

•  Pulmonary  aspiration 

•  Cough 

Selected  late  complications  after  extubation 

•  Laryngeal  injury 

•  Stenosis 

•  Granuloma  formation 

•  Tracheal  injury 

•  Stenosis 


Complications  During  the  Intubation  Procedure 

The  frequency  of  intubation  complications  depends  pri- 
marily on  the  skill  of  the  operator,  the  urgency  of  the 


procedure,  and  the  patient's  underlying  medical  condition. 
The  rate  of  complications  attributed  solely  to  the  intuba- 
tion procedure  in  critical  care  settings  has  not  been  well 
defined.  Schwartz  et  al  reported  that  all  of  297  consecu- 
tive, supervised  endotracheal  intubations  (92%  oral,  8% 
nasal)  in  the  intensive  care  unit  (ICU)  of  a  teaching  hos- 
pital were  successful,  and  89%  were  successful  on  the  first 
or  second  attempt.'"  Eight  percent  of  the  intubations  were 
described  as  "difficult."  These  investigators  reported  esoph- 
ageal intubation  in  25  cases,  main  bronchus  intubation  in 
10  cases,"  pneumothorax  in  2  cases,  and  suspected  aspi- 
ration in  12  cases.'"  For  these  immediate  adverse  events 
alone,  the  rate  of  complications  was  16%.  In  an  earlier 
prospective  study,  we  recorded  the  same  complications  in 
42  (19%)  of  226  intubations. '2 

In  the  emergency  rooms  of  teaching  hospitals,  reported 
intubation  complication  rates  range  from  8%'-''  to  56%.'-* 
In  a  prospective  study  of  prehospital  emergency  endotra- 
cheal intubation  (96%  oral)  by  staff  physicians  and  nurse 
anesthetists  of  mobile  ICUs  in  France,  689  (99.1%)  of  691 
consecutive  intubation  attempts  were  successful,  compared 
to  success  rates  of  51-97.4%  in  other  series  that  the  au- 
thors reviewed. '5  Mechanical  complications  of  intubation, 
such  as  esophageal  intubation,  main  bronchus  intubation, 
and  dental  trauma  occurred  in  15.9%  of  noncardiac  arrest 
patients,  and  8.1%  of  cardiac  arrest  patients. 

The  latter  data  suggest  that  endotracheal  intubation  of 
critically  ill  adults  by  skilled  personnel  is  nearly  always 
successful.  The  overall  complication  rate  of  endotracheal 
intubation  in  critically  ill  adults  is  about  10-20%,  and  the 
rate  may  be  lower  in  cardiac  arrest  patients  than  in  others. 

Cardiac  Arrest.  Cardiac  arrest  from  the  endotracheal 
intubation  procedure  itself  is,  fortunately,  rare.  We  ob- 
served one  cardiac  arrest  in  226  intubations  in  ICUs.'-  In 
the  emergency  room  setting,  3  (0.5%)  of  603  patients  stud- 
ied in  one  series  suffered  cardiac  arrest  after  intubation, 
and  in  only  one  instance  was  the  intubation  itself  impli- 
cated.'^ Taryle  et  al  prospectively  observed  no  cardiac 
arrests  in  43  patients  intubated  in  the  emergency  room.''* 
In  the  anesthesia  experience,  Keenan  and  Boyan  reported 
cardiac  arrest  in  1.7  cases  and  death  in  0.9  cases  per  10,000 
anesthesias.'*  The  rate  of  cardiac  arrest  directly  attribut- 
able to  endotracheal  intubation  in  their  study  was  not  stated, 
but  failure  to  ventilate  the  patient  adequately  accounted  for 
nearly  half  of  the  cardiac  arrests  they  observed.  Mateer  et 
al  documented  hypoxemia  (defined  as  oxyhemoglobin  sat- 
uration less  than  90%)  in  45  (21%)  of  211  emergency 
endotracheal  intubations.'^ 

Deaths  attributed  to  endotracheal  intubation  itself  are, 
apparently,  rare.  Adnet  et  al  reported  that  no  deaths  oc- 
curred in  a  series  of  358  patients  intubated  in  the  prehos- 
pital setting,  although  4  cardiac  arrests  (1.1%)  were  attrib- 
uted to  the  intubation  procedure.'''  In  their  prospective 


Respiratory  Care  •  July  1999  Vol  44  No  7 


829 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


study  of  297  intubations  in  critically  ill  adults.  Schwartz  et 
al  attributed  no  deaths  to  the  intubation  procedure  itself.'" 
However,  7  (3%)  of  270  patients  died  at  the  time  of  or 
within  30  minutes  after  endotracheal  intubation,  and  sys- 
tolic hypotension  was  identified  as  a  risk  factor  for  death.'" 

Nasal  and  Oral  Trauma.  Minor  nasal  bleeding  occurs 
in  about  half  of  nasal  intubations  in  ICUs.'-  Serious  nasal 
hemorrhage  and  turbinate  dislodgment  are  rare.  Dental 
trauma  during  intubation  has  been  reported  in  0.9%  of 
prehospital  intubations,'-^  0.1%  of  anesthesia  intubations"* 
and  in  about  2%  of  critical  care  intubations. '^  Dental  in- 
jury during  intubation  is  a  common  source  of  malpractice 
litigation."* 

Pharyngeal  and  Hypopharyngeal  Trauma.  Laceration 
of  the  walls  of  the  pharynx  and  hypopharynx  by  intubation 
equipment  is  a  serious  but,  fortunately,  rare  complication 
of  intubation.-*  Experience  with  these  events  is  limited  to 
case  reports  and  small  series. '''•2°  Bleeding  is  the  most 
common  immediate  finding.  Barotrauma  from  positive 
pressure  ventilation  can  result  in  subcutaneous  emphy- 
sema, pneumomediastinum,  pneumothorax,  and  cardiac  ar- 
rest.2'  Later  complications  include  the  formation  of  hema- 
tomas and  abscesses,  which  can  grow  large  enough  to 
obstruct  the  airway. 

Laryngeal  and  Tracheal  Trauma.  Laryngeal  injury  oc- 
curs in  about  5-6%  of  anesthesia  intubations. ^^  Lacera- 
tions of  the  mucosa  of  the  larynx  or  trachea  during  intu- 
bation can  result  in  immediate  bleeding  and  hematoma 
formation.  Vocal  cord  hematoma,  which  is  usually  left- 
sided,  is  the  most  common  laryngeal  injury  of  intubation. 
Arytenoid  dislocation  is  less  common.-''  Tracheal  lacera- 
tion by  the  tip  of  the  ETT,  a  very  rare  event,  may  present 
with  findings  of  barotrauma.--* 

Main  Bronchus  Intubation.  Right  main  bronchus  intu- 
bation complicated  about  9%  of  critical  care  intubations  in 
separate  prospective  studies  performed  during  the 
1970s. '2-5  In  a  study  of  emergency  intubation  of  critically 
ill  adults,  in  which  anesthesia  residents  and  attending  phy- 
sicians were  involved  in  many  of  the  intubations,  right 
main  bronchus  intubation  occurred  in  10  (3.7%)  of  271 
intubations."  In  the  prehospital  setting,  main  bronchus 
intubation  (unspecified)  occurred  in  17  (2.5%)  of  691  in- 
tubations.''' Left  main  bronchus  intubation  is  rare. 

Inadvertent  right  main  bronchus  intubation  is,  of  course, 
avoidable.  If  it  does  occur,  early  detection  by  immediate 
examination  of  the  post-intubation  chest  radiograph  may 
prevent  sequelae  such  as  right-sided  pneumothorax  and 
atelectasis  of  the  left  lung.  Note  that  the  chest  x-ray  is 
superior  to  chest  physical  examination  for  detecting  right 
main  bronchus  intubation."-'' 


Pulmonary  Aspiration.  The  exact  frequency  of  clini- 
cally significant  pulmonary  aspiration  during  intubation  in 
nonanesthesia  settings  is  not  known.  Rates  of  8%'-  in  the 
ICU  population  and  3.5%-''  to  19%'^*  in  the  emergency 
room  population  have  been  reported. 

Esophageal  Intubation.  Esophageal  intubation  is  prob- 
ably the  most  serious  complication  of  emergency  intuba- 
tion, as  it  may  result  in  irreversible  brain  injury  from  an- 
oxia-" and  cardiorespiratory  arrest.  Inadvertent  esophageal 
intubation  occurred  in  33  (5.5%)  of  603  patients  intubated 
in  an  emergency  department,'''  in  37  (5.4%)  of  691  pa- 
tients in  the  prehospital  setting  in  France,'-''  and  in  25  (8%) 
of  297  intubation  attempts  in  critically  ill  adults.'"  Esoph- 
ageal intubation  accounted  for  4  (15%)  of  27  cardiac  ar- 
rests during  intubation  in  a  review  of  163,240  anesthesias 
over  a  15-year  period."'  Esophageal  intubation  is  more 
likely  to  occur  in  the  setting  of  cardiopulmonary  resusci- 
tation than  in  more  controlled  settings.  Early  detection  of 
esophageal  intubation  is  possible  with  the  use  of  colori- 
metric  carbon  dioxide  detectors. 

Complications  While  the  Endotracheal  Tube 
Is  in  Place 

Complications  occurring  while  the  ETT  is  in  place  are, 
typically,  insidious,  and  many  of  them  do  not  become 
apparent  until  after  extubation,  but  they  are  often  avoid- 
able if  care  providers  maintain  a  high  level  of  suspicion 
and  vigilance. 

Nasal  and  Oral  Inflammation  and  Ulceration.      In  a 

prospective  study  of  379  ICU  patients  with  nasal  endotra- 
cheal intubation,  Holdgaard  et  al  found  inflammation  of 
the  nostril  or  nasal  septum  in  76  patients  (20.3%),  nostril 
or  septal  ulceration  in  1 10  patients  (29%),  nasal  bleeding 
in  67  patients  (18.8%),  and  damage  to  the  conchae  in  40 
patients  (10.6%).-'^ 

Lip  ulceration  and  cellulitis  occasionally  develop  during 
prolonged  tran.soral  intubation.  Lip  edema,  hemorrhage, 
and  hemorrhagic  crusts  are  commonly  observed  with 
prolonged  intubation,  but  the  pathogenesis  of  these  le- 
sions, including  the  role  of  herpes  virus  infection,  is  not 
certain.  We  observed  that  12  (15%)  of  81  critically  ill 
adults  had  ulcers  or  cellulitis  of  the  lips  by  the  time  of 
extubation.'-  Diligent  respiratory  care  may  prevent  these 
occurrences."-'"-" 

Oral  mucosal  ulceration  from  oral  ETTs  is  rare  but  some- 
times severe,  particularly  if  an  oropharyngeal  airway  is  in 
place.'2  We  found  that  ulceration  of  the  palate  had  oc- 
curred in  6  (8%)  of  81  patients  by  the  time  of  extubation. '^ 

Sinus  Effusions  and  Sinusitis.  Sinus  effusions  occur  in 
the  majority  of  intubated  patients,  and  computed  tomog- 


830 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


raphy  (CT)  scan  evidence  of  sinusitis  is  found  early  in  the 
course  of  endotracheal  intubation.'^  Radiographic  evidence 
of  maxillary  sinus  intlammation  on  CT  scans  was  found  in 
45  (30%)  of  149  patients  with  nasal  intubation  and  33 
(22%)  of  15 1  patients  with  oral  intubation  in  1  prospective 
study.'-* 

Frank  maxillary  sinus  infection  (nosocomial  sinusitis) 
complicates  both  nasal  and  oral  endotracheal  intubation 
(and  the  use  of  nasogastric  tubes)  and  is  a  risk  factor  for 
ventilator-associated  pneumonia  (VAP).''  Clinical  experi- 
ence in  the  1980s  suggested  that  up  to  one  half  of  pro- 
longed nasal  intubations  are  complicated  by  sinus  infec- 
tions.''' "  In  more  recent,  carefully  conducted  studies,  from 
38%"  to  69%''*  of  intubated  patients  with  radiographic 
maxillary  sinusitis  had  frank  maxillary  sinus  infection. 
Rouby  et  al  reported  VAP  in  67%  of  patients  with  infec- 
tious maxillary  sinusitis,  and  in  38%  of  these  patients  the 
organisms  isolated  from  sinus  aspirates  were  identical  to 
those  isolated  from  the  lung  by  bronchoalveolar  lavage." 
Holzapfel  et  al  observed  that  nosocomial  maxillary  sinus- 
itis increased  the  risk  of  VAP  by  a  factor  of  3.8,  and  that 
there  were  no  significant  differences  between  the  nasal 
and  the  oral  routes  of  intubation  in  the  occurrence  rate 
of  nosocomial  sinusitis  or  VAP.'**  The  risk  of  infectious 
sinusitis  appears  to  increase  with  the  duration  of 
intubation.""* 

True  sinusitis,  as  opposed  to  simple  sinus  effusion,  is 
difficult  to  diagnose  in  intubated  patients.  Recent  studies 
have  emphasized  the  use  of  CT  scanning  followed  by  sur- 
gical aspiration  and  culture  of  secretions  to  establish  the 
diagnosis.  Clinical  findings  such  as  purulent  nasal  secre- 
tions alone  are  not  reliable  in  the  diagnosis.  Gram-negative 
bacteria  are  the  most  common  pathogens  isolated  in  intu- 
bation-associated sinusitis,  but  Gram-positive  bacteria,  an- 
aerobic organisms,  and  fungi  are  isolated  often  enough  to 
make  broad  spectrum  anti-microbial  therapy  necessary  in 
most  cases.  Practice  guidelines  have  not  been  developed 
for  the  diagnosis  and  treatment  of  sinus  effusions  and  si- 
nus infection  in  the  setting  of  prolonged  endotracheal  in- 
tubation."^ For  an  established  diagnosis  of  nosocomial  si- 
nusitis, antibiotic  therapy  is  advised.  Conversion  from  the 
nasal  to  the  oral  route  of  intubation  has  also  been  recom- 
mended." One  report  suggests  that  surgical  drainage  is 
infrequently  necessary  in  managing  nosocomial  sinusitis.-"' 

Otitis.  Endotracheal  intubation  can  interfere  with  nor- 
mal eustachian  tube  function.-*'  We  noted  that  1 1  (8.7%)  of 
126  adult  ICU  patients  developed  evidence  of  otitis  media 
or  otitis  externa  while  intubated.'-  Co-existing  prolonged 
nasogastric  intubation  was  identified  as  a  risk  factor.  Mid- 
dle ear  effusions  have  been  reported  in  87%  of  pediatric 
ICU  patients  with  nasotracheal  intubation.-*-  and  in  29%  of 
adults  intubated  for  longer  than  48  hours.-*'  In  tympano- 
centesis  results,  Gram-negative  organisms  predominate.'*' 


Orotracheal  intubation  is  more  of  a  risk  factor  for  middle 
ear  effusions  than  nasotracheal  intubation. 

Laryngeal  Injury.  Numerous  investigators  have  ob- 
served that  nearly  all  patients  who  survive  prolonged  en- 
dotracheal intubation  for  critical  illness  display  some  fea- 
tures of  laryngeal  injury  by  the  time  of  extubation,  which 
indicates  that  laryngeal  injury  occurs  while  the  ETT  is  in 
place.  Thomas  et  al  found  some  evidence  of  laryngeal 
pathology  at  extubation  in  88%  of  adult  and  pediatric  pa- 
tients.-*'* Colice  et  al  prospectively  observed  some  degree 
of  laryngeal  injury  immediately  after  prolonged  endotra- 
cheal intubation  in  77  (94%)  of  82  patients,  and  severe 
injury  in  19  patients  (23%).-*^  In  an  excellent  prospective 
study,  Santos  et  al  reported  laryngeal  injury  ranging  from 
erythema  (90-95%)  to  ulceration  (65-79%)  and  granu- 
loma formation  (35-45%)  in  62  men  surviving  after  oral 
endotracheal  intubation  (mean  5-6  days)."**  Few  studies 
have  attempted  to  examine  the  larynx  with  fiberoptic  en- 
doscopy during  the  period  of  intubation,  because  of  the 
difficulty  of  visualizing  the  endolarynx  while  an  ETT  is  in 
place. 

A  wide  range  of  supraglottic,  glottic,  and  subglottic  com- 
plications have  been  observed,  including  simple  edema, 
inflammation,  and  minor  submucosal  hemorrhage,  vocal 
cord  paralysis  and  paresis,  vocal  cord  hematomas,  granu- 
loma formation,  and  severe  mucosal  ulceration.  Santos  et 
al  reported  laryngeal  erythema  in  90-95%  of  survivors 
after  5-6  days  of  oral  endotracheal  intubation,  resolution 
of  which  required  as  long  as  9  weeks.-*^  In  their  analysis, 
the  use  of  a  larger  (size  8.0)  ETT  and  nasogastric  intuba- 
tion were  significant  risk  factors  for  laryngeal  erythema.-*^ 

The  most  common  and  most  worrisome  laryngeal  com- 
plication while  an  ETT  is  in  place  is  injury  to  the  glottis. 
Concern  about  silent  laryngeal  damage  from  the  ETTs 
pressure  against  the  posterior  laryngeal  wall  is  the  primary 
justification  for  performing  tracheotomy  for  long-term  air- 
way maintenance.  Posterior  vocal  cord  and  arytenoid  ul- 
ceration is  the  most  common  serious  complication  of  en- 
dotracheal intubation,  occurring  in  37%,-*^  51%,'-  76%,'*^ 
and  79%-"*  of  patients  in  several  prospective  studies.  Pres- 
sure exerted  by  the  shaft  of  the  ETT  on  the  posterior  rim 
of  the  glottis,  which  serves  as  a  fulcrum  for  the  leveraging 
action  of  the  ETT,  ulcerates  the  mucosal  surfaces  of  the 
arytenoids,  the  interarytenoid  space,  the  cricoarytenoid 
joints,  and  the  posterolateral  aspects  of  the  cricoid  carti- 
lage. (Fig.  i)s. 12.23.48-50  jfi  severe  cases  ulceration  is  deep 
enough  to  destroy  laryngeal  cartilage,  inviting  local  infec- 
tion*"'  and  further  intense  inflammation.  Cricoid  cartilage 
abscess  can  eventually  develop  at  the  site  of  posterior 
glottic  ulceration.'''^  In  survivors,  healing  of  these  ulcers 
is  remarkably  efficient,  as  severe  granuloma  formation 
or  laryngeal  stenosis''-  is  unusual  (see  further  discussion 
below). 


Respiratory  Care  •  July  1999  Vol  44  No  7 


8.31 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


Fig.  1.  The  pathogenesis  of  laryngeal  injury  from  endotracheal 
intubation.  Because  the  endotracheal  tube  is  round  and  the  glottis 
is  pentagonal,  the  ETT  applies  pressure  on  the  posterior  glottis. 
The  arrows  indicate  the  points  of  highest  pressure.  (From  Refer- 
ence 50,  with  permission.) 


Tracheal  Injury.  Tracheal  injury  that  occurs  while  the 
ETT  is  in  place,  like  laryngeal  injury,  ranges  in  severity 
from  mild  to  severe.  Ciliostasis,  superficial  mucosal  in- 
flammation, hyperemia,  and  mild  edema  at  the  cuff  site  are 
inevitable  consequences  of  tracheal  intubation."* 

Cinematographic  techniques  and  scanning  and  transmis- 
sion electron  microscopy  have  detected  impairment  of  mu- 
cociliary clearance  and  damage  to  the  ciliated  tracheal 
epithelium,  with  actual  loss  of  cilia  as  a  result  of  tracheal 
intubation. ^''•^'*  Airway  colonization  by  bacteria,  and  squa- 
mous metaplasia  of  the  tracheal  epithelium''^ ''''  also  are 
common  and  unavoidable  effects  of  an  ETT,  which  rep- 
resents a  foreign  body  in  the  trachea."  Epithelial  trauma 
from  suctioning  the  trachea  is  unavoidable,  but  can  be 
minimized  with  proper  suctioning  technique. 

Most  of  the  interest  in  tracheal  injury  from  endotracheal 
intubation  has  focused  on  cuff  site  ulceration  from  the 
lateral  tracheal  wall  pressures  exerted  by  the  inflated  cuff. 
A  great  deal  has  been  learned  about  this  problem  over  the 
last  30  years.  New  understandings  of  the  pathogenesis  of 
cuff  site  injury  have  led  to  the  universal  use  in  ICUs  of 
high-volume,  low-pressure  cuffs  on  modern  ETTs  and  TTs, 
which  has  substantially  reduced  the  frequency  of  severe 
cuff  site  ulceration."*  We  found  tracheal  mucosal  ulceration 
at  autopsy  in  only  15%  of  patients  after  prolonged  endo- 
tracheal intubation  with  soft-cuff  ETTs.'^ 


The  pathogenesis  of  tracheal  cuff  site  ulceration  has 
been  studied  more  thoroughly  than  that  of  any  other  com- 
plication of  artificial  airways.  Figure  2  illustrates  the  piv- 
otal role  of  capillary  perfusion  pressure  and  lateral  tracheal 
wall  pressure  from  the  inflated  cuff.  The  normal  capillary 
perfusion  pressure  in  the  tracheal  mucosa  has  been  esti- 
mated in  animal  models  to  be  about  22  mm  Hg.'''  "■*  Main- 
tenance of  cuff  inflation  pressures  below  20-22  mm  Hg 
greatly  reduces  the  risk  of  cuff  site  ischemia  and  eventual 
ulceration,  compared  to  the  higher  pressures  exerted  by 
low-volume,  high-pressure  cuffs  or  overinflated  soft 
cuffs.'''*-*'  However,  maintaining  cuff  pressures  slightly 
lower  than  this  (20  cm  HiO  or  15  mm  Hg)  is  associated 
with  an  increased  risk  of  pneumonia.*'-  The  dilemma  of 
maintaining  intracuff  pressures  high  enough  to  seal  the 
airway  and  prevent  aspiration  yet  low  enough  to  avoid 
mucosal  ischemia  has  been  recognized  for  many  years.''' 
Based  on  studies  of  blue  dye  aspiration  in  patients  under 
general  anesthesia,  Bemhard  et  al  advised  maintaining  in- 
tracuff pressures  of  25-34  cm  HjO  (18-25  mm  Hg)  in 
soft-cuff  ETTs  to  avoid  aspiration."  The  available  data 
suggest  that  an  intracuff  pressure  in  the  narrow  window  of 
25-30  cm  HjO  (18-22  mm  Hg)  is  the  best  compromise 
between  the  risk  of  aspiration  and  the  risk  of  ischemia. 

Other  tracheal  complications  while  the  ETT  is  in  place 
include  granuloma  formation  and  submucosal  hemorrhage. 
Tracheal  cartilage  necrosis  from  infection  and  cuff  site 
ulceration,  tracheoarterial  fistula,  and  tracheoesophageal 
fistula  are  rare  complications  during  endotracheal  intuba- 
tion with  soft-cuff  ETT.  Tracheal  dilation  during  the  pe- 
riod of  intubation  has  been  observed  in  13.5%  of  patients, 
and  this  finding  usually  portends  a  poor  outcome.''" 

Pulmonary  Complications.  Aspiration  and  pneumonia 
are  the  main  pulmonary  complications  of  endotracheal  in- 
tubation. Retention  of  lower  airway  secretions,  leading  to 
atelectasis  and  poor  gas  exchange,  is  another  common 
problem.  Bronchoconstriction  also  occurs  and  can  be  a 
difficult  management  challenge  in  patients  with  underly- 
ing chronic  obstructive  pulmonary  disease  or  asthma. 

Gross  aspiration  of  large  volumes  of  gastric  contents  or 
upper  airway  secretions  is  uncommon  during  endotracheal 
intubation,  because  the  cuffed  tube  protects  the  lower  air- 
way. Aspiration  is  more  common  in  patients  with  TT  than 
those  with  ETT,''''  but  any  type  of  cuffed  intratracheal  tube 
can  impair  swallowing  and  increase  the  risk  of  aspira- 
tion.'''' Leakage  of  fluid  along  the  folds  of  the  ETT  cuff 
fabric  and  into  the  trachea  has  been  observed  in  trachea 
models  and  excised  human  tracheas.''^  Some  authorities 
advise  maintaining  a  minimum  intracuff  pressure  of  20-25 
cm  HiO  to  reduce  the  occurrence  of  this  micro-aspiration 
phenomenon.''''  This  recommendation  is  supported  by  the 
results  of  Rello  et  al,  who  found  that  the  risk  of  VAP  is 


832 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


Pathogenesis  of  Tracheal  Cuff  Site  Injury 


High  cufT  pressure 

vl/ 

High  lateral  tracheal  wall  pressure, 

exceeding  capillary  perfusion  pressure 

si/ 
Mucosal  ischemia  and  inflammation 

Mucosal  necrosis 

si/ 

Mucosal  ulceration 


Extubation    1^ 

^  Continued  intubation 

Healing  process 

Destruction  of  tracheal  cartilage 

k:       si/      ^ 

4/ 

Restoration      Granuloma      Tracheal 

Loss  of  structural  integrity  of 

of  normal          formation       stenosis 

tracheal  wall 

structure 

1^       s|/       iJ 

Erosion  into    Tracheal    Tracheomalacia 

adjacent      dilatation 

structures 

1^        iJ 

Tracheovascular  fistula  Tracheoesophageal  fistula 

Fig.  2.  The  pathogenesis  of  tracheal  injury  at  the  cuff  site.  (Modified  from  Reference  4,  with  permission.) 


reduced  by  maintaining  cuff  pressure  above  20  mm  Hg 
(about  26  cm  W.O).^^- 

Occult  aspiration  of  material  from  the  hypopharynx  does 
occur,  as  determined  by  staining  of  tracheal  secretions 
after  blue  dye  is  placed  on  the  tongue.  In  one  study  it  was 
observed  in  20%  of  patients  with  soft-cuff  ETTs,''**  and 
another  study  observed  a  frequency  of  17-25%.''-''  The 
clinical  importance  of  these  findings  is  not  entirely  clear. 
Nevertheless,  aspiration  of  hypopharyngeal  secretions 
contaminated  with  Gram-negative  bacilli  and  other  micro- 
organisms colonizing  the  upper  airway  and  the  stomach 
sets  the  stage  for  VAP.  The  frequency  of  VAP  during 
endotracheal  intubation  ranges  from  9%  to  22%,  and  the 
mortality  may  be  as  high  as  71%.'''*™  More  than  one  re- 
intubation  during  a  period  of  mechanical  ventilation  has 
been  found  to  be  an  independent  risk  factor  for  the  devel- 
opment of  VAP.™ 

The  pathogenesis  of  VAP  has  been  studied  extensively 
in  the  last  decade.  The  roles  of  contaminated  gastric  se- 
cretions, sinusitis,  the  leakage  of  contaminated  subglottic 
secretions  into  the  trachea,  and  other  risk  factors  have 
received  special  attention.^'  Rello  et  al  reported  that  leak- 
age of  colonized  subglottic  secretions  past  the  ETT  cuff  is 


the  most  important  risk  factor  for  VAP  in  the  first  8  days 
after  intubation.*^  Preliminary  tests  of  an  ETT  designed 
with  a  channel  that  allows  continuous  aspiration  of  secre- 
tions above  the  cuff  suggest  that  this  device  does  decrease 
the  risk  of  VAP.«-72 

Unplanned  Extubation.  Unplanned  extubation,  whether 
intentional  or  inadvertent,  often  results  in  serious  cardiac 
or  respiratory  complications. ^''■^■^  Self-extubation  occurs  in 
about  10-20%  of  intubated  patients  in  ICUs,"*  and  is  a 
quality-of-care  issue.  The  rate  of  self-extubation  may  be 
reduced  by  staff  vigilance  and  appropriate  practice  guide- 
lines.^'-''^ About  two  thirds  of  self-extubations  are  delib- 
erate acts  by  the  patient.''''  ''*'  Approximately  half  of  self- 
extubating  patients  require  reintubation.--'''''^-''' 

A  recent  large  prospective,  multicenter  study  in  France 
recorded  unplanned  extubations  in  46  (10.8%)  of  426  me- 
chanically ventilated  patients.**"  Agitation  was  observed  at 
the  time  of  the  unplanned  extubation  in  61%  of  the  pa- 
tients. Multivariate  analysis  revealed  4  factors  that  predis- 
pose to  unplanned  extubation:  (1)  chronic  respiratory  fail- 
ure, (2)  ETT  fixation  with  thin  adhesive  tape,  (3)  oral  route 
of  intubation,  and  (4)  lack  of  intravenous  sedation.  A  re- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


cent  prospective  case-control  study  confirmed  that  oral 
intubation  and  inadequate  sedation  are  key  risi^  factors  for 
unplanned  extubation.*'  Another  recent  investigation  em- 
phasized the  importance  of  agitation  and  a  hospital-ac- 
quired adverse  event  as  significant  independent  risk  fac- 
tors for  self-extubation.**2  Close  monitoring  of  agitated 
patients  during  intubation  is  a  fundamental  component  of 
guidelines  aimed  at  reducing  the  frequency  of  unplanned 
extubation. 

Mechanical  Problems  with  the  ETT  and  Cuff:  Mal- 
position. Mechanical  problems  with  ETT  position  and 
performance  are  observed  in  about  6%  of  endotracheal 
intubations  in  critically  ill  adults.'-  The  most  common  of 
these  problems  are  upward  or  downward  migration  of  the 
ETT,  partial  or  complete  ETT  occlusion,  disconnections 
from  the  ventilator,  and  faulty  cuff  inflation.  Misplace- 
ment of  the  ETT  during  the  period  of  intubation  was  ob- 
served in  22  (7.9%)  of  278  critically  ill  adults  in  the  ret- 
rospective arm  of  a  recent  study  by  Kollef  et  al,  and  in  5 
cases,  the  consequences  of  tube  misplacement  were  seri- 
ous.**-^ After  instituting  a  quality  improvement  program, 
the  authors  observed  113  (46%)  ETT  misplacements  in 
246  prospectively  studied  patients,  and  no  serious  conse- 
quences developed.**^ 

Inability  to  seal  the  airway  with  ETT  cuff  inflation  is  a 
vexing  problem  in  1 1%**'*  to  25%*''  of  endotracheal  intu- 
bations. When  an  ETT  is  removed  because  of  an  alleged 
"massive  air  leak,"  a  defect  in  the  ETT  cuff  is  found  in 
only  in  a  minority  of  cases,  and  tube  malposition  is  im- 
plicated as  the  most  likely  cause  of  the  apparent  leak.**'' 

Patient  Discomfort.  The  pain  and  suffering  experienced 
by  patients  during  endotracheal  intubation  has,  unfortu- 
nately, received  little  attention.  A  telephone  survey  of  pa- 
tients who  survived  endotracheal  intubation  for  critical 
illness  revealed  a  high  level  of  distress  related  to  inability 
to  communicate,  anxiety,  pain,  distress  in  clearing  airway 
secretions,  panic  reactions,  discomfort  during  tracheal  suc- 
tioning and  extubation,  and  other  unpleasant  experienc- 
es.*'' More  clinical  investigation  is  needed  to  understand 
the  distress  of  intubated  patients  and  to  develop  more  ef- 
fective intervention. 

Complications  During  and  Immediately 
After  Extubation 

Serious  complications  at  the  time  of  extubation  in  the 
critical  care  setting  are,  fortunately,  unusual.  In  the  anes- 
thesia experience,  complications  of  tracheal  extubation  are 
also  very  uncommon.  Adverse  events  in  anesthesia  prac- 
tice (reviewed  elsewhere)***  include  difficulty  in  tube  re- 
moval, airway  trauma,  tracheomalacia,  laryngospasm,  la- 
ryngeal edema,  airway  obstruction,  vocal  cord  paralysis. 


laryngeal  incompetence,  and  exaggerated  heart  rate  and 
blood  pressure  responses.  Asai  et  al  prospectively  recorded 
symptoms  and  complications  in  195  (19.4%)  of  1,005  pa- 
tients after  extubation  following  general  anesthesia.****  The 
most  frequent  problems  observed  immediately  after  extu- 
bation were  coughing  (6.6%),  desaturation  (arterial  satu- 
ration oxygen  <  90%)  (2.4%),  breath-holding  (2.0%),  air- 
way obstruction  (1.9%),  and  laryngospasm  (1.7%).**' 

Sore  Throat.  We  found  that  29  (42%)  of  69  patients 
complained  of  sore  throat  after  prolonged  intubation.  '^  This 
contrasts  with  a  14-15%  reported  incidence  of  sore  throat 
following  tracheal  intubation  for  general  anesthesia.'"'  "^ 

Stridor.  Mild  to  moderate  degrees  of  stridor  occur  in  up 
to  5%  of  extubations  in  critical  care  settings, ^'^  while  se- 
vere stridor  occurs  in  less  than  1%  of  cases.'^  Stridor  is 
usually  a  result  of  glottic  or  subglottic  edema,  not  frank 
laryngospasm."-  Although  laryngeal  edema  is  observed  in 
about  half  of  patients  at  or  immediately  after  extubation,"^ 
it  is  rarely  severe  enough  to  cause  stridor.  Airway  obstruc- 
tion by  secretions,  blood,  or  foreign  material  can  also  cause 
postextubation  stridor.  Arytenoid  dislocation  and  vocal  cord 
paresis  or  paralysis  are  infrequently  responsible  for  post- 
extubation stridor.'*  Only  1%  of  patients  experiencing  post- 
extubation stridor  require  re-intubation.'^.'^'* 

Topical  epinephrine  and  parenteral  corticosteroids  are 
commonly  prescribed  for  management  of  postextubation 
stridor,  but  available  data  have  not  shown  these  treatments 
to  be  effective  in  adults.''^  One  recent  study  of  small  chil- 
dren suggests  that  pretreatment  with  dexamethasone  does 
reduce  the  frequency  of  postextubation  stridor  and  other 
signs  of  airway  obstruction.**-^ 

Hoarseness.  The  frequency  of  hoarseness  following  ex- 
tubation in  prospective  studies  of  critically  ill  adult  pa- 
tients ranges  from  56%''''  to  71%,'-  being  more  common 
with  oral  intubation  and  with  larger  tubes.  In  a  large  study 
of  nasotracheal  intubation,  Holdgaard  et  al  reported  hoarse- 
ness in  40.7%  of  patients. 2**  Santos  et  al  reported  that  in  62 
men  surviving  after  5-6  days  of  oral  endotracheal  intuba- 
tion, 56%  of  those  intubated  with  size  7.5  ETT  and  69%  of 
those  with  size  8.0  ETT  suffered  hoarseness. 2^*  In  most 
cases,  complete  aphonia  was  observed  initially. 

Failure  of  postextubation  hoarseness  to  resolve  within  2 
weeks  suggests  the  presence  of  serious  complications  such 
as  vocal  cord  paralysis  or  paresis,  cricoarytenoid  joint  dys- 
function, laryngeal  granuloma,***  or  other  problems.  Pro- 
spective observations  of  the  resolution  of  laryngeal  injury 
after  extubation  support  the  use  of  endoscopic  evaluation 
if  hoarseness  persists  beyond  4-8  weeks."*'**'' 

Cough.  We  found  that  26%  of  ICU  patients  had  a  new 
cough  following  prolonged  endotracheal  intubation. '^ 


834 


Respiratory  Care  •  July  1 999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


Odynophagia.  Severely  painful  swallowing  and  painful 
phonation  immediately  after  extubation  are  very  rare.  When 
these  symptoms  occur,  diagnoses  to  consider  include  pos- 
terior glottic  infection  or  ulceration,  or  abscess  formation 
on  the  cricoid  cartilage.'' 

True  Vocal  Cord  Immobility.  Santos  et  al  observed 
true  vocal  cord  immobility  in  12  (19%)  of  62  patients  who 
survived  after  a  mean  of  5-6  days  of  endotracheal  intu- 
bation.'**' The  vocal  cord  immobility  was  unilateral  in  all 
but  one  case  and  was  significantly  related  to  the  duration 
of  intubation.  In  half  of  the  cases,  true  vocal  cord  immo- 
bility was  delayed,  appearing  1-10  weeks  after  extubation. 
Resolution  required  as  long  as  10  weeks.-"'  Bilateral  vocal 
cord  paralysis  after  endotracheal  intubation  is  a  severe  but 
very  rare  complication.'^** 

Pulmonary  Aspiration.  Santos  et  al  found  clinical  ev- 
idence of  aspiration  in  55-64%  of  men  after  extubation 
following  5-6  days  of  oral  intubation.'"'  Laryngeal  incom- 
petence following  extubation  can  permit  aspiration  into 
the  trachea.  A  sensory  deficit  that  compromises  protective 
hypopharyngeal  and  laryngeal  reflexes  has  been  impli- 
cated in  this  phenomenon.'*''  In  postoperative  patients,  la- 
ryngeal incompetence  can  persist  for  4  hours  after  extu- 
bation.'" 

Numerous  defects  in  deglutition  are  common  after  oro- 
tracheal intubation,  with  or  without  subsequent  tracheoto- 
my."* A  prospective  endoscopic  study  of  orally  intubated 
trauma  patients  revealed  that  9  (45%)  of  20  aspirated  blue 
dye  within  24  hours  of  extubation,  and  in  4  (44%)  of  the 
9  cases  aspiration  was  silent.'"'  None  of  the  patients  who 
aspirated  blue  dye  developed  pulmonary  complications. 
Burgess  et  al  found  that  even  alert  postoperative  cardiac 
surgery  patients  may  aspirate  contrast  dyes  immediately 
after  extubation  (33%)  and  up  to  4  hours  later  (20%), 
possibly  as  a  result  of  an  inability  of  the  larynx  to  sense 
foreign  material.''''  In  the  ICU  population,  this  "sensory 
denervation"  was  found  by  Colice  and  co-workers  in  13 
(24%)  of  54  men  following  extubation.-'''  Aspiration  of 
pharyngeal  material  may  occur  even  when  the  gag  reflex  is 
intact.' 00 


Late  Complications  After  Extubation 

Most  of  the  late  complications  after  extubation  repre- 
sent abnormal  healing  of  ETT-induced  laryngeal  and  tra- 
cheal injury.  Airway  stenosis  typically  appears  weeks  to 
months  after  extubation.  Laryngeal  granulomas  typically 
form  while  the  ETT  is  in  place  and  are  commonly  seen  by 
the  time  of  extubation,  but  granulomas  can  also  develop  in 
the  healing  process  late  after  extubation. 


Table  3.      Prospective  Studies  of  Laryngeal  and  Tracheal  Stenosis 


Author 

Intubation* 

Tracheotomyt 

Lindholm"" 

1/206 

16/44 

Andrews  et  al'^' 

— 

8/103 

Dane  et  al'-'* 

— 

4/25 

Stauffer  et  al'^ 

2/27 

3/15 

Pecoraetal'" 

oni 

— 

Kastanos  et  al'*' 

2/19 

— 

Whited" 

12/200 

— 

Colice  et  al*' 

0/54 

— 

Santos  et  al*" 

0/62 

(V17 

van  Heurn  et  alt'*' 

— 

3/54 

TOTAL 

17/589(2.9%) 

34/258(13.2%) 

*Glottic/subgloltic  stenosis  from  endotracheal  inluliation. 

tTracheal  stenosis  from  tracheotomy.  Data  are  included  if  the  airway  diameter  was  reduced 

s  25''f  or  the  patient  had  symptoms  of  tracheal  stenosis. 

^Percutaneous  dilational  tracheotomy. 

(Modified  from  Reference  39.) 


