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What happens between injury and our
perception of pain? This book is about the first unifying law of Pain that
explains the origin of all types of pain: from Arthritis to Fibromyalgia and
from Migraine to Sciatica.
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Designed for quick access to pain drugs
information, Sota Omoigui's Pain Drugs Handbook is a complete clinical guide
in a handy portable format
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As a synopsis of anesthetic pharmacology
it is a useful review for the beginning trainee and the advanced
practitioner. An all-time best seller, The Anesthesia Drugs Handbook has
been translated into Italian, Japanese, Malaysian, Polish and Portuguese.
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This booklet is written to guide those who
suffer or know someone suffering from pain. It provides the most current
information about the common painful syndromes, the right medications,
useful herbs and various treatments that can be utilized in the home, clinic
or hospital to successfully ease pain.
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One of the best books on Self Improvement
and Management ever published. Animals have been taking care of business
much longer than humans and they do it with an instinct few humans possess.
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The Universal
Drug Infusion Ruler
Drug Infusions Made Easy
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To obtain a phone consultation from pain
specialist, Dr. Sota Omoigui, click here.
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MEDICAL PUBLICATIONS
Med Hypotheses. 2005;65(3):559-69
Cholesterol Synthesis is the Trigger
Omoigui S. MD.
L.A. Pain Clinic, Los Angeles, California, USA.
Read the full Article
Pain Med.
2005 Mar-Apr;6(2):149-51
Treatment of ptosis as a complication of botulinum toxin
injection
Omoigui S, Irene S.
L.A. Pain Clinic, Los Angeles, California, USA.
Read the full Article
Pain Med. 2004 Jun;5(2):229-30
Subcutaneous Injection of Anakinra
Omoigui S. MD.
L.A. Pain Clinic, Los Angeles, California, USA.
Read the full Article
Regional Anesthesia and Pain Medicine 23 (4): 427,
1998
A Safer Technique for Epidural Lysis of Adhesions
Omoigui S. MD.
L.A. Pain Clinic, Los Angeles, California, USA.
Read the full Article |
Anesth Analg. 1991 Mar;72(3):392-3
Blind nasal intubation with Audio-Capnometry
Omoigui S,
Glass
P,
Martel
DL,
Watkins K,
Williams KL,
Whitefield SM,
Wooten
LL.
Duke University Medical Center, Durham, North Carolina.
Introduction
Nasotracheal intubation
is performed electively for intraoral
operations when anatomic abnormalities or disease of the upper
airway make direct laryngoscopy difficult or impossible and,
occasionally, when long term mechanical intubation of the lungs
is anticipated. Fiberoptic or blind nasotracheal intubation are
usually reserved for situations in which direct laryngoscopy
would be impossible or induction of anesthesia before
neuromuscular blockade would be hazardous. The flexible
fiberoptic bronchoscope may not be available and success may be
limited under emergency conditions due to blood and secretions
blurring the field. In these clinical situations, awake blind
nasotracheal intubation may be the technique of choice.
To ensure maximum patient
comfort and nasal patency, and to
minimize the chances of epistaxis associated with nasotracheal
intubation, the nasal mucosa is anesthetized and constricted
with
topical cocaine. If cocaine is not available, vasoconstriction
may be produced by topical phenylephrine (neosynephrine). The
endotracheal tube is passed through the nares into the
oropharynx
and advanced towards the glottic opening as long as breath
sounds
are maximal as detected by listening to exhaled air passing from
the proximal end of the tube. This requires the intubator to
keep
an ear close to the tube connector to readily detect changes in
breath sounds. Alternate techniques utilized in enhancing
success
with blind nasal intubation include observation of condensation
in the endotracheal tube[1],
inflation of the cuff[2],
use of a
suction catheter[3],
attaching a microphone to the end of the
endotracheal tube to magnify breath sounds[4],
or guiding the
endotracheal tube by observation of the CO2 waveform on a
capnograph[5].
Disadvantages of these methods include difficulty in
hearing breath sounds or observing condensation and exposure of
the intubator to contamination with body secretions especially
occurring when the tube is passed into the glottis with an
explosive cough. The need to look up at the CO2 waveform may be
a
distraction at a time when concentration is most needed.
Nevertheless measurement of endtidal CO2 is the most reliable
method for confirmation of endotracheal tube placement and the
use of audio-capnometry to guide the endotracheal tube
eliminates
the need to look up. This is based on the logical postulate that
the concentration of CO2 in the oropharynx is maximal over the
glottis during expiration. Several blind nasotracheal
intubations
have been performed using an audiocapnometry intubation device,
and the case report presented below adequately describes our
experience with this device.
