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The easiest method to perform this technique is the needle cricothyrotomy ( also referred to as a percutaneous <unk> cricothyrotomy ) , in which a large @-@ bore ( 12 – 14 gauge ) intravenous catheter is used to puncture the cricothyroid membrane . Oxygen can then be administered through this catheter via jet insufflation . However , while needle cricothyrotomy may be life @-@ saving in extreme circumstances , this technique is only intended to be a <unk> measure until a definitive airway can be established . While needle cricothyrotomy can provide adequate oxygenation , the small diameter of the cricothyrotomy catheter is insufficient for elimination of carbon dioxide ( ventilation ) . After one hour of <unk> oxygenation through a needle cricothyrotomy , one can expect a PaCO2 of greater than 250 mm Hg and an arterial pH of less than 6 @.@ 72 , despite an oxygen saturation of 98 % or greater . A more definitive airway can be established by performing a surgical cricothyrotomy , in which a 5 to 6 mm ( 0 @.@ 20 to 0 @.@ 24 in ) endotracheal tube or tracheostomy tube can be inserted through a larger incision .
Several manufacturers market prepackaged cricothyrotomy kits , which enable one to use either a wire @-@ guided percutaneous <unk> ( Seldinger ) technique , or the classic surgical technique to insert a <unk> catheter through the cricothyroid membrane . The kits may be stocked in hospital emergency departments and operating suites , as well as ambulances and other selected pre @-@ hospital settings .
= = = Tracheotomy = = =
Tracheotomy consists of making an incision on the front of the neck and opening a direct airway through an incision in the trachea . The resulting opening can serve independently as an airway or as a site for a tracheostomy tube to be inserted ; this tube allows a person to breathe without the use of his nose or mouth . The opening may be made by a scalpel or a needle ( referred to as surgical and percutaneous techniques respectively ) and both techniques are widely used in current practice . In order to limit the risk of damage to the recurrent laryngeal nerves ( the nerves that control the voicebox ) , the tracheotomy is performed as high in the trachea as possible . If only one of these nerves is damaged , the patient 's voice may be impaired ( dysphonia ) ; if both of the nerves are damaged , the patient will be unable to speak ( aphonia ) . In the acute setting , indications for tracheotomy are similar to those for cricothyrotomy . In the chronic setting , indications for tracheotomy include the need for long @-@ term mechanical ventilation and removal of tracheal secretions ( e.g. , comatose patients , or extensive surgery involving the head and neck ) .
= = = Children = = =
There are significant differences in airway anatomy and respiratory physiology between children and adults , and these are taken into careful consideration before performing tracheal intubation of any pediatric patient . The differences , which are quite significant in infants , gradually disappear as the human body approaches a mature age and body mass index .
For infants and young children , orotracheal intubation is easier than the nasotracheal route . <unk> intubation carries a risk of dislodgement of adenoids and nasal bleeding . Despite the greater difficulty , nasotracheal intubation route is preferable to orotracheal intubation in children undergoing intensive care and requiring prolonged intubation because this route allows a more secure fixation of the tube . As with adults , there are a number of devices specially designed for assistance with difficult tracheal intubation in children . Confirmation of proper position of the tracheal tube is accomplished as with adult patients .
Because the airway of a child is narrow , a small amount of <unk> or tracheal swelling can produce critical obstruction . Inserting a tube that is too large relative to the diameter of the trachea can cause swelling . Conversely , inserting a tube that is too small can result in inability to achieve effective positive pressure ventilation due to retrograde escape of gas through the glottis and out the mouth and nose ( often referred to as a " leak " around the tube ) . An excessive leak can usually be corrected by inserting a larger tube or a cuffed tube .
The tip of a correctly positioned tracheal tube will be in the mid @-@ trachea , between the <unk> on an <unk> chest radiograph . The correct diameter of the tube is that which results in a small leak at a pressure of about 25 cm ( 10 in ) of water . The appropriate inner diameter for the endotracheal tube is estimated to be roughly the same diameter as the child 's little finger . The appropriate length for the endotracheal tube can be estimated by doubling the distance from the corner of the child 's mouth to the ear canal . For premature infants 2 @.@ 5 mm ( 0 @.@ 1 in ) internal diameter is an appropriate size for the tracheal tube . For infants of normal gestational age , 3 mm ( 0 @.@ 12 in ) internal diameter is an appropriate size . For normally nourished children 1 year of age and older , two formulae are used to estimate the appropriate diameter and depth for tracheal intubation . The internal diameter of the tube in mm is ( patient 's age in years + 16 ) / 4 , while the appropriate depth of insertion cm is 12 + ( patient 's age in years / 2 ) .
