This paper concerns improving endotracheal tube (ETT) insertion through advanced computational science modelling. The study aims to better understand endotracheal intubation (ETI) and reduce medical errors in intensive and critical care units since ETT insertion is unique for each patient, depending on age, gender, size, physiology, and underlying health conditions. We have employed computational fluid dynamics and biomechanics modelling to investigate the effect of ETT for three ventilation modes on (a) local oxygen delivery to the lungs, (b) air pressure and wall shear stress at the tracheal walls, and (c) oscillatory elastic deformation of the tracheal tissues and muscle. For the first time, we reveal how the ventilation mode and ETT insertion in the trachea may induce major complications, especially in long periods of ETT. We show that rotating the ETT or displacing it by 2 mm only can induce a significant rise in the tracheal pressure up to 177 cmH2O. This study, for the first time, shows the vital role of computers in biology and medicine to provide enhanced decision-making-support to clinicians and medical doctors dealing with ETI.

Objectives. - The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation.Study design. - Prospective.Population. - Emergency physicians.Methods. - Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan(R) simulator (Laerdal(R)) was assessed.Results. - Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor.Conclusion. - We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered. (C) 2009 Elsevier Masson SAS. All rights reserved.

OBJECTIVE:To assess the performance of the COPA device during general anaesthesia.STUDY DESIGN:Prospective, clinical, open study.PATIENTS:Eighty patients scheduled for short elective surgical procedures under general anaesthesia not requiring tracheal intubation.METHOD:After premedication (midazolam, atropine), anaesthesia was induced with propofol (154 +/- 40 mg = 2.47 +/- 0.8 mg.kg-1) and alfentanil (1.14 +/- 0.43 mg). The COPA device was inserted in a fashion similar to a Guedel airway device. The device was evaluated on the following criteria: correct choice of COPA size, ease of insertion, ability to obtain or maintain patent airway. Adverse reactions were noted, such as coughing, nausea, regurgitation, inhalation, and sore throat. The overall rating of the COPA as a "hand free device" was evaluated on the basis of excellent, good, fair, and poor.RESULTS:Insertion of the device was easy and in 70 cases successful on the first attempt. Jaw thrust on head tilt was necessary in half the cases. No patient necessitated intubation because of hypoxaemia or airway obstruction. Adverse reactions occurred in few cases and consisted of sore throat (always moderate) in 10% of the cases. COPA was evaluated as excellent or good in 80% of the cases.CONCLUSION:COPA is a convenient device for airway management in fasting patients undergoing general anaesthesia for elective surgery in the supine position, in whom tracheal intubation is not indicated.

The Cook airway exchange catheter is mainly used in ICU patients to exchange endotracheal tubes. We report three cases where this device was used during anaesthesia in patients with damaged tubes in critical circumstances (oropharyngeal bleeding, head and neck surgery). It allowed a fast and atraumatic exchange of the tubes.

Objectifs : Comparer les pressions dans le ballonnet de deux types de sonde au cours de l'utilisation de protoxyde d'azote. Type d'etude : Etude clinique prospective ouverte. Patients : 50 patients devant beneficier d'une intervention chirurgicale en ORL ou en stomatologie d'une duree superieure ou egale a deux heures, necessitant une intubation et une ventilation controlee. Methode : Les patients etaient intubes soit au moyen d'une sonde standard (Portex Blue-Line ballonnet basse pression contact BP ) (groupe T) soit au moyen d'une sonde pernettant la rediffusion du protoxyde d'azote (Mallinckrodt Hi-Contour Brandt®) (groupe B). Apres intubation, le ballonet de la sonde etait gonfle a l'air a une pression de 20 cm H 2 O. La pression etait mesuree 5, 10, 15 minutes apres l'introductio du protoxyde d'azote (FiN 2 O = 50%), puis toutes les 15 minutes jusqu'a 120 minutes. Resultats : Des l'administration du N 2 O, la pression augmente dans les deux groupes, mais l'augmentation est plus importante dans le groupe T (P < 0,0001). De plus, les pressions atteignent dans ce groupe la valeur critique de 40 cm d'eau en 60 a 75 minutes, alors que dans le groupe Brandt, cette valeur n'est jamais atteinte. Conclusion : La sonde Mallinckrodt Brandt, de par son systeme de rediffusion du protoxyde d'azote permet de diminuer les pressions exercees sur la trachee par le ballonnet de la sonde d'intubation. L'usage et le positionnement de la sonde n'ont pose aucun probleme pratique. Leur usage systematique pourrait diminuer l'incidence des complications tracheales en particulier lors de chirurgies longues.