Laryngeal  Injury.  In  one  carefully  designed  prospec- 
tive study,  serial  endoscopy  of  54  survivors  was  performed 
after  extubation  to  study  the  healing  of  laryngeal  injury 
from  endotracheal  intubation.'*^''^  In  42  (78%)  healing  by 
reepithelialization  was  complete  within  8  weeks.''''  Hoarse- 
ness disappeared  as  laryngeal  injury  resolved  over  time, 
and  complete  laryngeal  healing  was  evident  within  8-12 
weeks.  The  healing  of  laryngeal  injury  after  extubation  has 
been  observed  over  3-5  months  by  other  investigators. '"^ 
Complaints  of  dyspnea,  hoarseness,  or  stridor  in  the 
year  following  prolonged  endotracheal  intubation  should 
alert  the  clinician  to  the  possibility  of  laryngeal  stenosis.  In 
one  report,  3  (10%)  of  30  survivors  of  acute  respiratory 
distress  syndrome  (ARDS)  presented  with  symptoms  of 
laryngeal  stenosis  4-12  months  after  hospital  discharge. '"^ 

Laryngeal  Stenosis.  Laryngeal  stenosis  is  the  most  feared 
late  complication  of  endotracheal  intubation.  However,  it 
is  important  to  emphasize  that  this  is  an  uncommon  com- 
plication of  endotracheal  intubation  for  critical  illness  in 
adults.  Prospective  studies  of  laryngeal  stenosis  from  en- 
dotracheal intubation  report  frequencies  ranging  from 
0%46.97  (Q  6%  52  jhg  mean  rate  of  laryngeal  stenosis  com- 
plicating endotracheal  intubation  in  10  prospective  studies 
over  the  last  30  years  is  2.9%,  a  rate  which  compares 
favorably  to  the  13.2%  rate  of  tracheal  stenosis  of  25%  or 
greater  in  survivors  following  tracheotomy  (Table  3).  How- 
ever, it  must  be  recognized  that  laryngeal  stenosis  is  al- 
ways symptomatic  and  difficult  to  manage,  especially  if 
the  posterior  commissure  is  stenotic.^  Tracheal  stenosis 
below  the  cricoid  ring,  on  the  other  hand,  is  not  always 
symptomatic,  even  when  it  exceeds  25%,  and  is  more 
easily  managed  surgically  than  laryngeal  stenosis.  Dilation 


Respiratory  Care  •  July  1999  Vol  44  No  7 


8.15 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


procedures,  stent  placement,  and  laser  therapy  are  the  main 
treatment  options.'' 

Laryngeal  Granuloma.  Laryngeal  granulomas  are  small 
tufts  of  granulation  tissue  that  can  form  at  the  site  of 
laryngeal  mucosal  injury  from  intubation.  They  typically 
grow  at  the  margins  of  laryngeal  ulcers,  are  usually  bilat- 
eral, and  involve  the  true  vocal  cords."**  As  complications 
of  endotracheal  intubation,  they  are  more  common  than 
tracheal  granulomas.  Laryngeal  granulomas  complicating 
endotracheal  intubation  occur  in  7%*^  to  27%'*''  of  criti- 
cally ill  adults  after  extubation.  They  have  not  been  ob- 
served in  children''^  and  are  very  rare  from  anesthesia 
intubation. '""'  They  usually  resolve  spontaneously  and  are 
rarely  large  enough  to  compromise  the  airway  or  to  require 
surgical  excision. 

The  time  course  of  development  of  laryngeal  granulo- 
mas is  of  interest.  We  reported  that  only  one  (2%)  of  41 
patients  dying  while  intubated  and  examined  at  autopsy 
had  a  true  vocal  cord  granuloma. '^  Two  prospective  stud- 
ies using  laryngoscopy  to  evaluate  the  larynx  after  extu- 
bation both  reported  the  frequency  of  true  vocal  cord  gran- 
ulomas to  be  42%  after  intubation  for  1  day"*^  to  3  days."** 
Santos  et  al  reported  that  57%  of  the  laryngeal  granulomas 
in  their  series  of  97  patients  developed  an  average  of  4 
weeks  after  extubation."**  Serial  laryngoscopy  indicates  that 
most  of  these  lesions  resolve  with  time.'**'*''  These  findings 
suggest  that  laryngeal  granulomas  develop  at  various  times 
in  the  healing  phase  of  true  vocal  cord  ulceration,  with 
eventual  resolution  in  most  cases. 

Tracheal  Injury.  Tracheal  stenosis  is  the  most  impor- 
tant late  complication  of  endotracheal  intubation  involving 
the  trachea.  Tracheal  dilation,  tracheomalacia,  and  tracheal 
granuloma  formation  are  very  rare  complications  of  endo- 
tracheal intubation  in  the  modem  era  of  soft-cuff  ETTs."* 

Tracheal  Stenosis.  Since  the  advent  of  the  soft-cuff  ETT, 
significant  tracheal  stenosis  following  endotracheal  intu- 
bation is  very  unusual. '"^"^  We  detected  asymptomatic 
mild  (s  25%  narrowing)  tracheal  stenosis  in  3  (1 1%)  of 
27  patients  studied  with  tracheal  tomography  after  extu- 
bation.'^  Kastanos  et  al  detected  cuff-site  tracheal  stenosis 
(25-  30%  narrowing)  in  2  (11%)  of  19  patients  studied 
after  intubation  periods  of  9  and  14  days."^  Santos  et  al 
reported  no  evidence  of  "laryngotracheal"  stenosis  in  62 
adults  surviving  prolonged  endotracheal  intubation."** 

Little  is  known  about  the  natural  course  of  tracheal  ste- 
nosis that  complicates  endotracheal  intubation.  In  our  pro- 
spective series,  one  patient  with  mild  tracheal  stenosis 
after  endotracheal  intubation  showed  resolution  on  subse- 
quent tracheal  tomograms,  whereas  tracheal  stenosis  after 
tracheotomy  persisted  in  3  patients. '^ 


It  is  important  for  clinicians  to  maintain  a  high  index  of 
suspicion  in  order  to  make  the  correct  diagnosis  of  tracheal 
stenosis.  Symptomatic  tracheal  stenosis  following  endo- 
tracheal intubation  (or  tracheotomy)  typically  presents  from 
several  weeks  to  12  months  following  extubation  or  de- 
cannulation  with  labored  breathing,  difficulty  clearing  se- 
cretions, cough,  dyspnea,  hoarseness,  stridor,  or  combina- 
tions of  these  symptoms,  ■o''-  'o*  Inspiratory  stridor  reportedly 
occurs  only  when  the  tracheal  lumen  is  reduced  to  3-4 
mm  diameter  or  less.'"*  Unfortunately,  the  symptoms  of 
advanced  tracheal  stenosis  are  often  misattributed  to  chronic 
obstructive  pulmonary  disease,  asthma,  other  underlying 
respiratory  diseases,  or  even  hysteria.  Appropriate  imag- 
ing studies  (CT  or  magnetic  resonance  imaging)  of  the 
larynx  and  trachea  and/or  fiberoptic  bronchoscopy  are  re- 
quired to  confirm  the  diagnosis  of  tracheal  stenosis.  The 
physical  examination  and  pulmonary  function  tests  (flow- 
volume  loop)  may  suggest  the  diagnosis  of  severe  airway 
stenosis,  but  they  are  neither  sensitive  nor  specific  enough 
to  establish  the  diagnosis  with  certainty.' 2- '"^ 

Selected  Complications  of  Tracheotomy 

The  complications  of  cricothyroidotomy  and  minitra- 
cheotomy  are  not  addressed  in  this  review,  and  those  of 
percutaneous  dilational  tracheotomy  are  addressed  only 
briefly  herein.  Complications  of  standard  tracheotomy  have 
been  reviewed  elsewhere.^'"''-"'''  '"  Selected  complica- 
tions of  tracheotomy  are  listed  in  Table  4. 

The  overall  mortality  rate  of  tracheotomy  in  the  1950s 
and  1960s  was  0-5.3%. "^."^  Death  rates  of  2.8%"*  and 
3.4%"^  were  reported  in  large  personal  series  of  trache- 
otomies. In  a  more  recent  prospective  series  of  124  adult 
tracheotomies,  Goldstein  et  al  reported  no  deaths. "^ 

Stemmer  et  al  reviewed  403  deaths  in  tracheotomized 
patients."*  The  operation  itself  accounted  for  36  (8.9%)  of 
the  deaths,  and  hemorrhage  was  the  most  common  fatal 
complication.  In  a  literature  review  of  1,928  tracheotomies 
in  1 972,  in  which  the  overall  mortality  rate  of  tracheotomy 
was  1 .6%,  the  most  common  fatal  complications  (in  de- 
creasing order)  were  tracheotomy  hemorrhage,  displace- 
ment of  the  TT,  infection,  and  tube  obstruction."^ 

Several  prospective  investigations  have  compared  the 
airway  management  complication  rates  of  patients  receiv- 
ing early  tracheotomy  versus  late  tracheotomy. '"2- "'*"'^  In 
a  study  of  74  trauma  patients,  Dunham  and  LaMonica 
found  no  significant  differences  in  rates  of  major  compli- 
cations, laryngotracheal  pathology,  or  pulmonary  infection 
between  patients  who  had  tracheotomy  at  3-4  days  and 
those  who  had  tracheotomy  at  14  days  after  endotracheal 
intubation."**  Another  study  of  106  trauma  patients  re- 
vealed that  tracheotomy  in  the  first  week  of  mechanical 
ventilation  significantly  reduced  duration  of  mechanical 
ventilation  and  length  of  stay  in  the  ICU  and  the  hospital 


836 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


Table  4.      Selected  Complications  of  Tracheotomy 

During  the  tracheotomy  operation 

•  Cardiac  arrest 

•  Paratracheal  tube  placement 

•  Hemorrhage 

•  Recurrent  laryngeal  nerve  injury 

•  Pneumothorax,  pneumomediastinum,  and  subcutaneous  emphysema 

While  the  tracheostomy  tube  (TT)  is  in  place 

•  Stomal  infection 

•  Hemorrhage 

•  Tracheal  injury 

•  Tracheomalacia 

•  Granuloma 

•  Tracheoesophageal  fistula 

•  Tracheovascular  fistula 

•  Incidental  dislodgement  and  decannulation 

•  Pulmonary  complications 

•  Mechanical  problems  with  TT  or  cuff 

During  and  immediately  after  decannulation 

•  Difficult  removal  of  TT  due  to  tight  stoma 

Late  complications  after  decannulation 

•  Poor  wound  healing 

•  Scar  and  keloid 

•  Persistent  open  fistula 

•  Tracheal  injury 

•  Stenosis 

•  Dilatation 


when  compared  to  tracheotomy  after  8-21  days  of  me- 
chanical ventilation."''  However,  a  recent  multicenter,  ran- 
domized, prospective  study  failed  to  demonstrate  that  ear- 
lier tracheotomy  reduced  the  frequency  of  airway 
complications,  ICU  length  of  stay,  nosocomial  pneumonia, 
or  death  in  head  trauma,  nonhead  trauma,  or  critically  ill 
nontrauma  adults. '"^  The  authors  observed  more  vocal  cord 
ulceration  and  subglottic  inflammation  in  the  patients  who 
underwent  tracheotomy  later  (ie,  had  prolonged  endotra- 
cheal intubation).  None  of  these  randomized  prospective 
studies  have  reported  statistically  significant  reduction  in 
laryngeal  or  tracheal  injury  by  performing  tracheotomy 
early  in  the  course  of  prolonged  airway  maintenance. 


and  airway  suctioning  have  also  been  implicated  as  causes 
of  sudden  death  during  or  immediately  after  tracheoto- 
n^y  109.1 16  Bradycardia  from  tracheal  manipulation  is  also  a 
concern. '09.120 

Paratracheal  Tube  Placement.  "False  passage"  or  mal- 
position of  the  TT  at  the  time  of  tracheotomy  occurs  when 
the  tip  of  the  TT  is  inadvertently  directed  into  the  para- 
tracheal tissues,  usually  the  pretracheal  space.  Inability  to 
ventilate  and  oxygenate  the  patient  is  the  usual  presenting 
sign  of  this  disaster. '^o 

Hemorrhage.  Because  published  reports  do  not  clearly 
distinguish  intraoperative  from  postoperative  bleeding,  this 
complication  is  discussed  below. 

Recurrent  Laryngeal  Nerve  Injury.  Inadvertent  tran- 
section of  one  or  both  recurrent  laryngeal  nerves  from 
tracheotomy  incisions  that  are  too  wide  or  deep  can  cause 
vocal  paralysis  that  is  not  evident  until  after  decannula- 
tion.'^°  Laryngoscopy  while  the  TT  is  in  place  may  also 
identify  this  problem.'"''  The  exact  frequency  of  this  com- 
plication is  unknown,  but  it  appears  to  be  a  very  rare  event. 

Pneumothorax,  Pneumomediastinum,  and  Subcutane- 
ous Emphysema.  Pneumothorax  complicates  as  many 
as  4-5%  of  tracheotomies.""'"-^"'*  In  a  personal  series  of 
389  tracheotomies  performed  during  the  1950s.  McClel- 
land found  that  16  patients  (4.1%)  developed  "surgical 
emphysema"  and/or  pneumothorax."^  Stock  et  al  observed 
that  2  (2.5%)  of  81  neurosurgical  patients  requiring  elec- 
tive tracheotomy  had  supraclavicular  subcutaneous  em- 
physema following  the  operation.'-'  This  complication  is 
much  more  common  in  children  than  in  adults'"''  and  is 
reported  to  be  the  most  common  fatal  complication  of 
tracheotomy  in  children. '^2  False  passage  of  the  tracheal 
tube  into  the  paratracheal  space,  injury  to  the  apical  pleu- 
rae, spontaneous  rupture  of  lung  blebs,  and  dissection  of 
air  into  the  mediastinum  through  the  stoma  during  forceful 
inspiratory  efforts  have  been  implicated  as  the  causes  of 
this  complication. "^'2' 

Complications  While  the  Tracheostomy  Tube 
Is  in  Place 


Complications  During  the  Tracheotomy  Operation 

Cardiac  Arrest.  Cardiac  arrest  during  tracheotomy  is 
very  rare.  In  our  series,  one  patient  with  erroneous  surgical 
placement  of  the  tracheostomy  tube  into  the  pretracheal 
space  suffered  a  cardiac  arrest  on  the  operating  table. '- 
The  patient  was  subsequently  resuscitated.  Malposition  of 
the  TT,  apnea,  and  hypotension  during  emergency  trache- 
otomy for  acute  respiratory  failure,  traction  on  the  trachea. 


Stomal  Infection.  We  prospectively  observed  mild  peris- 
tomal cellulitis  or  excessive  purulent  exudate  at  the  stoma 
in  19  (36%)  of  51  patients  after  elective  tracheotomy.'-  In 
contrast,  a  retrospective  study  reported  stomal  infection  in 
only  4%  of  84  neurosurgical  patients  after  tracheotomy.'" 
Severe  cellulitis  and  mediastinal  abscess  formation  are  very 
unusual  complications  of  standard  tracheotomy.'"''  Stomal 
infection  is  reportedly  less  common  with  percutaneous  di- 
lationai  tracheotomy  than  with  standard  tracheotomy.  None 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


of  124  consecutive  adult  patients  who  underwent  bedside 
tracheotomy  developed  stomal  cellulitis.'" 

Hemorrhage.  The  reported  frequency  of  hemorrhage 
from  tracheotomy  ranges  from  0%  to  37%.'"  We  recorded 
stoma  site  blood  oozing  of  more  than  mild  degree  in  19 
(36%)  of  51  ICU  patients  following  tracheotomy.'-  Major 
hemorrhage  was  observed  in  only  one  of  the  5 1  patients  as 
a  result  of  tracheal  erosion  at  the  level  of  the  TT  cuff  into 
the  inferior  thyroid  artery.  In  a  recent  retrospective  study 
of  470  consecutive  tracheotomy  operations,  Upadhyay  et 
al  found  that  bleeding  was  the  most  common  complication 
of  the  procedure,  occurring  in  20  (4.3%)  cases. '-''  In  a 
prospective  study  of  bedside  tracheotomy  in  124  ICU  pa- 
tients, only  2  (1.6%)  experienced  minor  hemorrhage,  and 
none  had  major  hemorrhage  from  the  procedure."''  Four 
(10%)  of  40  tracheotomy  patients  in  another  prospective 
series  experienced  hemorrhage,  which  was  major  in  2  cas- 
es.'-'' In  an  older  series  of  389  tracheotomies,  McClelland 
reported  4  deaths  from  major  hemorrhage."''  Aspiration  of 
blood  from  venous  hemorrhage  accounted  for  7  deaths  in 
a  series  of  36  tracheotomy-related  deaths.'"' 

Tracheal  Injury.  Tracheal  mucosa  and  tracheal  wall 
injuries  follow  the  same  pattern  as  those  created  by  ETT 
cuffs  and  suction  catheters.  We  observed  tracheal  cuff  site 
submucosal  hemorrhage  at  autopsy  in  3  (14%)  of  22  pa- 
tients who  died  following  prolonged  endotracheal  intuba- 
tion followed  by  tracheotomy  with  soft-cuff  TTs.'^  Mod- 
erate or  greater  mucosal  inflammation  and/or  edema,  and 
frank  mucosal  ulceration  were  both  observed  in  9  (41  %)  of 
these  patients. '2 

Mucosal  ulceration  is  attributed  to  excessively  high  lat- 
eral tracheal  wall  pressure  exerted  by  the  cuff  of  the 
77-126,127  Mechanical  forces  exerted  by  a  TT  on  the  tra- 
chea wall  can  be  greater  than  those  generated  by  an  ETT, 
because,  without  the  anchoring  effect  of  the  mouth  (or 
no.se)  and  glottis,  the  forces  are  more  directly  transmitted 
to  the  trachea.  Tracheal  injury  from  TT  is  superimposed 
upon  injury  caused  by  ETT  used  prior  to  tracheotomy. 
This  may  account  for  the  fact  that  mucosal  cuff  site  ulcer- 
ation is  more  frequently  observed  in  tracheotomy  patients 
than  in  patients  who  only  had  endotracheal  intubation. '^ 

Tracheomalacia.  Tracheomalacia  complicating  short- 
term  tracheotomy  has  been  considered  rare  since  the  ad- 
vent of  soft-cuff  TTs.  The  finding  of  tracheomalacia  should 
raise  the  possibility  of  other  causes,  such  as  neoplasm, 
radiation  therapy,  trauma,  necrotizing  tracheal  infection, 
or  polychondritis. 

Law  et  al  performed  fiberoptic  bronchoscopy  prior  to 
decannulation,  and  observed  a  high  frequency  of  tracheo- 
malacia in  brain-injured  adults  with  a  mean  of  4.9  months 
of  intubation  with  TT.'^"  Using  fiberoptic  bronchoscopy, 


they  observed  a  malacial  .segment  with  forced  coughing  or 
labored  respiration  only  above  the  stoma  in  19  (23%)  of  81 
patients.  The  clinical  importance  of  these  observations  and 
the  mechanisms  of  tracheomalacia  in  this  population  and 
in  the  broader  population  of  tracheotomy  patients  are  not 
known.  However,  the  authors  recommend  that  all  candi- 
dates for  tracheal  decannulation  undergo  anatomic  exam- 
ination of  the  larynx  and  trachea  beforehand.'-** 

Tracheal  Granuloma.  Mucosal  granulomas  can  appear 
in  the  healing  phase  of  tracheal  injury  at  the  level  of  the 
stoma,  cuff  site,  or  any  area  of  mucosal  ulceration.  They 
are  observed  during  bronchoscopy  and  are  usually  incon- 
sequential. Law  et  al  found  suprastomal  tracheal  granulo- 
mas in  45  (56%)  of  81  patients  with  long-term  TTs  in 
place.'-**  These  lesions  appeared  to  originate  at  the  stoma, 
and  were  pedunculated  or  sessile. 

Tracheoesophageal  Fistula.  This  rare  complication  of 
tracheotomy  has  been  attributed  to  high  cuff  inflation  pres- 
sure leading  to  necrosis  of  the  tracheal  and  esophageal 
walls,  often  in  the  simultaneous  presence  of  an  indwelling 
esophageal  tube.  Erosion  of  the  posterior  tracheal  wall  by 
the  TT  tip  and  penetration  by  TT  suction  catheters  also 
have  been  implicated  in  this  severe  injury.'-''  It  can  also 
occur  from  incision  of  the  posterior  tracheal  wall  during 
the  tracheotomy  operation.'** 

Stemmer  et  al  recorded  5  ( 1 .2%)  cases  of  tracheoesoph- 
ageal fistula  in  a  series  of  403  tracheotomies,'"'  but  in  a 
review  of  1,928  tracheotomies,  only  3  cases  (0.2%)  were 
reported."^  In  one  prospective  study  of  tracheotomy  where 
103  patients  were  available  for  follow-up,  Andrews  and 
Pearson  reported  2  ( 1 .9%)  cases  of  tracheoesophageal  fis- 
tula.'^''  However,  many  of  the  TTs  used  in  that  study  were 
red  rubber  tubes  with  hard  cuffs.  In  1972,  Harley  reported 
44  collected  cases  of  ulcerative  tracheoesophageal  fistula 
following  tracheotomy  and  mechanical  ventilation,  and  em- 
phasized the  importance  of  avoiding  motion  between  the 
tube  and  the  patient  in  preventing  this  complication.'-"'  In 
patients  with  burns,  a  high  rate  (9%)  of  tracheoesophageal 
fistula,  as  well  as  tracheal  stenosis  (11%)  and  tracheoar- 
terial  fistula  (3%),  has  been  reported,'"  suggesting  that 
burn  patients  are  at  increased  risk  for  severe  tracheal  ero- 
sive injuries. 

In  the  modem  era  of  soft-cuff  TTs,  tracheoesophageal 
fistula  appears  to  be  very  rare.  A  MEDLINE  literature 
search  found  no  reports  of  tracheoesophageal  fistula  as  a 
complication  of  tracheotomy  during  the  1990s.  In  a  con- 
.secutive  series  of  470  tracheotomies,  no  cases  of  tracheo- 
esophageal fistula  were  found.'-'  CT  has  been  recom- 
mended as  the  preferred  method  of  diagnosis  of 
tracheoesophageal  fistula.' ^2- '"  Without  immediate  surgi- 
cal intervention,  tracheoesophageal  fistula  is  considered  to 
be  uniformly  fatal. '^^ 


838 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


Tracheovascular  Fistula.  Erosion  of  the  tracheal  wall 
into  a  surrounding  major  artery  or  vein  is  a  catastrophic 
complication  of  tracheotomy.  The  thyroid  arteries  and  veins 
and  the  innominate  artery  are  most  commonly  involved. 
Fortunately,  this  complication  is  now  exceedingly  rare. 
Upadhyay  et  al  found  no  cases  of  tracheoinnominate  artery 
fistula  in  reviewing  470  tracheotomy  operations  performed 
between  1989  and  1992. '2-» 

Fistulas  occur  at  the  level  of  the  stoma  or  the  TT  cuff.'"^  '* 
Many  patients  with  this  complication  of  tracheotomy  are 
at  special  risk  because  of  head  and  neck  malignancy,  ra- 
diation therapy  to  the  neck,  or  other  factors. 

Tracheoinnominate  artery  fistula,  the  most  common  and 
severe  type  of  tracheovascular  fistula,  is  a  rare  but  usually 
fatal  complication  of  standard  tracheotomy"-''^''  or  medi- 
astinal tracheotomy.'"  Three  (8%)  of  36  tracheotomy- 
related  deaths  in  a  Veterans  Administration  patient  popu- 
lation were  caused  by  tracheal  erosion  into  the  innominate 
artery  at  the  point  where  it  crosses  the  trachea  anterior- 
ly."*' Management  of  tracheoinnominate  artery  fistula  con- 
sists of  immediate  digital  compression  of  the  innominate 
artery  behind  the  sternum,""  cuff  overintlation,  mainte- 
nance of  airway  patency,  and  emergency  surgical  repair 
via  median  sternotomy. '3*''"' 

Incidental  Dislodgment  and  Decannulation.  Dislodg- 
ment  of  the  TT  occurs  in  up  to  7%  of  patients,  and  can  be 
life-threatening."''  A  retrospective  series  by  Upadhyay  et 
al  found  tube  dislodgment  within  5  days  of  the  operation 
in  8  (1.7%)  of  470  cases. '^^  In  our  prospective  series,  2 
(4%)  of  5 1  tracheotomy  patients  experienced  tube  dislodg- 
ment, one  on  the  operating  table  and  the  other  in  the  ICU; 
cardiac  arrest  occurred  in  both  cases.'-  In  one  of  2  cases 
reported  in  another  series,  pneumothorax  resulted  from 
dislodgment  of  the  TT.""*  Tube  migration  into  the 
subcutaneous  tissue  of  the  neck  accounted  for  2  deaths  in 
one  series  of  403  tracheotomies.'"'  These  anecdotal  expe- 
riences indicate  that  migration  of  the  TT  is  an  uncommon 
but  potentially  life-threatening  complication  of 
tracheotomy. 

Pulmonary  Complications.  The  problems  that  follow 
tracheotomy  parallel  those  that  follow  endotracheal  intu- 
bation (aspiration,  pneumonia,  retained  secretions,  and  at- 
electasis). Both  symptomatic  and  silent  aspiration  events 
are  common  in  patients  with  TTs  in  place.  Santos  et  al 
reported  that  all  of  17  patients  surviving  prolonged  intu- 
bation and  tracheotomy  displayed  clinical  evidence  of  as- 
piration.'"' In  a  recent  study  using  videofluoroscopy.  about 
50%  of  adult  patients  receiving  long-term  mechanical  ven- 
tilation via  TT  displayed  aspiration  of  feedings,  and  77% 
of  aspirations  were  silent.'^"  Patients  with  TTs  can  aspirate 
blue  dye  placed  on  the  tongue.  In  one  study,  5  (25%)  of  20 
patients  with  TTs  displayed  staining  of  tracheal  secretions 


after  methylene  blue  dye  was  placed  on  the  tongue,  in 
contrast  to  none  of  30  patients  with  ETTs  (p  <  0.01).'"*' 
Abnormalities  in  deglutition  have  also  been  identified  in 
patients  with  TT.'^ 

Torres  et  al  found  VAP  in  13  (46%)  of  28  tracheotomy 
patients  who  required  mechanical  ventilation  for  more  than 
48  hours.™  Compared  to  patients  with  ETTs  (relative  odds 
ratio  =  1 ),  the  relative  odds  ratio  for  VAP  in  patients  with 
TTs  was  3.05  (p  =  0.0041).™  However,  tracheotomy  was 
not  an  independent  risk  factor  for  VAP  in  that  study.  Gold- 
stein et  al  reported  that  none  of  1 24  patients  developed  pneu- 
monia as  a  direct  complication  of  bedside  U"acheotomy."^ 

Mechanical  Problems  with  the  Tracheotomy  Tube  and 
Cuff.  In  one  report,  airway  obstruction  (6  cases)  was  sec- 
ond to  hemorrhage  (10  cases)  as  a  cause  of  death  in  a  series 
of  36  fatal  complications  of  the  tracheotomy  procedure."* 
The  lumen  of  the  TT  can  become  obstructed  by  secretions, 
crusts,  blood,  or  flaps  of  tissue,  or  by  partial  dislodgment. 

Complications  During  and  Immediately  After 
Decannulation 

Difficult  Removal  of  Tracheotomy  Tube  Due  to  Tight 
Stoma.  A  tight  stoma  can  make  decannulation  pain- 
ful.'-*^ Otherwise,  decannulation  is  usually  uneventful. 

Late  Complications  After  Decannulation 

Scar  and  Keloid.  In  a  literature  review.  Chew  and 
Cantrell  found  only  one  case  of  stomal  keloid  in  1,928 
tracheotomies."^  Cosmetic  results  are  reportedly  better 
with  percutaneous  dilational  tracheotomy  than  conventional 
tracheotomy  because  of  the  smaller  stoma. '■*■*  Van  Heum 
et  al  observed  that  13  (20%)  of  66  patients  had  scar  re- 
traction after  percutaneous  dilational  tracheotomy.'"''' 

Persistent  Open  Fistula.  Persistent  tracheocutaneous  fis- 
tula is  an  uncommon  event  after  decannulation.  In  one 
series,  2  (3%)  of  66  patients  followed  after  percutaneous 
dilational  tracheotomy  had  this  complication.'-'''  In  a  ret- 
rospective study  of  150  patients,  5  (3.3%)  had  tracheocu- 
taneous fistula.'''''  Surgical  repair  may  close  the  tract.'"'''-''' 

Tracheal  Stenosis.  Tracheal  stenosis  is  the  most  com- 
mon and  potentially  serious  late  complication  of  tracheot- 
omy. Following  decannulation.  it  occurs  at  the  level  of  the 
stoma,  cuff  site,  or  TT  tip.  Our  experience '^  and  that  of 
others'"**'-'-'-^  suggests  that  stenosis  is  more  common  at 
the  site  of  the  tracheotomy  stoma,  although  one  group  has 
reported  that  cuff  site  stenosis  predominates.'"**  Scarring 
and  stricture  formation  at  the  site  of  the  incision  into  the 
anterior  tracheal  wall  is  responsible  for  post-decannulation 
tracheal  stenosis.  Accordingly,  most  tracheal  stenoses  af- 


Respiratory  Care  •  July  1999  Vol  44  No  7 


s  ^^y 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


ter  tracheotomy  are  located  anteriorly  or  anterolaterally. 
Infection  has  also  been  implicated  in  the  pathogenesis. 
Prospective  studies  suggest  that  the  overall  frequency  of 
tracheal  stenosis  (of  25%  or  greater)  following  tracheot- 
omy is  approximately  13%  (see  Table  3). 

Because  of  widely  different  definitions  of  stenosis,  the 
reported  frequency  of  stomal  site  tracheal  stenosis  ranges 
from  0%  to  85%."-  We  observed  tracheal  stenosis  (de- 
fined as  a  greater  than  10%  reduction  in  the  transverse  air 
column  diameter  on  anteroposterior  tracheal  tomograms) 
in  9  (60%)  of  15  adult  patients  after  decannulation.'-  Eight 
of  the  9  stenoses  occurred  at  the  level  of  the  stoma  and  one 
at  the  level  of  the  cuff.  Two  of  the  9  stenoses  were  severe 
(greater  than  50%).  and  1  patient  died  as  a  direct  result  of 
airway  obstruction  from  tracheal  stenosis.  In  another  pro- 
spective study,  Dane  and  King  reported  that  8%  of  survi- 
vors following  decannulation  required  surgical  repair  for 
symptomatic  stomal  site  tracheal  stenosis.'-''  One  patient 
in  that  series  had  an  80%  stomal  stenosis. 

Surgical  resection  and  reconstructive  surgery  are  nec- 
essary in  severe  cases  of  tracheal  stenosis,  and  experience 
with  the.se  techniques  has  advanced  to  the  point  that  good 
surgical  results  are  achieved  in  many  cases.''""  Grillo  et  al 
reported  good  or  satisfactory  results  in  94%  of  over  500 
surgically  treated  patients.''''' 

Tracheal  Dilatation.  Dilatation  of  the  trachea  is  a  rare 
but  serious  complication  of  tracheotomy  and  endotracheal 
intubation."  ''^"  Widening  of  the  trachea  at  the  cuff  site 
while  the  TT  is  in  place  is  reported  to  be  a  risk  factor  for 
severe  tracheal  damage  resulting  in  tracheal  stenosis  or 
tracheomalacia.''^ 

REFERENCES 

1.  MacEwen  W.  Clinical  observations  on  the  introduction  of  tracheal 
tubes  by  the  mouth  instead  of  performing  tracheotoiny  or  laryngot- 
omy.  BMJ  1880;2:122-124.  la-Vie.*!. 

2.  Jackson  C.  Tracheotomy.  Laryngoscope  1909;19:285-290. 

3.  Blanc  VF.  Tremblay  NA.  The  complications  of  tracheal  intubation: 
a  new  classification  with  a  review  of  the  literature.  Anesth  Analg 
1974;53(2);202-213. 

4.  Stauffer  JL.  Complications  of  Iranslaryngeal  intubation.  In:  Tobin 
MJ.  editor.  Principles  and  practice  of  mechanical  ventilation.  New 
York:  McGraw-Hill;l994:7ll-747. 

5.  Weymuller  EA  Jr,  Bishop  MJ.  Santos  PM.  Problems  associated  with 
prolonged  intubation  in  the  geriatric  patient.  Otolaryngol  Clin  North 
Am  1990:23(6):  1057-1074.  Piihlisheil  erratum  appears  in  Otolar- 
yiiKoI  Clin  Nortli  Am  I9<il:24(6):xi. 

6.  McCulloch  TM.  Bishop  MJ.  Complications  of  translaryngeal  intu- 
bation (review).  Clin  Chest  Med  I99I;I2(3):.5()7-52I . 

7.  Streitz  JM  Jr,  Shapshay  SM.  Airway  injury  after  tracheotomy  and 
endotracheal  intubation  (review).  Surg  Clin  North  Am  1991:71(6): 
1211-1230. 

X.  Weymuller  EA  Jr.  Prevention  and  management  of  intubation  injury 

of  the  larynx  and  trachea  (review).  Am  J  Otolaryngol  1992:13(3): 

1.19-144. 
9.  Bcnjiimin  B.  Prolonged  intubation  injuries  of  the  larynx:  endoscopic 

di;ii:nosis.  classification,  and  treatment.  Ann  Otol  Rhinol  Laryngol 

SuppI  1993:160:1-15. 


10.  Schwartz  DE,  Matthay  MA,  Cohen  NH.  Death  and  other  complica- 
tions of  einergency  airway  management  in  critically  ill  adults:  a 
pro.spective  investigation  of  297  tracheal  intubations.  Anesthesiol- 
ogy 1995:82(2):367-376. 

1 1 .  Schwartz  DE.  Lieberman  JA,  Cohen  NH.  Women  are  at  greater  risk 
than  men  for  malpositioning  of  the  endotracheal  tube  after  emergent 
intubation.  Crit  Care  Med  1994:22(71:1127-1131. 

12.  Stauffer  JL.  Olson  DE.  Petty  TL.  Complications  and  consequences 
of  endotracheal  intubation  and  tracheotomy:  a  prospective  study  of 
150  critically  ill  adults.  Am  J  Med  1981:70(l):65-76. 

13.  Sakles  JC,  Laurin  EG.  Rantapaa  AA.  Panacek  EA.  Airway  manage- 
ment in  the  emergency  department:  a  one-year  study  of  610  tracheal 
intubations.  Ann  Emerg  Med  1998:3l(3):325-332. 

14.  Taryle  DA.  Chandler  JE.  Good  JT  Jr.  Potts  DE.  Sahn  SA.  Emergency 
room  intubations:  complications  and  survival.  Chest  I979:75(5):541- 
543. 

15.  Adnet  F.  Jouriles  NJ,  LeToumelin  P.  Hennequin  B.  Taillandier  C, 
Rayeh  F.  el  al.  Survey  of  out-of-hospital  emergency  intubations  in 
the  French  prehospital  medical  system:  a  multicenter  study.  Ann 
Emerg  Med  1998:32(4):454-^60. 

16.  Keenan  RL.  Boyan  CP.  Cardiac  arrest  due  to  anesthesia:  a  study  of 
incidence  and  causes.  JAMA  I985:25.3(16):237.V2377. 

17.  Mateer  JR.  Ol.son  DW.  Stueven  HA.  Aufderheide  TP.  Continuous 
pulse  oximetry  during  emergency  endotracheal  intubation.  Ann  Emerg 
Med  l993;22(4):67.5-679. 

18.  Lockhart  PB.  Feldbau  EV.  Gabel  RA,  Connolly  SF.  Silversin  JB. 
Dental  complications  during  and  after  tracheal  intubation.  J  Am  Dent 
Assoc  1986;1I2(4):480^83. 

19.  O'Neill  JE.  Giffin  JP.  Cotrell  JP.  Pharyngeal  and  esophageal  perfo- 
ration following  endotracheal  intubation.  Anesthesiology  I984;60(5): 
487^88. 

20.  Wolff  AP,  Kuhn  FA,  Ogura  JH.  Pharyngeal-esophageal  perforations 
associated  with  rapid  oral  endotracheal  intubation.  Ann  Otol  Rhinol 
Laryngol  I972:8I(2):258-261. 

21 .  Stauffer  JL,  Petty  TL.  Accidental  intubation  of  the  pyriform  sinus:  a 
complicationof  "roadside"  resuscitation.  JAMA  1 977:237(2 1):2324- 
2325. 

22.  Peppard  SB,  Dickens  JH.  Laryngeal  injury  following  short-term  in- 
tubation. Ann  Otol  Rhinol  Laryngol  1983:92(4  Pt  l):327-330. 

23.  Burns  HP.  Dayal  VS.  Scott  A.  van  Nostrand  AW.  Bryce  DP.  La- 
ryngotracheal trauma:  observations  on  its  pathogenesis  and  its  pre- 
vention following  prolonged  orotracheal  Intubation  in  the  adult.  La- 
ryngoscope 1979:89(8):  1 3 16-1 325. 

24.  Orta  DA,  Cou.sar  JE  3rd.  Yergin  BM.  Olsen  GN.  Tracheal  laceration 
with  massive  subcutaneous  emphysema:  a  rare  complication  of  en- 
dotracheal intubation.  Thorax  1979:34(5):665-669. 

25.  Zwillich  CW.  Pierson  DJ.  Creagh  CE.  Sutton  FD.  Schatz  E.  Petty 
TL.  Complications  of  assisted  ventilation:  a  prospective  study  of  354 
consecutive  episodes.  Am  J  Med  I974:57(2):16l-170. 

26.  Brunei  W,  Coleman  DL.  Schwartz  DE,  Peper  E.  Cohen  NH.  Assess- 
ment of  routine  chest  roentgenograms  and  the  physical  examination 
to  confirm  endotracheal  tube  position.  Chest  1989:96(5):  1043-1045. 

27.  Thibodeau  LG.  Verdile  VP,  Bartfield  JM.  Incidence  of  aspiration 
after  urgent  intubation.  Am  J  Emerg  Med  l997:l5(6):562-565. 

28.  Caplan  RA,  Posner  KL.  Ward  RJ,  Cheney  FW.  Adverse  respiratory 
events  in  anesthesia:  a  closed  claims  analysis.  Anesthesiology  1990; 
72(5):828-833. 

29.  Holdgaard  HO,  Pedersen  J,  Schurizek  BA.  Melsen  NC.  Juhl  B.  Com- 
plications and  late  sequelae  following  nasotracheal  intubation.  Acta 
Anaesthesiol  Scand  1993;37(5):475^80. 

30.  Stauffer  JL.  Monitoring  the  use  of  tracheal  tubes.  In:  Tobin  MJ, 
editor.  Principles  and  practice  of  intensive  care  monitoring.  New 
York:  McGraw-Hill:  1 998:667-682. 


840 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


31.  Stauffer  JL.  Medical  management  of  the  airway.  Clin  Chest  Med 
199I:I2(3):449^82. 

32.  Stauffer  JL,  Petty  TL.  Cleft  tongue  and  ulceration  of  the  hard  palate: 
complications  of  oral  intubation.  Chest  I978;74(3):3I7-318. 

33.  Rouby  JJ,  Laurent  P,  Gosnach  M.  Cambau  E,  Lamas  G.  Zouaoui  A. 
et  al.  Risk  factors  and  clinical  relevance  of  nosocomial  maxillary 
sinusitis  in  the  critically  ill.  Am  J  Respir  Crit  Care  Med  1 994;  150(3): 
776-783. 

34.  Holzapfel  L.  Chevrel  S.  Madinier  G.  Ohen  F.  Demingeon  G,  Coupry 
A.  Chaudet  M.  Influence  of  long-term  oro-  or  nasotracheal  intuba- 
tion on  nosocomial  maxillary  sinusitis  and  pneumonia:  results  of  a 
prospective,  randomized,  clinical  trial.  Crit  Care  Med  I993;2I(8): 
1 132-1 138. 

35.  Bach  A.  Boehrer  H,  Schmidt  H.  Geiss  HK.  Nosocomial  sinusitis  in 
ventilated  patients:  nasotracheal  versus  orotracheal  intubation.  An- 
ae.sthesia  l992;47(4):335-339. 

36.  O'Reilly  MJ.  Reddick  EJ.  Black  W.  Carter  PL.  Erhardt  J.  Fill  W,  et 
al.  Sepsis  froin  sinusitis  in  nasotracheally  intubated  patients:  a  diag- 
nostic dilemma.  Am  J  Surg  1984;l47(5):6()l-6()4. 