= = = Newborns = = =
In newborns free flow oxygen used to be recommended during intubation however as there is no evidence of benefit the 2011 NRP guidelines no longer do .
= = Predicting difficulty = =
Tracheal intubation is not a simple procedure and the consequences of failure are grave . Therefore , the patient is carefully evaluated for potential difficulty or complications beforehand . This involves taking the medical history of the patient and performing a physical examination , the results of which can be scored against one of several classification systems . The proposed surgical procedure ( e.g. , surgery involving the head and neck , or bariatric surgery ) may lead one to anticipate difficulties with intubation . Many individuals have unusual airway anatomy , such as those who have limited movement of their neck or jaw , or those who have tumors , deep swelling due to injury or to allergy , developmental abnormalities of the jaw , or excess fatty tissue of the face and neck . Using conventional <unk> techniques , intubation of the trachea can be difficult or even impossible in such patients . This is why all persons performing tracheal intubation must be familiar with alternative techniques of securing the airway . Use of the flexible fiberoptic bronchoscope and similar devices has become among the preferred techniques in the management of such cases . However , these devices require a different skill set than that employed for conventional laryngoscopy and are expensive to purchase , maintain and repair .
When taking the patient 's medical history , the subject is questioned about any significant signs or symptoms , such as difficulty in speaking or difficulty in breathing . These may suggest obstructing lesions in various locations within the upper airway , larynx , or tracheobronchial tree . A history of previous surgery ( e.g. , previous cervical fusion ) , injury , radiation therapy , or tumors involving the head , neck and upper chest can also provide clues to a potentially difficult intubation . Previous experiences with tracheal intubation , especially difficult intubation , intubation for prolonged duration ( e.g. , intensive care unit ) or prior tracheotomy are also noted .
A detailed physical examination of the airway is important , particularly :
the range of motion of the cervical spine : the subject should be able to tilt the head back and then forward so that the chin touches the chest .
the range of motion of the jaw ( the temporomandibular joint ) : three of the subject 's fingers should be able to fit between the upper and lower incisors .
the size and shape of the upper jaw and lower jaw , looking especially for problems such as maxillary hypoplasia ( an underdeveloped upper jaw ) , micrognathia ( an abnormally small jaw ) , or <unk> ( misalignment of the upper and lower jaw ) .
the <unk> distance : three of the subject 's fingers should be able to fit between the Adam 's apple and the chin .
the size and shape of the tongue and palate relative to the size of the mouth .
the teeth , especially noting the presence of prominent maxillary incisors , any loose or damaged teeth , or crowns .
Many classification systems have been developed in an effort to predict difficulty of tracheal intubation , including the Cormack @-@ Lehane classification system , the Intubation Difficulty Scale ( IDS ) , and the <unk> score . The <unk> score is drawn from the observation that the size of the base of the tongue influences the difficulty of intubation . It is determined by looking at the anatomy of the mouth , and in particular the visibility of the base of palatine uvula , <unk> pillars and the soft palate . Although such medical scoring systems may aid in the evaluation of patients , no single score or combination of scores can be trusted to specifically detect all and only those patients who are difficult to intubate . Furthermore , one study of experienced anesthesiologists , on the widely used Cormack – Lehane classification system , found they did not score the same patients consistently over time , and that only 25 % could correctly define all four grades of the widely used Cormack – Lehane classification system . Under certain emergency circumstances ( e.g. , severe head trauma or suspected cervical spine injury ) , it may be impossible to fully utilize these the physical examination and the various classification systems to predict the difficulty of tracheal intubation . In such cases , alternative techniques of securing the airway must be readily available .
= = Complications = =
Tracheal intubation is generally considered the best method for airway management under a wide variety of circumstances , as it provides the most reliable means of oxygenation and ventilation and the greatest degree of protection against regurgitation and pulmonary aspiration . However , tracheal intubation requires a great deal of clinical experience to master and serious complications may result even when properly performed .
Four anatomic features must be present for orotracheal intubation to be straightforward : adequate mouth opening ( full range of motion of the temporomandibular joint ) , sufficient pharyngeal space ( determined by examining the back of the mouth ) , sufficient submandibular space ( distance between the thyroid cartilage and the chin , the space into which the tongue must be displaced in order for the <unk> to view the glottis ) , and adequate extension of the cervical spine at the <unk> @-@ occipital joint . If any of these variables is in any way compromised , intubation should be expected to be difficult .