Objectives: To evaluate the difficulty of intubation in relation with the localisation and spread of cervico-facial cellulitis of odontogenic origin and to recognize the optimal technique of intubation in such circumstances.Study design: Prospective clinical open study.Patients: Hundred patients, including 16 children, undergoing surgical drainage of a cervico-facial cellulitis of odontogenic: origin under general anesthesia were studied.Methods: Difficulty of intubation was evaluated with the following four criteria: active mouth opening in the awake patient, Mallampati's classifying system, presence of trismus, clinical and radiological control of localisation and extension of the cellulitis (mandibular, maxillar or mouth floor). In case of a foreseen difficult intubation, a fibrescope was used in the awake patient. Otherwise the endotracheal tube was inserted after administration of propofol (3 mg . k(-1)) and alfentanil (10 to 20 mu g . kg(-1)). A Cormack's grading was performed during intubation.Results: Mouth opening depended on the localisation of the cellulitis. Trismus occurred more often with mandibular than maxillary localisations. Trismus and a Mallampati's class > 2 were associated with difficulty in intubation (Cormack's grade > 2), except in maxillary localisations.Conclusions: The localisation of cellulitis of odontogenic origin is responsible for the difficulty grade of intubation. Awake fibreoptic intubation should be systematically performed in patients with a floor of the mouth cellulitis to reduce the risk of rupture of the abscess by a laryngoscope blade. As trismus associated with mandibular localisations is not relieved by general anaesthesia, awake fibreoptic endotracheal intubation should be preferred.

To evaluate the difficulty of intubation in relation with the localisation and spread of cervico-facial cellulitis of odontogenic origin and to recognize the optimal technique of intubation in such circumstances.Prospective clinical open study.Hundred patients, including 16 children, undergoing surgical drainage of a cervico-facial cellulitis of odontogenic origin under general anesthesia were studied.Difficulty of intubation was evaluated with the following four criteria: active mouth opening in the awake patient, Mallampati's classifying system, presence of trismus, clinical and radiological control of localisation and extension of the cellulitis (mandibular, maxillar or mouth floor). In case of a foreseen difficult intubation, a fibrescope was used in the awake patient. Otherwise the endotracheal tube was inserted after administration of propofol (3 mg.k-1) and alfentanil (10 to 20 micrograms.kg-1). A Cormack's grading was performed during intubation.Mouth opening depended on the localisation of the cellulitis. Trismus occurred more often with mandibular than maxillary localisations. Trismus and a Mallampati's class > 2 were associated with difficulty in intubation (Cormack's grade > 2), except in maxillary localisations.The localisation of cellulitis of odontogenic origin is responsible for the difficulty grade of intubation. Awake fibreoptic intubation should be systematically performed in patients with a floor of the mouth cellulitis to reduce the risk of rupture of the abscess by a laryngoscope blade. As trismus associated with mandibular localisations is not relieved by general anaesthesia, awake fibreoptic endotracheal intubation should be preferred.

Intermittent left bundle branch block is uncommon. During anaesthesia,, left bundle branch block may be related to hypertension or tachycardia and its occurrence makes the diagnosis of acute myocardial ischaemia or infarction difficult. Patients with intermittent left bundle branch block often develop established left bundle branch block, which may represent an earlier state of ischaemic heart disease. Cardiological investigation of our patient after operation did not point towards an organic cause of intermittent left bundle branch block.