Abstracts 653

need for determination of electrolyte, calcium, and magne- sium levels should be based on physical examination find- ings.

??SAFETY AND EFFICACY OF THEOPHYLLINE IN CHILDREN WITH ASTHMA. Hendeles L, Weinberger M, Szefler S, Ellis E. J Pediatr. 1992;120:177-83.

This article was written in response to the growing con- cern over the potentially adverse effects of theophylline in children. Theophylline-induced seizures with subsequent encephalopathy as well as possible learning and behavior disorders are addressed. The benefits of theophylline in severe asthma as a maintenance drug often outweigh the risks. There were two reported cases of encephalopathy due to severe seizures; however, the parents failed to recog- nize repeated vomiting as a sign of toxicity. Further, the FDA released a review concluding that there is insufficient data to prove any learning or behavioral problems to be due to theophylline. Parents should be educated to recog- nize the signs of theophylline toxicity as well as conditions or drugs that can change the existing serum theophylline level. This article has a detailed chart on dosing, as well as an algorithm for slow clinical titration of theophylline based on the serum concentration. The recommended guidelines to ensure the safe use of theophylline include:

awake tracheal intubation over the study period. Between 1980 and 1987 the charts of all patients with cervical spine injuries (with or without spinal cord injury) were reviewed. Patients were excluded if they were intubated under general anesthesia (mainly at the referring hospital), received a sur- gical airway, had a cervical spine injury of indeterminate age, or had severe head injury precluding the adequate assessment of spinal function. Eighty patients were ex- cluded. Of the remaining 454 patients, 289 controls did not require tracheal intubation, and 165 cases required tracheal intubation. Intubations were performed without the aid of general anesthesia or muscle relaxants. The comparison of neurological status between admission and discharge re- vealed no statistically significant difference in neurological deterioration between the controls (2.4%) and the cases (2.4%). There was no ‘documented evidence of aspiration in the case group. These results occurred despite the case group having a higher injury severity score. The authors note that 42 patients (25%) were intubated before any form of rigid immobilization was applied, and that 64 patients (39%) were intubated. under emergent conditions. They conclude that awake tracheal intubation is a safe method of airway management in patients with cervical spine in- juries. [Steven A. Kohler, MD]

Editor’s Comment: Endotracheal intubation was achieved with fiberoptic guidance in almost half of these patients and may be the method of choice in cases of cervi- cal spine injury when time allows.

??Always guide final dosage by serum theophylline con- centrations.

??Theophylline should be withheld for persistent head- ache, nervousness, tachycardia, nausea, or vomiting.

??Reduce dosage by half for fever sustained more than 24 hours.

??Reduce dosage by one-third if the patient begins erythromycin or ciprofloxacin, and by half for cimeti- dine, troleandomycin, or oral contraceptives.

??Reduce dosage by half if carbamazepine or phenytoin is discontinued.

??Provide adequate instruction so that everyone under- stands the benefits and risks of theophylline.

[Susan Taylor, MD]

Editor’s Comment: With encouraging data regarding the long-term use of inhaled corticosteroids, the risk/bene- fit ratio of chronic theophylline therapy needs to be reex- amined.

0 THE SAFETY OF AWAKE TRACHEAL INTUBA- TION IN CERVICAL SPINE INJURY. Meschino A, Hugh Devitt J, Koch J-P, Szalai JP, Schwartz ML. Can J Anaesth. 1992;39:2.

This retrospective, case control study reviewed the fre- quency of neurological deterioration and aspiration associ- ated with awake tracheal intubation of cervical spine in- jured patients. It was undertaken at a referral center for cervical spine injuries. This institution routinely performed

0 MANAGEMENT OF THE DIFFICULT ADULT AIR- WAY WITH SPECIAL EMPHASIS ON AWAKE TRA- CHEAL INTUBATION. Bleubuyck JF. Anesthesiology. 1991;75: 1087-l 10.

Management of the difficult airway is an area of critical concern to the fields of emergency medicine and anesthesi- ology. In this article, the author provides an extensive re- view of methods of recognizing and securing the difficult airway with particular attention to techniques of awake intubation, the method of choice when difficulty in secur- ing an airway is expected. Methods of upper airway anes- thesia include topical anesthesia, lingual block, and supe- rior laryngeal nerve block, with an emphasis on safety. Various methods of tracheal intubation are described and contrasted, including direct laryngoscopy, blind nasal intu- bation, retrograde intubation, and flexible fiberoptic bron- choscopy. Special situations such as the patient with a full stomach and the patient who is obtunded are discussed. Finally, methods of securing an airway when a patient can- not be ventilated by bag-valve-mask are discussed, such as the combitube, laryngeal mask airway, and transtracheal jet ventilation. [Michael D. Witting, MD]

0 PREDICTING DIFFICULT INTUBATION. Frerk CM. Anaesthesia. 1991;46:1005-8.