37.  Grindlinger  GA,  Niehoff  J,  Hughes  SL.  Humphrey  MA.  Simpson  G. 
Acute  paranasal  sinusitis  related  to  nasotracheal  intubation  of  head- 
injured  patients.  Crit  Care  Med  1987;I5(3):2I4-2I7. 

38.  Pedersen  J.  Schurizek  BA.  Melsen  NC,  Juhl  B.  The  effect  of  naso- 
tracheal intubation  on  the  parana.sal  sinuses:  a  prospective  study  of 
4M  intensive  care  patients.  Acta  Anaesthesiol  Scand  199l;35(  l):l  1- 
13. 

.39.  Blo.s.ser  SA.  Stauffer  JL.  Intubation  of  critically  ill  patients  (review). 
Clin  Chest  Med  1996;17(3):.355-378. 

40.  Borman  KR.  Brown  PM,  Mezera  KK.  Jhaveri  H.  Occult  fever  in 
surgical  intensive  care  unit  patients  is  seldom  caused  by  sinusitis. 
Am  J  Surg  I992;I64(5):4I2-416. 

41.  Presswood  G.  Zamboni  WA.  Stephenson  LL.  Santos  PM.  Effect  of 
artificial  airway  on  ear  complications  froin  hyperbaric  oxygen.  La- 
ryngoscope I994;I04(I1  Pt  1  ):1383-I384. 

42.  Persico  M,  Barker  GA,  Mitchell  DP.  Purulent  otitis  media:  a  "silent" 
source  of  sepsis  in  the  pediatric  intensive  care  unit.  Otolaryngol 
Head  Neck  Surg  l985;93(3):330-.334. 

43.  Lucks  D,  Consiglio  A,  Stankiewicz  J.  O'Keefe  P.  Incidence  and 
microbiologic  etiology  of  middle  ear  effusion  complicating  endotra- 
cheal intubation  and  mechanical  ventilation.  J  Infect  Dis  1988:157(2): 
368-369. 

44.  Thomas  R.  Kumar  EV.  Kameswaran  M.  Shamim  A.  al  Ghamdi  S. 
Mummigatty  AP.  Okafor  BC.  Post  intubation  laryngeal  sequelae  in 
an  intensive  care  unit.  J  Laryngol  Otol  I995;1()9(4):3I3-3I6. 

45.  Colice  GL,  Stukel  TA,  Dain  B.  Laryngeal  complications  of  pro- 
longed intubation.  Chest  1989;96(4):877-884. 

46.  Santos  PM,  Afrassiabi  A,  Weymuller  EA  Jr.  Risk  factors  associated 
with  prolonged  intubation  and  laryngeal  injury.  Otolaryngol  Head 
Neck  Surg  1994;1 1 1(4):453-459. 

47.  Kastanos  N,  E.stopa  Miro  R,  Marin  Perez  A,  Xaubct  Mir  A,  Agusti- 
Vidal  A.  Laryngotracheal  injury  due  to  endotracheal  intubation:  in- 
cidence, evolution,  and  predisposing  factors.  A  prospective  long- 
term  study.  Crit  Care  Med  1983;l  l(5):362-367. 

48.  Lindholm  CE.  Prolonged  endotracheal  intubation.  Acta  Anaesthesiol 
.Scand  Suppl  1970;33:1-131. 

49.  Whited  RE.  Posterior  commis.sure  stenosis  post  long-term  intuba- 
tion. Laryngoscope  I983;9.3(  I0):I3I4-I318. 

50.  Ouartararo  C.  Bishop  MJ.  Complications  of  tracheal  intubation:  pre- 
vention and  treatment.  Semin  Anesth  I990;9:l  19-127. 

51.  Donnelly  WH.  Histopathology  of  endotracheal  intubation.  Arch 
Pathol  I969;88(5):5I  1-520. 

52.  Whited  RE.  A  prospective  study  of  laryngotracheal  sequelae  in  long- 
term  intubation.  Laryngoscope  1984;94(3):367-377. 


53.  Klainer  AS,  Tumdorf  H,  Wu  WH,  Maewal  H,  Allender  P.  Surface 
alterations  due  to  endotracheal  intubation.  Am  J  Med  1975;58(5): 
674-683. 

54.  Konrad  F,  Schiener  R.  Marx  T.  Georgieff  M.  Ultrastructure  and 
mucociliary  transport  of  bronchial  respiratory  epithelium  in  intu- 
bated patients.  Intensive  Care  Med  l995;2l(6):482-489. 

55.  Severson  JM.  Ketter  GW,  Belson  TP.  Pacgle  RD,  Toohill  RJ.  Ex- 
perimental induction  of  squamous  metaplasia  in  the  dog  trachea  with 
cuffed  endotracheal  tubes.  Otolaryngol  Head  Neck  Surg  1982:90(5): 
555-560. 

56.  Paegle  RD.  Bernhard  WN.  Squamous  metaplasia  of  tracheal  epithe- 
lium associated  with  high-volume,  low  pressure  airway  cuffs.  Anesth 
Analg  l975;.54(3):.340-344. 

57.  Nordin  U.  The  trachea  and  cuff-induced  tracheal  injury:  an  experi- 
mental study  on  causative  factors  and  prevention.  Acta  Otolaryngol 
Suppl  (Stockh)  I977;.345:I-71. 

58.  Leigh  JM,  Maynard  JP.  Pressure  on  the  tracheal  mucosa  from  cuffed 
tubes.  Br  Med  J  I979;I(6I72):1 173-1 174. 

59.  Ching  NP,  Ayres  SM,  Paegle  RP,  Linden  JM,  Nealon  TF  Jr.  The 
contribution  of  cuff  volume  and  pressure  in  tracheostomy  lube  dam- 
age. J  Thorac  Cardiovasc  Surg  197I:62(3):4()2-4I0. 

60.  Seegobin  RD,  van  Hasselt  GL.  Endotracheal  cuff  pressure  and  tra- 
cheal mucosal  blood  flow:  endoscopic  study  of  effects  of  four  large 
cuffs.  Br  Med  J  (Clin  Res  Ed)  1984;288(6422):965-968. 

61.  Cooper  JD,  Grillo  HC,  Experimental  production  and  prevention  of 
injury  due  to  cuffed  tracheal  tubes.  Surg  Gynecol  Obstet  1 969;  1 29(6): 
123.5-1241. 

62.  Rello  J.  Sonora  R.  Juberl  P,  Artigas  A,  Rue  M,  Valles  J.  Pneumonia 
in  intubated  patients:  role  of  respiratory  airway  care.  Am  J  Respir 
Crit  Care  Med  1 996;  L54(  1 ):  1 1 1  - 1 1 5. 

63.  Bernhard  WN,  Cottrell  JE,  Sivakumaran  C,  Patel  K,  Yost  L,  Turn- 
dorf  H.  Adjustment  of  intracuff  pressure  to  prevent  aspiration.  An- 
esthesiology 1979;50(4):363-366. 

64.  Khan  F,  Reddy  NC.  Enlarging  intratracheal  tube  cuff  diameter:  a 
quantitative  roentgenographic  study  of  its  value  in  the  early  predic- 
tion of  serious  tracheal  damage.  Ann  Thorac  Surg  I977;24(  l):49-53. 

65.  Elpern  EH.  Jacobs  ER.  Bone  RC.  Iticidence  of  aspiration  in  Irache- 
ally  intubated  adults.  Heart  Lung  I987;16(5):527-53l. 

66.  Elpern  EH.  Pulmonary  aspiration  in  hospitalized  adults.  Nutr  Clin 
Pract  I997;I2(I):.5-I3. 

67.  Young  PJ,  Ridley  SA,  Downward  G.  Evaluation  of  a  new  design  of 
tracheal  tube  cuff  to  prevent  leakage  of  fluid  to  the  lungs.  Br  J 
Anaesth  l998;80(6):796-799. 

68.  Spray  SB,  Zuidema  GD,  Cameron  JL.  Aspiration  pneumonia:  inci- 
dence of  aspiration  with  endotracheal  tubes.  Am  J  Surg  1976:131(6): 
701-703. 

69.  Meduri  GU.  Ventilator-associated  pneumonia  in  patients  with  respi- 
ratory failure:  a  diagnostic  approach  (review).  Chest  1990:97(5): 
1208-1219. 

70.  Torres  A.  Aznar  R.  Gatell  JM.  Jiminez  P,  Gonzalez  J,  Ferrer  A.  et  al. 
Incidence,  risk,  and  prognosis  factors  of  nosocomial  pneumonia  in 
mechanically  ventilated  patients.  Am  Rev  Respir  Dis  1990:142(3): 
52.3-528. 

7 1 .  Kollef  MH,  Silver  P.  Ventilator-associated  pneumonia:  an  update  for 
clinicians.  Respir  Care  1995;40(  1 1 ):  1 1 30- 1 140. 

72.  Valles  J.  Artigas  A,  Rello  J.  Bonsoins  N.  Fontanals  D.  Blanch  L.  et 
al.  Continuous  aspiration  of  subglottic  secretions  in  preventing  ven- 
tilator-associated pneumonia.  Ann  Intern  Med  1 995;  122(3):  179- 1 86. 

73.  Coppolo  DP.  May  JJ.  Self-extubations:  a  1 2-month  experience.  Chest 
1990:98(1):  165-169. 

74.  Listello  D.  SesslerCN.  Unplanned  extubation:  clinical  predictors  for 
reintubation.  Chest  1994;I05(5):1496-L503. 

75.  Tindol  GA  Jr.  DiBenedetto  RJ,  Kosciuk  L.  Unplanned  extubations. 
Chest  1 994;  105(6):  1 804- 1 807. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


84  i 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


76.  Crimlisk  JT,  Bernardo  J,  Blansfield  JS,  Loughlin  M,  McGonagle  EG, 
McEachern  G,  et  al.  Endotracheal  reintubation:  a  closer  look  at  a 
preventable  condition.  Clin  Nurse  Spec  1997:1 1(4):I45-150. 

77.  Maguire  GP,  DeLorenzo  LJ.  Moggie  RA.  Unplanned  extubation  in 
the  intensive  care  unit:  a  quality-of-care  concern.  Crit  Care  Nurs  Q 
1994:17(3):40-47. 

78.  Ripoll  1,  Lindholm  CE,  Carroll  R,  Grenvik  A.  Spontaneous  disloca- 
tion of  endotracheal  tubes.  Anesthesiology  1978:49(1  ):50-52. 

79.  Betbese  AJ,  Perez  M,  Bak  E.  Rialp  G,  Mancebo  J.  A  prospective 
study  of  unplanned  endotracheal  extubation  in  intensive  care  unit 
patients.  Crit  Care  Med  1998;26(7):1 180-1 186. 

80.  Boulain  T.  Unplanned  extubations  in  the  adult  intensive  care  unit:  a 
prospective  multicenter  study.  Association  des  Reaniniateurs  du  Cen- 
tre-Ouest.  Am  J  RespirCrit  Care  Med  1998:157(4  Pt  1):1 131-1 137. 

81.  Chevron  V,  Menard  JF,  Richard  JC,  Girault  C,  Leroy  J,  Bonmarc- 
hand  G.  Unplanned  extubation:  risk  factors  of  development  and  pre- 
dictive criteria  for  reintubation.  Crit  Care  Med  1998:26(6):  1049- 
1053. 

82.  Atkins  PM,  Mion  LC,  Mendelson  W,  Palmer  RM,  Slomka  J,  Franko 
T.  Characteristics  and  outcomes  of  patients  who  self-extubate  from 
ventilatory  support:  a  case-control  study.  Chest  1997:1 12(5):  1317- 
1323. 

83.  Kollef  MH,  Legare  EJ,  Damiano  M.  Endotracheal  tube  misplace- 
ment: incidence,  risk  factors,  and  impact  of  a  quality  improvement 
program.  South  Med  J  1994:87(2):248-254. 

84.  Astrachan  DI,  Kirchner  JC,  Goodwin  WJ  Jr.  Prolonged  intubation 
vs.  tracheotomy:  complications,  practical  and  psychological  consid- 
erations. Laryngoscope  1988:98(1 1):1 165-1 169. 

85.  Rashkin  MC,  Davis  T.  Acute  complications  of  endotracheal  intuba- 
tion. Relationship  to  reintubation,  route,  urgency,  and  duration.  Chest 
1986;89(2):165-167. 

86.  Kearl  RA,  Hooper  RG.  Massive  airway  leaks:  an  analysis  of  the  role 
of  endotracheal  tubes.  Crit  Care  Med  1993:21(4):518-521. 

87.  Bergbom-Engberg  1,  Haljainae  H.  Assessment  of  patients'  experi- 
ence of  discomforts  during  respirator  therapy.  Crit  Care  Med  1989: 
17(10):  1068- 1072. 

88.  Hartley  M,  Vaughan  RS.  Problems  associated  with  tracheal  extuba- 
tion (review).  Br  J  Anaesth  1993:71(4):561-568. 

89.  Asai  T,  Koga  K,  Vaughan  RS.  Respiratory  complications  associated 
with  tracheal  intubation  and  extubation.  Br  J  Anaesth  1998:80(6): 
767-775. 

90.  Sanou  J,  llboudo  D,  Rouamba  A,  Traore  O.  [Sore  throat  after  tra- 
cheal intubation.)  Cah  Anesthesiol  1996;44(3):203-206. 

91.  Christensen  AM,  Willemoes-Larsen  H,  Lundby  L,  Jakobsen  KB. 
Postoperative  throat  complaints  after  tracheal  intubation.  Br  J  An- 
aesth 1994:73(6):786-787. 

92.  Mackenzie  CF,  Shin  B,  McAslan  TC,  Blanchard  CL,  Cowley  RA. 
Severe  stridor  after  prolonged  endotracheal  intubation  using  high- 
volume  cuffs.  Anesthesiology  1979:50(3):235-239. 

93.  Ho  LI,  Ham  HJ,  Lien  TC,  Hu  PY,  Wang  JH.  Postextubation  laryn- 
geal edema  in  adults:  ri.sk  factor  evaluation  and  prevention  by  hy- 
drocortisone. Intensive  Care  Med  1996:22(9):933-936. 

94.  Darmon  JY,  Rauss  A,  Dreyfuss  D,  Bleichner  G,  Elkharrat  D,  Schlem- 
mer  B,  et  al.  Evaluation  of  risk  factors  for  laryngeal  edema  after 
tracheal  extubation  in  adults  and  its  prevention  by  dexamethasone:  a 
placebo-controlled,  double-blind  multicenter  study.  Anesthesiology 
1992:77(2):245-251. 

95.  Anene  O,  Meert  KL,  Uy  H,  Simpson  P,  Sarnaik  AP.  Dexamethasone 
for  the  prevention  of  postextubation  airway  obstruction:  a  prospec- 
tive, randomized,  double-blind,  placebo-controlled  trial.  Cril  Care 
Med  1996:24(10):  1666- 1669. 

96.  Jones  MW,  Catling  S,  Evans  E,  Green  DH,  Green  JR.  Hoarseness 
aftei  tracheal  intubation.  Anaesthesia  I992:47(3):213-216. 


97.  Colice  GL.  Resolution  of  laryngeal  injury  following  translaryngeal 
intubation.  Am  Rev  Respir  Dis  1992:145(2  Pt  1):36 1-364. 

98.  Cheong  KF,  Chan  MY,  Sin-Fai-Lam  KN.  Bilateral  vocal  cord  pa- 
ralysis following  endotracheal  intubation.  Anaesth  Intensive  Care 
1994:22(2):206-208. 

99.  Burgess  GE  3rd,  Cooper  JR  Jr,  Marino  RJ,  Peuler  MJ,  Warriner  RA 
3rd.  Laryngeal  competence  after  tracheal  extubation.  Anesthesiol- 
ogy 1979:51(0:73-77. 

100.  DeVita  MA,  Spierer-Rundback  L.  Swallowing  disorders  in  patients 
with  prolonged  orotracheal  intubation  or  tracheostomy  tubes.  Crit 
Care  Med  1990: 18(1 2):  1328-1 330. 

101.  Leder  SB,  Cohn  SM,  Moller  BA.  Fiberoptic  endoscopic  documen- 
tation of  the  high  incidence  of  aspiration  following  extubation  in 
critically  ill  trauma  patients.  Dysphagia  1998;13(4):208-212. 

102.  Sugerman  HJ,  Wolfe  L,  Pasquale  MD,  Rogers  FB,  O'Malley  KF, 
Knudson  M,  et  al.  Multicenter,  randomized,  prospective  trial  of 
early  tracheostomy.  J  Trauma  1997:43(5):74I-747. 

103.  Elliott  CG,  Rasmusson  BY,  Crapo  RO.  Upper  airway  obstruction 
following  adult  respiratory  distress  syndrome:  an  analysis  of  30 
survivors.  Chest  1988:94(3):526-530. 

104.  Balestrieri  F,  Watson  CB.  Intubation  granuloma  (review).  Otolar- 
yngol Clin  North  Am  1982:15(3):567-569. 

105.  Rubio  PA,  Farrell  EM,  Bautista  EM.  Severe  tracheal  stenosis  after 
brief  endotracheal  intubation.  South  Med  J  1979;72(12):1628-1629. 

106.  Brooks  R,  Bartlett  RH,  Gazzaniga  AB.  Management  of  acute  and 
chronic  disorders  of  the  trachea  and  subglottis.  Am  J  Surg  1985: 
15()(1):24-31. 

107.  Wood  DE,  Mathisen  DJ.  Late  complications  of  tracheotomy.  Clin 
Chest  Med  1991:12(3):597-609. 

108.  Friman  L,  Hedenstierna  G,  Schildt  B.  Stenosis  following  tracheos- 
tomy: a  quantitative  study  of  long-term  results.  Anaesthesia  1976; 
31(4):479^93. 

109.  Myers  EN.  Carrau  RL.  Early  complications  of  tracheotomy.  Inci- 
dence and  management.  Clin  Chest  Med  1991:12(3):589-595. 

1 10.  Heffner  JE,  Ca.sey  K,  Hoffman  C.  Care  of  the  mechanically  venti- 
lated patient  with  a  tracheotomy.  In:  Tobin  MJ,  editor.  Principles 
and  practice  of  mechanical  ventilation.  New  York:  McGraw-Hill: 
1994:749-774. 

111.  Lewis  RJ.  Tracheostomies:  indications,  timing,  and  complications 
(review).  Clin  Chest  Med  1992:13(1):137-149. 

1 1 2.  Stauffer  JL,  Silvestri  RC.  Complications  of  endotracheal  intuba- 
tion, tracheostomy,  and  artificial  airways.  Respir  Care  1982:27(4): 
417-434. 

1 13.  Gold.stein  SI,  Breda  SD,  Schneider  KL.  Surgical  complications  of 
bedside  tracheotomy  in  an  otolaryngology  residency  program.  La- 
ryngoscope 1 987:97(  1 2):  1 407- 1 409. 

1 1 4.  Meade  JW.  Tracheotomy — its  complications  and  their  management: 
a  study  of  212  cases.  N  Engl  J  Med  1961;265:519-523. 

1 15.  McClelland  RM.  Complications  of  tracheostomy.  Br  Med  J  1965; 
2:567-569. 

116.  Stemmer  EA,  Oliver  C,  Carey  JP,  Connolly  JE.  Fatal  complications 
of  tracheotomy.  Am  J  Surg  1976:1 31  (3):288-290. 

117.  Chew  JY,  Cantrell  RW.  Tracheostomy:  complications  and  their 
management  (review).  Arch  Otolaryngol  1972;96(6):538-545. 

118.  Dunham  CM,  LaMonica  C.  Prolonged  tracheal  intubation  in  the 
trauma  patient.  J  Trauma  1984;24(2):120-124. 

1 19.  Rodriguez  JL,  Steinberg  SM,  Luchetti  FA,  Gibbons  KJ,  Taheri  PA, 
Flint  LM.  Early  tracheostomy  for  primary  airway  management  in 
the  surgical  critical  care  setting.  Surgery  1990:108(4):655-659. 

120.  Kenan  PD.  Complications  a.ssociated  with  tracheostomy:  prevention 
and  treatment.  Otolaryngol  Clin  North  Am  1979;12(4):8()7-816. 

121.  Stock  MC,  Woodward  CG,  Shapiro  BA,  Cane  RD,  Lewis  V,  Pecaro 
B.  Perioperative  complications  of  elective  tracheostomy  in  criti- 
cally ill  patients.  Crit  Care  Med  1986:l4(10):861-863. 


842 


RESPIRATORY  Care  •  JULY  1999  VoL  44  No  7 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


122.  Ameye  F,  Mallelin  W,  Ingels  K,  Bradwell  R.  Bilateral  pneumulho- 
rax  after  emergency  tracheotomy:  two  case  reports  and  a  review  of 
the  literature.  J  Laryngol  Otol  1994;l08(l):69-70. 

123.  Miller  JD,  Kapp  JP.  Complications  of  tracheostomies  in  neurosur- 
gical patients.  Surg  Neurol  I984;22(2):I86-188. 

124.  Upadhyay  A,  Maurer  J,  Turner  J.  Tiszenkel  H,  Rosengart  T.  Elec- 
tive bedside  tracheo.stomy  in  the  intensive  care  unit.  J  Am  Coll  Surg 
1996:182(1  ):5 1 -55. 

125.  Dane  TE,  King  EG.  A  prospective  study  of  complications  after 
tracheostomy  for  assisted  ventilation.  Chest  I975;67(4):398^04. 

126.  Ching  NP,  Nealon  TF  Jr.  Clinical  experience  with  new  low-pres- 
sure high-volume  tracheostomy  cuffs:  importance  of  limiting  inlra- 
cuff  pressure.  NY  State  J  Med  1974:74(1 3):2379-2384. 

127.  Andrews  MJ.  Pearson  FG.  Incidence  and  pathogenesis  of  tracheal 
injury  following  cuffed  tube  tracheostomy  with  assisted  ventilation: 
analysis  of  a  two-year  prospective  study.  Ann  Surg  1971:173(2): 
249-263. 

128.  Law  JH.  Bamhart  K,  Rowlett  W,  de  la  Rocha  O.  Lowenberg  S. 
Increased  frequency  of  obstructive  airway  abnormalities  with  long- 
term  tracheostomy.  Chest  I993:I04(I):136-I38. 

129.  Thomas  AN.  Management  of  tracheoesophageal  fistula  caused  by 
cuffed  tracheal  lubes.  Am  J  Surg  I972:I24(2):181-I89. 

1 30.  Barley  HR.  Ulcerative  tracheo-oesophageal  fistula  during  treatment 
by  tracheostomy  and  intermittent  positive  pressure  ventilation.  Tho- 
rax 1972;27(3):338-352. 

131.  Jones  WG.  Madden  M,  Finkelstein  J,  Yurt  RW,  Goodwin  CW. 
Tracheostomies  in  burn  patients.  Ann  Surg  I989;209(4):471^74. 

132.  Leeds  WM,  Morley  TF.  Zappasodi  SJ,  Giudice  JC.  Computed  to- 
mography for  diagnosis  of  tracheoesophageal  fistula.  Crit  Care  Med 
l986:l4(6):59i-592. 

133.  Berkmen  YM.  Auh  YH.  CT  diagnosis  of  acquired  tracheoesopha- 
geal fistula  in  adults.  J  Comput  Assist  Tomogr  I985:9(2):.302-.3()4. 

134.  Silen  W,  Spieker  D.  Fatal  hemorrhage  from  the  innominate  artery 
after  tracheostomy.  Ann  Surg  1965:162(6): l(X)5-l  112. 

135.  Mehalic  TF,  Farhat  SM.  Tracheoarlerial  fi.stula:  a  complication  of 
tracheostomy  in  patients  with  brain  stem  injury.  J  Trauma  1972: 
I2(2):I40-143. 

136.  Jones  JW.  Reynolds  M,  Hewitt  RL.  Drapanas  T.  Tracheo-innomi- 
nate  artery  erosion:  successful  surgical  inanagement  of  a  devastat- 
ing complication.  Ann  Surg  I976;184(2):  194-204. 


140 


141 


137.  Maipang  T,  Singha  S,  Panjapiyakul  C,  Tolemckokchyakarn  P.  Me- 
diastinal tracheostomy.  Am  J  Surg  I996;17I(6):58l-586. 

138.  Wright  CD.  Management  of  tracheoinnominate  artery  fistula  (re- 
view). Chest  Surg  Clin  N  Am  I996:6(4):865-873. 

139.  Keceligil  HT.  Erk  MK,  Kolbakir  F.  Yildirim  A,  Yilman  M.  Unal  R. 
Tracheoinnominate  artery  fistula  following  tracheostomy.  Cardio- 
vasc  Surg  1995:3(5):509-510. 

Elpem  EH,  Scott  MG.  Petro  L.  Ries  MH.  Pulmonary  aspiration  in 
mechanically  ventilated  patients.  Chest  1994;I05(2):563-566. 
Lien  TC,  Wang  JH.  [Incidence  of  pulmonary  aspiration  with  dif- 
ferent kinds  of  artificial  airways.  |  Chung  Hua  I  Hsueh  Tsa  Chih 
(Taipei)  1 992:49(5  ):348-353. 

142.  Shaker  R,  Milbrath  M,  Ren  J,  Campbell  B,  Toohill  R,  Hogan  W. 
Deglutitive  aspiration  in  patients  with  tracheostomy:  effect  of  tra- 
cheostomy on  the  duration  of  vocal  cord  closure.  Gastroenterology 
I995:108(5):I357-I360. 

143.  Pavlin  EG,  Nelson  E.  Pulliam  J.  Difficulty  in  removal  of  tracheos- 
tomy tubes.  Anesthesiology  1976:44(1  ):69-70. 

144.  Ivatury  R,  Siegel  JH,  Stahl  WM,  Simon  R,  Scorpio  R,  Gens  DR. 
Percutaneous  tracheostomy  after  trauma  and  critical  illness.  J  Trauma 
1992;32(2):133-I40. 

145.  van  Heurn  LW,  Goei  R,  de  Ploeg  I,  Ramsay  G,  Brink  PR.  Late 
complications  of  percutaneous  dilatational  tracheotomy.  Chest  1996; 
1 10(6):  1572-1576. 

146.  Waldron  J,  Padgham  ND,  Hurley  SE.  Complications  of  emergency 
and  elective  tracheostomy:  a  retrospective  study  of  150  consecutive 
cases.  Ann  R  Coll  Surg  Engl  1990:72(4):2l8-220. 

147.  Berenholz  LP,  Vail  S,  Berlet  A.  Management  of  tracheocutane- 
ous  fistula.  Arch  Otolaryngol  Head  Neck  Surg  1992:118(8): 
869-871. 

148.  Geffin  B,  Pontoppidan  H.  Reduction  of  tracheal  damage  by  the  pre- 
stretching  of  infiatable  cuffs.  Anesthesiology  1969:3 1(5):462^63. 

149.  Grillo  HC.  Donahue  DM.  Post  intubation  tracheal  stenosis.  Semin 
Thorac  Cardiovasc  Surg  l996:8(4):370-380. 

150.  Fryer  ME,  Marshall  RD.  Tracheal  dilatation.  Anaesthesia  1976: 
3l(4):470-478. 

151.  Pecora  DV,  Seinige  U.  Prolonged  endotracheal  intubation  (letter). 
Chest  1982:82(1):  130. 


Discussion 

Heffner:  I  wonder  how  we  might 
weight  the  complications.  I  think  it  wa.s 
stated  earlier  that  the  clinical  implica- 
tions of  subglottic  stenosis  are  greater  in 
terms  of  the  opportunity  for  repair,  com- 
pared to  tracheal  stenosis.  When  we  look 
at  those  proportions,  even  though  we 
know  they're  coming  from  different 
studies,  how  could  we  possibly  weight 
those  proportions  on  the  basis  of  clini- 
cal significance  so  we  can  find  out  which 
procedure  would  be  preferred  in  terms 
of  airway  injury? 


Stauffer:  From  looking  at  these  pa- 
pers, I  don't  think  that  we  can  assign 
a  weight  in  terms  of  the  associated 
morbidity  and  mortality.  Clearly  we 
need  new  information  about  the  mor- 
bidity of  laryngeal  and  tracheal  steno- 
sis, I  have  little  doubt  that  subglottic 
and  glottic  stenosis  is  a  much  more 
serious  problem  than  bottleneck  ste- 
nosis of  the  trachea,  which  can  usu- 
ally be  repaired  with  laser  therapy  or 
with  resectional  operations.  However, 
1  would  defer  to  the  experience  of  oto- 
laryngologists and  surgeons  who  have 
dealt  with  this  personally. 


Bishop:  One  thing  that's  interesting 
to  me  is  why  only  the  occasional 
patient  develops  laryngeal  stenosis, 
and  most  heal  so  readily.  In  dog 
studies,  we  maintained  ETTs  in  dogs 
and  scoped  them  on  a  regular  basis. 
The  tubes  were  sutured  in  place,  but 
one  dog  chewed  the  suture  and 
coughed  out  the  tube.  The  next  day 
when  we  looked  at  it,  the  very  signif- 
icant ulcers  that  had  been  there  a  day 
or  2  before  were  already  largely 
healed,  I  think  that's  what  Gene  Co- 
lice's  study  showed,  as  well — that 
complete  healing  took  place  in  the  vast 


Respiratory  Care  •  July  1999  Vol  44  No  7 


84.^ 


Complications  of  Endotracheal  Intubation  and  Tracheotomy 


majority  of  patients.  It  was  amazing 
to  me  how  quickly  the  mucosa  healed 
in  the  vast  majority  of  cases.  One  of 
the  puzzles  is  why  it  should  only  be 
the  rare  patient  who  actually  gets  into 
trouble  with  scarring  and  stenosis. 

REFERENCE 

I.  Colice  GL.  Resolution  of  laryngeal  injury 
following  translaryngeal  intubation.  Am  Rev 
RespirDis  1992;145(2  Pt  l):361-364. 

Reibel:  1  don't  think  it's  just  the 
folks  who  have  mucosal  injury.  I  think 
there  have  to  be  other  factors  involved 
and  that  one  very  significant  factor  is 
gastroesophageal  reflux  or  laryngo- 
pharyngeal reflux.  Koufman  has  writ- 
ten extensively  on  laryngopharyngeal 
reflux,  and  I  think  he's  really  on  to 
something.''^  Two  of  the  worst  ste- 
notic problems  I've  ever  encountered 
were  both  in  women  who  had  had  very 
short  intubations  and  were  both  symp- 
tomatic refluxers  prior  to  their  surgery 
and  the  development  of  their  compli- 
cations. They'd  never  had  treatment, 
and  basically  were  at  a  Stage  4  steno- 
sis, with  no  airway.  The  best  thing  is 
to  be  aware  of  the  problems  and  try  to 
prevent  them.  If  a  patient  will  have  an 
orogastric  or  nasogastric  tube,  try  to 
use  a  small,  soft  tube.  If  you  think  it's 
going  to  be  there  for  a  while,  think 
about  doing  a  G-tube.  If  they  have 
any  history  of  reflux,  treat  them  ag- 
gressively. 

REFERENCES 

1 .  Koufman  JA  .  The  otolaryngologic  manifes- 
tations of  gastroesophageal  reflux  disease 
(GERD):  a  clinical  investigation  of  225  pa- 


tients using  ambulatory  24-hour  pH  moni- 
toring and  an  experimental  investigation  of 
the  role  of  acid  and  pepsin  in  the  develop- 
ment of  laryngeal  injury.  Laryngoscope 
1991;101(4  Pt  2  Suppl  53):l-78. 
2.  Koufman  J.  Sataloff  RT,  Toohill  R.  Laryn- 
gopharyngeal reflux:  consensus  conference 
report.  J  Voice  1996;I0(3):215-216. 

Stauffer:  Investigators  have  looked 
at  a  number  of  potential  risk  factors 
for  laryngeal  ulceration  from  endotra- 
cheal intubation,  and  there  is  contin- 
ued debate  about  the  role  of  duration 
of  endotracheal  intubation  in  the 
pathogenesis  of  these  ulcers.  They  can 
appear  with  very  short-term  intuba- 
tions; the  shortest  duration  I  have  read 
about  is  15  minutes.  I've  seen  some 
case  reports  where  patients  were  intu- 
bated for  many  weeks  without  evi- 
dence of  ulceration.  Yet,  several  pro- 
spective studies  have  concluded  that 
duration  of  intubation  is  significant. 
Hypotension,  corticosteroid  therapy, 
gender,  tube  size,  infection,  move- 
ment, and  other  possible  risk  factors 
have  been  studied,  but  I  don't  think 
any  conclusive  remarks  can  be  made 
about  them.  Still,  I  welcome  Dr 
Reibel 's  comment  about  the  potential 
role  of  gastroesophageal  reflux.  We 
know  that's  a  cause  of  hoarseness,  and 
perhaps  it  plays  a  role  in  the  patho- 
genesis of  laryngeal  ulceration. 

Heffner:  We  typically  look  at  cer- 
tain "hard"  outcomes  that  are  easy  to 
measure  and  appear  important  to  us, 
such  as  survival  and  evidence  of  tra- 
cheal stenosis,  but  when  we  study  dif- 
ferent, more  subtle  outcomes  that  are 
valued  by  patients,  we  often  obtain 


different  findings.  I  was  impressed  by 
one  study  of  long-term  nasotracheal 
intubation,'  which  measured  the  prev- 
alence of  sinus  symptoms,  voice  qual- 
ity, the  ability  to  sing,  and  other  pa- 
tient-centered outcome  measures  of 
complications  from  airway  manage- 
ment. I  was  impressed  with  the  high 
proportion  of  patients  who  reported 
subtle  complications  and  the  central- 
ity  of  these  complications  to  their  self- 
perceived  quality  of  life.  I  wonder  if 
you're  aware  of  any  other  studies  that 
looked  at  these  types  of  outcomes. 

REFERENCE 

I .  Holdgaard  HO,  Pedersen  J.  Schurizek  BA. 
Melsen  NC.  Juhl  B.  Complications  and 
late  sequelae  following  na.sotracheal  intu- 
bation. Acta  Anaesthesiol  Scand   1993; 

37(5):475-480. 

Stauffer:  Colice  reported  that  heal- 
ing of  laryngeal  injury  from  prolonged 
translaryngeal  intubation  occurs 
within  8  weeks,  and  parallels  the  res- 
olution of  symptoms  such  as  hoarse- 
ness.' So,  laryngeal  injury  is  revers- 
ible, but  it  takes  time. 

REFERENCE 

1.  Colice  GL.  Resolution  of  laryngeal  injury 
following  translaryngeal  intubation.  Am  Rev 
Respir  Dis  I992;I45(2  Pt  l):36l-364. 

Bishop:  It's  interesting  that  serious 
singers  don't  even  want  to  be  intu- 
bated for  routine  surgical  procedures, 
because  injury  and  some  voice  changes 
take  place  even  in  the  brief  period  of 
the  surgical  procedure. 


844 


Respiratory  Care  •  July  1999  Vol  44  No  7 


The  Effects  of  Tracheostomy  Tube  Placement  on 
Communication  and  Swallowing 


Maxine  K  Orringer  MA  CCC-SLP 


Introduction 

Communication  Skill  Development 

The  Effect  of  Tracheostomy  on  Communication  Skill  Development 
Assessment  and  Treatment  of  Communication  Disorders 

Family  Involvement  in  the  Treatment  Process 
Speaking  Valves 
Other  Options 
The  Team  Approach 
Feeding  and  Swallowing 

The  Normal  Swallow 

The  Impact  of  the  Tracheostomy  on  Feeding  and  Swallowing 
Tracheostomy  Tubes  and  Aspiration 
Evaluation  of  Feeding  and  Swallowing 
Treatment 
Summary 

[RespirCare  1999;44(7):845-853]  Key  words:  tracheostomy,  speaking  trache- 
ostomy valve,  communication,  swallowing,  aspiration,  feeding. 


Introduction 


Communication  Skill  Development 


While  the  placement  of  a  tracheostomy  tube  has  signif- 
icant medical  ramifications,  both  positive  and  negative,  it 
also  has  equally  significant  effects  on  communication  skill 
development  and  feeding.  This  review  addresses  the  im- 
pact of  the  presence  of  a  tracheostomy  on  the  development 
of  speech  (the  production  of  sound),  language  (compre- 
hension and  production  of  words  and  sentences),  and  feed- 
ing abilities  in  children.  We  also  discuss  modes  of  assess- 
ment and  intervention  in  these  areas,  and  the  team  members 
involved.  Perhaps  the  most  important  member  of  the  team 
is  the  family,  for  whom  the  risks  and  benefits  have  the 
greatest  impact. 


Maxine  K  Orringer  MA  CCC-SLP  is  affiliated  with  the  Department  of 
Audiology  and  Communication  Disorders,  Children's  Hospital  of  Pitts- 
burgh, Pittsburgh,  Pennsylvania. 

Correspondence:  Maxine  K  Orringer  MA  CCC-SLP.  Communication 
Disorders  Department,  Children's  Hospital  of  Pittsburgh.  3705  Fifth 
Avenue  at  DeSoto  Street.  Pittsburgh  PA  15213-2538.  E-mail: 
katzorm@chplink.CHP.EDU. 


Communication  skill  development  begins  at  the  mo- 
ment the  newborn  and  parents  meet.  It  is  natural  for  par- 
ents to  talk  to  their  infants  and  to  wait  with  great  antici- 
pation for  some  type  of  vocal  response.  Each  response  is 
met  with  delight  from  the  infant's  family,  which  reinforces 
the  child's  continued  vocalization.  Great  attention  is  paid 
to  the  month-by-month  acquisition  of  new  communication 
skills,  from  babbling,  to  jargoning,  to  using  true  words.  By 
one  year  of  age,  children  are  adept  at  conveying  a  variety 
of  messages.  Prizant  and  Wetherby's  1990  article  outlines 
Bruner's  3  categories  of  communicative  intent  that  emerge 
by  the  end  of  the  first  year  of  life.  Via  verbal  and  nonver- 
bal means,  children  use  signals  for  behavioral  regulation 
(requesting  objects  and  actions,  and  protesting),  social  in- 
teraction (requesting  comfort,  calling,  greeting,  showing 
off,  requesting  permission),  and  joint  attention  (comment- 
ing on  an  object,  action,  or  event,  and  requesting  informa- 
tion).' At  this  age  the  child  is  producing  approximately  15 
words,  and  by  age  2  is  putting  words  together  into  sen- 
tences. Language  learning  is  closely  related  to  the  devel- 
opment of  emotional  and  cognitive  skills.-  As  the  child 
continues  to  acquire  a  variety  of  inter-related  skills,  speech 


Respiratory  Care  •  July  1999  Vol  44  No  7 


6  '■:  .-> 


Tracheostomy:  Communication  and  Swallowing 


and  language  serve  as  the  bridge  to  his  or  her  intellectual 
and  emotional  development. 

The  Effect  of  Tracheostomy  on  Communication 
Skill  Development 

The  acquisition  of  communication  skills  is  a  fragile  pro- 
cess, which  can  be  affected  by  a  number  of  factors,  in- 
cluding tracheostomy  tube  placement.  Earlier  diagnosis 
and  intervention  of  airway  obstruction  in  infants  and  new- 
boms  have  led  to  increased  survival  rates  for  this  popula- 
tion. There  are  not  only  more  children  with  tracheosto- 
mies, but  the  duration  of  tube  placement  has  also  increased, 
and  tube  placement  is  more  likely  to  continue  into  the 
linguistic  period  (ie,  the  time  when  use  of  language,  verbal 
and/or  nonverbal  should  emerge),  resulting  in  an  extended 
period  during  which  the  tube  inhibits  communication  skill 
development.^  Most  researchers  would  agree  that  children 
with  tracheostomies  are  at  risk  for  delays  in  communica- 
tion skill  development  if  therapeutic  intervention  is  not 
provided,''  especially  if  the  tracheostomy  tube  is  placed  in 
the  pre-linguistic  period,''  but  there  is  some  disagreement 
regarding  the  exact  impact  of  the  presence  of  a  tracheos- 
tomy on  communication  skill  development.  Hill  and  Sing- 
er's 1990  study  found  that  tracheotomized  children  with- 
out primary  neurological  disorders  or  mental  retardation 
appeared  to  have  articulation  and  expressive  language  def- 
icits, but  developed  receptive  language  skills  commensu- 
rate with  their  overall  cognitive  abilities.^  Other  research- 
ers have  found  that  these  children  do  have  receptive 
language  impairment,  although  to  a  lesser  degree.* 

For  many  children,  the  underlying  medical  issues  that 
necessitate  the  tracheostomy  (eg,  extreme  prematurity,  neu- 
rological disorders)  also  impinge  on  the  child's  develop- 
ment. At  the  most  basic  level,  children  receive  tracheos- 
tomies for  airway  management,  and  may  experience  subtle 
episodes  of  hypoxia  prior  to  or  after  tracheostomy  place- 
ment.^ Neuromotor  involvement,  cognitive  deficits,  and 
social/emotional  difficulties  provide  additional  etiologic 
features  contributing  to  possible  delays.  The  need  for  me- 
chanical ventilation  can  further  complicate  this  picture,  not 
only  by  limiting  the  child's  ability  to  vocalize,  but  also  by 
requiring  the  child  to  adapt  his  speech  rate  to  the  ma- 
chine's ventilatory  cycle  and  to  learn  to  vocalize  during 
the  inspiratory  cycle.  Mechanical  ventilation  restricts  the 
child's  mobility  and  ability  to  engage  in  social  interac- 
tions,'' which  affects  the  development  of  communication 
skills  and  the  child's  motivation  to  use  these  skills. 