The (a.c.i.d.) audio-capnometry
intubation device (fig 1), which
has not previously been described was developed by Sota Omoigui
MD at Duke
University Hospital. It consists of a Puritan Bennett Datex CO2
monitor coupled to a voltage controlled oscillator with a
speaker. This yields an audible tone with a pitch that varies
linearly with the concentration of CO2. The Datex monitor was
used as it has the least time lag compared with the Ohmeda and
Novometrix CO2 monitors. Detection of small changes in the
concentration of CO2 is facilitated by the use of an
endotracheal
tube with a gas sampling port at the tip as with the Portex Blue
line tracheal tube for gas monitoring (Concord/Portex, Keene,
New
Hampshire Ref: 100 198/080).
Report of a Case
A 62 yr old white female
following coronary artery bypass surgery
developed increasing respiratory distress while in the Acute
Care
Unit. Arterial blood gas tensions with an FiO2 of 0.5 by Face
Mask were pH 7.24 pO2 62mm Hg pCO2 51mm Hg SaO2 86.4%.
Respiratory rate was 40/min and Heart rate was 90/min. There
were
occasional premature ventricular complexes recorded on the
E.K.G.
Due to incipient respiratory failure, mechanical ventilation via
an endotracheal tube was indicated and an awake nasal intubation
was planned. Oxygen (100%) was then administered by face mask
which resulted in a O2 saturation by pulse oximeter of 97%.
After
topicalization of the nasal mucosa with Cetacaine, a well
lubricated 8.0mm Portex Blue Line Gas monitoring tracheal tube
(Ref: 100198/080) with the CO2 sampling port attached to the
audible capnograph was inserted in the left nostril. The
a.c.i.d.
was turned on and, as the tube was advanced, changes in pitch
were heard in synchrony with the patient's respirations. The
pitch of the tone suddenly decreased and the patient was then
noted to be have bradycardia. Oxygen saturation was 95%. The
endotracheal tube was withdrawn by a few cm.The heart rate
returned to normal and the tube was readvanced while listening
to
the pitch of the sound. As the tube was advanced to the 25cm
mark, an oscillating high pitch was constantly heard despite
difficulty in hearing air movement out of the endotracheal tube.
The cuff was inflated and verification of tube placement was
confirmed by visual CO2 monitor, the presence of bilateral
breath
sounds and ultimately by chest X-ray. Vital signs were stable
with O2 saturation of 99%. Time for intubation was less than 3
minutes.
The above case report
illustrates the utilization of
audiocapnometry to guide blind nasotracheal intubation. Hearing
a
high pitch assures the user that the endotracheal tube is within
the vicinity of the glottis. A sudden decrease in the pitch
alerts the user that the endotracheal tube is being misdirected
away from the glottis and allows for immediate correction. In
the
case report the decrease in pitch preceded the signs of vagal
stimulation and prevented esophageal intubation. The a.c.i.d.
allows the user another method of guiding the endotracheal tube
in blind nasal intubations without sole reliance on breath
sounds.
The user can concentrate
on the procedure with minimal risks of
contamination by body secretions. It confirms immediately
appropriate placement of the endotracheal tube. Secretions and
blood interfere less with this technique than with fiberoptic
bronchoscopy. Furthermore O2 can be provided through the
nasotracheal tube during the procedure whereas in the fiberoptic
scope, O2 is provided through the suction port. Conceivably it
could be adapted with fiberoptic bronchoscopy or used during
anesthesia as a substitute for visual waveforms.
A potential problem in
the design of the Portex tube is that
excessive secretions may be suctioned into the CO2 monitoring
line plugging it and causing a falsely low CO2 tone to be
emitted
thus necessitating verification of tube placement by another
method. Furthermore the device needs to be improved to increase
it's sensitivity to small changes in CO2 concentration. Despite
these limitations, audio-capnometry offers a distinct advantage
during the performance of blind nasotracheal intubation. The
device required is simple and easily assembled.
Figure 1. Audiocapnometry
intubation device. It consists of a Puritan Bennett Datex CO2
monitor coupled to a voltage controlled
oscillator with a speaker.
[1]
Shapiro H, Unger R. Blind,but not deaf or dirty,
intubations. Anesthesiology 1986; 64:(2):297
[2]
Gorback M. Inflation of the endotracheal tube cuff as an
aid
to blind nasal endotracheal intubation. Anesth Analg
1987;66:916-917
[3]
Meyer R. Suction catheter to facilitate blind nasal
intubation. Anesth-Analg 1989;68:701
[4]
Patil VL, Stehling L, Zauder H, Chilcoat R. An aid
to
blind endotracheal intubation. Anesth-Analg 1984;65:882.
[5]
King H,Wooten D. Blind nasal intubation by
monitoring end tidal CO2. Anesth Analg 1989;69:412-413
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