Minor complications are common after laryngoscopy and insertion of an orotracheal tube . These are typically of short duration , such as sore throat , lacerations of the lips or gums or other structures within the upper airway , chipped , fractured or dislodged teeth , and nasal injury . Other complications which are common but potentially more serious include accelerated or irregular heartbeat , high blood pressure , elevated intracranial and <unk> pressure , and bronchospasm .
More serious complications include <unk> , perforation of the trachea or esophagus , pulmonary aspiration of gastric contents or other foreign bodies , fracture or dislocation of the cervical spine , temporomandibular joint or <unk> cartilages , decreased oxygen content , elevated arterial carbon dioxide , and vocal cord weakness . In addition to these complications , tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially severe nasal bleeding . Newer technologies such as flexible fiberoptic laryngoscopy have fared better in reducing the incidence of some of these complications , though the most frequent cause of intubation trauma remains a lack of skill on the part of the laryngoscopist .
Complications may also be severe and long @-@ lasting or permanent , such as vocal cord damage , esophageal perforation and retropharyngeal abscess , bronchial intubation , or nerve injury . They may even be immediately life @-@ threatening , such as <unk> and negative pressure pulmonary edema ( fluid in the lungs ) , aspiration , unrecognized esophageal intubation , or accidental disconnection or dislodgement of the tracheal tube . Potentially fatal complications more often associated with prolonged intubation and / or tracheotomy include abnormal communication between the trachea and nearby structures such as the innominate artery ( <unk> fistula ) or esophagus ( <unk> fistula ) . Other significant complications include airway obstruction due to loss of tracheal rigidity , ventilator @-@ associated pneumonia and narrowing of the glottis or trachea . The cuff pressure is monitored carefully in order to avoid complications from over @-@ inflation , many of which can be traced to excessive cuff pressure restricting the blood supply to the tracheal mucosa . A 2000 Spanish study of bedside percutaneous tracheotomy reported overall complication rates of 10 – 15 % and procedural mortality of 0 % , which is comparable to those of other series reported in the literature from the Netherlands and the United States .
Inability to secure the airway , with subsequent failure of oxygenation and ventilation is a life @-@ threatening complication which if not immediately corrected leads to decreased oxygen content , brain damage , cardiovascular collapse , and death . When performed improperly , the associated complications ( e.g. , unrecognized esophageal intubation ) may be rapidly fatal . Without adequate training and experience , the incidence of such complications is high . The case of Andrew Davis Hughes , from Emerald Isle , NC is a widely known case in which the patient was improperly intubated and , due to the lack of oxygen , suffered severe brain damage and died . For example , among paramedics in several United States urban communities , unrecognized esophageal or <unk> intubation has been reported to be 6 % to 25 % . Although not common , where basic emergency medical technicians are permitted to intubate , reported success rates are as low as 51 % . In one study , nearly half of patients with misplaced tracheal tubes died in the emergency room . Because of this , recent editions of the American Heart Association 's Guidelines for <unk> Resuscitation have de @-@ emphasized the role of tracheal intubation in favor of other airway management techniques such as bag @-@ valve @-@ mask ventilation , the laryngeal mask airway and the <unk> .
One complication — unintentional and unrecognized intubation of the esophagus — is both common ( as frequent as 25 % in the hands of inexperienced personnel ) and likely to result in a deleterious or even fatal outcome . In such cases , oxygen is inadvertently administered to the stomach , from where it cannot be taken up by the circulatory system , instead of the lungs . If this situation is not immediately identified and corrected , death will ensue from cerebral and cardiac anoxia .
Of 4 @,@ 460 claims in the American Society of <unk> ( ASA ) Closed Claims Project database , 266 ( approximately 6 % ) were for airway injury . Of these 266 cases , 87 % of the injuries were temporary , 5 % were permanent or disabling , and 8 % resulted in death . Difficult intubation , age older than 60 years , and female gender were associated with claims for perforation of the esophagus or pharynx . Early signs of perforation were present in only 51 % of perforation claims , whereas late sequelae occurred in 65 % .
= = Alternatives = =
Although it offers the greatest degree of protection against regurgitation and pulmonary aspiration , tracheal intubation is not the only means to maintain a patent airway . Alternative techniques for airway management and delivery of oxygen , volatile anesthetics or other breathing gases include the laryngeal mask airway , i @-@ gel , cuffed oropharyngeal airway , continuous positive airway pressure ( CPAP mask ) , nasal <unk> mask , simple face mask , and nasal cannula .