An  important  factor  contributing  to  delayed  speech  and 
expressive  language  development  in  the  tracheotomized 
infant  may  be  his  inability  to  vocalize  (ie,  the  child  is 
unable  to  pass  air  around  the  tracheostomy  tube  and  up 
through  the  vocal  folds,  resulting  in  the  inability  to  create 
voice),  rhis  is  due  in  part  to  the  fact  that  the  child  does  not 


have  the  opportunity  to  practice  vocalizing  and  developing 
the  oral  motor  patterns  necessary  for  sound  production.  If 
this  vocal  deprivation  extends  into  the  linguistic  period  (ie, 
when  symbolic  language  is  used),  the  child  may  experi- 
ence significant  speech  and  language  delays  after  decan- 
nulation.5  Other  important  parent-child  interactions  that 
occur  early  in  the  speech  and  language  learning  process, 
such  as  reciprocal  sound  play  and  imitation,  may  also  be 
missing.  Parents  may  stop  talking  to  their  babies  when 
their  own  communication  attempts  are  met  with  silence. 
This  is  a  difficult  time  for  parents.  They  wonder  if  their 
child  will  ever  talk  and  what  they  can  do  to  encourage 
communication  skill  development.  According  to  Mac- 
Donald,  "Communication  is  the  universal  tool  families 
have  to  build  relationships  with  children".'  It  is  an  impor- 
tant part  of  the  speech-language  pathologist's  job  to  ad- 
dress these  concerns  and  to  encourage  the  continuation  of 
parent-child  communication  through  all  available  sensory 
channels.  This  is  the  beginning  of  the  speech  therapy  pro- 
cess. 

Assessment  and  Treatment  of 
Communication  Disorders 

While  care  should  be  taken  not  to  overwhelm  families 
of  children  with  new  tracheostomies,  therapeutic  interven- 
tion with  a  strong  focus  on  parent  education  should  begin 
as  soon  as  the  child  is  medically  stable.  The  process  begins 
with  evaluation  of  the  child's  receptive/expressive  lan- 
guage, ability  to  produce  voice,  vocal  quality,  resonance, 
and  oral  motor  skills.  When  appropriate,  feeding  and  swal- 
lowing abilities  are  also  assessed.  And  finally,  the  child's 
medical  status  and  overall  cognitive  and  social  develop- 
ment (including  hearing  and  vision)  must  be  taken  into 
consideration.  The  evaluation  is  accomplished  via  a  vari- 
ety of  channels,  including  parental  interview,  ob.servation 
of  the  child,  and  administration  of  standardized  evalua- 
tions. 

Family  Involvement  in  the  Treatment  Process 

Once  the  assessment  is  complete,  the  therapist  can  pro- 
vide family  members  with  information  and  practical  sug- 
gestions regarding  speech/language  development.  This  in- 
formation provides  parents  with  a  positive  way  of 
interacting  with  their  child,  and  a  means  of  nurturing  de- 
velopmental gains.  Parents  can  learn  to  identify  nonvocal 
communication  behaviors  that  are  observable  in  infants 
during  the  first  8  to  10  months  of  life.'  These  behaviors, 
which  communicate  the  infant's  emotional  or  physiologi- 
cal state  include  changes  in  body  tone,  movement,  and  rate 
of  breathing.  By  12-24  months  of  age,  children  are  com- 
municating via  conventional  gestures,  including  pointing, 
waving,  reaching,'  facial  expression,  eye  contact  or  eye 


846 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheostomy:  Communication  and  Swallowing 


Fig.  1 .  Left:  Passy-Muir  Speaking  Valve.  Middle:  Kistner  Valve  (no 
longer  made).  Right:  Shiley  Speaking  Valve. 

aversion,  and  body  posture,  to  convey  pleasure  as  well  as 
protest.  Increasing  parents'  awareness  of  their  child's  non- 
verbal signals  helps  them  become  better  "listeners."  If  the 
child  is  not  yet  using  these  skills,  parents  can  be  taught  to 
stimulate  nonverbal  communication.  By  acknowledging 
and  enhancing  the  infant  or  young  child's  natural  commu- 
nication, we  are  providing  him  or  her  with  the  opportunity 
to  develop  interpersonal  and  cognitive  skills  as  well. 

Additional  skills  that  are  prerequisite  to  expressive  lan- 
guage development  include  social  and  purposeful  play  and 
turn-taking — skills  that  parents  can  nurture  in  the  course 
of  their  daily  interactions."'  Parents  can  also  be  taught  a 
variety  of  techniques  to  encourage  both  receptive  and  ex- 
pressive language  development,  including  self-talk  (talk- 
ing to  the  child  about  what  he  or  she  is  doing  with  the 
child)  and  parallel  talk  (talking  about  what  the  child  is 
doing).  These  techniques  provide  the  child  with  meaning- 
ful language  relevant  to  his  or  her  world. 

Speaking  Valves 

In  older  children  who  require  tracheostomy,  the  issues 
may  not  be  articulation  or  language  development.  These 
children  may  have  difficulties  producing  clear  voice  or 
adequate  vocal  volume.  A  speaking  valve  can  assist  with 
these  difficulties.  By  preventing  air  escape  through  the 
tracheostomy  during  exhalation,  breath  is  channeled  around 
the  tracheostomy  and  up  through  the  vocal  cords,  allowing 
for  voice  production.  With  a  cuffed  tracheostomy  tube,  the 
cuff  must  be  deflated.  It  is  extremely  important  to  remem- 
ber that  a  child  should  never  be  left  unattended  when  the 
speaking  valve  is  in  place.  Secondary  benefits  of  a  speak- 
ing valve  include  decreased  secretions  and  increased  ol- 
faction, possibly  because  of  redirection  of  air  flow  through 
the  oral  and  nasal  passages.** 

There  are  a  number  of  types  of  speaking  tracheostomy 
valves,  including:  the  Passy-Muir  (Passy-Muir  Inc,  Irvine, 


Fig.  2.  Olympic  Trach-Talk.  During  inspiration,  a  spring  keeps  the 
valve  open.  During  expiration  the  valve  closes.  (Tube  provided 
courtesy  of  Olympic  Medical). 


California)  (Fig.  1);  Shiley  (Mallinckrodt,  Pleasanton,  Cal- 
ifornia) (see  Fig.  1);  Olympic  (Olympic  Medical,  Seattle, 
Washington)  (Fig.  2);  and  the  Montgomery  (Stuart  K  Mont- 
gomery, Westborough,  Massachusetts).  These  valves  vary 
in  regard  to  air  resistance  during  inhalation  and  safeguards 
during  exhalation.'  For  example,  while  it  is  not  uncommon 
for  valves  to  be  ejected  during  coughing,  the  Montgom- 
ery's diaphragm  partially  opens  to  allow  the  forceful  ex- 
halation to  escape  without  blowing  it  off  the  trach  hub. 

Not  all  children  are  candidates  for  a  speaking  valve.  The 
use  of  a  pulse  oximeter  during  speaking  valve  trials  is 
helpful  in  determining  if  the  child  can  maintain  adequate 
Oj  levels.  If  the  space  between  the  tracheostomy  tube  and 
tracheal  wall  does  not  allow  for  adequate  exhalation,  or  if 
the  tracheostomy  has  been  placed  as  a  result  of  stenosis, 
the  child  can  experience  air  trapping  and  respiratory  com- 
plications, including  pneumothorax  and  subcutaneous  em- 
physema. One  way  to  test  for  air  trapping  is  to  listen  for  a 
"puff  of  air  when  the  speaking  valve  is  removed.  The 
"puff  is  created  when  air  that  could  not  be  exhaled  orally 
escapes  via  the  tracheostomy.  Other  symptoms  that  should 
result  in  discontinuation  of  valve  use  include  significantly 
increased  heart  rate,  increased  coughing,  change  in  respi- 
ratory pattern  or  respiratory  effort,  or  the  child's  report  of 
discomfort.'"  The  valve  can  be  used  with  some  patients 
requiring  mechanical  ventilation  (Fig.  3),  but  it  is  contra- 
indicated  for  patients  with  laryngeal  and  pharyngeal  dys- 
function and  those  with  very  low  lung  compliance  and 
increased  airway  resistance."  These  patients  cannot  re- 
ceive adequate  ventilation  when  the  cuff  is  deflated. 

Given  the  various  factors  that  must  be  taken  into  con- 
sideration, the  decision  to  use  a  speaking  valve  must  be 
made  by  a  team  including  the  speech/language  pathologist, 
otolaryngologist,  and  respiratory  therapist.  While  families 
are  often  very  anxious  to  begin  using  a  speaking  valve,  it 
is  important  to  keep  in  mind  that  a  child  can  vocalize 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheostomy:  Communication  and  Swallowing 


Passy-Muir  Tracheostomy 
Speaking  Valve  connects 
directly  to 
tracheostomy  tube 
with  15-mm  hub 


Wide  mouth  short  flex 
tubing  slides  over  valve 


Adapter  connects 
short  flex  tubing 
to  respiratory  line 


Valve  placement 
with  standard  — 
swivel  adapter 


Fig.  3.  Passy-Muir  Speaking  Valve  adapted  for  use  with  ventilated 
patients.  (Figure  courtesy  of  Passy-Muir  Inc.) 


without  the  use  of  a  speaking  valve.  Although  cannula  size 
is  dependent  on  the  child's  respiratory  needs,  selecting  the 
smallest  cannula  possible  to  meet  those  needs  will  aid  the 
child  in  obtaining  the  best  possible  vocal  volume  and  qual- 
ity. Even  without  a  speaking  valve,  children  requiring  me- 
chanical ventilation  are  often  better  able  to  produce  voice 
with  the  presence  of  a  leak  around  the  tracheostomy.  Vo- 
calization during  mechanical  ventilation  is  produced  on 
inspiration  rather  than  expiration,  as  is  normally  the  case. 

Other  Options 

Another  option  for  encouraging  vocalization  is  digital 
occlusion  of  the  tracheostomy  tube.  This  technique  is  not 
appropriate  in  children  for  whom  a  speaking  valve  cannot 


be  used.  When  appropriate,  this  is  an  especially  good  way 
of  encouraging  vocalization  in  small  infants.  The  clinician 
listens  carefully  for  the  child  to  inhale  and  then  covers  the 
tracheostomy  during  exhalation  (not  just  when  at  rest  but 
also  when  laughing  or  crying),  once  again  encouraging  air 
to  pass  around  the  tracheostomy  tube  and  through  the  vo- 
cal cords.  It  is  important  to  feel  the  rhythm  of  the  child's 
breathing  and  initially  to  occlude  the  tracheostomy  only 
briefly.  Stimulating  the  infant  to  laugh  or  coo  during  tra- 
cheostomy occlusion  is  very  often  the  first  means  of  hav- 
ing the  child  vocalize.  Toddlers  often  will  learn  to  simply 
drop  their  chins  to  occlude  the  tracheostomy  and  produce 
vocalizations.  The  "blue  baskets"  used  to  prevent  a  child 
from  inadvertently  interfering  with  breathing  can  be  re- 
moved during  therapy  or  periods  of  vocal  stimulation.  For 
some  toddlers  who  refuse  a  speaking  valve,  digital  occlu- 
sion of  their  tracheostomy  is  more  successful,  as  they  have 
complete  control  over  when  to  occlude  the  trach.  Because 
finger  occlusion  can  result  in  infection,  this  technique  might 
be  most  desirable  for  short-term  use.'^ 

The  use  of  esophageal  voice  is  another  communication 
option.  While  this  is  more  commonly  thought  of  in  the 
adult  population,  normal  children  have  been  observed  to 
experiment  with  the  production  of  esophageal  speech  by 
belching.''' 

The  use  of  speaking  tracks  is  yet  another  means  of 
facilitating  sound  production  in  the  tracheotomized  child. 
A  fenestrated  tracheostomy  has  one  large  or  several  small 
holes  on  the  outer  curve  of  the  tube,  which  allow  air  to 
escape  from  the  tracheostomy  and  pass  through  the  vocal 
folds  to  produce  voice.  These  tubes  can  be  cuffed  or  cuffless, 
with  or  without  an  inner  cannula.  Although  the  fenestrated 
tracheostomies  are  useful  for  some  children,  the  fenestrae 
can  become  occluded  with  secretions  that  reduce  air  flow 
and  increase  airway  resistance.  When  used  with  a  venti- 
lator-dependent patient,  the  ventilator  tubing  can  pull  on 
the  tube,  causing  it  to  rotate.  With  the  change  in  position, 
the  fenestra  may  become  occluded  by  the  tracheal  wall. 
Fenestrated  tracheostomies  are  not  appropriate  for  patients 
with  a  history  of  aspiration.' 

There  are  also  several  varieties  of  cuffed  tracheostomy 
tubes  that  allow  the  patient  to  speak  with  the  cuff  inflated, 
such  as  the  Portex  Trach-Talk  Blue  Line  Tracheostomy  Tube 
(Sims  Portex,  Keene,  New  Hampshire)  (Fig.  4).  These  tubes 
have  an  additional  small  piece  of  tubing  above  the  cuff 
that  attaches  to  an  external  air  source.  This  additional  air 
is  channeled  through  the  vocal  cords,  producing  voice. 
While  this  device  is  effective,  the  increased  airflow  can 
cause  throat  dryness  and  concomitant  discomfort  in  some 
patients. 

If  the  tracheostomized  child  is  unable  to  vocalize  or 
obtain  adequate  vocal  volume,  the  use  of  a  total  commu- 
nication approach  is  required.  Such  an  approach  combines 
a  variety  of  communication  modalities,  including  natural 


848 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheostomy:  Communication  and  Swallowing 


Fig.  4.  Portex  Trach-Talk  Blue  Line  Tracheostomy  Tube  witli  cuff 
inflated. 


gesture,  sign  language,  facial  expression,  vocalization,  and 
augmentative  or  alternative  communication  systems.  Par- 
ents often  are  hesitant  to  have  their  children  begin  to  use 
manual  sign  language,  fearing  that  they  will  not  learn  to 
vocalize  and  use  spoken  language,  and  that  many  people 
will  not  be  able  to  understand  their  child.  It  is  my  expe- 
rience that  once  the  child  is  able  to  say  a  word  intelligibly, 
the  signed  version  of  the  word  is  abandoned.  In  regard  to 
the  child  being  understood  by  nonsigners,  many  of  the 
early  signs  are  iconic  (ie,  they  look  like  the  action  they 
represent).  For  example,  the  sign  for  "drink"  is  made  by 
pretending  to  hold  a  glass  and  drink.  "Eat"  is  conveyed  by 
touching  fingers  to  the  mouth. 

There  are  some  distinct  benefits  to  sign  language:  port- 
ability; absence  of  the  maintenance  functions  required  with 
electronic  communication  devices;  signing  can  be  used  in 
places  where  electronic  devices  cannot  (eg,  swimming  pool, 
bathtub);  signing  has  no  limit  in  regard  to  lexicon  size,  so 
it  can  expand  at  the  child's  rate  of  development;  and  par- 
ents can  begin  using  sign  at  birth  so  that  the  child  is 
exposed  to  manual  communication  in  the  same  way  that  he 
or  she  is  exposed  to  words.  Children  imitate  the  commu- 
nication models  used  in  their  environment,-  and  will  model 
sign  if  vocalization  is  not  an  option  available  to  them. 
While  it  is  not  uncommon  to  teach  adapted  signs  to  chil- 
dren with  impaired  fine  motor  skills,  signing  may  not  be 
an  option  for  a  child  with  extremely  poor  motor  skills,  as 
his  or  her  productions  may  be  unintelligible.  In  that  case, 
another  mode  of  communication  should  be  selected. 

A  communication  system  is  augmentative  if  it  supple- 
ments a  child's  communication  efforts,  or  alternative  if 
used  in  place  of  traditional  spoken  communication.  The 
level  of  sophistication  of  the  device  depends  upon  the 
abilities  and  needs  of  the  child  (Fig.  5  and  Fig.  6).  Highly 
sophisticated  computerized  devices  can  be  accessed  via 
touch  or  a  variety  of  switches,  including  optical  head  point- 
ers, pneumatic  "sip  and  puff  switches,  or  manual  switches. 


Fig.  5.  Speak  Easy  Communication  Device.  The  device  can  be 
controlled  by  pressing  individual  touch  pads  or  via  svi/itch  access. 
(Both  the  device  and  switch  are  products  of  Able  Net  Inc,  Minne- 
apolis, Minnesota.  Picture  communication  symbols  used  wth  the 
permission  of  the  Mayer  Johnson  Company,  copyright  1 981  -1 998.) 


Fig.  6.  Dual  Clock  Communicator  (with  the  Say  It  Play  It  Switch 
Plate).  The  patient  selects  objects  by  depressing  a  switch  that 
causes  the  hand  to  move  until  the  patient  stops  the  hand  near  the 
desired  object.  (Enabling  Devices  and  Toys  for  Special  Children 
Inc,  Hastings-on-Hudson,  New  York). 


When  activated,  such  devices  generally  speak  a  phrase  or 
sentence.  In  some  systems  the  patient  or  therapist  can  even 
select  a  voice  appropriate  for  the  patient.  Such  devices 
have  a  wide  variety  of  applications,  ranging  from  basic 
communication  to  high  level  "written"  work  that  can  be 
downloaded  into  a  computer  and  printed. 

A  less  technical  augmentative  system  might  be  as  sim- 
ple as  a  communication  picture  book.  The  child  commu- 
nicates by  pointing  to  pictures  to  convey  a  message.  For 
children  who  are  unable  to  point,  eye  gaze  can  be  used  to 
select  messages  from  a  communication  board.  Such  boards 
can  be  purchased  or  constructed  from  a  clear  piece  of 
lucite.  Pictures  are  mounted  on  the  Incite  board  and  the 
board  is  placed  between  the  child  and  the  communication 


Respiratory  Care  •  July  1999  Vol  44  No  7 


849 


Tracheostomy:  Communication  and  Swallowing 


partner  so  that  the  communication  partner  can  see,  through 
the  board,  which  picture  the  child  looks  at  to  convey  the 
desired  message. 

An  electrolarynx  can  also  be  helpful  when  working  with 
a  child  who  is  unable  to  produce  voice.  Typically  in  adults 
the  electrolarynx  is  placed  on  the  neck.  It  produces  an 
audible  tone  that  is  shaped  into  speech  sounds  as  the  user 
mouths  the  words.  Because  it  is  sometimes  difficult  to  find 
a  comfortable  place  on  a  the  child's  neck  for  placement  of 
the  device,  the  use  of  an  intra-oral  adapter  is  preferable. 
This  device  not  only  allows  the  child  to  produce  "voice" — it 
also  provides  the  child  with  the  oral  motor  component  of 
speech  so  that  after  decannulation  he  has  had  practice  with 
the  movements  required  to  produce  speech.  There  are  many 
obstacles  to  the  use  of  this  device.  Many  patients  and 
parents  do  not  readily  accept  this  mode  of  communication 
because  the  voice  produced  by  the  electrolarynx  is  quite 
mechanical.  Some  practice  is  required  in  order  for  the 
patient  to  achieve  intelligible  speech  with  this  device. 
Words  must  be  spoken  slowly  and  articulated  precisely. 
Adequate  strength  to  hold  and  activate  the  electrolarynx 
while  coordinating  its  use  with  speaking  is  also  necessary. 

The  Team  Approach 

While  many  of  these  issues  can  be  addressed  by  a  speech/ 
language  pathologist,  a  team  approach  is  critical  in  work- 
ing with  the  tracheostomized  child.  The  physical  therapist 
may  need  to  work  with  the  child  to  achieve  appropriate 
positioning.  This  is  crucial  for  children  with  neurological 
deficit,  so  that  they  can  obtain  optimal  use  of  their  hands 
for  signing  or  activation  of  a  switch-controlled  augmenta- 
tive communication  device.  Good  head  positioning  is  nec- 
essary for  a  child  to  use  eye  gaze.  The  occupational  ther- 
apist may  need  to  provide  splints  or  assist  in  switch 
selection.  The  respiratory  therapist  may  need  to  adjust 
ventilator  settings  during  therapy  to  accommodate  in- 
creased activity.  In-home  nurses  can  become  partners  in 
the  therapeutic  process,  encouraging  carry-over  of  therapy 
goals  into  the  daily  environment.  Most  importantly,  par- 
ents, through  natural  interactions  with  their  child,  can  fos- 
ter the  child's  desire  to  communicate  and  use  the  new 
skills  introduced  by  the  therapists. 

More  than  one  agency  may  be  involved  in  providing  the 
child's  therapy  and  medical  care.  Coordination  and  com- 
munication between  agencies  and  therapists  are  essential 
to  assure  an  organized  therapy  program  with  complemen- 
tary goals.  However,  in  designing  a  treatment  program,  the 
child's  respiratory  condition,  neurologic  status,  tolerance 
for  positioning/activity,  and  the  effects  of  medications  on 
the  child's  status  must  all  be  taken  into  consideration."* 
Once  again,  parents  should  be  viewed  as  critical  members 
of  the  treatment  team,  since  they  know  their  child  best  and 


can  often  provide  invaluable  insight  into  the  needs  and 
abilities  of  the  child. 

An  important  component  required  to  fully  attend  to  a 
child's  communication  needs  is  the  monitoring  of  hearing. 
Children  with  long-term  tracheostomies  are  at  risk  for  sen- 
sorineural or  conductive  hearing  losses'^  and  should  be 
evaluated  by  a  certified  audiologist.  Unidentified  and  un- 
remediated  hearing  loss  provides  yet  another  roadblock  for 
the  language-learning  child. 

Feeding  and  Swallowing 
The  Normal  Swallow 

The  swallowing  process  is  divided  into  4  phases.'*  Dur- 
ing the  oral  preparatory  phase  food  is  presented  into  the 
oral  cavity.  Lip  closure  prevents  anterior  loss  of  the  ma- 
terial while  the  velum  rests  against  the  base  of  the  tongue 
to  prevent  posterior  loss  of  the  bolus.  Food  is  transported 
by  the  tongue  to  the  chewing  surfaces  of  the  teeth.  Via 
rotary  movement  of  the  mandible  and  tongue,  solid  foods 
are  broken  down  into  pieces  appropriately  sized  for  safe 
swallowing.  The  masticated  material  is  combined  with  sa- 
liva and  formed  into  a  cohesive  bolus.  The  oral  phase  of 
the  swallow  is  initiated  when  the  tongue  begins  to  trans- 
port the  bolus  to  the  posterior  portion  of  the  oral  cavity. 
When  the  bolus  passes  the  anterior  faucial  arches  the  oral 
phase  is  ended.  At  this  point,  the  swallow  is  triggered, 
marking  the  beginning  of  the  pharyngeal  phase  where  the 
bolus  is  propelled  into  the  pharynx.  Now  the  velum  ele- 
vates to  prevent  food  from  entering  the  nasopharynx.  The 
vocal  cords  approximate,  the  epiglottis  closes,  the  larynx 
moves  anteriorly/superiorly  and  the  cricopharyngeus  re- 
laxes to  allow  the  bolus  to  pass  through  into  the  esopha- 
gus. The  esophageal  phase  occurs  when  the  bolus  passes 
through  the  cricopharyngeus  and  into  the  cervical  esophagus. 

The  Impact  of  the  Tracheostomy  on  Feeding  and 
Swallowing 

The  physical  act  of  swallowing  is  neurologically  and 
physiologically  complex.  Successful  swallowing  requires 
the  coordination  of  as  many  as  3 1  pairs  of  striated  muscles 
and  5  cranial  nerves.'*  Yet,  for  most  children,  develop- 
ment of  feeding  and  swallowing  skills  occurs  in  a  seamless 
progression  along  the  feeding  continuum,  beginning  with 
bottle  feeding  and  ending  with  the  introduction  of  table 
food  at  1 2  months  of  age.  While  many  children  with  tra- 
cheostomies experience  no  difficulty  with  feeding  and  swal- 
lowing, for  others  the  presence  of  a  tracheostomy  may 
create  obstacles  resulting  in  dysphagia  (ie,  impaired  ability 
to  chew  or  swallow  liquids  and/or  solids),  aspiration,  food 
refusal,  and,  ultimately,  poor  nutrition. 


850 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheostomy:  Communication  and  Swallowing 


Presence  of  the  tracheostomy  interrupts  normal  glottic 
and  subglottic  air  flow.  This  can  result  in  decreased  laryn- 
geal sensation  and  reduced  cough  effectiveness,'"'  which 
affect  swallowing  as  well  as  the  ability  to  protect  the  air- 
way. Typically,  expiration  following  completion  of  the 
normal  swallow  helps  to  clear  residue  remaining  in  the 
airway  or  pharynx.  Breathing  through  the  tracheostomy 
eliminates  expiratory  air  flow  through  the  pharynx,  thus 
eliminating  another  protective  mechanism.  Insertion  of  a 
tracheostomy  causes  the  larynx  to  be  anchored  in  place, 
preventing  normal  anterosuperior  laryngeal  excursion  dur- 
ing the  swallow.  The  presence  of  ventilator  tubing  and/or 
a  cuffed  tracheostomy  tube  further  impedes  the  upward 
movement  of  the  larynx  as  the  tubing  provides  extra  weight 
and  the  cuff  is  dragged  along  the  tracheal  walls  with  each 
swallow.'^  Impaired  laryngeal  excursion  may  result  in  in- 
adequate protection  of  the  airway  and  aspiration  after  the 
swallow  has  been  completed.  Excessive  cuff  pressures  can 
result  in  stricture  formation  or  tracheal  dilatation  at  the 
level  of  the  cuff,  '**  which  can  also  affect  swallowing.  The 
presence  of  an  open  tracheostomy  in  an  otherwise  closed 
system  affects  the  patency  of  the  swallow  by  disrupting 
airway  pressures.  This  airway  pressure,  generated  by  the 
base  of  the  tongue  on  the  bolus,  assists  with  bolus  move- 
ment through  the  pharynx  and  into  the  esophagus.  Alter- 
ation in  this  pressure  results  in  pharyngeal  residue  follow- 
ing the  swallow.''' 

The  medical  disorders  leading  to  tracheostomy  place- 
ment can  result  in  dysphagia,  as  can  the  medications  used 
to  treat  the  illness.  Breakdown  can  occur  during  any  phase 
of  the  swallow.  In  the  oral  preparatory  phase,  weak  oral 
musculature  in  an  infant  can  result  in  a  poor  lip  seal  around 
the  nipple.  This  causes  loss  of  formula  anteriorly  and  in- 
sufficient ability  to  extract  liquid  from  the  bottle.  In  an 
older  child,  weak  musculature  can  make  chewing,  bolus 
preparation,  and  transport  difficult.  If  the  child  is  unable  to 
control  the  bolus,  it  may  leave  the  oral  cavity  prematurely, 
spilling  into  the  pharynx  and  possibly  into  the  open  air- 
way. During  the  pharyngeal  phase,  low  tone  can  result  in 
poor  palatal  elevation,  causing  nasopharyngeal  reflux.  Med- 
ications such  as  decongestants  or  antihistamines  that  cause 
xerostomia  (dry  mouth)  may  make  bolus  preparation  and 
transport  difficult.  Conversely,  medications  that  increase 
production  of  secretions  may  place  children  who  aspirate 
at  greater  risk. 

Tracheostomy  Tubes  and  Aspiration 

Patients  with  tracheostomy  tubes  are  at  significant  risk 
for  aspiration.  The  indicators  of  aspiration  are  coughing 
and  choking  during  feeding,  increased  congestion  during 
or  after  feeding,  increased  fussiness  during  feeding,  fre- 
quent or  persistent  respiratory  illnesses,  persistent  low  grade 
fever,  a  wet  vocal  quality  during  or  after  feeding,  or  failure 


of  the  child  to  progress  to  the  next  developmental  level  of 
feeding.  Very  often,  children  are  aware  of  their  swallow- 
ing difficulties  and  will  limit  their  diet  to  foods  they  feel 
they  can  manage  safely.  A  child  may  prefer  to  stay  with 
pureed  baby  food  rather  than  progress  to  more  highly  tex- 
tured foods  if  he  or  she  has  experienced  choking  or  diffi- 
culty swallowing  with  that  consistency.  Children  who  si- 
lently aspirate  thin  liquids  (ie,  they  are  not  coughing  or 
choking  in  reaction  to  aspiration)  are  often  described  as 
not  liking  to  drink  or  as  becoming  fussy  as  soon  as  the 
bottle  is  presented.  In  these  instances,  food  refusal  may  be 
the  result  of  the  child's  attempt  to  protect  his/her  airway. 
Once  again,  the  child's  behavior  must  be  viewed  as  a 
communication  regarding  his  or  her  feeding  and  swallow- 
ing ability.  If  he  or  she  is  refusing  a  particular  food  con- 
sistency, it  is  important  to  explore  the  reason  for  that  re- 
fusal. 

Evaluation  of  Feeding  and  Swallowing 

Assessment  of  a  child's  feeding  and  swallowing  abili- 
ties is  performed  by  a  team  of  professionals,  which  may 
include  a  dietitian,  physician,  speech/language  pathologist, 
occupational  therapist,  physical  therapist,  psychologist, 
and/or  social  worker.  The  evaluation  begins  with  a  thor- 
ough history  of  the  child's  medical,  developmental,  nutri- 
tional, oral  motor,  and  feeding  status.  Next,  a  feeding  ob- 
servation, often  referred  to  as  a  "bedside  assessment"  is 
conducted.  During  this  portion  of  the  evaluation,  the  team 
observes  the  parents  as  they  feed  their  child,  noting  the 
parents"  technique  as  well  as  the  child's  responses.  Only 
the  oral  preparatory  phase  can  be  observed  in  this  situa- 
tion, beginning  with  observation  of  lip  closure  during  drink- 
ing and  clearing  food  from  eating  utensils.  Buccal  tone  is 
noted  because  lax  cheek  muscles  can  result  in  food  pock- 
eting in  the  buccal  spaces,  from  which  it  can  be  aspirated 
later.  Tongue  and  jaw  movement  are  noted  in  regard  to 
bolus  preparation. 

Behavioral  issues  also  are  addressed  during  this  assess- 
ment. Food  refusal  can  result  from  oral  hypersensitivity, 
possibly  because  of  ongoing  unpleasant  stimulation  such 
as  frequent  oral  suctioning  or  prolonged  tube  feedings. 
Malnourished  children  might  also  be  subjected  to  forced 
feedings  because  of  a  caregiver's  anxiety  regarding  the 
child's  need  for  calories  and  fluid.  Food  refusal  may  result 
from  the  child's  negative  association  with  feeding  itself 
This  is  frequently  the  case  with  children  who  suffer  gas- 
troesophageal reflux,  who  learn  to  associate  feeding  with 
vomiting  and  discomfort.  Similarly,  ventilator-dependent 
infants  who  have  difficulty  sucking  find  feeding  uncom- 
fortable because  of  abdominal  distention  and  the  need  for 
frequent  burping.''  Behavioral  feeding  difficulties  can  also 
occur  as  a  result  of  prolonged  hospitalizations,  chronic 
illness,  and  multiple  feeders  or  care  givers.  Also,  the  lack 


Respiratory  Care  •  July  1999  Vol  44  No  7 


851 


Tracheostomy:  Communication  and  Swallowing 


of  air  flow  via  the  upper  airway  affects  the  olfactory  aspect 
of  feeding,  which  also  may  affect  the  child's  willingness 
to  eat. 

When  children  severely  limit  the  quantity  or  variety  of 
foods  they  are  willing  to  consume,  malnutrition  can  result. 
Compromised  nutritional  status  affects  the  immune  sys- 
tem, leading  to  recurrent  illnesses,  during  which  time  the 
child  requires  (but  is  less  likely  to  consume)  increased 
caloric  intake,  thus  worsening  the  child's  nutritional  sta- 
tus."* Malnutrition  can  also  result  in  behavioral  changes 
and  weakness,  which  further  hinder  feeding. 

If  aspiration  is  suspected,  additional  testing  may  be  re- 
quired, because  it  is  difficult  to  accurately  determine  the 
presence  of  aspiration  during  the  clinical  evaluation.  In 
their  1988  study  Splaingard  et  a!"  compared  clinicians' 
bedside  diagnosis  of  aspiration  to  modified  barium  swal- 
low study  results,  and  found  that  experienced  clinicians 
significantly  underestimated  the  presence  of  aspiration,  ac- 
curately judging  its  presence  only  42%  of  the  time.  The 
Evans  blue  dye  test  can  be  used  as  an  initial  screening 
procedure  in  this  process.  This  evaluation  is  conducted  by 
first  suctioning  secretions  from  the  child's  tracheostomy 
and  oral  cavity.  If  present,  the  cuff  is  deflated.  The  patient 
then  swallows  a  small  amount  of  methylene  blue  dye  mixed 
with  food  or  liquid.  At  varying  intervals  following  intro- 
duction of  the  dye,  secretions  are  suctioned  via  the  trache- 
ostomy. The  presence  of  the  blue  dye  in  the  secretions 
does  not  indicate  that  oral  feeding  should  be  stopped  im- 
mediately, but  it  does  indicate  that  additional  assessment, 
such  as  a  modified  barium  swallow  study,  should  be  pur- 
sued. Due  to  the  possibility  of  false-negative  results  and 
the  lack  of  standardization,  the  efficacy  of  this  assessment 
is  in  question  by  many  researchers.'**  While  this  evaluation 
can  provide  some  insight  into  the  presence  of  immediate 
aspiration,  it  is  most  useful  when  used  in  conjunction  with 
careful  clinical  observation  and  a  modified  barium  swal- 
low study. 

The  clinical  evaluation  considers  only  the  oral  prepara- 
tory phase,  whereas  the  modified  barium  swallow  study 
evaluates  the  oral  and  pharyngeal  phases  as  well.  This 
dynamic  video  fluoroscopic  evaluation  differs  from  a  reg- 
ular barium  swallow  in  that  an  attempt  is  made  to  simulate 
normal  feeding.  The  child  is  placed  in  an  upright  position 
(or  position  approximating  that  in  which  the  child  is  typ- 
ically fed)  and  provided  with  a  variety  of  food  consisten- 
cies (combined  with  barium)  under  intermittent  video  flu- 
oroscopy. Food  is  presented  in  the  manner  typical  for  that 
child  (eg,  bottle,  sippie  cup,  or  spoon).  This  study  seeks  to 
determine  both  the  presence  and  etiology  of  aspiration, 
which  helps  the  clinician  decide  which  food  consistencies 
are  safe  and  what  additional  variables  can  be  manipulated 
to  achieve  safe  feeding.  The  use  of  a  Passy-Muir  speaking 
valve  has  been  found  to  improve  the  swallow  and  decrease 
aspiration.-"  Light  digital  occlusion  of  the  tracheostomy 2' 


may  also  have  the  same  effect.  Therefore,  swallows  may 
be  evaluated  both  with  and  without  a  valve  or  digital  oc- 
clusion, and  compared  during  the  modified  barium  swal- 
low study. 

Treatment 

Recommendations  for  treatment  are  based  on  the  results 
of  the  clinical  and  video  fluoroscopic  assessments.  Treat- 
ment may  involve  changing  the  order  of  food  presentation 
(eg,  alternating  food  and  liquid  to  clear  the  residue  in  the 
mouth  and  pharynx  and  eliminate  aspiration  occurring  af- 
ter the  swallow),  the  position  in  which  the  child  is  fed,  the 
equipment  used  to  feed  the  child,  and/or  the  rate  with 
which  food  is  presented.  Altering  the  volume  of  each  bite 
as  well  as  the  consistency  or  temperature  of  the  child's  diet 
is  often  necessary.  Oral  stimulation  may  be  initiated  to 
prevent  or  decrease  oral  hypersensitivity  and  the  resulting 
food  refusal.  Such  a  program  introduces  pleasant  stimula- 
tion to  the  oral  cavity,  using  a  variety  of  textures,  temper- 
atures, and  tastes  of  food  if  permitted.  Again,  parent  train- 
ing is  a  critical  part  of  this  therapeutic  endeavor,  especially 
in  children  with  behavioral  feeding  issues.  Teaching  par- 
ents techniques  for  safe  feeding  and  indicators  for  possible 
difficulties  helps  to  increase  their  level  of  confidence  and 
decrease  their  anxiety  around  meal  times.  Review  of  the 
taped  videofluorscopic  examination  is  a  helpful  tool  for 
teaching  parents  why  particular  recommendations  have 
been  made. 

Parents  derive  a  sense  of  accomplishment  and  normality 
when  they  are  able  to  nourish  their  children.  However, 
there  are  times  when  safe  feeding  cannot  be  accomplished 
or  nutritional  requirements  cannot  be  met  via  oral  feeding. 
In  these  instances  the  use  of  an  alternative  means  of  feed- 
ing, such  as  a  gastrostomy  or  nasogastric  tube  may  be 
necessary.  Tube  feedings  often  result  in  improved  nutri- 
tion and  decreased  respiratory  illness,  which  promotes  op- 
timal development.  When  possible,  tastes  of  food  for  plea- 
sure and  oral  stimulation  programming  will  continue  to 
pave  the  way  for  subsequent  introduction  of  feeding. 

Summary 

Tracheostomy  tubes  can  have  a  significant  effect  on  the 
child's  ability  to  acquire  communication  and  swallowing 
skills.  Early  assessment,  intervention,  and  parent  educa- 
tion are  critical  in  helping  these  children  to  achieve  opti- 
mal performance  in  both  areas.  A  team  approach  is  nec- 
essary, with  the  child's  parents  being  key  team  members. 

REFERENCES 

1 .  Prizant  M.  Wetherby,  AM.  Assessing  the  communication  of  infants 
and  toddlers:  integrating  a  socioemotional  perspective.  Zero  to  Three 
]990;ll(l). 

2.  Hall  SS,  Weatherly  KS.  Using  sign  language  with  Iracheotomized 
infants  and  children.  Pediatr  Nurs  l989;L'5(4);362-.'^67. 


852 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheostomy:  Communication  and  Swallowing 


10. 


12. 


Hill  BP,  Singer  LT.  Speech  and  language  development  after  infant 
tracheostomy.  J  Speech  Hear  Disord  l990;55(l):l5-20. 
Kaslon  KW,  Stein  RE.  Chronic  pediatric  tracheotomy:  assessment  13. 

and  implications  for  habilitation  of  voice,  speech  and  language  in 
young  children.  Int  J  Pediatr  Otorhinolaryngol  I985;9(2):l6.'i-I7l. 
Simon  BM.  Silverman  McGowan  J.  Tracheostomy  in  young  chil-  14. 

dren:  implication  for  a.ssessment  and  treatment  of  communication 
and  feeding  disorders.  Inf  Young  Children  1 989;  1(3):  I -9.  15. 

Mallory  GB  Jr,  Stillwell  PC.  The  ventilator-dependent  child:  issues  in 
diagnosis  and  management.  Arch  Phys  Med  Rehabil  1 99 1  ;72(  I  ):43-55.  1 6. 

MacDonald  JD.  Carrol  JY.  A  partnership  model  for  communicating 
with  infants  at  risk.  Inf  Young  Children  1992;4(3):2O-30.  17. 

Lichtman  SW.  Birnbaum  IL,  Sanfilippo  MR,  Pellicone  JT.  Damon 
WJ,  King  ML.  Effect  of  a  tracheostomy  speaking  valve  on  secre- 
tions, arterial  oxygenation,  and  olfaction:  a  quantitative  evaluation.  J  1 8. 
Speech  Hear  Res  l995;38(3):549-555. 

Fomataro-Clerici  L,  Zajac  DJ.  Aerodynamic  characteristics  of  tra- 
cheostomy speaking  valves.  J  Speech  Hear  Res  l993;36(3):529-532.  19. 
Jackson  D,  Albamonte  S.  Enhancing  communication  with  the  Passy- 
Muir  valve.  Pediatr  Nursl994;20(2):  149-153. 

Manzano  JL,  Lubillo  S,  Henrique?.  D,  Martin  JC.  Perez  MC,  Wilson  20. 

DJ.  Verbal  communication  of  ventilator-dependent  patients.  Crit  Care 
Med  I993;2I(4):5I2-5I7.  21. 

Silverman  McGowan  J,  Bleile  KM.  Fus  L,  Bamas  E.  Communica- 
tion disorders.  In:  Bleile,  KM,  editor.  The  care  of  children  with 


long-term  tracheostomies.  San  Diego:  Singular  Publishing  Group; 
1993:113-137. 

Kaslon  KW,  Grabo,  DE,  Ruben,  RJ.  Voice,  speech  and.  language 
habilitation  in  young  children  without  laryngeal  function.  Arch  Oto- 
laryngol l978;l04(12):737-739. 

Ahmann  E,  Lipsi  KA.  Early  intervention  for  technology-dependent 
infants  and  young  children.  Inf  Young  Children  l991;3(4):67-77. 
Logemann,  JA.  Evaluation  and  treatment  of  swallowing  disorders. 
San  Diego:  College  Hill  Press;  1983:18-26. 
Steven.son  RD,  Allaire  JH.  The  development  of  normal  feeding  and 
.swallowing.  Pediatr  Clin  North  Am  1991  ;38(6):  1439-1453. 
Dikeman  KJ.  Kazandjian  MS.  Communication  and  swallowing  man- 
agement of  iracheotomized  and  ventilator-dependent  adults.  San  Di- 
ego: Singular  Publishing  Group;  1997:243,  246. 
Higgins  DM,  Maclean  JC.  Dysphagia  in  the  patient  with  a  trache- 
ostomy: six  cases  of  inappropriate  cuff  deflation  or  removal.  Heart 
Lung  l997;26(3):2l5-220. 

Splaingard  ML.  Hutchins  B,  Sulton  LD,  Chaudhuri  G.  Aspiration  in 
rehabilitation  patients:  videofluoroscopy  vs  bedside  clinical  assess- 
ment. Arch  Phys  Med  Rehabil  1988;69(8):637-640. 
Eibling  DE,  Gross  RD.  Subglottic  air  pressure:  a  key  component  of  swal- 
lowing efficiency.  Ann  Otol  Rhinol  Laryngol  l996;105(4):253-258. 
Logemann  JA,  Pauloski  BR,  Colangelo  L.  Light  digital  occlusion  of 
the  tracheostomy  tube:  a  pilot  study  of  effects  on  aspiration  and 
biomechanics  of  the  swallow.  Head  Neck  1998;20(l):52-57. 


Discussion 

Heffner:  I  wonder  if  you  could  re- 
view the  protocol  for  reinitiating  feed- 
ing for  patients  who  have  been  recently 
extubated  in  the  ICU.  House  staff  of- 
ten follow  the  same  approach  they  use 
for  re  feeding  the  bowel  after  surgery, 
starting  with  liquids  and  working  their 
way  up.  What  would  you  recommend? 

Orringer:  I  would  definitely  recom- 
mend not  starting  with  liquids,  in  spite 
of  the  fact  that  that's  what  everyone 
does.  People  tend  to  think  liquids  are 
the  easiest  to  handle,  when  in  reality 
they  are  most  difficult.  I  prefer  start- 
ing with  semisolids,  but  even  before 
that,  there  are  steps  to  make  oral  feed- 
ing easier,  including  reintroducing 
taste.  With  children,  I  start  with  lolli- 
pops or  licorice  whips  or  minuscule 
drops  of  liquid  in  the  mouth  for  sen- 
sation and  taste.  Some  patients  are  so 
prone  to  aspiration  that  any  oral  stim- 
ulation leads  to  increased  secretions 
(salivation)  and  aspiration.  If  patients 
do  well  with  this  beginning,  I  move 
them  on  to  a  semisolid  diet,  but  start- 
ing with  liquids  is  asking  for  diffi- 
culty. 


Thompson:  Is  there  any  reason  to 
think  adults  would  be  different? 

Orringer:  No.  While  you  might 
not  want  to  use  lollipops  and  licorice 
whips  with  adults,  there  is  no  reason 
to  expect  adults  to  handle  liquids  well 
as  their  first  exposure  to  oral  intake 
after  intubation.  Liquid  is  just  diffi- 
cult to  handle.  It's  much  more  affected 
by  gravity,  and  there  isn't  really  any 
oral  preparatory  phase  for  liquids.  It 
passes  through  the  mouth  straight  to 
the  oral  phase.  This  makes  it  difficult 
to  tolerate  in  patients  of  all  ages. 

Durbin:  Is  there  any  worry  in  trying 
to  feed  patients  with  cuffed  endotra- 
cheal tubes  who  are  on  full  mechani- 
cal ventilation?  Certainly,  I've  never 
seen  a  normal-swallowing  study  in 
anyone  still  intubated.  Even  though 
they  look  good  clinically  and  wanted 
to  eat,  the  study  always  shows  enough 
abnormalities  that  everybody  gets  ner- 
vous. I  always  say  "They've  got  a 
cuffed  endotracheal  tube,  which  pre- 
vents aspiration.  No  big  deal."  I  find 
myself  debating  dietitians,  nurses,  and 
others  about  feeding.  Is  there  really 
anything  I  can  do  to  improve  swal- 


lowing in  intubated,  ventilated  pa- 
tients? If  they're  going  to  need  venti- 
lation for  weeks,  should  we  even 
bother  considering  oral  feedings? 

Orringer:  We  haven't  fed  patients 
with  endotracheal  tubes.  My  worry 
would  be  that  if  the  patient  is  pocket- 
ing food  on  top  of  the  cuff,  there  would 
be  a  risk  of  aspiration  through  the  chan- 
nels that  develop  between  the  trachea 
and  the  edge  of  the  cuff.  We  certainly 
expect  to  feed  patients  with  tracheos- 
tomy tubes  as  soon  as  their  general 
condition  permits,  again,  beginning 
with  soft  solids. 

Heffner:  We've  fed  some  intubated 
patients  orally.  Our  rationale  is  based 
on  the  ability  of  patients  with  long- 
term  tracheotomy  tubes  to  tolerate  oral 
diets.  We  reserve  oral  feedings  in  the 
ICU  for  patients  who  can  handle  it. 
Examples  include  neuromuscular  pa- 
tients with  intact  bulbar  control,  and 
ventilator-dependent  patients  with 
chronic  obstructive  pulmonary  disease 
who  are  up  in  the  chair  and  weaning 
with  a  tracheostomy  in  place.  I  think 
the  potential  for  an  oral  diet  is  one  of 
the  subtle  advantages  of  tracheostomy. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


853 


Tracheostomy:  Communication  and  Swallowing 


Durbin:  I  would  say  that  the  swal- 
lowing studies  in  those  folks  are  usu- 
ally abnormal.  They're  always  abnor- 
mal when  they  have  a  cuffed 
endotracheal  tube  or  tracheotomy  tube, 
and  require  positive  pressure  ventila- 
tion. This  is  in  contrast  to  someone 
who  can  tolerate  having  the  cuff  de- 
flated and  use  a  speaking  device. 

Heffner:  We  try  oral  feeding  in  the 
manner  you  recommend,  starting  with 
a  soft,  water-soluble  diet.  If  the  pa- 
tient aspirates  some  quantities,  no 
harm  is  done  and  we  progress  as  tol- 
erated. We  also  sometimes  have  orally 
fed  nasotracheally-intubated  patients, 
although  we  now  rarely  nasotrache- 
ally  intubate  anyone. 

Stolier:  You  described  the  modified 
barium  swallow,  which  I  would  re- 
gard as  a  subjective  test  in  the  sense 
that  one  looks  at  the  bolus  traversing 
the  appropriate  channels.  Have  there 
been  any  concordance  studies — that  is 
to  say,  2  observers  looking  at  modi- 
fied barium  swallow,  with  agreement 
or  disagreement  of  the  conclusions? 

Orringer:  Yes.  Many. 

Stolier:  How  do  they  perform?  What 
is  the  agreement  rate?  I've  often  won- 
dered in  patients  in  whom  they've  been 
done  serially  by  different  examiners 
whether  I'm  truly  seeing  improvement 
or  whether  it's  simply  inter-observer 
variation. 

Orringer:  Most  of  the  studies  show 
good  inter-observer  consistency.  At 
Children's  Hospital  of  Pittsburgh  we 
have  good  agreement  between  the  ra- 
diologists and  me.  A  paper  on  dys- 
phasia was  published  a  few  years  ago 
that  attempted  to  develop  a  rating  scale 
of  penetration  of  liquids  into  the  air- 
way.' I  hope  to  implement  this  scale 
at  our  institution  because  it  will  pro- 
vide a  common  language  for  every- 
one involved  with  these  patients.  This 


would  be  an  improvement  over 
whether  "aspiration"  means  penetra- 
tion just  to  the  tip  of  the  epiglottis, 
into  the  supraglottic  space,  down  to 
the  cords,  or  into  the  lungs. 


REFERENCE 


I.  Rosenbek  JC,  Robbins  JA,  Roecker  EB, 
Coyle  JL,  Wood  JL.  A  penetration-aspira- 
tion scale.  Dysphagia  1996  Spring;  1 1(2): 
93-98. 

Thompson:  Just  to  make  sure  it  was 
clear,  we  have  many  patients  who  are 
chronically  ventilated  (chronic  being 
defined  as  anywhere  from  a  few 
months  to  forever)  who  are  routinely 
eating  normal  foods. 

Durbin:  My  point  is  that  if  we  use  a 
normal  swallowing  study  as  the  gold 
standard,  we  would  never  feed  any- 
one. We  have  fed  people  who  don't 
have  normal  swallowing  studies,  and 
some  do  well. 

Orringer:  There  are  patients  who 
don't  do  well  on  the  study,  but  we 
also  try  to  assess  what  they  may  be 
able  to  tolerate,  then  we  advance  them 
very  carefully.  It's  not  a  perfect  test, 
but  it's  the  best  way  we  have  of  as- 
sessing them  and  knowing  where  to 
begin.  If  fluid  is  difficult,  it's  very 
easy  to  hydrate  patients  with  baby 
food,  which  is  80%  water,  and  there 
are  adult  equivalents.  So,  in  most  cases 
we  can  feed  patients  something. 

Heffner:  Also,  I  think  there  are  sub- 
groups in  the  acute  setting  of  their  re- 
covery from  respiratory  failure  under- 
going a  prolonged  weaning  protocol 
who  have  a  trach  in  place — if  you  care- 
fully assess  and  monitor  them,  you 
may  be  able  to  initiate  feeding  before 
they're  off  the  ventilator.  I  think  that, 
like  speech,  the  ability  to  eat  in  the 
ICU  is  a  very  rewarding  experience, 
and  we've  noticed  a  parallel  tapering 
of  sedatives  and  antidepressant  agents 


as  the  patient  begins  to  resume  their 
normal  functions.  I 

Orringer:  I  think  it  calms  everybody 
down.  It  calms  the  families  and  the 

patients.  . 

.1 

Stauffer:  What  is  the  importance,  if 
any,  of  coloring  enteral  feeding  for- 
mulas with  blue  dye?  What  does  it 
mean  if  we  see  blue  dye  in  an  endo- 
tracheal or  tracheostomy  tube  aspirate? 
Should  that  finding  alter  our  manage- 
ment? I 

Orringer:  Finding  blue  dye  usually 
means  that  the  patient  has  reflux  and 
is  experiencing  retrograde  aspiration. 
An  alternative  is  use  of  glucose  oxi- 
dase strips,  although  I'm  not  sure 
they  give  any  more  information  than 
the  dye. 

Stauffer:  My  question  is  what  do  we 
do  with  the  results?  How  does  color- 
ing tube  feedings  blue  compare  with 
our  clinical  assessment  of  aspiration? 

Ritz:  In  our  adult  population,  we  do  a 
lot  of  bedside  blue  dye  tests  on  pa- 
tients who  are  being  evaluated  for  as- 
piration risk  with  placement  of 
fenestrae  to  the  tracheostomy  tube.  I 
don't  have  any  numbers,  but  you  get 
blue  dye  out  of  the  airway  in  trace-to- 
moderate  amounts  frequently.  One  of 
the  bedside  considerations  is  how  good 
is  their  cough.  The  ability  of  the  pa- 
tient to  clear  their  own  airway  may  be 
the  more  important  bedside  judge- 
ment. ^ 

Watson:  I  feel  it  incumbent  upon  me 
to  comment  that  this  whole  discussion 
involves  a  piece  of  the  well  organized 
critical  care  system  that  can  only  be 
managed  in  a  setting  where  one  cen- 
tralizes and  brings  these  resources  to- 
gether. In  the  community  hospital 
where  I  am,  with  8  different  ICUs,  the 
concept  of  working  up  somebody  for 
swallowing  dysfunction  is  a  bit  of  a 
joke.  It  isn't  to  say  we  don't  have  re- 
sources, but  it's  clear  that,  with  one 


854 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Tracheostomy:  Communication  and  Swallowing 


chronically-ventilated  child  a  month, 
we  don't  have  the  kinds  of  resources 
that  a  centralized  pediatric  critical  care 
system  can  have.  And  it's  an  issue 
that  should  be  addressed  in  the  com- 
munity hospital  environment.  It's  very 
difficult  to  bring  these  resources  to- 
gether in  that  setting,  and  yet,  it's  very 


clear  that  it  changes  the  lives  and  the 
feelings  and  attitudes  of  the  people  in 
the  units — the  adults  who  are  nurtured, 
so  to  speak,  by  being  managed  and 
having  their  feeding  addressed,  and 
having  their  ability  to  speak  addressed, 
as  opposed  to  having  that  ignored,  as 
with  the  children. 


Campbell:  Just  a  follow-up  to  that. 
Something  that  we're  doing  at  the 
University  of  Cincinnati  is  that  the 
respiratory  therapists  now  are  respon- 
sible for  doing  the  swallow  assess- 
ments on  the  patients.  So  that's  some- 
thing they  can  incorporate  into  their 
practice. 


as 


4  5^"     INTERNATIONAL 


RESPIRATORY     CONGRESS 


D  EC  EMBER     1   s'-J^  ,_J^  9  9 

■    f 

Las   Vecbas^    Nevada 


QQi) 


Respiratory  Care  •  July  1999  Vol  44  No  7 


8.^5 


Decannulation:  How  and  Where 


James  F  Reibel  MD 


Introduction 

Evaluation 

Venue 

Downsizing  and  Capping 

Obturation 

Closure 

Summary 

[Respir  Care  1999;44(7):856- 

cheotomy,  tracheostomy. 


859]  Key  words:  decannulation,  evaluation,  tra- 


Introduction 

Successful  decannulation  marks  the  completion  of  tra- 
cheotomy management.  Contemplation  of  decannulation 
assumes  resolution  of  the  underlying  condition  that  neces- 
sitated the  tracheotomy.  At  this  stage  the  patient  must  be 
able  to  protect  the  airway,  clear  secretions,  and  have  no 
significant  compromise  of  the  airway.  Additionally,  there 
should  not  be  other  mitigating  factors  such  as  anatomic 
abnormalities  or  planned  surgery  that  would  make  preser- 
vation of  the  tracheotomy  tract  desirable. '^ 

Evaluation 

Generally  healthy  patients  tracheotomized  for  airway 
control,  and  others  tracheotomized  for  respiratory  failure 
who  have  not  required  long-term  ventilator  support,  usu- 
ally can  be  decannulated  directly.  Those  patients  who  have 
required  prolonged  ventilation,  patients  with  significant 
comorbidities,  and  children  benefit  from  a  more  cautious 
approach.  As  the  patient's  progress  allows  weaning  from 
mechanical  ventilation,  resolution  of  infiltrates,  and  de- 
crease in  volume  of  secretions,  planning  for  decannulation 
begins.  Resumption  of  a  more  normal  activity  level  estab- 
lishes the  patient's  ability  to  maintain  adequate  oxygen- 
ation and  eliminate  pulmonary  secretions  effectively,  with- 


James  F  Reibel  MD  is  affiliated  with  the  Department  of  Otolaryngology, 
Head  and  Neck  Surgery,  University  of  Virginia  Medical  Center,  Char- 
lottesville, Virginia. 

Correspondence:  James  F  Reibel  MD,  Department  of  Otolaryngology, 
Head  and  Neck  Surgery,  University  of  Virginia  Medical  Center,  Char- 
lottesville VA  22908.  E-mail:  JFR2J@hscmail.mcc.virginia.edu. 


out  the  need  for  frequent  suctioning.  Ingestion  of  an 
adequate  oral  intake  to  maintain  nutrition  without  aspira- 
tion demonstrates  ability  to  protect  the  airway.  At  this 
stage  inspection  of  the  airway  to  confirm  an  adequate  lu- 
men is  appropriate. 

Flexible  fiberoptic  endoscopy  is  easily  performed  at  the 
bedside  or  in  the  clinic  in  the  adult  or  adolescent  patient. 
This  equipment  is  portable  and  available  in  almost  every 
hospital  or  specialty  clinic  (Fig.  1).  The  nose  and  upper 
airway  are  topically  anesthetized,  and  topical  anesthesia  is 
also  applied  to  the  tracheal  mucosa  through  the  tracheot- 
omy cannula,  which  causes  the  patient  to  cough.  The  pa- 
tient should  be  advised  of  this  in  advance,  and  also  advised 
that  some  of  the  anesthesia  will  be  coughed  up  into  the 
pharynx,  resulting  in  the  patient's  ability  to  taste  the  an- 
esthetic. This  will  anesthetize  the  larynx,  facilitating  the 
fiberoptic  exam  of  the  larynx  and  subglottis  from  above. 

Once  adequate  topical  anesthesia  is  obtained,  the  flex- 
ible fiberoptic  scope  (fiberscope)  is  introduced  through  the 
tracheotomy  tube  and  the  distal  trachea  is  inspected.  Care- 
ful note  is  made  of  the  character  and  viscosity  of  secre- 
tions, lesions,  or  granulation  at  the  tip  of  the  tube.  Cultures 
can  be  taken  if  the  secretion  is  purulent. 

Next,  the  fiberscope  is  passed  via  the  anesthetized  naris 
to  inspect  the  upper  airway.  Purulent  nasal  cavity  secre- 
tions can  be  cultured.  Inspection  of  the  larynx  discloses 
any  lesions,  and  inspection  during  quiet  respiration,  pho- 
nation,  cough,  and  sniff  maneuvers  notes  any  limitation  of 
vocal  fold  mobility.  The  fiberscope  is  then  passed  through 
the  glottis  to  inspect  the  subglottis  and  upper  trachea  for 
stenosis,  granulation,  or  tracheomalacia.  Provided  the  ex- 
amination is  relatively  normal  to  this  point,  the  tracheot- 
omy tube  can  be  removed  and  the  trachea  inspected  during 


856 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Decannulation:  How  and  Where 


Fig.  1.  Flexible  fiberoptic  scope  and  light  source. 


quiet  respiration,  forced  inspiration,  and  cough.  Any  dy- 
namic or  fixed  obstruction  is  noted.  In  otFierwise  healthy 
patients,  this  examination  will  confirm  an  adequate  airway 
to  permit  decannulation.  Some  patients  will  have  stenosis 
or  granulations  requiring  additional  evaluation  and  treat- 
ment. These  patients,  and  all  children, '-^-^  require  rigid 


Fig.  2.  Ventilating  bronchoscope  in  place,  with  anesthesia  circuit 
connected  to  ventilation  port. 

endoscopy  under  general  anesthesia  prior  to  attempting 
decannulation. 

During  the  examination  under  anesthesia,  the  patient's 
larynx  is  examined  directly  during  spontaneous  ventilation 
to  assess  vocal  fold  mobility,  as  well  as  the  presence  of 


Fig.  3.  A:  Cup  forceps  and  suction  cannulas  for  endoscope-assisted  removal  of  stomal  granulation.  B:  Ventilating  bronchoscope  pushes 
granulation  tissue  into  stomal  tract,  facilitating  removal  with  cup  forceps. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


857 


Decannulation:  How  and  Where 


f^^^^^l 

OLYMPIC 
TBACH-BUTTON 

nOLYMPIC  MEDICAL  _ 

Fig.  4.  A:  Stomal  obturator  with  spacers.  B:  Stomal  obturator  with  solid  central  core  in  place  (arrows  point  to  dilated  retention  flange)  (These 
obturators  are  made  by  Olympic  Medical  Corporation,  Seattle,  Washington). 


any  glottic  lesions,  such  as  granuloma  or  web.  After  com- 
pleting direct  laryngoscopic  examination,  the  ventilating 
bronchoscope  is  passed  through  the  glottis,  allowing  in- 
spection of  the  subglottis  and  upper  trachea  to  the  level  of 
the  stomal  margin. 

Provided  the  examination  discloses  an  adequate  lumen 
to  this  point,  the  tracheotomy  tube  is  removed  and  the 
bronchoscope  is  advanced  to  examine  the  trachea  to  the 
level  of  the  mainstem  bronchi.  Ventilation  is  maintained 
via  connection  to  the  ventilation  port  of  the  bronchoscope 
(Fig.  2).  Purulent  secretions  can  be  cultured.  Areas  of 
stenosis  and  tracheomalacia  can  be  "sized"  with  the  bron- 
choscope and  the  length  and  cross-sectional  extent  of  the 
lesion  noted.  Small  stenotic  bands,  webs,  or  granulations 
can  be  treated  at  this  time'-^-*  (Fig.  3).  Upon  completion  of 
rigid  bronchoscopy,  the  tracheotomy  tube  is  replaced  un- 
der direct  vision,  the  tube  reconnected,  and  ventilation 
reestablished  prior  to  removal  of  the  bronchoscope.  Any 
significant  lesions  identified  by  this  examination  require 
additional  investigation  (eg,  computed  tomography)  prior 
to  continuing  with  plans  for  decannulation. 

In  some  patients  with  neuromuscular  impairment,  the 
decision  may  hinge  on  their  ability  to  consistently  clear 
secretions.  Bach  and  Saporito"*  found  that  the  ability  to 
generate  peak  cough  flow  of  160  L/min  successfully  pre- 
dicts ability  to  clear  secretions,  and  thus  permits  extuba- 
tion  or  decannulation.  Peak  cough  flow  determination  is 


warranted  for  this  patient  group,  since  these  patients  will 
require  closer  monitoring  and  supervision  in  an  in-patient 
setting  during  their  decannulation  trial. 

Venue 

Decannulation  of  otherwise  healthy  adult  and  adoles- 
cent patients  who  meet  all  decannulation  criteria  does  not 
require  observation  in  a  controlled  setting.  Children,'--' 
and  adults  with  concerns  about  their  ability  to  tolerate 
decannulation,  are  best  observed  as  in-patients.  This  may 
not  require  hospitalization  in  an  acute  care  setting,  but 
appropriately  skilled  nurses,  respiratory  therapists,  and  phy- 
sicians must  be  immediately  available  if  a  nonacute  care 
setting  is  chosen  (eg,  a  rehabilitation  unit). 

Downsizing  and  Capping 

In  children'--'  and  in  adults  with  concerns  about  their 
ability  to  tolerate  decannulation,  a  protocol  of  downsizing 
and  capping  is  usually  employed.  By  the  time  decannula- 
tion is  contemplated,  most  patients  have  already  had  their 
initial  tube  replaced  by  one  of  smaller  caliber.  If  additional 
size  reduction  is  desired,  the  tracheotomy  tube  is  further 
reduced  in  size  and  the  patient  is  observed  under  appro- 
priate monitoring  and  supervision.  When  the  smaller  tube 
is  tolerated  without  difficulty,  the  tube  is  capped  and  the 


858 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Decannulation:  How  and  Where 


patient  further  observed  during  activity  and  sleep.  Moni- 
toring children  during  sleep  may  require  polysomnogra- 
phy if  there  is  concern  about  obstructive  apnea.^  Once  the 
patient  has  shown  the  ability  to  tolerate  the  capped,  down- 
sized tube,  the  tube  can  be  removed  and  the  tracheotomy 
wound  covered  with  an  occlusive  dressing.  Children  should 
be  observed  for  at  least  one  additional  night  after  decan- 
nulation, with  special  attention  to  observation  during  sleep. 
An  alternative  to  this  combined  downsizing  and  capping 
method  is  a  tube  occlusion  protocol  described  by  Rumbak 
et  al.*^  The  criterion  for  successful  decannulation  in  this 
protocol  is  the  ability  to  tolerate  breathing  via  a  capped, 
fenestrated  #8  tracheotomy  tube.  Inability  to  tolerate  an 
occluded  #8  tube  leads  to  a  repeat  trial  with  an  occluded 
#7  fenestrated  tube.  Ability  to  tolerate  an  occluded  #7 
fenestrated  tube  also  predicted  successful  decannulation. 
Since  the  Rumbak  et  al  study  dealt  exclusively  with  adults, 
these  results  might  not  extrapolate  to  children,  and  this 
technique  should  be  used  with  extreme  caution  and  only  in 
a  controlled  setting. 

Obturation 

Use  of  a  stomal  obturator  represents  a  compromise  in 
that  the  patient  breathes  totally  via  the  nose  and  mouth,  but 
the  tract  to  the  tracheal  opening  is  maintained  by  an  in- 
dwelling device  (Fig.  4).  This  device  can  be  used  to  pre- 
serve airway  access  for  patients  who  will  need  to  undergo 
additional  surgical  procedures,  most  commonly  head  and 
neck  or  maxillofacial  operations.  Obturation  is  useful  for 
patients  with  obstructive  sleep  apnea  treated  by  tracheot- 
omy. Patients  with  neuromuscular  disease  and  severe 
chronic  obstructive  pulmonary  disease  are  also  appropriate 
candidates  for  stomal  obturation  and  observation  prior  to 
decannulation. 

Closure 

Surgical  closure  is  seldom  required  in  the  acute  setting 
of  decannulation.  Direct  surgical  closure  is  occasionally 


advantageous  for  head  and  neck  patients,  because  it  may 
facilitate  their  speech  and  swallowing  rehabilitation.  More 
commonly,  the  tracheotomy  wound  is  covered  with  an 
occlusive  dressing  and  allowed  to  close  secondarily,  in 
order  to  avoid  the  expense  of  a  second  procedure.  Given 
sufficient  time,  nearly  every  tracheotomy  wound  heals  with 
an  acceptable  cosmetic  result.  Rarely,  a  tract  will  epithe- 
lialize  and  persist  as  a  tracheocutaneous  fistula.  The  epi- 
thelialized  tract  must  be  excised,  the  tracheal  margins  fresh- 
ened and  closed,  and  the  strap  muscles  re-approximated. 
The  skin  is  usually  not  closed  if  the  closure  is  not  airtight. 

Summary 

Most  patients  are  anxious  about  removal  of  their  tra- 
cheotomy tube.  While  eager  to  be  rid  of  the  device,  they 
are  concerned  about  the  ability  to  breathe,  clear  secretions, 
and  protect  the  airway  upon  removal  of  the  tube.  With 
careful  assessment  of  clinical  progress  and  endoscopic  con- 
firmation of  adequate  upper  and  lower  airway,  decannu- 
lation can  be  planned  and  safely  carried  out  with  a  high 
probability  of  success.  For  children  and  certain  adults, 
decannulation  is  best  carried  out  in  a  closely  controlled 
environment. 

REFERENCES 

1.  Johnson  JT.  Reilly  JS,  Mallory  GB.  Decannulation.  In:  Myers  EN, 
Stool  SE.  Johnson  JT.  editors.  Tracheotomy.  New  York:  Churchill 
Livingstone;  1985:201-210. 

2.  Gray  RF,  Todd  NW,  Jacobs  IN.  Tracheostomy  decannulation  in  chil- 
dren: approaches  and  techniques,  l^aryngoscope  1998;108(  1  Pt  1  ):8-12. 

3.  Merritt  RM.  Bent  JP,  Smith  RJH.  Suprastomal  granulation  tissue  and 
pediatric  tracheostomy  decannulation.  Laryngoscope  1997;107(7): 
868-871. 

4.  Bach  JR,  Saporito  LR.  Criteria  for  extubation  and  tracheostomy  tube 
removal  for  patients  with  ventilatory  failure:  a  different  approach  to 
weaning.  Chest  I996;l  1 0(6): I. '566-1571. 

5.  Rumbak  MJ.  Graves  AE,  Scott  MP.  Sporn  GK.  Walsh  FW.  Ander- 
son WM.  Goldman  AL.  Tracheostomy  lube  occlusion  protocol 
predicts  significant  tracheal  obstruction  to  air  flow  in  patients 
requiring  prolonged  mechanical  ventilation.  Crit  Care  Med  1997; 
25(3):413-417. 


Discussion 

Tliompson:  How  is  it  that  patients 
can  breathe  through  or  around  an  oc- 
cluded tracheostomy  tube  (in  the  case 
of  an  adult)  or  a  proportionately 
smaller  one  (in  the  case  of  a  child)?  It 
seems  to  me  that  this  amounts  to  a 
plug  occupying  two  thirds  or  three 
quarters  of  the  airway.  If  there  was 
ever  trial  by  fire,  this  is  certainly  an 
example.  Why  do  we  use  this  as  a  test 


of  readiness  for  decannulation?  Why 
does  it  work? 

Reibel:  The  more  recent  pediatric 
papers'"  try  to  size  the  lumen  when 
they  do  the  rigid  endoscopy,  and  then 
they  try  to  reduce  the  size  of  the  tube 
they're  going  to  leave  in  place  to  about 
50%  of  the  tracheal  lumen.  If  the  child 
can  breathe  around  the  tube,  tolerate 
normal  activity,  and  clear  secretions 
around  that  significant  obstruction,  the 


decannulation  should  be  successful.  In 
the  adult  studies,  these  were  fenes- 
trated 7s  and  8s,  so  the  patients  were 
breathing  somewhat  around  and  some- 
what through  the  fenestration  as  well, 
but  your  point  is  well  taken. 

REFERENCES 

1.  Gray  RF,  Todd  NW.  Jacobs  IN.  Tracheos- 
tomy decannulation  in  children:  approaches 
and  techniques.Laryngoscope  1998:108(1  Pt 
1):8-I2. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


859 


Dec  ANNUL  ation:  How  and  Where 


2.  Merritt  RM,  Bent  JP,  Smith  RJ.  Suprastomal 
granulation  tissue  and  pediatric  tracheotomy 
decannulation.  Laryngoscope  1997;  107(7): 
868-871. 

Thompson:  It's  interesting  to  me 
that  a  50%  occlusion  might  be  an  in- 
dication for  a  tracheostomy,  and  here 
we're  using  it  as  a  criterion  for  decan- 
nulation. 

Reibel:  That's  the  point.  Most  tra- 
cheae, after  a  tracheotomy/tracheos- 
tomy,  have  some  element  of  tracheal 
stenosis.  I  don't  think  surgeons  would 
disagree  with  that.  Fortunately,  only 
when  stenosis  approaches  50%  do  pa- 
tients start  to  have  symptoms.  There- 
fore, what  degree  of  tracheal  stenosis 
after  a  tracheotomy/tracheostomy  is 
clinically  relevant?  In  terms  of  how  it 
is  going  to  affect  management  of  the 
patient,  probably  50%  is  the  cut-off 
for  most  patients. 

Ritz:  Fleming  et  al  introduced  a  ma- 
nometer between  the  cap  and  the  tra- 
cheostomy tube  to  measure  the  tra- 
cheal pressure.'  It's  a  quick  trial.  If 
the  pressure  has  exceeded  more  than 
10  cm  HjO  of  positive  or  negative 
expiratory  pressure,  that's  bad.  But  it's 
kind  of  a  quick  and  dirty  way  to  as- 
sess the  tolerance  of  the  patient  to  a 
capped,  obstructing  tracheostomy 
tube. 

REFERENCE 

I.  Fleming  CM,  Hirsch  C,  Martianson  J,  Am- 
brosi  D,  Holmes  L,  Johnson  DC.  Airway 
pressure  in  patients  with  three  different 
speaking  valves  (abstract).  Am  J  Respir  Crit 
Care  Med  1998;3:A307. 

Reibel:  Have  you  had  the  occasion 
to  use  peak  cough  flows?  Have  you 
found  it  helpful? 

Durbin:  Is  that  without  the  endo- 
tracheal tube,  measuring  that  peak  flow 
or  with  a  fenestration  tube,  or  with  the 
cuff  deflated? 


Reibel:  These  were  in  tracheostomy 
tubes  or  in  endotracheal  tubes.  They 
were  using  this  as  a  predictor  for  ei- 
ther decannulation  of  a  tracheostomy 
tube  or  an  endotracheal  tube. 

Hess:  We  put  in  an  endotracheal  tube 
and  think  we  have  to  put  on  a  little  bit 
of  pressure  support  to  overcome  the 
resistance  through  the  endotracheal 
tube,  but  now  you're  talking  about  a 
patient  needing  to  be  able  to  tolerate  a 
pretty  significant  obstruction  of  their 
airway  before  you  take  out  the  trach 
tube. 

Campbell:  I  would  say  that  this  is  a 
test.  It's  not  a  maneuver  to  try  to  pre- 
pare the  patient.  It's  just  to  assess  their 
ability.  We  think  we  can  do  that  as 
well  without  pressure  support. 

Hurford :  B  ut  we  don '  t  normally  cap 
the  endotracheal  tube  as  a  trial  prior  to 
extubation. 

Campbell:  It' s  not  uncommon  to  let 
the  cuff  down  and  assess  the  leak, 
though. 

Hurford:  Right,  but  you  don't  leave 
the  tube  capped  for  24  hours,  as  many 
people  do  for  a  tracheostomy  tube. 

Bishop:  There' s  a  big  difference,  be- 
cause the  larynx  closes  down  around 
the  endotracheal  tube.  A  normal  adult 
size  trachea  is  18  mm  by  13  mm  in 
terms  of  the  largest  dimensions,  as  I 
recall.  So,  it  turns  out  that  with  a  7 
mm  tube  in  there,  we're  really  only 
very  minimally  affecting  the  resistance 
of  it.  The  trachea  is  made  to  allow  you 
to  run  hard  for  a  mile.  So  that  even 
with  a  very  substantial  occlusion  of  it, 
you  ought  to  be  able  to  handle  it  pretty 
well.  As  you  pointed  out,  a  50%  ob- 
struction will  probably  begin  to  affect 
someone  functionally.  If  their  minute 
ventilation  isn't  especially  high,  they 


can  tolerate  a  short  obstruction  of  even 
substantially  more  than  50%. 

Reibel:  If  you  read  between  the  lines 
in  the  pediatric  literature,  a  lot  of  this 
is  to  psychologically  prepare  the  pa- 
tient and  family.  Everybody  wants  to 
be  rid  of  the  device,  but  they've  had  it 
in  for  a  while  and  are  apprehensive 
about  its  removal.  This  is  to  give  them 
psychological  preparation  that  they  are 
going  to  be  able  to  breathe  and  clear 
their  secretions  adequately.  Properly 
done,  this  is  something  that  ought  to 
be  nearly  100%  successful. 

Watson:  Did  I  understand  you  to 
say  that  you'd  do  an  endoscopy  on 
every  child  that  you  decannulate?  Is 
this  recommended? 

Reibel:     Yes  it  is. 

Watson:  Is  that  the  standard  of  prac- 
tice around  the  country,  by  your  un- 
derstanding? 

Reibel:  Yes.  It's  in  the  literature  in 
many  places.'"^ 

REFERENCES 

1.  Johnson  JT,  Reilly  JS.  Mallory  GB.  Decan- 
nulation. In:  Myers  EN,  Stool  SE,  Johnson 
JT,  editors.  Tracheotomy  (first  edition).  New 
York:  Churchill  Livingstone;  1985:201-210. 

2.  Gray  RF,  Todd  NW,  Jacobs  IN.  Tracheos- 
tomy decannulation  in  children;  approaches 
and  techniques.  Laryngoscope  1998;108 
(1  Pt  1);8-12. 

3.  Merritt  RM,  Bent  JP,  Smith  RJ.  Suprastomal 
granulation  tissue  and  pediatric  tracheotomy 
decannulation.  Laryngoscope  1997;  107(7): 
868-871. 

Thompson:  I  agree.  It  is  our  prac- 
tice, and  every  paper  I've  reviewed  by 
pediatric  otolaryngologists  mentions 
endoscopy  as  a  necessary  preparation 
for  decannulation.  Among  other  prob- 
lems, granulation  tissue  that  might 
cause  difficulty  at  decannulation  is  of- 
ten present,  and  can  usually  be  re- 
moved at  the  time  of  endoscopy. 


860 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Artificial  Airways:  Conference  Summary 


John  E  Heffner  MD 


Introduction 
Practice  Variation 
Rule  of  Rescue 
Resource  Allocation 

Practice  Guidelines  and  Algorithmic  Care 
Outcomes  Research 
Patient-Centered  Investigations 
Critical  Evaluation  of  Current  Practices 
Costs  of  Care 
Technology  Assessment 
Future  Directions 

[Respir  Care  1999;44(7):861-865]  Key  words:  artificial  airway,  airway  man- 
agement, practice  variation,  rule  of  rescue,  resource  allocation,  practice  guide- 
lines, outcomes  research,  patient-centered  investigations. 


Introduction 

It  is  indeed  a  challenge  to  summarize  in  the  brief  time 
allotted  the  remarkable  presentations  we  heard  on  airway 
management  during  these  last  2  days.  In  considering  a 
theme  for  my  comments,  I  have  focused  on  the  recurring 
impression  I  had  from  the  discussions  that  the  upper  re- 
spiratory tract  is  truly  elegant  in  both  its  structure  and 
function.  We  heard  from  Rich  Branson  that  the  upper  air- 
way's tremendous  efficiency  for  humidifying  and  warm- 
ing inspired  gases  surpasses  our  ability  to  simulate  these 
functions  with  mechanical  devices  such  as  artificial  noses. 
We  heard  from  Maxine  Orringer  that  the  act  of  swallow- 
ing, which  can  transpire  without  our  conscious  effort,  rep- 
resents the  orchestrated  interaction  of  32  muscles  and  5 
nerves.  We  also  learned  that  verbal  communication  is  one 
of  the  most  important  factors  in  developing  and  maintain- 
ing relationships  with  our  families,  communities,  and  care- 
givers. The  larynx,  as  the  source  of  phonation,  facilitates 
the  subtleties  and  nuances  of  communication  necessary  for 
interacting  with  the  world  around  us  in  a  meaningful  way. 
It  appears  that  the  upper  airway  is  not  only  an  integral 


John  E  Heffner  MD  is  affiliated  with  the  Department  of  Medicine,  Med- 
ical University  of  South  Carolina.  Charleston,  South  Carolina. 

Correspondence:  John  E  Heffner  MD,  Department  of  Medicine.  Medical 
University  of  South  Carolina,  Charleston  SC  29425.  E-mail: 
heffnerj  @  musc.edu 


element  in  respiratory  function  but  also  contributes  to  our 
personal  sense  of  self. 