General anesthesia is often administered without tracheal intubation in selected cases where the procedure is brief in duration , or procedures where the depth of anesthesia is not sufficient to cause significant compromise in ventilatory function . Even for longer duration or more invasive procedures , a general anesthetic may be administered without intubating the trachea , provided that patients are carefully selected , and the risk @-@ benefit ratio is favorable ( i.e. , the risks associated with an unprotected airway are believed to be less than the risks of intubating the trachea ) .
= = History = =
Tracheotomy
The earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to around 3600 BC . The 110 @-@ page Ebers Papyrus , an Egyptian medical papyrus which dates to roughly 1550 BC , also makes reference to the tracheotomy . Tracheotomy was described in the Rigveda , a Sanskrit text of ayurvedic medicine written around 2000 BC in ancient India . The Sushruta Samhita from around 400 BC is another text from the Indian subcontinent on ayurvedic medicine and surgery that mentions tracheotomy . <unk> of Bithynia ( c . 124 – 40 BC ) is often credited as being the first physician to perform a non @-@ emergency tracheotomy . Galen of Pergamon ( AD 129 – 199 ) clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice . In one of his experiments , Galen used bellows to inflate the lungs of a dead animal . Ibn <unk> ( 980 – 1037 ) described the use of tracheal intubation to facilitate breathing in 1025 in his 14 @-@ volume medical encyclopedia , The Canon of Medicine . In the 12th century medical textbook Al @-@ <unk> , Ibn <unk> ( 1092 – 1162 ) — also known as <unk> — of Al @-@ Andalus provided a correct description of the tracheotomy operation .
The first detailed descriptions of tracheal intubation and subsequent artificial respiration of animals were from Andreas Vesalius ( 1514 – 1564 ) of Brussels . In his landmark book published in 1543 , De humani corporis fabrica , he described an experiment in which he passed a reed into the trachea of a dying animal whose thorax had been opened and maintained ventilation by blowing into the reed intermittently . Antonio Musa <unk> ( 1490 – 1554 ) of Ferrara successfully treated a patient suffering from peritonsillar abscess by tracheotomy . <unk> published his account in 1546 ; this operation has been identified as the first recorded successful tracheotomy , despite the many previous references to this operation . Towards the end of the 16th century , Hieronymus Fabricius ( 1533 – 1619 ) described a useful technique for tracheotomy in his writings , although he had never actually performed the operation himself . Fabricius was the first to introduce the idea of a tracheostomy tube . In 1620 the French surgeon Nicholas <unk> ( 1550 – 1624 ) published a report of four successful tracheotomies . In 1714 , anatomist Georg <unk> ( 1671 – 1747 ) of the University of Rostock performed a tracheotomy on a drowning victim .
Despite the many recorded instances of its use since antiquity , it was not until the early 19th century that the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction . In 1852 , French physician Armand Trousseau ( 1801 – 1867 ) presented a series of 169 tracheotomies to the Académie Impériale de Médecine . 158 of these were performed for the treatment of croup , and 11 were performed for " chronic maladies of the larynx " . Between 1830 and 1855 , more than 350 tracheotomies were performed in Paris , most of them at the Hôpital des Enfants <unk> , a public hospital , with an overall survival rate of only 20 – 25 % . This compares with 58 % of the 24 patients in Trousseau 's private practice , who fared better due to greater postoperative care .
In 1871 , the German surgeon Friedrich Trendelenburg ( 1844 – 1924 ) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia . In 1888 , Sir Morell Mackenzie ( 1837 – 1892 ) published a book discussing the indications for tracheotomy . In the early 20th century , tracheotomy became a life @-@ saving treatment for patients afflicted with paralytic poliomyelitis who required mechanical ventilation . In 1909 , Philadelphia laryngologist Chevalier Jackson ( 1865 – 1958 ) described a technique for tracheotomy that is used to this day .
<unk> and non @-@ surgical techniques
In 1854 , a Spanish singing teacher named Manuel García ( 1805 – 1906 ) became the first man to view the functioning glottis in a living human . In 1858 , French pediatrician Eugène Bouchut ( 1818 – 1891 ) developed a new technique for non @-@ surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria @-@ related <unk> . In 1880 , Scottish surgeon William <unk> ( 1848 – 1924 ) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with <unk> edema to breathe , as well as in the setting of general anesthesia with chloroform . In 1895 , Alfred Kirstein ( 1863 – 1922 ) of Berlin first described direct visualization of the vocal cords , using an <unk> he had modified for this purpose ; he called this device an <unk> .