In  view  of  the  elegant  design  of  the  upper  airway,  it  is 
alarming  to  consider  its  fragile  nature.  Jack  Stauffer's  ex- 
tensive list  of  airway  complications  related  to  tracheotomy 
and  translaryngeal  intubation  underscores  the  considerable 
risk  of  serious  sequelae  from  airway  interventions.  From 
this  conference  I  have  gained  a  greater  sense  of  respect, 
caution,  and  humility  for  managing  the  airways  of  patients 
who  require  intubation  and  ventilatory  support. 

It  is  fortunate  that  we  have  a  rich  diversity  of  medical 
specialties  with  an  interest  in  caring  for  such  an  important 
structure  as  the  upper  respiratory  tract.  The  content  of  the 
conference  presentations  emerges  from  decades  of  obser- 
vations recorded  by  general  surgeons,  anesthesiologists, 
speech  therapists,  nurses,  intensivists,  pulmonary  physi- 
cians, and  respiratory  therapists,  to  name  a  few.  Unfortu- 
nately, this  diversity  risks  the  sequestering  of  knowledge 
because  of  the  limited  forums  that  exist  for  specialists 
from  different  fields  to  share  their  unique  expertise.  For 
this  reason,  I  congratulate  the  organizers  of  this  conference 
for  convening  such  a  broad- based  group  of  experts  on 
airway  support. 

Jamie  Stoller  set  the  tone  of  the  conference  and  my 
summary  comments  in  his  review  of  the  history  of  airway 
support.  He  outlined  3  millennia  of  advances  in  airway 
support,  and  blended  these  events  with  insights  into  the 
social  and  scientific  evolution  of  medicine.  He  reminded 


Respiratory  Care  •  July  1999  Vol  44  No  7 


861 


Artihcial  Airways:  Conference  Summary 


us  of  the  challenges  facing  clinicians  in  noting  the  signif- 
icance of  new  clinical  observations,  translating  these  ob- 
servations into  improved  clinical  care,  and  disseminating 
innovations.  The  challenges  faced  by  early  pioneers  of 
airway  support  sound  surprisingly  contemporary,  consid- 
ering our  modem-day  efforts  to  limit  practice  variation, 
disseminate  clinical  practice  guidelines,  and  promote  best 
clinical  practices.  1  have  borrowed  concepts  from  Jamie's 
presentation  to  serve  as  the  outline  for  my  summary,  which 
focuses  on  practice  variation,  outcomes  research,  consid- 
erations of  cost-effectiveness,  technology  assessment,  clin- 
ical decision  analysis,  and  the  future  of  improving  airway 
management. 

Practice  Variation 

In  regard  to  practice  variation,  we  learned  from  Bill 
Hurford  that,  outside  of  the  operating  room,  37%  of  intu- 
bation efforts  have  complications  and  22%  of  emergency 
intubation  efforts  require  3  or  more  attempts  before  an 
airway  is  successfully  placed.  Our  group  discussions  in- 
dicated that  such  high  rates  of  complications  would  not  be 
tolerated  in  the  operating  room.  Also,  intubation  trays  are 
often  unreliably  stocked  in  medical  centers,  so  resuscita- 
tion teams  are  advised  to  bring  their  own  airway  kits  to 
cardiopulmonary  arrests.  Ann  Thompson  taught  us  that 
cricothyroidotomy  is  contraindicated  in  pediatric-aged  pa- 
tients, yet  she  receives  referred  children  who  have  had  this 
procedure  performed.  As  Charlie  Durbin  points  out,  more 
standards  exist  for  the  manufacture  of  endotracheal  and 
tracheostomy  tubes  than  for  ensuring  their  proper  insertion 
and  care. 

In  attempting  to  understand  the  practice  variation  that 
surrounds  airway  management,  we  might  consider  how 
physicians  develop  their  clinical  approaches  to  care.  Clem 
McDonald  suggested  several  years  ago  that  physicians  tend 
to  treat  patients  with  personal,  informal  clinical  "policies" 
derived  from  our  personal  knowledge  and  experiences  de- 
veloped over  years  of  trial  and  error.'  We  often  adopt 
clinical  practices  that  seem  to  work  on  average  for  most 
patients.  This  heuristic  approach  to  health  care  slows  the 
dissemination  of  innovation,  delays  widespread  adoption 
of  best  clinical  practices,  and  allows  variations  in  practice 
to  persist. 

Rule  of  Rescue 

I  believe  that  an  additional  factor  underlies  variations  in 
practice  and  standards  for  airway  support.  The  "rule  of 
rescue"  permits  health  care  providers  to  bypass  informed 
consent  when  administering  emergency  life-saving  care, 
such  as  intubation  for  respiratory  failure.  This  "assumed 
con.sent"  allows  physicians  to  omit  our  usual  pre-proce- 
dure  practices  of  carefully  explaining  risks  and  benefits 


and  assuring  patients  that  every  precaution  has  been  taken 
to  bring  about  the  best  possible  clinical  outcome.  Unfor- 
tunately, the  necessary  omission  of  these  patient-physician 
discussions  under  the  time  pressure  of  an  emergency  event 
creates  a  "do  the  best  you  can  under  the  less  than  ideal 
circumstances"  mentality  in  managing  unstable  airways. 
To  improve  clinical  practices  in  airway  support,  we  need 
to  apply  to  emergency  airway  practices  the  high  standards, 
safeguards,  training  requirements,  accountability,  and  ex- 
pectations for  satisfactory  outcomes  that  are  attached  to 
intubation  in  the  operating  room  and  trauma  room.  Oth- 
erwise, we  may  perpetuate  unacceptable  variations  in  air- 
way support  practices,  which  could  lead  to  the  following 
imaginary  but  not  at  all  implausible  scenario: 

A  68-year-old  retired  nurse  anesthetist  suffering  an  acute 
exacerbation  of  chronic  obstructive  pulmonary  disease  is 
admitted  with  severe  dyspnea. 

Patient:  "If  I  worsen  during  the  night,  who  will  intubate 
me?" 

Physician:  "I'm  not  sure,  probably  one  of  the  house 
staff." 

Patient:  "Will  the  house  officer  be  well  trained  and  cer- 
tified in  intubation?" 

Physician:  "1  don't  know." 

Patient:  "How  many  intubations  have  they  performed?" 

Physician:  "1  don't  know." 

Patient:  "What  are  my  chances  for  a  quick  and  success- 
ful intubation?" 

Physician:  "That's  a  good  question." 

Resource  Allocation 


Providing  needed  training  and  experienced  personnel  to 
guarantee  a  high  likelihood  that  a  capable  caregiver  will  be 
available  to  initiate  and  maintain  airway  support  requires 
the  expenditure  of  money  and  redirection  of  health  care 
resources.  We  have  heard  several  times  during  the  confer- 
ence that  medical  centers  often  balk  at  expending  resources 
to  improve  emergency  intubation  services,  because  other 
worthy  health  care  needs  would  go  unfunded.  When  deal- 
ing with  questions  of  resource  allocation,  we  might  con- 
sider an  ethical  technique  that  assists  in  .selecting  among 
competing  health  care  services  for  funding  when  resources 
are  limited.  This  approach  asks  individuals  who  have  not 
yet  developed  a  condition  that  requires  any  of  the  health 
care  services  under  consideration  to  value  the  relative  im- 
portance of  the  different  interventions.  A  healthy  segment 
of  the  population,  for  instance,  might  be  asked  to  order  the 
relative  importance  of  providing  cardiac  transplantation 
for  adults  with  coronary  artery  disease  versus  chemother- 
apy for  patients  with  Stage  III  lung  cancer.  1  would  suggest 
that  this  technique  would  rank  high  for  resource  allocation 
the  need  to  provide  access  to  personnel  who  can  place 


862 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Artificial  Airways:  Conference  Summary 


emergency  airways  with  an  acceptable  degree  of  success 
and  expertise. 

Practice  Guidelines  and  Algorithmic  Care 

The  first  step  in  developing  and  applying  this  expertise 
requires  health  care  providers  to  develop  practice  guide- 
lines that  utilize  standardized  algorithms  for  intubation. 
Mike  Bishop's  presentation  on  his  institution's  approach 
to  improving  outcomes  of  intubation  represents  a  model  of 
algorithmic  care.  The  features  that  ensure  success  in  his 
approach  are  several.  First,  the  algorithm  provides  an  ex- 
plicit, exact,  and  unambiguous  decision-tree.  For  instance, 
the  exact  number  of  minutes  before  intubation  would  be 
anticipated  to  be  necessary  is  explicitly  stated.  Second,  the 
guideline  selects  personnel  on  the  basis  of  their  demon- 
strated skills  for  intubation  rather  than  on  their  background, 
formal  training,  or  professional  degrees.  In  this  instance, 
anesthesiologists  and  respiratory  therapists  with  skills  and 
interest  in  intubation  were  selected  for  participation.  Third, 
participating  respiratory  therapists  were  not  assumed  to 
maintain  competency,  but  instead  underwent  ongoing  mon- 
itoring of  their  intubation  skills  and  outcomes.  These  ele- 
ments of  preparation  appear  to  improve  the  quality  of  per- 
formance, and  seem  applicable  to  other  health  care  facilities. 

The  role  of  respiratory  therapists  in  participating  in  in- 
tubation protocols  may  engender  concern  on  the  part  of 
some  physicians  regarding  the  dilution  of  expertise  in  air- 
way management.  These  concerns  arise  from  questions  of 
qualifications  or  from  turf-related  issues  of  alterations  of 
traditional  professional  roles.  As  Jim  Reibel  pointed  out, 
however,  we  "need  to  do  what's  best  for  the  patient  and  for 
the  institution  as  a  whole,  and  relegate  our  turf  issues  and 
professional  positions  in  our  traditional  approaches  of  the 
past  to  a  lower  level  of  concern."  No  specialty  "owns"  the 
airway;  we  need  to  muster  the  properly-prepared  and  avail- 
able personnel  at  the  right  points  in  time  to  improve  air- 
way supportive  care. 

As  Charlie  Watson  pointed  out,  the  specific  content  of 
institutionally-based  guidelines  may  be  less  important  than 
the  fact  that  such  guidelines  exist.  The  process  of  health 
care  providers  coming  together  to  develop  and  monitor 
guidelines  has  a  quality-enhancing  effect  of  its  own.  The 
content  of  guidelines  put  into  practice  can  evolve  as  cli- 
nicians observe  the  guidelines'  effects  on  clinical  practice 
and  refine  the  guidelines  to  achieve  their  intended  goals. 
Charlie  Watson  also  pointed  out  that  health  care  quality 
oversight  bodies  increasingly  expect  the  existence  of  for- 
malized quality-enhancing  guidelines. 

Outcomes  Research 

A  discussion  of  clinical  practice  guidelines  leads  us  from 
practice  variation  to  outcomes  research.  The  proceedings 


of  this  conference  encourage  us  to  limit  unnecessary  prac- 
tice and  standard  variation  in  airway  management,  but  also 
to  maintain  our  awareness  of  the  individual  patient' s  unique 
clinical  needs.  The  field  of  outcomes  research  emphasizes 
the  importance  of  patient-centered  approaches  to  studying 
the  airway.  In  designing  research  studies,  we  should  in- 
clude more  than  the  traditional  end  points  (survival,  inci- 
dence of  pneumonia,  or  risk  for  airway  injury  from  various 
airway  interventions).  We  should  also  include  more  qual- 
itative outcomes,  such  as  patient  comfort,  ability  to  com- 
municate, and  overall  patient  satisfaction  with  care  in  the 
context  of  their  individual  values  and  needs. 

Patient-Centered  Investigations 

In  terms  of  outcomes  research,  few  patient-centered  in- 
vestigations have  occurred.  We  need  to  know  the  effects  of 
tracheotomy  on  sedation  use,  patient  mobility,  the  quality 
of  verbal  communication,  and  general  patient  well-being. 
Outcomes  research  also  warns  us  about  overgeneralizing 
our  research  conclusions  and  applying  results  of  studies  to 
all  patient  groups.  We  heard  in  the  conference  that  the 
secretion-clearing  endotracheal  tubes  have  been  shown  to 
decrease  risk  for  ventilator-associated  pneumonia.  Over- 
generalizing  from  this  measured  outcome  would  appear  to 
dictate  that  these  tubes  should  be  put  into  general  clinical 
practice.  As  Charlie  Durbin  warns,  however,  these  tubes 
are  stiffer  than  traditional  endotracheal  tubes  and  may 
present  a  greater  risk  for  laryngeal  injury.  We  need  to 
measure  all  foreseeable  outcomes — both  beneficial  and 
adverse — before  we  change  our  clinical  approaches  on  the 
basis  of  emerging  results. 

We  also  need  to  be  careful  not  to  assume  that  study 
results  apply  to  all  patient  populations.  The  results  of  clin- 
ical trials  often  do  not  have  sufficient  power  to  determine 
if  all  patient  subgroups  in  the  study  responded  similarly  to 
the  study  intervention.  On  the  basis  of  this  limitation,  Dean 
Hess  warns  us  not  to  overinterpret  the  observations  from 
weaning  studies  that  patients  weaned  with  T-bars  achieve 
extubation  as  soon  as  patients  weaned  by  pressure  support. 
An  overinterpretation  of  these  observations  might  suggest 
that  the  resistance  of  breathing  through  an  endotracheal 
tube  does  not  delay  successfully  weaning.  However,  there 
may  be  subgroups  of  patients  with  marginal  ventilatory 
capacity  who  will  fail  weaning  unless  the  work  of  breath- 
ing necessary  to  overcome  tube  resistance  is  supported  by 
pressure  support  or  some  other  intervention.  Additional 
studies  are  needed  to  examine  this  specific  question. 

Critical  Evaluation  of  Current  Practices 

This  conference  included  the  suggestion  that  we  clini- 
cians tend  to  overgeneralize  from  our  research  or  clinical 
experiences.  This  habit  generates  clinical  shibboleths  that 


Respiratory  Care  •  July  1999  Vol  44  No  7 


863 


Artificial  Airways:  Conference  Summary 


often  escape  critical  examination.  We  have  heard  of  sev- 
eral poorly  supported  but  entrenched  clinical  practices  that 
have  fallen  aside  when  critically  appraised.  We  were  told 
in  the  past  not  to  orally  intubate  patients  with  head  inju- 
ries, but  now  learn  that  mask  ventilation  and  nasotracheal 
intubation  are  associated  with  greater  neck  movement.  We 
were  told  in  earlier  decades  that  nasotracheal  intubation 
was  the  preferred  route  in  critically  ill  patients,  but  now 
learn  that  oral  intubation  has  a  lower  risk  of  nosocomial 
sinusitis.  We  were  also  told  that  nasotracheal  intubation  is 
contraindicated  in  patients  with  basilar  skull  fracture,  but 
now  learn  that  the  risk  from  this  route  of  intubation  is 
negligible.  This  conference  emphasizes  the  importance  of 
critically  evaluating  our  airway  practices  with  scientifi- 
cally sound  clinical  and  basic  science  investigation. 

Costs  of  Care 

Throughout  the  conference  we  focused  on  improving 
the  quality  of  airway  care,  but  we  also  emphasized  the 
importance  of  considering  the  costs  of  care.  At  times  our 
discussions  have  stated  that  various  approaches  are  or  are 
not  "cost-effective."  We  should  clearly  state  the  differ- 
ence, however,  between  the  "cost-effectiveness"  of  care 
and  efforts  to  minimize  the  cost  of  doing  business  for  our 
health  care  institutions.  Health  care  economists  tell  us  to 
describe  health  care  interventions  as  being  cost-effective 
only  if  rigorous  cost-effectiveness  evaluations  have  been 
performed.  This  conference  has  illuminated  the  fact  that 
very  little  in-depth  cost-effectiveness  research  has  been 
performed  in  the  field  of  airway  management. 

Also,  to  determine  if  a  clinical  approach  is  "cost-effec- 
tive" we  need  to  know  whose  perspective  is  being  used. 
Health  care  economists  argue  that  it  is  necessary  to  take 
the  societal  perspective  to  perform  cost-effectiveness  eval- 
uations. We  need  to  capture  all  of  the  costs  assumed  by 
society  for  the  health  care  interventions  and  their  conse- 
quences. The  limited  perspective  of  the  health  care  insti- 
tution, an  insurer,  or  a  managed  care  organization  may  be 
warranted  in  developing  budgets  and  considering  profits, 
but  has  little  to  do  with  the  determination  of  whether  an 
approach  to  airway  care  is  cost-effective.  We  need  to  fos- 
ter more  cost-effectiveness  research  in  airway  manage- 
ment, to  balance  the  cost  minimization  strategies  of  our 
health  care  institutions.  The  results  of  this  research  should 
be  disseminated  so  that  patients  can  determine  if  health 
care  institutions  have  too  much  interest  in  decreasing  costs 
by  their  resource  allocation  decisions  and  not  enough  in- 
terest in  promoting  best  patient  outcomes. 

Technology  Assessment 

In  discussing  airway  management,  this  conference  also 
emphusi/ed  that  we  clinicians  need  to  learn  more  about 


technology  assessment.  How  do  we  evaluate  and  balance 
potential  benefit  and  risk  from  the  infiltration  of  new  tech- 
nology into  our  airway  management  approaches?  When 
have  sufficient  clinical  practice  and  investigational  work 
been  achieved  to  determine  if  new  technology  can  be  con- 
sidered "safe?"  We  have  heard  in  the  conference  that  per- 
cutaneous dilational  tracheotomy  has  been  determined  to 
be  as  safe  as  standard  surgical  tracheotomy,  yet  Jack 
Stauffer  clearly  described  the  limitations  of  the  long-term 
follow-up  studies  that  examined  the  safety  of  percutaneous 
dilational  tracheotomy.  Perhaps  we  need  to  develop  a  "post- 
marketing" safety  surveillance  program  akin  to  how  drugs 
are  examined  after  they  achieve  Food  and  Drug  Adminis- 
tration approval. 

Much  of  the  foregoing  discussion  can  be  considered  to 
contain  elements  appropriate  for  examination  by  clinical 
decision  analysis.  Many  approaches  to  airway  control  can 
be  directed  by  simple  maxims  or  rules,  such  as  "do  not 
perform  cricothyroidotomy  in  children"  or  "maintain  en- 
dotracheal cuff  pressures  within  defined  parameters."  Many 
problems  pertaining  to  airway  control,  however,  are  com- 
plex and  defy  simple  maxims  and  rules.  Individual  clini- 
cians have  difficulty  analyzing  these  complex  problems 
because  we  use  simplifying  strategies  that  limit  the  num- 
ber of  variables  considered.  In  approaching  these  complex 
problems,  such  as  timing  tracheotomy,  we  should  better 
acquaint  ourselves  with  formal  approaches  to  decision  anal- 
ysis that  incorporate  varying  probabilities  of  benefit  and 
risk  with  competing  strategies  of  care.  These  approaches 
also  consider  the  utility  or  value  of  the  various  outcomes 
from  a  patient-centered  perspective. 

Future  Directions 

While  academic  medical  centers  are  challenged  by  the 
need  to  disseminate  their  airway  discoveries  to  the  hinter- 
lands of  patient  care,  this  conference  has  highlighted  that 
many  valuable  observations  in  the  form  of  performance 
improvement  projects  surface  in  community  hospitals  but 
are  never  published.  How  do  we  disseminate  these  discov- 
eries from  the  community  hospital  setting?  Jamie  StoUer's 


Technological 
Advances 


Effort  and  Resources  Expended 


Fig.  1 .  Trajectory  of  technological  advances  compared  to  resources 
expended.  It  becomes  more  difficult  to  improve  the  technology  as 
a  field  matures. 


864 


Respiratory  Care  •  July  1999  Vol  44  No  7 


Artificial  Airways:  Conference  Summary 


historical  perspective  outlines  the  trajectory  of  technology 
improvement  in  airway  management  over  the  last  several 
centuries.  As  with  all  technology  development,  the  benefit 
achieved  from  the  resources  expended  tend  to  plateau  as 
the  field  matures  (Fig.  1).  Perhaps  in  the  coming  decades, 
we  need  to  place  more  effort  on  the  dissemination  of  our 
cognitive  and  procedural  skills  in  the  form  of  guidelines 
and  standards  of  care  to  improve  outcomes  in  airway  care. 
We  also  should  not  forget  Ann  Thompson's  statement 
that  "fundamentals  are  fundamentally  important."  Airway 
management  is  taking  care  of  basics.  It  involves  no  glam- 
our or  glitz,  but  often  represents  the  important  difference 


between  a  good  clinical  outcome  and  a  catastrophic  event. 
This  conference  is  a  point  on  the  curve  of  progress  that 
began  with  the  ancient  Egyptians  and  leads  toward  im- 
proved clinical  application  of  fundamentally  important  best 
practices  in  airway  care.  The  presentations  in  this  confer- 
ence are  a  testimony  to  all  of  the  clinicians  and  investiga- 
tors who  continue  to  push  us  up  along  this  curve. 

REFERENCE 

1.  McDonald  CJ.  Medical  heuristics:  the  silent  adjudicators  of  clinical 
practice.  Ann  Intern  Med  1996;I24(I  Pt  l):56-62. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


865 


Listing  and  Reviews  of  Books  and  Other  Media.  Note  to  publishers:  Send  review  copies  of  books, 
films,  tapes,  and  software  to  Respiratory  Care,  600  Ninth  Avenue,  Suite  702,  Seattle  WA  98104. 


Books,  Films, 
Tapes,  &  Software 


Mechanical  Ventilation:  Physiological 
and  Clinical  Applications,  3"'''  ed,  Susan 
P  Pilbeam  MS  RRT.  Soft-cover,  illustrated, 
460  pages.  St  Louis:  Mosby,  1998.  $42.00. 

This  book  covers  5  major  asjjects  of  me- 
chanical ventilation.  Part  1  addresses  the 
basic  concept  of  mechanical  ventilation  and 
is  subdivided  into  5  chapters,  covering  the 
history  of  resuscitation,  intubation  and  early 
mechanical  ventilation,  arterial  blood  gas 
evaluation,  basic  concepts  of  mechanical 
ventilation,  basics  of  ventilator  graphics, 
and  physical  aspect  of  mechanical  ventila- 
tion. 

Part  2  describes  monitoring  in  mechan- 
ical ventilation — noninvasive  monitoring 
and  hemodynamic  monitoring  of  the  ven- 
tilated patient.  Effects  and  complications  of 
mechanical  ventilation,  which  delineate  the 
physiologic  effects  and  complication  of  pos- 
itive pressure  ventilation  are  the  subject  of 
Part  3. 

Part  4  covers  patient  management  in  me- 
chanical ventilation  in  8  chapters;  estab- 
lishing the  need  for  mechanical  ventilation; 
selecting  initial  parameters  and  settings; 
special  issues  related  to  ventilator  set  up; 
basic  patient  assessment  and  methods  to 
improve  ventilation;  methods  to  improve 
oxygenation;  airways,  circuits  changes, 
medications,  positioning,  and  other  patient 
issues;  problem-solving  and  troubleshoot- 
ing; and  weaning  and  discontinuation. 

The  final  part  addresses  special  tech- 
niques and  patient  populations,  including 
subjects  such  as  ventilatory  support  of  new- 
bom  and  pediatric  patients,  home  mechan- 
ical ventilation,  and  special  techniques  in 
ventilatory  support. 

The  book  is  directed  primarily  to  stu- 
dents of  respiratory  therapy  programs  and 
nursing  schools,  and  to  respiratory  thera- 
pists and  nurses.  It  would  also  be  useful  for 
medical  students  and  residents.  Overall,  the 
book  meets  its  objective  to  serve  as  an  ed- 
ucational tool  for  the  intended  readers.  Each 
chapter  is  clearly  presented  and  simple  to 
read.  At  the  end  of  each  chapter,  review 
questions  highlight  the  important  points. 
Decision-making  and  problem-solving  are 
emphasized  throughout  the  text.  Answers 
to  review  and  problem-solving  questions 
are  compiled   at  the  end  of  the   book 


and  should  prove  very  helpful  for  those  read- 
ers who  have  to  capture  such  a  broad  topic 
within  a  finite  time.  By  and  large  the  con- 
tents are  up  to  date,  and  most  recent  cited 
references  (1996)  are  only  2  years  behind 
the  publication  date  (1998). 

However,  organization  and  accuracy  of 
the  topic  presented  could  be  improved  in 
the  next  edition.  Basic  ventilator  graphics 
could  be  consolidated  in  Part  2  on  "Moni- 
toring in  Mechanical  Ventilation."  In  the 
chapter  on  "Noninvasive  Monitoring  in  Me- 
chanically Ventilated  Patients,"  the  unit  of 
work  of  breathing  has  to  be  clearly  pre- 
sented either  as  Joules  per  breath  or  per 
liter  of  tidal  volume.  The  chapter  "Ad- 
vanced Steps  in  Arterial  Blood  Gas  Eval- 
uation" needs  to  be  presented  in  more  pre- 
cise terms;  the  term  "compensated" 
metabolic  acidosis  is  inaccurate.'-^ 

Similarly,  in  the  chapter  on  "Physiolog- 
ic Effects  and  Complications  of  Positive 
Pressure  Ventilation,"  the  major  cause  of 
oxygen-induced  hypoventilation  is  not 
elimination  of  hypoxic  drive.'*  In  the  chap- 
ter on  "Methods  to  Improve  Oxygenation," 
shunt  equation  should  be  presented  in  a  sim- 
ple manner.  The  derivation  of  the  complex 
equation  shown  in  the  book  should  be 
presented.  As  written,  the  issue  of  "opti- 
mum posidve  end-expiratory  pressure," 
whether  it  was  based  on  best  oxygen  trans- 
port, or  lower  inflection  point  on  the  pres- 
sure-volume curve,  or  both,  can  be  con- 
fusing. 

For  the  most  part,  the  figures  are  clearly 
presented,  although  there  are  a  few  omis- 
sions of  labeling  that  may  confuse  those 
readers  who  are  not  quite  familiar  with  me- 
chanics of  breathing.  I  did  not  come  across 
typographical  error. 

In  summary,  this  book  meets  its  objec- 
tive for  its  intended  readership.  It  has  kept 
abreast  with  the  recent  rapid  development 
in  the  field  of  mechanical  ventilation,  but 
some  aspects  of  the  subject  need  to  be  more 
accurately  presented. 

Catherine  Sassoon  MD 

Pulmonary  and  Critical  Care  Section 

Veterans  Affairs  Medical  Center 

Long  Beach,  California 


REFERENCES 

1.  Haber  RJ.  A  practical  approach  to  acid-base 
disorders.  West  J  Med  1991;155:146-151. 

2.  Narins  RG,  Emmett  M.  Simple  and  mixed 
acid-base  disorders:  a  practical  approach. 
Medicine  (Baltimore)  1 980;59(3):  1 6 1  -1 87. 

3.  Aubier  M,  Murciano  D,  Fournier  M,  Milic- 
Emili  J,  Pariente  R,  Derenne  JP.  Central  re- 
spiratory drive  in  acute  respiratory  failure  of 
patients  with  chronic  obstructive  pulmonary 
disease.  Am  Rev  Respir  Dis  1980;  122(2): 
191-199. 

4.  Sassoon  CSH,  Hassell  KT,  Mahutte  CK.  Hy- 
poxic-induced  hypercapnia  in  stable  chronic 
obstructive  pulmonary  disease.  Am  Rev  Re- 
spir Dis  1987;135(4):907-911. 

Sleep  Disorders  Sourcebook,  Jenifer  Swan- 
son,  ed.  (Health  Reference  Series.)  Hardback, 
439  pages.  Detroit  MI:  Omnigraphics;  1999. 
$78.00. 

Why  do  we  sleep?  Does  exercise  improve 
sleep?  Is  napping  good  or  bad?  What  is  sud- 
den infant  death  syndrome  (SIDS)?  Do  we 
need  less  sleep  as  we  grow  older?  What  are 
effective  treatments  for  sleep  apnea?  Are 
over-the-counter  sleep  medications  safe? 
How  do  chronic  illnesses  affect  sleep?  If  you 
have  questions  similar  to  these,  where  can 
you  get  the  answers?  The  Sleep  Disorders 
Sourcebook  is  a  newly  published  reference 
source  for  health  care  consumers  that  answers 
these  and  other  questions  of  interest. 

Sleep  is  something  we  all  do,  and  some- 
thing that  can  also  be  disturbed  at  some  time 
for  most  of  us.  Despite  the  relevance  of  sleep, 
the  level  of  knowledge  about  it  among  health 
care  providers  and  the  public  has  been  inad- 
equate. The  Sleep  Disorders  Sourcebook,  a 
compendium  of  previously  published  mate- 
rial, provides  basic  information  about  sleep, 
its  disorders,  and  treatment  options. 

The  book  is  not  bulky,  has  very  readable 
type,  and  an  excellent  index.  It  is  421  pages 
long  and  consists  of  53  chapters.  The  chap- 
ters are  divided  into  6  sections.  "Understand- 
ing Sleep  Requirements  and  the  Costs  of 
Sleep  Deprivation"  includes  chapters  on  the 
biology  of  sleep  and  estimates  and  the  con- 
sequences of  sleep  deprivation.  "Sleep 
through  the  Lifespan"  has  chapters  on  SIDS, 
sleep  disorders  in  children  and  older  persons. 
"The  Major  Sleep  Disorders"  includes  chap- 
ters on  sleep  apnea,  narcolepsy,  restless  leg 
syndrome,  and  insomnia.  "Sleep  Medica- 


866 


Respiratory  Care  •  July  99  Vol  44  No  7 


Books,  Films,  Tapes,  &  Software 


tions"  includes  chapters  on  over-the-counter 
medications,  melatonin,  and  benzodiaz- 
epines. "Sleep  and  Other  Disorders"  has 
chapters  on  mood  disorders,  chronic  head- 
aches, and  cancer.  Finally,  "Additional  Help 
and  Information"  provides  chapters  on  ad- 
ditional reading  and  resources  on  sleep  dis- 
orders. 

Individual  chapters  are  derived  from  a 
variety  of  previously  published  material,  in- 
cluding National  Institutes  of  Health  (NIH) 
publications,  journal  articles,  and  the  pub- 
lications of  major  organizations  concerned 
with  sleep.  The  variety  of  sources  for  indi- 
vidual chapters  is  both  a  strength  and  a  weak- 
ness of  the  book.  It  is  hard  to  imagine  that 
a  book  as  comprehensive  and  authoritative 
could  be  derived  from  a  single  author.  On 
the  other  hand,  the  use  of  different  sources 
at  times  leads  to  some  degree  of  redundancy, 
and  the  differing  styles  of  writing  in  indi- 
vidual chapters  could  be  disconcerting  to 
someone  who  is  reading  an  entire  section  or 
the  entire  book.  For  this  reason,  the  book  is 
probably  best  used  as  a  reference  to  consult 
with  questions  on  a  specific  topic  rather  than 
as  a  book  to  be  read  from  cover  to  cover. 

The  sources  chosen  for  the  individual 
chapters  are  for  the  most  part  excellent.  The 
information  presented  is  accurate  and  up  to 
date  with  a  few  exceptions.  Most  of  the 
chapters  are  easily  accessible  to  an  educated 
reader,  though  several  chapters  present  in- 
formation at  a  level  that  is  more  appropriate 
to  a  health  care  provider.  With  its  broad 
range  of  topics,  the  book  achieves  its  mis- 
sion of  providing  basic  consumer  health  in- 
formation to  the  health  care  consumer. 

It  also  has  some  value  as  resource  for 
health  care  providers,  including  respiratory 
therapists,  nurses,  primary  care  physicians, 
and  pulmonary  specialists  who  deal  with 
sleep-related  disorders.  It  would  be  more 
appropriate  for  health  care  providers  to  con- 
sult standard  sleep  medicine  texts  for  infor- 
mation on  pathophysiology  and  treatment 
of  major  sleep  disorders.  Nevertheless,  there 
are  topics  covered  in  this  reference  that  are 
not  always  addressed  adequately  in  these 
standard  texts.  Examples  include  the  role  of 
exercise  in  treating  insomnia,  the  role  of 
sleep  disorders  in  chronic  headaches,  and 
the  uses  of  melatonin  in  insomnia.  The  in- 
formation in  these  chapters  could  be  useful 
in  patient  diagnosis,  therapy,  and  education. 

The  Sleep  Disorders  Sourcebook  is  a 
useful  resource  that  provides  accurate,  rel- 
evant and  accessible  information  on  sleep 
to  the  general  public.  Health  care  providers 


who  deal  with  sleep  disorders  patients  may 
also  find  it  helpful  in  being  prepared  to  an- 
swer some  of  the  questions  patients  ask. 

Vishesh  Kapur  MD  MPH 

Division  of  Pulmonary  and 

Critical  Care  Medicine 

Department  of  Medicine 

University  of  Washington 

Seattle,  Washington 

Professional  Ethics:  A  Guide  for  Reha- 
bilitation Professionals,  by  Ron  Scott  JD 
PT  OCS.  Soft-cover,  231  pages.  St  Louis: 
Mosby:  1998.  $29.95. 

Professional  Ethics:  A  Guide  for  Re- 
habilitation Professionals  is  a  concise  treat- 
ment of  the  varied  issues  .surrounding  ethics 
for  the  health  professional.  The  target  audi- 
ence for  this  text  is  the  rehabilitation  pro- 
fessional, including  the  respiratory  therapist. 
The  text  may  also  be  useful  to  anyone  in- 
volved in  patient  caie,  including  physicians, 
physician  assistants,  nurse  practitioners,  and 
others.  Each  chapter  begins  with  a  synopsis 
of  the  content  presented  in  that  chapter, 
which  helps  the  reader  establish  a  frame  of 
reference  for  the  material  to  be  presented. 
Each  chapter  is  neatly  summarized.  In  ad- 
dition, a  case  presentation  and  questions  with 
suggested  answers  follow  each  chapter — a 
format  that  challenges  the  learner  to  apply 
the  concepts  presented. 

The  cases  and  questions  have  the  poten- 
tial to  .stimulate  significant  discussion  among 
health  care  students  and  health  profession- 
als. Although  most  of  the  cases  presented 
use  a  physical  therapy  care  setting,  it  would 
be  easy  enough  to  apply  the  scenario  to  a 
respiratory  care  situation.  Each  chapter  is 
well  referenced  and  a  suggested  reading  list 
is  offered.  The  chapters  are  presented  in  a 
logical  order  with  each  new  chapter  build- 
ing on  the  information  presented  in  the  pre- 
vious chapters. 

The  book  is  written  for  the  working  pro- 
fessional but  would  also  be  appropriate  for 
junior  or  senior  heath  care  students.  First 
and  second  year  students  may  find  the  in- 
formation challenging  if  they  lack  the  clin- 
ical exposure  to  appreciate  the  cases  and 
concepts  presented.  Overall,  the  book  is 
readable,  and  the  author  uses  margin  bullets 
in  each  chapter  to  highlight  key  points.  The 
book  is  current  and  reminds  us  that  profes- 
sional ethics  have  not  changed,  even  in  light 
of  health  care  delivery  changes  brought  on 
by  managed  care. 


Chapter  1  provides  definitions  for  such 
ethical  concepts  as  morals,  ethics,  and  law. 
This  chapter  provides  the  basis  for  under- 
standing ethical  concepts  presented  in  sub- 
sequent chapters.  The  author  accomplishes 
this  through  presentation  of  fundamental 
biomedical  ethical  principles  and  provides  a 
basis  for  understanding  legal  duty.  The  chap- 
ter also  demonstrates  the  concept  that  when 
a  health  care  professional  violates  the  law, 
he  or  she  has  also  violated  professional  eth- 
ics. Several  cases  are  woven  into  this  first 
chapter  to  demonstrate  the  various  legal  and 
ethical  concepts  presented.  The  first  chapter 
also  utilizes  .several  charts  that  attempt  to 
help  the  reader  conceptualize  the  material. 
Some  of  these  charts  could  have  been  im- 
proved by  adding  additional  detail.  For  ex- 
ample, the  author  presents  a  rather  simplis- 
tic model  of  a  systems  approach  to  ethical 
decision-making  that  could  have  been  ex- 
panded to  include  intrinsic  and  extrinsic  im- 
plications of  various  outcomes  of  decisions 
made. 

Chapter  2  provides  a  description  of  the 
terminology  and  language  of  various  pro- 
fessional codes  of  ethics.  The  chapter  es- 
tablishes the  purpose  or  need  for  ethical 
codes  among  health  care  professions  and 
describes  the  roles  and  responsibilities  of 
organizations  that  develop  codes  of  ethics. 
The  chapter  helps  the  reader  differentiate 
between  directive  and  nondirective  language 
used  in  codes  of  ethics.  The  nondirective 
language  is  further  broken  down  into  state- 
ments of  permissive  and  recommended  con- 
duct, providing  the  reader  with  the  detail 
necessary  to  interpret  various  written  ethi- 
cal codes.  The  author  then  presents  exam- 
ples of  frameworks  for  codes  of  ethics  from 
the  fields  of  physical  therapy,  occupational 
therapy,  and  orthotics  and  prosthetics.  The 
codes  of  ethics  for  other  disciplines,  includ- 
ing respiratory  care,  are  presented  in  the 
appendixes  of  the  text.  The  disciplinary  pro- 
cesses for  the  3  health  fields  included  in  this 
chapter  are  described.  The  disciplinary  pro- 
cedures for  other  health  fields  are  absent 
from  both  the  chapter  and  the  appendixes. 
The  author  does  suggest  student  research 
into  the  judiciary  policies  of  other  disciplines 
with  a  challenge  to  compare  their  findings 
with  those  examples  presented  in  the  chap- 
ter. Due  process  is  described  and  a  chapter 
summary  is  provided. 

Chapter  3  tackles  the  ethical  concerns  of 
the  health  care  professional  as  they  relate  to 
informed  consent  for  interventions  and  re- 
search. The  components  of  a  complete  and 


Respiratory  Care  •  July  99  Vol  44  No  7 


867 


Books,  Films,  Tapes,  &  Software 


ethical  informed  consent  document  are  out- 
lined with  excellent  discussion  of  detailed 
subsections  such  as  diagnostic  findings, 
goals  of  the  intervention,  and  potential  as- 
sociated risks.  The  relationship  between  fail- 
ure to  obtain  informed  consent  and  ethical 
decision-making  is  highlighted.  The  chap- 
ter relates  the  positive  functional  outcome 
potentials  of  an  informed  patient  who  un- 
derstands the  objectives  of  the  various  in- 
terventions. The  patient's  "bill  of  rights"  is 
presented  and  discussed  as  an  ethical  stan- 
dard to  be  upheld.  The  chapter  then  describes 
the  emergency  doctrine  and  therapeutic  priv- 
ilege as  exceptions  to  the  requirement  to 
obtain  patient  informed  consent.  This  con- 
cept is  supported  with  a  brief  case.  Since 
respiratory  therapists  are  usually  members 
of  the  resuscitation  team,  this  section  is  of 
great  value,  as  are  the  next  topics  of  "do  not 
resuscitate"  orders  and  "living  wills."  Fed- 
eral regulations  regarding  the  use  of  human 
subjects  in  research  settings  are  concisely 
described.  The  rationales  for  the  federal  reg- 
ulations are  supported  with  historical  focus 
on  the  Nuremberg  Code  and  the  Helsinki 
Declarations  of  1964  and  1975.  The  chapter 
winds  up  with  a  discussion  of  the  impact  of 
managed  care  on  the  issues  of  informed  con- 
sent— specifically,  the  "gag  clauses"  used 
by  some  managed  care  groups,  which  would 
limit  full  disclosure  of  treatment-related  in- 
formation, which  would,  in  turn,  create  an 
ethical  dilemma. 

Chapter  4  covers  the  many  issues  regard- 
ing professional  practice  acts.  The  discus- 
sions and  case  examples  regarding  scope  of 
practice  encroachment  under  the  current 
managed  care  framework  are  particularly 
useful  and  timely.  After  presenting  back- 
ground on  the  development  of,  and  estab- 
lishing the  need  for  professional  practice 
acts,  the  chapter  describes  the  impact  of 
"multiskilling"  and  cross-training  on  health 
care  today.  The  ethical  concepts  of  patient 
and  provider  responsibilities  with  respect  to 
fees  and  payment  for  services  are  presented 
with  special  attention  to  "pro  bono  publico" 
service.  Malpractice  liability  is  presented  as 
an  ethical  responsibility  but  also  as  a  barrier 
to  pro  bono  services.  The  chapter  concludes 
with  discussions  of  patient  confidentiality 
issues,  including  patient  information  as  well 
as  proprietary  information.  Permissible  and 
mandatory  disclosures  are  explained,  such 
as  the  release  of  information  to  third  party 
payers.  The  chapter  provides  several  mini- 
cases  that  enhance  reader  understanding  of 
concepts  presented. 


Patient  and  provider  access  issues  are  de- 
scribed in  Chapter  5  with  an  initial  review 
of  the  federal  and  state  laws  that  facilitate 
specific  groups'  access  to  health  care.  Non- 
discrimination concepts  are  presented  with 
regards  to  diagnosis-based  bias,  as  well  as 
provider  concerns  such  as  the  Age  Discrim- 
ination in  Employment  Act,  Title  I  of  the 
Americans  with  Disabilities  Act,  the  Civil 
Rights  Acts,  and  the  Family  and  Medical 
Leave  Act.  The  chapter  concludes  with  a 
discussion  of  restrictive  covenants  in  em- 
ployment contracts  and  the  "any  willing  pro- 
vider" laws  found  in  many  states.  As  in  pre- 
vious chapters,  several  mini-cases  add  to  the 
understanding  of  the  somewhat  complex  is- 
sues surrounding  patient  and  provider  ac- 
cess issues. 

Chapter  6  presents  information  related  to 
professional  business  arrangements  as  they 
relate  to  ethical  clinical  practice.  Ethical  is- 
sues of  conflict  of  interest,  referral  of  pa- 
tients for  profit,  business  contracts,  adver- 
tising, and  fraud  and  abuse  are  presented, 
with  several  cases  used  to  elaborate  on  these 
important  areas.  Salient  rules  of  conduct  re- 
lated to  the  issues  discussed  are  included. 

Sexual  harassment  and  sexual  miscon- 
duct are  presented  in  Chapter  7.  Sexual  as- 
sault is  clearly  defined,  and  examples  of 
ethical  codes  regarding  sexual  harassment 
or  misconduct  are  discussed.  Scott  differen- 
tiates between  provider-patient  issues  and 
harassment  issues  in  the  workplace.  Em- 
ployer responsibilities  regarding  employer 
sexual  harassment  education  are  outlined. 
Scott  includes  a  brief  section  on  sexual  ha- 
rassment and  misconduct  in  the  health  pro- 
fessional education  setting. 

In  Chapter  8  Scott  presents  the  legal  and 
ethical  implications  surrounding  the  issue 
of  life  and  death  decision-making.  Passive 
and  active  euthanasia  are  discussed,  with 
terms  such  as  "terminally  ill  patient"  and 
"vegetative  state"  being  clearly  defined.  The 
assessment  of  patient  competency  to  make 
end-of-life  decisions  is  considered,  followed 
by  a  presentation  of  the  ethical  concerns 
regarding  "do  not  resuscitate"  orders.  Ap- 
propriate legislation  such  as  the  Patient  Self- 
Determination  Act  of  1990  is  presented  with 
an  assessment  of  the  impact  of  such  acts  on 
health  professionals.  "Living  wills"  and  "du- 
rable power  of  attorney  for  health  care  de- 
cisions "are  described,  with  examples  from 
state  statutes  provided.  The  questions  sur- 
rounding whether  a  constitutional  right  to 
die  exists  are  addressed  using  United  States 
Supreme  Court  case  examples.  The  chapter 


concludes  with  a  brief  consideration  of  the 
issue  of  human  cloning. 

The  final  chapter  deals  with  the  ethical 
issues  surrounding  the  areas  of  research,  ed- 
ucation, and  patient  care  delivery.  Subject 
protection  in  human  research  is  discussed 
with  examples  from  physical  and  occupa- 
tional therapy  codes  of  ethics  as  they  relate 
to  research.  Issues  of  disclosure,  confiden- 
tiality, and  informed  consent  are  revisited. 
Student  and  faculty  ethical  responsibilities 
are  presented  as  well  as  student-faculty  in- 
teraction concerns.  Scott  states  that  the  char- 
acteristics of  the  patient-client  relationship 
also  apply  in  the  academic  .setting.  The  au- 
thor presents  a  brief  description  of  ethics 
committees  of  health  care  institutions  and 
concludes  Chapter  9  with  the  contrast  be- 
tween the  managed  care  paradigm  and  health 
care  professional  ethics,  with  mention  of  the 
changes  in  managed  care  that  are  being  leg- 
islated or  demanded  by  the  public. 

Overall,  the  book  is  a  comprehensive 
treatment  of  an  increasingly  complex  sub- 
ject. Respiratory  therapists  will  find  the  chap- 
ters relating  to  understanding  the  basics — 
informed  consent,  nondiscrimination 
regarding  patient  access,  sexual  harassment, 
life  and  death  decision-making,  and  ethics 
in  education  and  research — very  useful.  Of 
less  use  to  the  respiratory  therapist  aie  the 
chapters  regarding  private  practice  and  busi- 
ness arrangements.  As  the  respiratory  care 
profession  evolves,  the  background  provided 
related  to  private  practice  and  business  ar- 
rangements will  become  more  applicable. 

The  book  is  very  timely,  using  current 
statutes,  codes,  and  cases  as  examples.  Chap- 
ter cases  serve  as  an  excellent  tool  for  stim- 
ulating thought  and  understanding  chapter 
concepts.  The  appendixes  are  extensive  and 
provide  support  for  the  chapter  content.  The 
index  is  well  structured  and  detailed.  Since 
the  author  uses  mostly  physical  therapy  and 
occupational  therapy  examples  in  the  text 
and  chapter  cases,  the  respiratory  therapist 
would  need  to  relate  cases  within  our  pro- 
fession to  enhance  his  or  her  understanding 
and  applicability  of  chapter  concepts.  A  sup- 
plement of  respiratory  care-related  cases 
would  have  been  very  helpful  for  the  respi- 
ratory care  educator.  In  the  current  and  an- 
ticipated health  care  environment  of  man- 
aged care,  this  text  would  be  a  useful  part  of 
our  respiratory  care  curriculum,  as  it  orga- 
nizes and  presents  ethical  concepts  in  a 
meaningful  way.  Physicians  serving  on  in- 
stitutional ethics  committees  may  find  the 
contents  useful;  however,  I  feel  the  most 


868 


Respiratory  Care  •  July  99  Vol  44  No  7 


Books,  Films,  Tapes,  &  Software 


appropriate  use  of  this  book  is  in  educa- 
tional programs,  post-graduate  course  woric, 
workshops,  or  in  the  workplace. 

Ronald  G.  Beckett,  PhD,  RRT 

Respiratory  Care  Program 

Department  of  Cardiopulmonary  Sciences 

and  Diagnostic  Imaging 

Quinnipiac  College 

Hamden,  Connecticut 

Introductory  Medical  Statistics,  3'''*  ed. 

Richard  F  Mould.  (Medical  Science  Series.) 
Soft-cover,  illustrated,  403  pages.  Bristol, 
UK  and  Philadelphia:  Institute  of  Physics 
Publishing;  1998.  $49.00. 

Introductory  Medical  Statistics  is  part 
of  the  Medical  Science  Series  of  books, 
which  is  the  official  book  series  of  the  In- 
ternational Federation  for  Medical  and  Bi- 
ological Engineering  and  the  International 
Organization  for  Medical  Physics.  The  text 
was  initially  based  on  a  class  taught  to  med- 
ical students,  but  its  intended  audience  now 
includes  all  medical  professionals — nurses, 
respiratory  therapists,  pharmacists,  and  phy- 
sicians. The  editor  of  the  new  edition  has 
made  a  number  of  significant  additions  that 
are  essential  in  understanding  the  increas- 
ingly complex  medical  literature.  The  new 
additions  include  sections  on  epidemiolog- 
ical study  design,  survival  analysis,  multi- 
variate analysis,  additional  nonparametric 
tests,  sensitivity  and  specificity,  risk  speci- 
fication, and  analysis  of  treatment  success. 

Chapters  1  and  2  are  basic  introductions 
to  the  pre.sentation  and  distribution  of  data. 
Chapter  3  introduces  the  concept  of  the  nor- 
mal distribution.  Chapters  4  through  7  dis- 
cuss sampling,  followed  by  descriptions  of 


the  binomial  and  Poisson  probability  distri- 
butions. Chapter  8  introduces  the  concept 
of  statistical  inference.  Chapters  9  through 
13  and  Chapter  15  include  the  basic  de- 
scription of  statistical  methods  essential  to 
any  introductory  text.  These  methods  in- 
clude, chi-squared  tests,  Fisher's  exact  test, 
Student's  /-test,  McNemar's  test,  sign  tests, 
log-rank,  and  Mantel-Haenszel  tests.  Chap- 
ters 16  and  17  address  regression,  correla- 
tion coefficients,  and  analysis  of  variance 
(ANOVA).  Chapters  14  and  18  deal  with 
survival  analysis  with  the  Kaplan-Meier 
method,  life  tables,  and  Cox  proportional 
hazards  models.  Chapters  19  through  23  dis- 
cuss sensitivity  and  specificity,  randomized 
and  observational  trials,  assessments  of  treat- 
ment success,  and  risk  specification. 

Overall,  each  chapter  is  well  written  and 
the  text  contains  few  typographical  errors. 
The  organization  of  the  chapters  generally 
follows  a  logical  progression;  however,  as 
an  introductory  text,  the  Student's  f-test  is 
conceptually  easier  to  understand  and  would 
seem  more  appropriate  to  precede  the  chap- 
ters on  the  chi-squared  and  Fisher's  exact 
tests.  It  would  also  make  more  sense  to  group 
the  survival  analysis  methods  as  a  sequence 
of  chapters  after  the  discussions  of  regres- 
sion and  ANOVA.  As  a  "stand  alone"  text 
for  a  class  on  medical  statistics,  the  material 
is  generally  complete  and  sufficient;  how- 
ever, no  additional  exercises,  aside  from  the 
worked  examples,  are  included.  If  the  pur- 
pose of  a  class  were  to  learn  the  apphcation 
of  statistical  methods,  this  text  would  re- 
quire supplementation  with  additional  exer- 
cises. The  text  is  quite  sufficient  to  give  the 
reader  an  appreciation  of  the  difficulties 
faced  in  the  clinical  literature. 


The  author  uses  pragmatic  and  interest- 
ing examples  from  history,  incorporating  a 
good  deal  of  humor  and  life  into  a  subject 
matter  that  is  often  considered  dull.  More 
importantly,  this  approach  makes  the  read- 
ing material  much  more  engaging.  The  au- 
thors also  stress  the  important  distinction 
between  statistical  inference  and  declaration 
of  facts,  and  point  out  the  difference  be- 
tween statistical  significance  and  clinical 
"significance"  (importance).  The  additional 
sections  of  this  text  are  particularly  valuable 
to  the  clinician.  In  particular,  clinicians  need 
to  understand  the  difference  between  sensi- 
tivity and  specificity  and  how  they  are  re- 
lated to  the  positive  and  negative  predictive 
value  of  a  test.  This  text  also  provides  the 
basic  framework  to  help  the  reader  under- 
stand the  most  common  observational  study 
designs  and  their  limitations.  The  glossary 
of  rates  and  ratios  is  a  valuable  resource  to 
help  make  sense  of  confusing  epidemiologic 
terminology.  The  sections  on  survival  anal- 
ysis and  specification  of  treatment  success, 
cure,  and  quality  of  life  are  very  appropriate 
and  germane  to  clinical  practice. 

Overall,  this  text  is  a  valuable  resource 
and  would  benefit  any  medical  professional 
who  wishes  to  gain  a  better  understanding 
of  the  medical  literature  and  biostatistics. 

David  Au  MD 

Senior  Fellow 

Division  of  Pulmonary  and 

Critical  Care  Medicine 

Department  of  Medicine 

University  of  Washington 

Seattle,  Washington 


CORRECTION  TO  BOOK  INFORMATION 

In  the  review  by  Michael  W  Prewitt  PhD  RRT  of  Critical  Thinking:  Cases  in  Respiratory  Care. 

Kathleen  J  Wood  MEd  RRT.  Soft-cover,  151  pages.  Philadelphia:  F  A  Davis  Co;  1998.  $23.95,  and 

Instructor's  Guide  to  Critical  Thinking:  Cases  in  Respiratory  Care.  Kathleen  J  Wood  MED 

RRT  with  Lawrence  A  Dahl  EdD  RRT  Soft-cover,  118  pages.  Philadelphia:  F  A  Davis  Co;  1998 

[Respir  Care  1999:44(3):367-368),  the  price  of  the  Instructors  Guide  was  incorrectly  quoted  as 

$23.95. 

The  Instructor's  Guide  is  not  a  companion  text  and  is  not  available  for  sale.  It  is  a  free  resource 

available  only  to  educators  to  help  them  in  preparing  their  course.  The  Journal  regrets  the  error. 


Respiratory  Care  •  July  99  Vol  44  No  7 


869 


News  releases  about  new  products  and  services  will  be  considered  for  publication  in  this  section. 

There  is  no  charge  for  these  listings.  Send  descriptive  release  and  glossy  black  and  white  photographs 

to  RESPIRATORY  CARE,  New  Products  &  Services  Dept,  1 1030  Abies  Lane.  Dallas  TX  75229-4593. 

The  Reader  Service  Card  can  be  found  at  the  back  of  the  Journal. 


New  Products 
&  Services 


Drug  Management  System.  Medtrac 
Technologies  Inc  launches  MDILog'"''^  and 
PeakLogT^'^,  an  integrated  pulmonary  drug 
management  system  designed  for  chronic 
respiratory  patients  with  conditions  like 
asthma  or  COPD.  According  to  Medtrac, 
this  new  system  electronically  monitors 
lung  function,  medication  compliance,  and 
patient  technique  and  also  provides  treat- 
ment outcomes  data.  Company  literature 
says  the  data  can  be  downloaded  to  a  PC 
for  future  reference.  For  more  information 
from  Medtrac  Technologies,  circle  num- 
ber 153  on  the  reader  service  card  in  this 
issue,  or  send  your  request  electronically 
via  "Advertisers  Online"  at  http://www. 
aarc.org/buyers_guide/ 


Ventilator  has  expanded  the  respiratory 
capabilities  of  the  740  Ventilator  providing 
pressure  control  ventilation  (PCV)  as  well 
as  volume  control  ventilation  (VCV)  for 
mandatory  breaths.  The  company  also  says 
the  new  device  allows  clinicians  to  set  the 
rise  time  factor  in  PCV  and  pressure  sup- 
port ventilation  (PSV).  Mallinckrodt  says 
that  the  new  ventilator  also  allows  for 
adjustable  flow  sensitivity  for  PSV  breaths 
and  that  VCV  or  PCV  breaths  are  avail- 
able in  apnea  ventilation.  For  more  infor- 
mation from  Mallinckrodt,  circle  number 
1 54  on  the  reader  service  card  in  this  issue, 
or  send  your  request  electronically  via 
"Advertisers  Online"  at  http://www. 
aarc.org/buyers_guide/ 


Ventilator.  Mallinckrodt  introduces  the 
new  Puritan-Bennett®  760'"^  Ventilator. 
A  Mallinckrodt  press  relea.se  says  the  760 


Sleep  Diagnostic  System.  Cadwell  Lab- 
oratories introduces  its  Easy®  II  Sleep  sys- 
tem. According  to  Cadwell,  this  new 
device  offers  full  PSG  capabilities  with  its 
simplified  32-channel  Windows®  95/98 
recording  and  reviewing.  A  company  press 
release  says  the  system  allows  for  the  col- 
lection of  virtually  unlimited  user-defin- 
able montages  to  perform  PSGs  at  night 


and  EEGs  during  the  day.  Cadwell  says  the 
Easy  II  system  can  be  added  to  an  exist- 
ing Windows  95  computer  or  a  Dell  com- 
puter can  be  purchased  from  Cadwell.  For 
more  information  from  Cadwell  Labora- 
tories, circle  number  155  on  the  reader  ser- 
vice card  in  this  issue,  or  send  your  request 
electronically  via  "Advertisers  Online"  at 
http://www.aarc.org/buyers_guide/ 

ICU  Patient  Speech  Device.  Sunrise  Med- 
ical's DynaVox  Systems  introduces 
VitalVoice.  Sunrise  describes  this  new 
product  as  a  communication  device 
designed  for  ICU  patients  who  are  ven- 
tilated or  are  temporarily  unable  to  speak 
for  other  medical  reasons.  According  to 
the  company,  VitalVoice  allows  patients 
to  choose  from  among  many  prerecorded 
messages  or  (especially  for  non-English 
speakers  or  small  children)  from  among 
various  icons.  Sunrise  says  the  device  is 
equipped  with  a  colorful  touch-screen  dis- 
play and  high  quality  synthesized  speech. 
For  more  information  from  Sunrise  Med- 
ical circle  number  156  on  the  reader  ser- 
vice card  in  this  issue,  or  send  your  request 
electronically  via  "Advertisers  Online"  at 
http://www.aarc.org/buyers_guide/ 


870 


RESPIRATORY  CARE  •  JULY    1 999  VOL  44  NO  7 


American  Association  for  Respiratory  Care 


JJ. 


Please  read  the  eligibility  requirements  for  each  of  the  classifications  in  the 
right-hand  column,  then  complete  the  applicable  section.  All  information 
requested  below  must  be  provided,  except  where  indicated  as  optional. 
See  other  side  for  more  information  and  fee  schedule.  Please  sign  and  date 
application  on  reverse  side  and  type  or  print  clearly.  Processing  of  applica- 
tion takes  approximately  15  days. 

D  Active 
Associate 

□  Foreign 

n  Physician 

n  Industrial      ' 
D  Special 
D  Student 


Last  Name  _ 
First  Name 


Social  Security  No.  . 
Home  Address 

City 


State 


.Zip 


Phone  No. 


Primary  Job  Responsibility  fcfieclr  one  only) 

n  Technical  Director 

n  Assistant  Technical  Director 

n  Pulmonary  Function  Specialist 

n  Instructor/Educator 

Q  Supervisor 

D  Staff  Therapist 

n  Staff  Technician 

□  Rehabilitation/fHome  Care 

n  Medical  Director 

n  Sales 

I  D  Student 

I  n  Other,  specify 


Type  of  Business 

n  Hospital 

D  Skilled  Nursing  Facility 

D  DME/HME 

n  Home  Health  Agency 

D  Educational  Institution 

n  Manufacturer  or  supplier 

n  Other,  specify 


Date  of  Birth  (optional) 


Sex  (optional) 


U.S.  Citizen? 


Yes 


No 


Have  you  ever  been  a  member  of  the  AARC? 


If  so,  when?  From 


to 


4f 


For  office  use  only 


FOR  ACTIVE  MEMBER 

An  individual  is  eligible  if  he/she  lives  in  the  U.S.  or  its  territories  or  v^^os  on  Active  Member 
prior  to  moving  outside  its  borders  or  territories  and  meets  ONE  of  the  follov/ing  criteria:  [1  ]  is 
legally  credentialed  os  a  respiratory  care  professional  if  employed  in  a  state  that  mandates 
such,  OR  [21  is  a  graduate  or  an  accredited  educationol  program  in  respiratory  care,  OR  [31 
holds  a  crecfential  issued  by  the  NBRC.  An  individual  who  is  on  AARC  Active  Member  in  good 
standing  on  December  8,  1 994,  will  continue  as  such  provided  his/her  membership  remains  in 
good  standing. 

PLEASE  USE  THE  ADDRESS  OF  THE  LOCATION  WHERE  YOU  PERFORM  YOUR  JOB,  NOT 
THE  CORPORATE  HEADQUARTERS  IF  IT  IS  LOCATED  ELSEWHERE. 

Place  of  Employment 

Address 

City 

State 


.Zip 


Phone  No. 


Medical  Director/Medical  Sponsor . 


FOR  ASSOCIATE  OR  SPECIAL  MEMBER 

Individuals  who  hold  a  position  related  to  respiratory  core  but  do  not  meet  the  requirements  of 
Active  Member  shall  be  Associate  Members.  They  hove  all  the  rights  and  benefits  of  the  Asso- 
ciation except  to  hold  office,  vote,  or  serve  as  chair  of  a  standing  committee.  The  following  sub- 
classes of  Associate  Membership  are  available:  Foreign,  Physician,  and  Industrial  [individuals 
whose  primary  occupation  is  directly  or  indirectly  devoted  to  the  manufacture,  sale,  or  distribu- 
tion of  respiratory  care  eauipment  or  supplies).  Special  Members  are  those  not  working  in  a 
respiratory  core-related  field. 

PLEASE  USE  THE  ADDRESS  OF  THE  LOCATION  WHERE  YOU  PERFORM  YOUR  JOB,  NOT 
THE  CORPORATE  HEADQUARTERS  IF  IT  IS  LOCATED  ELSEWHERE. 

Place  of  Employment 

Address 


City_ 
State 


-Zip 


Phone  No. 


FOR  STUDENT  MEMBER 

Individuals  will  be  classified  as  Student  Members  if  they  meet  oil  the  requirements  for  Associate 
Membership  and  are  enrolled  in  on  educational  program  in  respiratory  care  occredited  by,  or 
in  the  process  of  seeking  accreditation  from,  on  AARC-recognized  agency. 

SPECIAL  NOTICE  —  Student  Members  do  not  receive  Continuing  Respiratory  Core  Education 
[CRCE)  transcripts.  Upon  completion  of  your  respiratory  core  education,  continuing  education 
credits  may  be  pursued  upon  your  reclassificotion  to  Active  or  Associate  Member. 

School/RC  Program 

Address 


City_ 
State 


.Zip 


Phone  No. 


Length  of  program 

n    1  year 
D   2  years 

Cxpe€ted  Date  of  Graduation  (REQUIRED 
INFORMATION) 


□  4  years 

D  Other,  specify . 


Month 


Year 


Preferred  mailing  address:     ._     Home    •  .   Business 
American  Association  for  Respiratory  Care  .  11 030  Abies  Lane  •  Dallas,  TX  75229-4593  •  [972]  243-2272  •  Fax  [972!  434-2720 


American  Association  for  Respiratory  Care 


embehship  appucation 


Demographie  Questions 

We  request  that  you  answer  these  questions  in  order  to  help  us 
design  services  and  programs  to  meet  your  needs. 


Cfiecit  the  Highest  Degree  Earned 

D  High  School 

D   RC  Graduate  Technician 

D  Associate  Degree 

n   Bachelor's  Degree 

D  Master's  Degree 

n   Doctorate  Degree 


Number  of  Years  in  Respiratory  Care 

□  a2  years  □    11-15  Years 

D  3-5  years  n   1 6  years  or  more 

D  6-10  years 


Job  Status 

n  Full  Time 

n   Port  Time 

Credentials 

n  RRT 

n  LVN/LPN 

n  CRT 

n  CPFT 

n   Physician 

n  RPFT 

D  CRNA 

n  Perinatal/Pediotric 

D  RN 

Salary 


n  Less  than  $10,000 
D  $10,001 -$20,000 
D  $20,001 -$30,000 
D  $30,001 -$40,000 
D  $40,000  or  more 


PLEASE  SIGN 

I  hereby  apply  for  membership  in  the  American  Association  for  Respiratory  Care 
and  have  enclosed  my  dues.  If  approved  for  membership  in  the  AARC,  I  v/ill  abide 
by  its  bylavt/s  and  professional  code  of  ethics.  I  authorize  investigation  of  all  state- 
ments contained  herein  and  understand  that  misrepresentations  or  omissions  of 
facts  called  for  is  cause  for  rejection  or  expulsion. 

A  yeorly  subscription  to  RESPIRATORY  CARE  journal  and  AARC  Times  magazine 
includes  an  allocation  of  $1  1 .50  from  my  dues  for  each  of  these  publications. 

NOTE:  Contributions  or  gifts  to  the  AARC  are  not  tax  deductible  as  charitable  con- 
tributions for  income  tax  purposes.  However,  they  may  be  tax  deductible  as  ordi- 
nary and  necessary  business  expenses  subject  to  restrictions  imposed  as  a  result  of 
association  lobbying  activities.  The  AARC  estimates  that  the  nondeductible  portion 
of  your  dues  —  the  portion  v^hich  is  allocable  to  lobbying  —  is  26%. 

SignafutB 

DafB 


iMembersftip  Fees 

Payment  must  accompany  your  application  to  the  AARC.  Fees  are  for  12 
montfis.  (NOTE:  Renewal  fees  are  $75.00  Active,  Associate-Industrial  or  Associ- 
ate-Pfiysician,  or  Special  status;  $90.00  for  Associate-Foreign  status;  and 
$45.00  for  Student  status). 


n  Active 

$  87.50 

D  Associate  (Industrial  or  Physician) 

$  87.50 

D  Associate  (Foreign) 

$102.50 

D  Special 

$  87.50 

D  Student 

$  45.00 

TOTAL 

$ 

Spetialty  Sections 

Established  to  recognize  the  specialty  areas  of  respiratory  care,  these  sections 
publish  a  bi-monthly  newsletter  that  focuses  on  issues  of  specific  concern  to  that 
specialty.  The  sections  also  design  the  specialty  programming  at  the  notional 
AARC  meetings. 


n  Adult  Acute  Care  Section 

$15.00 

n  Education  Section 

$20.00 

D   Perinatal-Pediatric  Section 

$15.00 

n   Diagnostics  Section 

$15.00 

D  Continuing  Core- 

Rehabilitation  Section 

$15.00 

D  Management  Section 

$20.00 

D  Transport  Section 

$15.00 

n  Home  Care  Section 

$15.00 

n  Subacute  Care  Section 

$15.00 

TOTAL 

$ 

GRAND  TOTAL  =  Membership 

fee 

plus  optional  sections 

$ 

n  Total  Amount  Enclosed/Charged       $ 
n  Please  charge  my  dues  (see  below| 

To  charge  your  dues,  complete  the  follov/ing: 
n  MasterCard 
D  Visa 

Card  Number 


Cord  Expires /_ 

Signature 


Mail  application  and  appropriate  fees  to: 
American  Association  for  Respiratory  Care  •  1 1030  Abies  Lane  •  Dallas,  TX  75229-4593 


[972]  243-2272  •  Fax  [972]  484-2720 


I 


RE/PIRAJORy  QVRE 


Manuscript  Preparation  Guide 


General  Information 

Respiratory  Care  welcomes  original  manuscripts  related  to  the 
science  and  technology  of  respiratory  care  and  prepared  accord- 
ing to  these  Instructions  and  the  Uniform  Requirements  for 
Manuscripts  Submitted  to  BiomedicalJoumals  [Respir  Care  1997; 
42(6):623-634].  Manuscripts  are  blinded  and  reviewed  by  pro- 
fessionals who  are  experts  in  their  fields.  Authors  are  responsible 
for  all  aspects  of  the  manuscript  and  receive  galleys  to  proofread 
before  publication.  Each  accepted  manuscript  is  copyedited  so  that 
its  message  is  clear  and  it  conforms  to  the  Journal's  style.  Published 
papers  are  copyrighted  by  Daedalus  Inc  and  may  not  be  published 
elsewhere  without  permission. 

Editorial  consultation  is  available  at  any  stage  of  planning  or  writ- 
ing. On  request,  specific  guidance  is  provided  for  all  publication  cat- 
egories. To  receive  these  Instructions  and  related  materials,  write 
to  Respiratory  Care,  600  Ninth  Avenue,  Suite  702,  Seattle  WA 
98104,  call  (206)  223-0558,  or  fax  (206)  223-0563. 

Publication  Categories  &  Structure 

Research  Article:  A  report  of  an  original  investigation  (a  study). 
It  includes  a  Title  Page,  Abstract,  Introduction,  Methods,  Results, 
Discussion,  Conclusions,  Product  Sources,  Acknowledgments,  Ref- 
erences, Tables,  Appendices,  Figures,  and  Figure  Captions. 

Evaluation  of  Device/IVIethod/Technique:  A  description  and  eval- 
uation of  an  old  or  new  device,  method,  technique,  or  modification. 
It  has  a  Title  Page,  Abstract,  Introduction,  Description  of  De- 
vice/Method/Technique,  Evaluation  Methods,  Evaluation  Results, 
Discussion,  Conclusions,  Product  Sources,  Acknowledgments,  Ref- 
erences, Tables,  Appendices,  Figures,  and  Figure  Captions.  Com- 
parative cost  data  should  be  included  wherever  possible. 

Case  Report:  A  report  of  a  clinical  case  that  is  uncommon,  or  was 
managed  in  a  new  way,  or  is  exceptionally  instructive.  All  authors 
must  be  associated  with  the  case.  A  case-managing  physician  must 
either  be  an  author  or  furnish  a  letter  approving  the  manuscript.  Its 
components  are  Title  Page,  Abstract,  Introduction,  Case  Summa- 
ry, Discussion,  References,  Tables,  Figures,  and  Figure  Captions. 

Review  Article:  A  comprehensive,  critical  review  of  the  literature 
and  state-of-the-art  summary  of  a  pertinent  topic  that  has  been  the 
subject  of  at  least  40  published  research  articles.  Title  Page,  Out- 
line, Introduction,  Review  of  the  Literature,  Summary,  Acknowl- 
edgments, References.  Tables,  Appendices,  and  Figures  and  Cap- 
tions may  be  included. 

Overview:  A  critical  review  of  a  pertinent  topic  that  has  fewer  than 
40  published  research  articles. 

Update:  A  report  of  subsequent  developments  in  a  topic  that  has 
been  critically  reviewed  in  this  Journal  or  elsewhere. 


Point-of-View  Paper:  A  paper  expressing  personal  but  substanti- 
ated opinions  on  a  pertinent  topic.  Title  Page,  Text,  References,  Tables, 
and  Illustrations  may  be  included. 

Special  Article:  A  pertinent  paper  not  fitting  one  of  the  foregoing 
categories  may  be  acceptable  as  a  Special  Article.  Consult  with  the 
Editor  before  writing  or  submitting  such  a  paper. 

Editorial:  A  paper  drawing  attention  to  a  pertinent  concern;  it  may 
present  an  opposing  opinion,  clarify  a  position,  or  bring  a  problem 
into  focus. 

Letter:  A  signed  communication,  marked  "For  publication," 
about  prior  publications  in  this  Journal  or  about  other  pertinent  top- 
ics. Tables  and  illustrations  may  be  included. 

Blood  Gas  Comer:  A  brief,  instructive  case  report  involving  blood 
gas  values — with  Questions,  Answers,  and  Discussion. 

Drug  Capsule:  A  mini-review  paper  about  a  drug  or  class  of  drugs 
that  includes  discussions  of  pharmacology,  pharmacokinetics, 
and  pharmacotherapy. 

Graphics  Comer:  A  briefcase  report  incorporating  waveforms  for 
monitoring  or  diagnosis — with  Questions,  Answers,  and  Discussion. 

Kittredge's  Comer:  A  brief  description  of  the  operation  of  respiratory 
care  equipment — with  information  from  manufacturers  and  edito- 
rial comments  and  suggestions. 

PFT  Corner:  Like  Blood  Gas  Comer,  but  involving  pulmonary 
function  tests. 

Cardiorespiratory  Interactions.  A  case  report  demonstrating  the 
interaction  between  the  cardiovascular  and  respiratory  systems.  It 
should  be  a  patient-care  scenario;  however,  the  case — the  central 
theme — is  the  systems  interaction.  CRI  is  characterized  by  figures, 
equations,  and  a  glossary.  See  the  March  1996  Issue  of  RESPIRA- 
TORY Care  for  more  detail. 

Test  Your  Radiologic  Skill:  Like  Blood  Gas  Corner,  but  involv- 
ing pulmonary  medicine  radiography  and  including  one  or  more  radio- 
graphs; may  involve  imaging  techniques  other  than  conventional 
chest  radiography. 

Review  of  Book,  Film,  Tape,  or  Software:  A  balanced,  critical 
review  of  a  recent  release. 

Preparing  the  Manuscript 

Print  on  one  side  of  white  bond  paper,  8.5  in.  x  1 1  in.  (216  x  279  mm) 
with  margins  of  at  least  1  in.  (25  mm)  on  all  sides  of  the  page.  Use 
double-spacing  throughout  the  entire  manuscript.  Use  a  standard 
font  (eg.  Times,  Helvetica,  or  Courier)  at  least  10  points  in  size,  and 


RESPIRATORY  CARE  Manuscript  Preparation  Guide,  Revised  2/98 


MANUSCRIPT  Preparation  Guide 


do  not  use  italics  except  for  special  emphasis.  Number  all  pages  in 
upper-right  comers.  Indent  paragraphs  5  spaces.  Do  not  justify.  Do 
not  put  authors'  names,  institutional  affiliations  or  allusions  to 
institutional  affiliations  in  tlie  text,  or  other  identification  any- 
where except  on  the  title  page.  Repeat  title  only  (no  authors)  on 
the  abstract  page.  Begin  each  of  the  following  on  a  new  page:  Title 
Page,  Abstract,  Text,  Product  Sources  List,  Acknowledgments,  Ref- 
erences, each  Table,  and  each  Appendix.  Use  standard  English  in 
the  first  person  and  active  voice. 

Center  main  section  headings  on  the  page  and  type  them  in  cap- 
ital and  small  letters  (eg.  Introduction,  Methods,  Results,  Discus- 
sion). Begin  subheadings  at  the  left  margin  and  type  them  in  cap- 
ital and  small  letters  (eg,  Patients,  Equipment,  Statistical  Analysis). 

References.  Cite  only  published  works  as  references.  Manuscripts 
accepted  but  not  yet  published  may  be  cited  as  references:  desig- 
nate the  accepting  journal,  followed  by  (in  press),  and  provide  3  copies 
of  the  in-press  article  for  reviewer  inspection.  Cite  references  in  the 
text  with  superscript  numerals.  Assign  numbers  in  the  order  that  ref- 
erences are  first  cited.  On  the  reference  page,  list  the  cited  works 
in  numerical  order.  Follow  the  Journal's  style  for  references.  Abbre- 
viate journal  names  as  in  Index  Medicus.  List  all  authors. 

Article  in  a  journal  carrying  pagination  throughout  volume: 

Rau  JL,  Harwood  RJ.  Comparison  of  nebulizer  delivery  methods 
through  a  neonatal  endotracheal  tube:  a  bench  study.  Respir  Care 
1992;37(11):  1233-1240. 

Article  in  a  publication  that  numbers  each  issue  beginning  with 
Page  1: 

Bunch  D.  Establishing  a  national  database  for  home  care.  AARC  Times 
1991;15(Mar):61,62,64. 

Corporate  author  journal  article: 

American  Association  for  Respiratory  Care.  Criteria  for  establish- 
ing units  for  chronic  ventilator-dependent  patients  in  hospitals.  Respir 
Care  1988;33(1 1):  1044-1046. 

Article  in  journal  supplement:  (Journals  differ  in  their  methods  of 
numbering  and  identifying  supplements.  Supply  sufficient  information 
to  promote  retrieval.) 

Reynolds  HY.  Idiopathic  interstitial  pulmonary  fibrosis.  Chest  1986; 
89(3Suppl):139S-143S. 

Abstract  in  journal:  (Abstracts  citations  are  to  be  avoided.  Those  more 
than  3  years  old  should  not  be  cited.) 

Stevens  DP.  Scavenging  ribavirin  from  an  oxygen  hood  to  reduce  envi- 
ronmental exposure  (abstract).  Respir  Care  1990;35(1 1):  1087-1088. 

Editorial  in  journal: 

Enright  P.  Can  we  relax  during  spirometry?  (editorial).  Am  Rev  Respir 
Dis  1993;148(2):274. 

Editorial  with  no  author  given: 

Negative-pressure  ventilation  for  chronic  obstructive  pulmonary  dis- 
ease (editorial).  Lancet  1992;340(8833):I440-1441. 

Letter  in  journal: 

Aelony  Y.  Ethnic  norms  for  pulmonary  function  tests  (letter).  Chest 
199l;99(4):1051. 


Paper  accepted  but  not  yet  published: 

Hess  D.  New  therapies  for  asthma.  Respir  Care  (year,  in  press). 

Personal  author  book:  (For  any  book,  specific  pages  should  be  cited 
whenever  possible.) 

DeRemee  RA.  Clinical  profiles  of  diffuse  interstitial  pulmonary  dis- 
ease. New  York:  Futura;  1990.  p.  76-85. 

Corporate  author  book: 

American  Medical  Association  Department  of  Dmgs.  AMA  drug  eval- 
uations, 3rd  ed.  Littleton  CO:  Publishing  Sciences  Group;  1977. 

Chapter  in  book  with  editor(s): 

Pierce  AK.  Acute  respiratory  failure.  In:  Guenter  CA,  Welch  MH,  edi- 
tors. Pulmonary  medicine.  Philadelphia:  JB  Lippincott;  1977:26-42. 

Tables.  Use  consecutively  numbered  tables  to  display  information. 
Start  each  table  on  a  separate  page.  Number  and  title  the  table  and 
give  each  column  a  brief  heading.  Place  explanations  in  footnotes, 
including  all  nonstandard  abbreviations  and  symbols.  Key  the  foot- 
notes with  conventional  designations  (*,  t,  t,  §,  II,  1,  **,  tt)  in  con- 
sistent order,  placing  them  superscript  in  the  table  body.  Do  not  use 
horizontal  or  vertical  rules  or  borders.  Do  not  submit  tables  as  pho- 
tographs, reduced  in  size,  or  on  oversize  paper.  Use  the  same  type- 
face as  in  the  text. 

Illustrations.  Graphs,  line  drawings,  photographs,  and  radiographs 
are  figures.  Use  only  illustrations  that  clarify  and  augment  the  text. 
Number  them  consecutively  as  Fig.  1 ,  Fig.  2,  and  so  forth  accord- 
ing to  the  order  by  which  they  are  mentioned  in  the  text.  Be  sure 
all  figures  are  cited.  If  any  figure  was  previously  published,  include 
copyright  holder's  written  permission  to  reproduce.  Figures  for 
publication  must  be  of  professional  quality.  Data  for  the  original 
graphs  should  be  available  to  the  Editor  upon  request.  If  color  is  essen- 
tial, consult  the  Editor  for  more  information.  In  reports  of  animal 
experiments,  use  schematic  drawings,  not  photographs.  A  letter  of 
consent  must  accompany  any  photograph  of  a  person.  Do  not  place 
titles  and  detailed  explanations  on  figures;  put  this  information  in 
figure  captions.  If  possible,  submit  radiographs  as  prints  and  full- 
size  copies  of  film. 

Drugs.  Identify  precisely  all  drugs  and  chemicals  used,  giving  gener- 
ic names,  doses,  and  routes  of  administration.  If  desired,  brand  names 
may  be  given  in  parentheses  after  generic  names.  Drugs  should  be 
listed  on  the  product-sources  page. 

Commercial  Products.  In  parentheses  in  the  text,  identify  any  com- 
mercial product  (including  model  number  if  applicable)  the  first  time 
it  is  mentioned,  giving  the  manufacturer's  name,  city,  and  state  or 
country.  If  four  or  more  products  are  mentioned,  do  not  list  any  man- 
ufacturers in  the  text;  instead,  list  them  on  a  Product  Sources  page 
at  the  end  of  the  text,  before  the  References.  Provide  model  num- 
bers when  available  and  manufacturer's  suggested  price,  if  the  study 
has  cost  implications. 

Ethics.  When  reporting  experiments  on  human  subjects,  indicate 
that  procedures  were  conducted  in  accordance  with  the  ethical  stan- 
dards of  the  World  Medical  Association  Declaration  of  Helsinki 
[Respir  Care  1997;42(6):635-636]  or  of  the  institution's  committee 


RESPIRATORY  CARE  Manuscript  Preparation  Guide,  Revised  2/98 


MANUSCRIPT  PREPARATION  GUIDE 


on  human  experimentation.  State  that  informed  consent  was 
obtained.  Do  not  use  patient's  names,  initials,  or  hospital  numbers 
in  text  or  illustrations.  When  reporting  experiments  on  animals,  indi- 
cate that  the  institution's  policy,  a  national  guideline,  or  a  law  on 
the  care  and  use  of  laboratory  animals  was  followed. 

Statistics.  Identify  the  statistical  tests  used  in  analyzing  the  data, 
and  give  the  prospectively  determined  level  of  significance  in  the 
Methods  section.  Report  actual  p  values  in  Results.  Cite  only  text- 
book and  published  article  references  to  support  choices  of  tests.  Iden- 
tify any  general-use  or  commercial  computer  programs  used,  nam- 
ing manufacturers  and  their  locations.  These  should  be  listed  on  the 
product-sources  page. 

Units  of  Measurement.  Express  measurements  of  length,  height, 
weight,  and  volume  in  metric  units  appropriately  abbreviated:  tem- 
peratures in  degrees  Celsius;  and  blood  pressures  in  millimeters  of 
mercury  (mm  Hg).  Report  hematologic  and  clinical-chemistry  mea- 
surements in  conventional  metric  and  in  SI  (Systeme  Internationale) 
units.  Show  gas  pressures  (including  blood  gas  tensions)  in  torr. 
List  SI  equivalent  values,  when  possible,  in  brackets  following  non- 
Si  values— for  example,  "PEEP,  10  cm  H2O  [0.98 1  kPa]."  For  con- 
version to  SI,  see  RESPIRATORY  CARE  l988;33(IO):86l-873  (Oct 
1988),  1989;34(2):145(Feb  1989),  and  1997;42(6):639-640  (June 
1997). 

Conflict  of  Interest  Authors  are  asked  to  disclose  any  liaison  or  finan- 
cial arrangement  they  have  with  a  manufacturer  or  distributor  whose 
product  is  part  of  the  submitted  manuscript  or  with  the  manufacturer 
or  distributor  of  a  competing  product.  (Such  arrangements  do  not 
disqualify  a  paper  from  consideration  and  are  not  disclosed  to  review- 
ers.) A  statement  to  this  effect  is  included  on  the  cover-letter  page. 
(Reviewers  are  screened  for  possible  conflict  of  interest.) 

Abbreviations  and  Symbols.  Use  standard  abbreviations  and  sym- 
bols. Avoid  creating  new  abbreviations.  Avoid  all  abbreviations 
in  the  title  and  unusual  abbreviations  in  the  abstract.  Use  an  abbre- 
viation only  if  the  term  occurs  several  times  in  the  paper.  Write  out 
the  full  term  the  first  time  it  appears,  followed  by  the  abbreviation 
in  parentheses.  Thereafter,  employ  the  abbreviation  alone.  Never 
use  an  abbreviation  without  defining  it.  Standard  units  of  mea- 
surement can  be  abbreviated  without  explanation  (eg,  10  L/min, 
15  torr,  2.3  kPa). 

Please  use  the  following  forms:  cm  H2O  (not  cmH20),  f  (not  bpm), 
L  (not  I),  LVmin  (not  LPM,  l/min,  or  1pm),  mL  (not  ml),  mm  Hg  (not 
mraHg),  pH  (not  Ph  or  PH),  p  >  0.001  (not  p>O.OOI ),  s  (not  sec), 
SpO:  (pulse-oximetry  saturation).  See  RESPIRATORY  CARE: 
Standard  Abbreviations  and  Symbols  [RespirCare  I997;42(6):637- 
642]. 

Submitting  the  Manuscript 

Mail  three  copies  [1  copy  with  author(s)  name(s),  affiliation(s).  2 
copies  without  name(s)  and  affiliation(s)  for  reviewers]  of  the  manu- 
script, figures,  and  I  diskette,  and  the  Cover  Letter  &  Checklist  to 
RESPIRATORY  CARE,  600  Ninth  Avenue,  Suite  702.  Seattle  WA 
98 104.  Do  not  fax  manuscripts.  Protect  figures  with  cardboard.  Keep 
a  copy  of  the  manuscript  and  figures.  Receipt  of  your  manuscript 


will  be  acknowledged. 

Computer  Diskettes.  Authors  are  encouraged  to  submit  electron- 
ic versions  of  manuscripts  as  well  as  printed  copies  (3.5  in.  diskettes 
in  Macintosh  or  IBM-DOS  format).  Label  each  diskette  with  date; 
author's  name;  name  and  version  of  word-processing  program  used; 
and  filename(s).  Software  used  to  produce  graphics  and  tables  should 
be  similarly  identified.  Do  not  write  on  diskette  labels  except  with 
felt-tipped  pen.  If  revision  of  a  manuscript  is  required  as  a  condi- 
tion of  acceptance  for  publication,  we  ask  that  an  electronic  version 
of  revision  be  supplied  to  facilitate  copyediting  and  production. 

Prior  and  Duplicate  Publication.  Work  that  has  been  published 
or  accepted  elsewhere  should  not  be  submitted.  In  special  instances, 
the  Editor  may  consider  such  material,  provided  that  permission  to 
publish  is  given  by  the  author  and  original  publisher.  Please  con- 
sult the  Editor  before  submitting  such  work. 

Authorship.  All  persons  listed  as  authors  should  have  participat- 
ed in  the  reported  work  and  in  the  shaping  of  the  manuscript;  all  must 
have  proofread  the  submitted  manuscript;  and  all  should  be  able  to 
publicly  discuss  and  defend  the  paper's  content.  A  paper  with  cor- 
porate authorship  must  specify  the  key  persons  responsible  for  the 
article.  Authorship  is  not  justified  solely  on  the  basis  of  solicitation 
of  funding,  collection  or  analysis  of  data,  provision  of  advice,  or  sim- 
ilar services.  Persons  who  provide  such  ancillary  services  exclusively 
may  be  recognized  in  an  Acknowledgments  section. 

Permissions.  The  manuscript  must  be  accompanied  by  copies  of 
permissions  to  reproduce  previously  published  material  (figures  or 
tables);  to  use  illustrations  of,  or  report  sensitive  personal  information 
about,  identifiable  persons;  and  to  name  persons  in  the  Acknowl- 
edgments section. 

Reviewers.  Please  supply  the  names,  credentials,  affiliations,  address- 
es, and  phone/fax  numbers  of  three  professionals  whom  you  con- 
sider expert  on  the  topic  of  your  paper.  Your  manuscript  may  be  sent 
to  one  or  more  of  them  for  blind  peer  review. 


Editorial  Office: 

RESPIRATORY  CARE 

600  Ninth  Avetiue,  Suite  702 
Seattle  W A  98104 

(206)  223-0558  (voice) 

(206)  223-0563  (fax) 

e-mail:  rcjournal@aarc.org 

kreilkamp@aarc.org 


RESPIRATORY  CARE  Manuscript  Preparation  Guide,  Revised  2/98 


COVER  LETTER  &  CHECKLIST 

A  copy  of  this  completed  form  must  accompany  all  manuscripts  submitted  for  publication. 


Title  of  Paper: 


Publication  Category; 


Corresponding  Author: Phone: FAX: 

Mailing  Address: 

Reprints:     □  Yes    □  No  E-mail  Address: 


"We,  the  undersigned,  have  all  participated  in  the  work  reported,  proofread  the  accompanying  manuscript,  and  approve  its  sub- 
mission for  publication."  Please  print  and  include  credentials,  title,  institution,  academic  appointments,  city  and  state.  If  more 
than  4  authors,  please  use  another  copy  of  this  form.* 


*First  Author:. 


Author  Signature/Date. 


'Second  Author: 


Author  Signature/Date. 


•Third  Author: 


Author  Signature/Date, 


*Fourth  Author: 


Author  Signature/Date, 


Has  this  research  been  presented  in  any  public  forum?       □  Yes    □  No 
If  yes,  where,  when  and  by  whom? 


Has  this  research  received  any  awards?         □  Yes    □  No 
If  yes,  please  describe. 


Has  this  research  received  any  grants  or  other  support,  financial  or  material?      □  Yes    □  No 
If  yes,  please  describe. 


Do  any  of  the  authors  of  this  manuscript  have  a  financial  interest  in  (or  a  commercial  or  consulting  relationship  to)  any  of  the 
products  or  manufacturers  mentioned  in  this  paper  or  any  competing  products  or  manufacturers?        □  Yes    □  No 


If  yes,  please  describe. 


□  Have  you  enclosed  a  copy  of  the  manuscript  on  diskette? 

□  Is  double-spacing  used  throughout  entire  manuscript? 

□  Are  all  pages  numbered  in  upper-right  corners? 

□  Are  all  references,  figures,  and  tables  cited  in  the  text? 

□  Has  the  accuracy  of  the  references  been  checked,  and  are  they  correctly  formatted? 

□  Have  SI  values  been  provided? 

□  Has  all  arithmetic  been  checked? 

□  Have  generic  names  of  drugs  been  provided? 

□  Have  necessary  written  permissions  been  provided?  : 

□  Have  authors'  names  been  omitted  from  text  and  figure  labels? 

□  Have  copies  of  'in  press'  references  been  provided? 
G  Has  the  manuscript  been  proofread  by  all  the  authors? 

□  Have  the  manufacturers  and  their  locations  been  provided  for  all  devices  and  equipment  used? 

Respiratory  Care  Manuscript  Preparation  Guide,  Revised  2/98 


Not-for-profit  organizations  are  offered  a  free  advertisement  of  up  to  eight  lines  to  appear,  on  a  space-available 

basis,  in  Calendar  of  Events  in  RESPIRATORY  CARE.  Ads  for  other  meetings  are  priced  at  $5.50  per  line  and  require 

an  insertion  order.  Deadline  is  the  20th  of  the  month  two  months  preceding  the  month  in  which  you  wish  the  ad  to  run. 

Submit  copy  and  insertion  orders  to  Calendar  of  Events.  RESPIRATORY  CARE.  1 1030  Abies  Lane,  Dallas  TX  75229-4593. 


Calendar 
of  Events 


AARC  &  AFFILIATES 

August  15-21— Cleveland.  Ohio 
The  OSRC  state  conference  will  be 
held  at  the  Holiday  Inn  in 
Independence,  just  south  of 
Cleveland.  Specialty  sessions  include 
critical  care,  pediatrics,  rehab/ 
continuing  care,  research,  and 
management. 

Contact:  Joe  Huff  at  (216)  861-6200, 
ext.  3892,  ewIul8a@prodigy.com  or 
Nancy  Johnson  at  (330)  929-7166, 
abbyru@aol.coiii. 

September  8-10 — Hot  Springs, 

Arkansas 

The  ASRC  presemts  its  28th  Annual 
State  Meeting  and  Education  Seminar 
at  the  Hot  Springs  Hilton  and 
Convention  Center.  Topics  will 
include  health  care  in  Arkansas, 
patient  rights,  disease  management, 
and  case  studies  by  area  RTs. 
Scheduled  to  speak  are  State 
Representative  Brenda  Gullett, 
Congressman  Vic  Snyder,  Tom 
Kallstrom  of  Cleveland,  OH,  ASRC 
President  John  Campbell.  AARC 
President  Dianne  Kimball,  and 

(Kristin  McFall  of  Denver,  CO  (topic: 
cystic  fibrosis). 

Contact:  John  Lindsey  at  (870)  541- 
7606,  jlindsey@ahecpb.uams.edu 

September  16-17 — Pittsburgh, 

,        Pennsylvania 

I  The  PSRC  will  host  their  26th  Annual 

Western  Pennsylvania  Regional 
Pulmonary  Medicine  and  Physiology 
Conference  at  the  Sheraton  Station 
Square.  Topics  include  management, 
critical  care,  sleep  diagnostics, 

(pulmonary  rehabilitation,  and  the 
physician  forum. 

Contact:  Debbie  Logan  at  (800)  545- 
4663,  ext.  112. 

September  24-25 — Cleveland,  Ohio 
The  AARC  presents  the  "Disease 
Management  of  Asthma"  seminar. 
Come  and  join  a  distinguished  faculty 
as  they  review  the  NIH  asthma 


guidelines,  marketing  the  asthma 
program,  pharmacology,  and 
numerous  other  aspects  of  asthma 
program  management. 
Contact:  The  AARC  Conventions 
Office  at  (972)  243-2272. 

October  1 — Melville,  New  York 
The  NYSSRC's  Southeastern  Chapter 
hosts  their  3 1  st  annual  symposium, 
"Respiratory  Care  —  A  Work  in 
Progress,"  at  the  Huntington  Hilton 
Hotel  in  Melville,  Long  Island.  The 
keynote  address  will  be  given  by  Carl 
Wiezalis,  vice-president  of  the  AARC. 
Contact:  For  information,  call  Jim 
Ganetisat(516)444-3181or 
www.nyssrc.org. 

October  20-22— Daniels,  West 

Virginia 

The  West  Virginia  Society  for 
Respiratory  Care  will  host  its  Annual 
Fall  Meeting  at  the  Glade  Springs 
Resort,  Country  Inns  and  Suites. 
Contact:  For  more  information, 
contact  Jay  Wildt,  co-chair  of 
program  and  education,  at 
(304)  442-7474. 

December  13-16 — Las  Vegas,  Nevada 
The  AARC's  45th  International 
Respiratory  Congress  is  scheduled  for 
Dec.  13-16  (Monday  through 
Thursday)  at  the  Las  Vegas 
Convention  Center.  Sessions 
appealing  to  all  levels  of  health  care 
providers  will  be  offered,  with  CRCE 
credit  available.  Exhibits  by 
international  manufacturers  of 
cardiopulmonary  equipment  will  be 
featured.  Additional  information  will 
be  available  in  the  fall. 

Other  Meetings 

August  19-20 — Cleveland,  Ohio 
The  Cleveland  Clinic  Foundation  is 
sponsoring  a  continuing  education 
program  titled  "Respiratory  Therapy," 
which  has  been  approved  for  Category 
1  accreditation.  It  will  be  held  at  the 
Omni  International  Hotel. 


Contact:  For  more  information,  call 
Laurie  Martel  at  (216)  444-5696  or 
(800)862-8173. 

September  16-19 — Phoenix.  Arizona 
The  American  Association  of 
Cardiovascular  and  Pulmonary 
Rehabilitation  will  hold  its  14th 
annual  meeting  at  the  Phoenix  Civic 
Center. 

Contact:  For  more  information,  call 
(608)  831-6989;  aacvpr@tmahq.com; 
http://www.aacvpr.org. 

October  1-3 — Ottawa,  Ontario, 

Canada 

The  Canadian  COPD  Alliance  will 
host  "Building  and  Enriching 
Partnerships  in  the  Management  of 
COPD"  at  the  Radisson  Hotel  Ottawa 
Centre.  This  conference  will  include 
plenary  sessions  on  the  epidemiology 
of  COPD  and  scientific  workshops  on 
spirometry,  smoking  cessation,  and  the 
evidence  to  support  management 
approaches  to  COPD.  Included  is  a 
series  of  practical  workshops  on 
rehabilitation  and  a  parallel  consumer 
track  for  those  who  live  with  COPD. 
Contact:  call  (613)  747-6776  or  see 
their  web  site  at  www.lung.ca/CCA/ 
conference. 

October  4-5 — Ann  Arbor,  Michigan 
The  Office  of  Continuing  Medical 
Education  at  the  University  of 
Michigan  is  sponsoring  a  conference, 
"Update  on  FVImonary  and  Critical 
Care  Medicine,"  at  the  Towsley  Center. 
Contact:  For  more  information, 
contact  Laura  Castellanos  at 
(734)  647-8784. 

October  31-November  4 — Chicago, 

Illinois 

The  American  College  of  Chest 
Physicians  will  host  their  65th  Annual 
International  Scientific  Assembly  at 
the  Lakeside  Center.  For  information, 
contact  Member  Services  at  (800) 
343-2227,  fax  (847)  498-5460,  or 
www.chestnet.org. 


Respiratory  Care  •  July  1999  Vol  44  No  7 


877 


Notices 


Notices  of  competitions,  scholarships,  fellowships,  examination  dates,  new  educational  programs. 

and  the  like  will  be  listed  here  free  of  charge.  Items  for  the  Notices  section  must  reach  the  Journal  60  days 

before  the  desired  month  of  publication  (January  I  for  the  March  issue,  February  1  for  the  April  issue,  etc).  Include  all 

pertinent  information  and  mail  notices  to  RESPIRATORY  CARE  Notices  Dept,  1 1030  Abies  Lane.  Dallas  TX  75229-4593. 


f^(/'fao 


^  Helpful  Lileb.Sites 

American  Association  for  Respiratory  Care 

http://www.aarc.org 

—  Current  job  listings 

—  American  Respiratory  Care  Foundation 
fellowships,  grants,  &  awards 

—  Clinical  Practice  Guidelines 

National  Board  for  Respiratory  Care 

http://www.nbrc.org 

RESPIRATORY  CARE  online 

http://www.rcjournal.com 

—  1 997  Subject  and  Author  Indexes 

—  Contact  the  editorial  staff 

Asthma  Management 
Model  System 

http://www.nhlbi.nih.gov 


The  National  Board  for  Respiratory  Care — 1999  Examination  Dates  and  Fees 


Examination 

Examination  Date 

Examination  Fee 

CRTT  (CRT)  Examination 

November  13,  1999 

$120   (new  applicant) 

Application  Deadline:  September  1,  1999 

80   (reapplicant) 

RRT  Examination 

December  4,  1999 

120   written  only  (new  applicant) 

Application  Deadline:  August  1 ,  1 999 

80   written  only  (reapplicant) 
130   CSE  only  (all  applicants) 
250   Both  (new  applicants) 
210   Both  (reapplicants) 

For  information  about  other  services  or  fees,  write  to  the  National  Board  for  Respiratory  Care, 
8310  Nieman  Road,  Lenexa  KS  66214,  or  call  (913)  599-4200,  FAX  (913)  54 l-0156,or  e-mail:  nbrc-info@nbrc.org 


878 


RESPIRATORY  CARE  •  JULY  1999  VOL  44  NO  7 


NOTICES 


WATCH     FOR 
SPECIAL    ISSUE 

THORACIC 

IMAGING  IN 

THE  INTENSIVE 

CARE  UNIT 

SE  PTEMBER    1999 


Asthma  Disease  Management  Course  Comes  to 
Cleveland 

"Disease  Management  of  Asthma,"  a  newly  designed  day- 
and-a-haif  course,  will  be  held  in  Cleveland  Sept  24-25. 
Drawing  on  the  expertise  of  a  nationally  recognized  fac- 
ulty, this  course  has  been  developed  in  accordance  with 
the  National  Institute  of  Health  Asthma  Guidelines  for 
the  Diagnosis  and  Management  of  Asthma.  Completing 
this  course  will  earn  respiratory  therapists  11  hours  of 
continuing  education  credit.  Topics  covered  include  dis- 
ease management,  pharmacology,  educational  strate- 
gies, marketing  your  program,  outcomes  management, 
and  age-specific  issues.  Register  on-line  or  call  the  AARC 
for  registration  materials.  The  program  will  be  held 
September  24-25,  at  the  Marriott  Cleveland  Airport 
Hotel.  Registration  before  August  30,  1999  is  $175  for 
AARC  members,  $250  for  non-members.  (After  August 
30,  register  for  $275  member,  $350  non-member) 

AARC  Exhibition  Becomes  'Selling  Showr' 

The  AARC's  45th  International  Respiratory  Congress 
will,  for  the  first  time  in  its  history,  provide  attendees 
and  exhibitors  the  opportunity  to  negotiate  sales  of  prod- 
ucts and  equipment  at  the  exhibitor  show,  December  13 
-16,  in  Las  Vegas.  More  than  200  equipment  manufac- 
turers, pharmaceutical  companies,  service  organiza- 
tions, and  supply  companies  will  exhibit  at  the  show. 
"We've  always  had  an  extremely  enthusiastic  response  to 
our  exhibiting  companies,"  said  AARC  Executive  Direc- 
tor Sam  Giordano.  "We  decided  to  take  that  approach 
this  year  to  make  attending  the  meeting  even  more  cost 
effective  —  and  the  show  specials  and  discounts  our 
exhibitors  are  providing  will  make  the  exhibition  an  even 
greater  success,"  he  said. 


New  Products  Help  with  Clinical  Practice 

These  products  from  the  AARC,  some  newly  introduced, 
will  help  in  both  clinical  practice  situations  and  in 
administration,  in  acute  care  and  post-acute  care.  Check 
them  out: 

Diagnostic  Training  and  Competence  Assessment  Man- 
ual for  Pulmonary  and  Noninvasive  Cardiology.  CDRom. 
$267  for  AARC  members.  This  manual  (on  compact  disk) 
is  ideal  for  use  in  course  development,  training,  orienta- 
tion, and  competence  assessment  for  individuals  in  the 
laboratory  setting.  A  pulmonary  diagnostics  section 
features  quality  control,  diffusing  capacity,  whole  body 
plethysmography,  arterial  blood  gas  sampling, 
bronchoscopy  and  seven  other  procedures.  The  noninva- 
sive cardiology  section  features  EEC,  stress  testing,  event 
monitoring,  exercise  testing  and  three  other  procedures. 

Asthma  Disease  State  Management.  Video  and 
workbook.  $79.95  for  members.  Provides  instruction  in 
how  to  create  an  effective  asthma  disease  management 
program  in  your  facility.  Covers  diagnosis,  pharmacolog- 
ical therapy,  environmental  controls,  patient/family  edu- 
cation, and  case  studies.  Approved  for  two  hours  of  CRCE 
credit  and  nursing  CE  credit. 

Orientation  and  Competency  Assurance  Documentation 
Manual.  Manual.  $65  for  members.  Provides  the  informa- 
tion, assessment  tools,  and  models  necessary  to 
demonstrate  that  the  competence  of  employees  is 
documented  according  to  JCAHO  requirements. 

Uniform  Reporting  Manual  for  Acute  Care.  Manual.  $65 
for  members.  Provides  you  with  nationally  recognized 
standards  for  documenting  workload  units  and  time 
standards.  Includes  patient  assessment  activities  and  cov- 
ers bronchial  hygiene,  supplemental  oxygen,  airway  care, 
diagnostic  tests,  and  cardiovascular  diagnostics. 

Uniform  Reporting  Manual  for  Subacute  Care.  Manual. 
$75  for  members.  Provides  tools  to  determine  productiv- 
ity, track  trends  in  the  utilization  of  respiratory  care  ser- 
vices, assist  in  determining  personnel  requirements, 
measure  demand  for  and  intensity  of  services,  and  meet 
the  requirements  of  prospective  payment  systems  (PPS). 

Respiratory  Home  Care  Procedure  Manual.  Manual.  $80 
for  members.  The  new  "Respiratory  Home  Care 
Procedure  Manual"  is  specifically  designed  for  the  home 
care  setting.  And,  it  is  easily  adaptable  to  any  alternate 
care  site  from  subacute  to  home  medical  equipment 
companies  and  nursing  agencies.  The  manual  features 
five  sections  of  information,  forms,  and  checklists  for  the 
patient  and  practitioner. 


RESPIRATORY  CARE  •  JULY  1999  VOL  44  NO  7 


879 


Authors 
in  This  Issue 


Au,  David 869 

Beckett,  Ronald  G 867 

Bishop,  Michael  J 750 

Campbell,  Robert  S 799 

Heffner,  John  E 807,  861 

Hess,  Dean  R 759 


Kapur,  Vishesh 866 

Orringer,  Maxine  K 845 

Reibel,  James  F 820,  856 

Sassoon,  Catherine 866 

Stauffer,  John  L 828 

Watson,  Charles  B 777 


Advertisers 
in  This  Issue 


To  advertise  in  RESPIRATORY  CARE,  contaci  Tim  Goldsbury,  20  Tradewinds  Circle,  Tequesta  FL  33469 
at  (561)  745-6793,  Fax  (561)  745-6795,  e-mail:  goldsbury@aarc.org,  for  rales  and  media  kits.  For  recruitment/ 
classified  advertising  contact  Beth  Binkley,  Marketing  Assistant  for  RESPIRATORY  CARE,  at  (972)  243-2272, 
Fax  (972)  484-6010.  Rick  Owen  is  the  Marketing  Director  for  RESPIRATORY  CARE. 


Blake  Medical,  Inc 

Circle  Reader  Service  No.  108 

Dale  Medical  Products  .  .  . 

Circle  Reader  Service  No.  107 

DEY  Laboratories 

Circle  Reader  Service  No.  1 13 

DHD  Healthcare 

Circle  Reader  Service  No.  106 

Hamilton  Medical,  Inc 

Circle  Reader  Service  No.  1 19 


733  Hans  Rudolph 735 

SEE  AD  Circle  Reader  Service  No.  1 04  Call  (800)  456-6695 

722  Kaleidoscope 73 1 

Call  (800)  343-3980  SEE  AD 

Cover  2  Passy-Muir  Inc 726 

Call  (800)  755-5560  Circle  Reader  Service  No.  105  Call  (800)  634-5397 

Cover  4  Siemens  Medical  Systems 724 

Call  (800)  847-8000  Circle  Reader  Service  No.  1 12  Call  (800)  333-8646 

Cover  3  University  of  Minnesota 741 

Call  (800)  HAM-MED-1  Circle  Reader  Service  No.  1 10  Call  (612)  626-7600 


COPYRIGHT  INFORMATION.  RESPIRATORY  CARE  is  copyrighted  by 
Daedalus  Enterprises  Inc.  Reproduction  in  whole  or  in  part  without  the  express 
written  permission  of  Daedalus  Enterprises  Inc  is  prohibited.  Permission  to 
photocopy  a  single  article  in  this  Journal  for  noncommercial  purposes  of 
scientific  or  educational  advancement  is  granted.  Permission  for  multiple 
photocopies  and  copies  for  commercial  purposes  must  be  requested  in  writ- 
ing, via  e-mail  (rcjoumalCs'aarc.org),  or  telephone  and  approved  by  RESPI- 
RATORY CARE.  Anyone  may,  without  permission,  quote  up  to  500  words  of 
material  in  this  journal  provided  the  quotation  is  for  noncommercial  use  and 
RESPIRATORY  CARE  is  credited.  Longer  quotation  requires  written  ap- 
proval by  the  author  and  publisher.  Single  reprints  are  available  only  from  the 
authors.  Reprints  for  commercial  use  may  be  purchased  from  Daedalus  En- 
terprises Inc.  For  more  information  and  prices  call  (972)  243-2272. 

Disclaimer.  The  opinions  expressed  in  any  article  or  editorial  are  those 
of  the  author  and  do  not  necessarily  reflect  the  views  of  the  Editors,  the 
American  Association  for  Respiratory  Care  (AARC),  or  Daedalus  Enter- 
prises Inc.  Neither  are  the  Editors,  the  AARC,  or  the  Publisher  responsible 
for  the  consequences  of  the  clinical  applications  or  use  of  any  methods  or  de- 
vices described  in  any  article  or  advertisement. 

Subscription  rates.  Individual  subscription  rates  are  $75  per  year 
(12  issues),  $145  for  2  years,  and  $215  for  3  years  in  the  US  and  Puerto 
Rico.  Rates  are  $90  per  year,  $  1 75  for  2  years,  and  $260  for  3  years  in  all  other 
countries  (add  $94  per  year  for  air  mail).  Single  copies  when  available  cost 
$7;  add  S9  for  air  mail  postage  to  overseas  countries.  Checks  should  be 


made  payable  to  RESPIRATORY  CARE  and  sent  to  the  subscription  office  at 
1 1030  Abies  Lane,  Dallas  TX  75229-4593. 

SUBSCRIPTION  Rates  for  associations.  Basic  annual  subscrip- 
tions are  offered  to  members  of  associations  according  to  their  member- 
ship enrollment:  101-500  members  =  $13.50/year;  501-1,500  =  $13/year; 
1,500-10,000  =  $12.50/year;  more  than  10,000  =  $1 1.50/year.  Individual 
subscriptions  ar  available  at  these  rates:  $75/year  ( 1 2  issues  in  the  United  States 
or  Puerto  Rico;  $90/year  in  other  countries.  For  information,  contact  Ray 
Masferrer  at  (972)  243-2272. 

Change  of  Address.  Notify  the  AARC  at  (972)  243-2272  as  soon  as  pos- 
sible of  any  change  in  address.  Note  the  subscription  number  (from  the 
mailing  label)  and  your  name,  old  address,  and  new  address.  Allow  6 
weeks  for  the  change.  To  avoid  charges  for  replacement  copies  of  missed  is- 
sues, requests  must  be  made  within  60  days  in  the  US  and  90  days  in  other 
countries. 

MANUSCRIPTS.  The  Journal  publishes  clinical  studies,  method/device 
evaluations,  reviews,  and  other  materials  related  to  cardiopulmonary  med- 
icine and  research.  Manuscripts  may  be  submitted  to  the  Editorial  Office,  RES- 
PIRATORY CARE,  600  Ninth  Avenue,  Suite  702,  Seattle  WA  98104.  In- 
structions for  authors  are  printed  in  every  issue.  An  expanded  version  of 
the  Instructions  is  available  from  the  editorial  office. 

Copyright  ©  1999,  by  Daedalus  Enterprises  Inc. 


880 


RESPIRATORY  CARE  •  JULY  1999  VOL  44  NO  7 


GALILEO 


Product 
Information 

For  AAftC  rt>emb*fihip  information,  circle  101 

101  102  103   104  105  106 

119  120   121    122  123  124 

137  138  139   140  141  142 

155  156   157    158  159  160 

173  174  175   176  177  178 

191  192    193    194  195  196 


To  receive  information  on  the  products 
and  services  mentioned  in  this  issue, 
circle  the  corresponding  category 
number  or  individual  manufacturer's 
number.  Fill  in  your  name  and  address 
and  mail  this  postage-paid  card. 
Information  will  be  sent  directly  to  you 
from  the  manufacturer.  Please  print; 
incomplete  forms  will  not  be 
processed.  For  faster  service,  fax  to 
(609)786-4415 

For  RiiPKAToin  Caw  lubscription  intormatioo,  circle  102. 

107    108  109  no    111  112   113    114  115  116 

125    126  127  128    129  130  131     132  133  134 

143   144  145  146   147  148  149   150  151  152 

161    162  163  164    165  166  167    168  169  170 

179   180  181  182   183  184  185   186  187  188 

197    198  199  200 

Pleat*  cirek  no  mon  than  1 S  Kemi. 


117  118 
135  136 
153  154 
171  172 
189  190 


Name 

Title 

Facility  Name 

Address 

City 

State 

Zip  Code 

Country 

I  TYPE  Of  INSnrUTKJN 
OS  PRACTICE 

1  D  Hospital 

2  n  Skilled  Nursing 

Facility 

3  D  Subacute  Care  Facility 

4  D  Home  Care  Practice 

5  D  School 

6  a  Distributor 

II  DEPARTMENT 

A  D  Respiratory  Care 
B   D  Cardiopulmonary 
C  D  Subacute  Care 
D  n  Home  Care 

III  SPECIALTY 


D  Clinician 

D  Perinatal/  Pediatrics 

D  Critical  Care 

D  Research 

D  Subacute  Care 


6  D  Diagnostics/ 

Pulmonary  Function 

7  D  Management 

8  D  Home  Care 

9  □  Rehabilitation 

10  D  Education 

IV  POSITION 

A  n  Department  Head 

B  a  Chief  Therapist 

C  D  Supervisor 

D  D  Staff  Therapist/ 

Technician 

E  D  Medical  Director 

F  D  Educator/Instructor 

C  D  Sales 

H  D  Other  (please  specify) 


V  AREYOUANAARC 
MEMBER? 

1    D  Yes    2   D  No 


TdeptKme 


PFiPIPATOPU  CABP 


■EO,  the  most 
tern.  Advanced 
naximum  in  patient 
into  the  future. 

■ring  the  clinician  a 


1EDICAL  at 


i/IILTON 

^IOLOGY  SERVE  MANKIND 

89 

5621 

1-641  9008,  Fax  0181-641  9054 

17  33 


Authors 
in  This  Issue 


Au,  David 

Beckett,  Ronald  G .  . 
Bishop,  Michael  J  .  . 
Campbell,  Robert  S . 
Heffner,  John  E  .  .  .  , 
Hess,  Dean  R 


....  869      Kapur,  Vishesh 866 

....  867      Orringer,  Maxine  K 845 

....  750      Reibel,  James  F 820,  856 

....  799      Sassoon,  Catherine 866 

,  807,  861       Stauffer,  John  L 828 

759      Watson,  Charles  B 777 


Adverti: 
in  This  Is 


Blake  Medical,  Inc  .  . 

Circle  Reader  Service  N 

Dale  Medical  Product 

Circle  Reader  Service  N 

DEY  Laboratories .  .  . 

Circle  Reader  Service  N 

DHD  Healthcare 

Circle  Reader  Service  N 

Hamilton  Medical,  In< 

Circle  Reader  Service  N 


BUSINESS  REPLY  MAIL 

FIRST-CLASS  MAIL  PERMIT  NO.  2480  Dallas.TX 


NO  POSTAGE 

NECESSARY 

IF  MAILED 

IN  THE 

UNITED  STATES 


POSTAGE  WILL  BE  PAID  BY  ADDRESSEE 

AARC  Subscriptions 

ATTN:  Beth  Binkley 
PO  BOX  29686 
Dallas  TX  75229-9691 


Copyright  inform, 

Daedalus  Enterprises  Inc. 
written  permission  of  Da 
photocopy  a  single  artic 
scientific  or  educational 
photocopies  and  copies  fi 
ing,  via  e-mail  (rcjoumal 
RATORY  Care.  Anyone 
material  in  this  journal  pr 
Respiratory  Care  U 
proval  by  the  author  and  p 
authors.  Reprints  for  corr 
terprises  Inc.  For  more  in 

Disclaimer.  The  opin 
of  the  author  and  do  nol 
American  AsscKiation  fc 
prises  Inc.  Neither  are  th( 
for  the  consequences  of  tf 
vices  described  in  any  an 

Subscription  Rate; 

(12  issues),  $145  for  2  y 
Rico.  Rates  are  $90  per  ye 
countries  (add  $94  per  ye 
$7;  add  $9  for  air  mail  | 


II., .1.1.1. ..I. I. .1.11. 1. .1.1... II. .1.1 Nil... I 


BUSINESS  REPLY  MAIL 

FIRST-CLASS  MAIL  PERMIT  NO.  881  Riverton,  NJ 


NO  POSTAGE 

NECESSARY 

IF  MAILED 

IN  THE 

UNITED  STATES 


POSTAGE  WILL  BE  PAID  BY  ADDRESSEE 


AARC  Publications 

PO  BOX  11605 
Riverton  NJ  08076-7205 


880 


I.mI..I.II...I...I.II..I...I..I.III....I.I..I.I.I 


GALILEO 


The  new  view  of  Ventilation 

Derived  from  years  of  advanced  research  and  practical  clinical  experience,  HAMILTON  MEDICAL  introduces  GALILEO,  the  most 
advanced  ventilator  in  the  world.  GALILEO  combines  the  newest  innovative  technology  in  an  easy  to  operate  system.  Advanced 
Rules  Based  Strategic  Modes  combined  (Adaptive  Support  Ventilation  ASV)  with  Virtual  Controls  provides  the  maximum  in  patient 
care  flexibility  GALILEO  defines  a  new  dimension  in  the  ventilator  management  of  critically  ill  patients  today  and  into  the  future. 

GALILEO  is  the  ventilator  of  choice  to  implement  comprehensive  clinical  pathways  for  all  ventilator  patients.  Offering  the  clinician  a 
new  dimension  in  respiratory  care.  Ventilation  without  Limitations. 

GALILEO  IS  available  from  your  local  HAMILTON  MEDICAL  partner.  For  further  information,  contact  HAMILTON  MEDICAL  at 
www.hamilton-medical.ch,  phone  +41-81-641-2627,  fax  +41-81-641-2689  or  call  our  local  representative. 


Circle  119  on  reader  service  card 


HAMILTON 
MEDICAL 

MAKING  TECHNOLOGY  SERVE  MANKIND 


International:  HAMILTON  MEDICAL  AG,  Via  Nova,  CH-7403  RhazOns/Switzerland,  Telephone  (+41)  81-  641  26  27,  Fax  (+41)  81-  641  26  89 

USA:  HAMILTON  MEDICAL  Inc.,  P.O.Box  30008,  Reno,  NV  89520,  Telephone  (702)  858-3201,  (800)  HAM-MED-1,  Fax  (702)  856-5621 

Great  Britain:  HAMILTON  MEDICAL  (G.B.)  Limited,  Kimpton  Business  Centre,  Kimpton  Road,  Sutton,  Surrey  5M3  9QR,  Telephone  0181-641  9008,  Fax  0181-641  9054 

Germany:  HAMILTON  Deutschland  GmbH,  Abt.  MEDICAL  Daimlerweg  5a,  D-64293  Darmstadt,  Tel.  (06151)  98020,  Fax  (06151)  89  17  33 


T« 


One. 


For  all. 


7/jemPEF 

Positive  Expiratory  Pressure  Ttierapy  System 


Patient-administered 
secretion  clearance 
and  reversal  of 
atelectasis. 


Simultaneous  aerosol 
drug  delivery  with 
nebulizer  while 
performing  therapy 
for  secretion  clearance 
and  atelectasis. 


Simultaneous  aerosol 
drug  delivery  with 
MDI  spacer  while 
performing  therapy 
for  secretion  clearance 
and  atelectasis. 


The  proven  choice  for  secretion  clearance  and  reversal  of  atelectasis. ' 


Today,  more  patients  than  ever  can  benefit  from  TheraPEP, 
the  first  system  designed  specifically  for  positive  expiratory 
pressure  therapy.  Now  indicated  for  use  with  simultaneous 
aerosol  drug  delivery,  TheraPEP  can  help  virtually  any 
patient  with  secretory  problems  mobilize  secretions  easily, 
conveniently  and  cost-effectively. 

Unlike  CPT,  PEP  therapy  can  be  self-administered  in  any 
setting,  helping  patients  maintain  an  effective  continuum  of 
care  outside  the  hospital.  TheraPEP  may  reduce  the  need  for 
postural  drainage  and  percussion,  and  can  be  performed  in 
less  than  half  the  time  of  a  conventional  CPT  session.^  This 
offers  significant  time  savings  for  both  patients  ani  clinicians. 

1  Mcllwaine,  RM.,  Wong,  L.T.,  Peacock,  D.,  Davidson,  G.F.  "Long-term 
comparative  trial  of  conventional  postural  drainage  and  percussion  versus 
positive  expiratory  pressure  physiotherapy  in  the  treatment  of  cystic  fibrosis." 
Ihe  \ourm\  of  Pediatrics,  October  1997. 

2  Protocol  of  the  Month,  University  of  Pittsburgh  Medical  Center,  Department  of 
Respiratoi  v  Care.  AARC  Times,  May  1997. 

/^I^C       125  Rasbach  Street  Canastota,  NY  13032  USA 

AWABD  ■»«,'»7«'>e     Tli.raPEP  is  a  registered  trademark  of  DHD  Healthcare  Corporation 


TheraPEP  is  even  more  efficient  when  used  with  a  nebulizer 
or  MDI  spacer.  The  patient  can  receive  aerosolized  medication, 
and  perform  therapy  for  secretion  clearance  and  atelectasis, 
in  the  time  of  one  treatment.  PEP  therapy  may  also  optimize 
delivery  of  bronchodilators  in  patients  receiving  bronchial 
hygiene  therapy.*  No  other  secretion  clearance  device  offers 
you  a  better  combination  of  therapy,  flexibility  and  efficiency. 
For  more  information,  call  DHD  Healthcare  toll-free  today: 


1-800-847-8000. 


gJDHD 


Healthcare 

Innovations  for  respiratory  care 


3  Mahlmeister  MJ,  Fink  JB,  Hoffman  GL,  Fifer  LF,  "Positive-expiratory-pressure 
mask  therapy:  Theoretical  and  Practical  Considerations  and  a  Review  of  the 
Literature",  Rfspirafory  Care,  1991;  36:1218-1230. 

4  "AARC  Clinical  Practice  Guideline:  'Use  of  Positive  Airway  Pressure  Adjuncts 
to  Bronchial  Hygiene  Therapy',"  Resp/rafory  Care,  1993;  38:516-521. 


(315)  697-2221 


FAX:  (315)  697-5191   •  www.dhd.com 

©  1999  DHD  Healthcare  Corporation 


Circle  106  on  reader  service  card