In 1913 , Chevalier Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea . Jackson introduced a new laryngoscope blade that incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope . Also in 1913 , New York surgeon Henry H. Janeway ( 1873 – 1921 ) published results he had achieved using a laryngoscope he had recently developed . Another pioneer in this field was Sir Ivan Whiteside Magill ( 1888 – 1986 ) , who developed the technique of awake blind nasotracheal intubation , the Magill forceps , the Magill laryngoscope blade , and several apparati for the administration of volatile anesthetic agents . The Magill curve of an endotracheal tube is also named for Magill . Sir Robert Reynolds Macintosh ( 1897 – 1989 ) introduced a curved laryngoscope blade in 1943 ; the Macintosh blade remains to this day the most widely used laryngoscope blade for orotracheal intubation .
Between 1945 and 1952 , optical engineers built upon the earlier work of Rudolph Schindler ( 1888 – 1968 ) , developing the first <unk> . In 1964 , optical fiber technology was applied to one of these early <unk> to produce the first flexible fiberoptic endoscope . Initially used in upper GI endoscopy , this device was first used for laryngoscopy and tracheal intubation by Peter Murphy , an English anesthetist , in 1967 . The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and <unk> in 1978 , using a central venous catheter .
By the mid @-@ 1980s , the flexible fiberoptic bronchoscope had become an indispensable instrument within the <unk> and anesthesia communities . The digital revolution of the 21st century has brought newer technology to the art and science of tracheal intubation . Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS active pixel sensor ( CMOS APS ) to generate a view of the glottis so that the trachea may be intubated .
= Maryland Route 704 =
Maryland Route 704 ( MD 704 ) is a state highway in the U.S. state of Maryland . Known as Martin Luther King Jr . Highway , the highway runs 6 @.@ 53 miles ( 10 @.@ 51 km ) from Eastern Avenue at the District of Columbia boundary in Seat Pleasant east to MD 450 in Lanham . MD 704 is a four- to six @-@ lane divided highway that connects the northern Prince George 's County communities of Seat Pleasant , Landover , Glenarden , and Lanham . The highway was constructed along the right of way of the abandoned Washington , Baltimore and Annapolis Electric Railway ( WB & A ) in the early 1940s . In the late 1950s and early 1960s , MD 704 served as a temporary routing of U.S. Route 50 ( US 50 ) while the U.S. Highway 's freeway was under construction from Washington to Lanham . The route was expanded to a divided highway between Seat Pleasant and US 50 in the late 1960s and early 1970s . MD 704 was completed as a divided highway when the portion east of US 50 was expanded in the late 1990s .
= = Route description = =
MD 704 begins at an intersection with Eastern Avenue near the eastern corner of the District of Columbia . The highway continues south as 63rd Street , which heads south toward Southern Avenue and East Capitol Street . MD 704 heads northeast as a six @-@ lane divided highway through the city of Seat Pleasant , where the highway intersects Addison Road at staggered intersections . Addison Road leads to St. Matthew 's Church , which is also known as the Addison Chapel . After leaving the city , the state highway crosses Cabin Branch and intersects Sheriff Road at an oblique angle . MD 704 passes through Landover , where the highway traverses <unk> Branch and meets MD 202 ( Landover Road ) at a full cloverleaf interchange . The highway continues through the city of Glenarden , where the highway intersects Ardwick Ardmore Road and crosses over Interstate 95 and I @-@ 495 ( Capital Beltway ) without access . MD 704 drops to four lanes again between Ardwick Ardmore Road and the five @-@ ramp partial cloverleaf interchange at US 50 ( John Hanson Highway ) , which is also unsigned I @-@ 595 . The interchange includes a direct ramp to northbound I @-@ 95 and I @-@ 495 toward Baltimore ; the ramp to westbound US 50 is used to access southbound I @-@ 95 and I @-@ 495 toward Richmond . MD 704 continues northeast as a six @-@ lane highway across Bald Hill Branch and veers east before reaching its eastern terminus at MD 450 ( Annapolis Road ) in Lanham .
MD 704 is a part of the National Highway System as a principal arterial from US 50 to MD 450 in Lanham .
= = History = =
MD 704 follows the abandoned right of way of the defunct WB & A Railway , an interurban railroad that included a north – south line between Washington and Baltimore and a branch to Annapolis from Naval Academy Junction in Odenton . Construction on the electric railway began in 1902 and service began between the three cities in 1908 . The WB & A went into receivership in 1931 and shut down in 1935 . The Maryland State Roads Commission converted the abandoned railroad right of way into a two @-@ lane highway from the District of Columbia line to US 50 ( now MD 450 ) near Lanham between 1942 and 1944 . The WB & A had a pair of timber bridges across its right of way . The Chapel Road bridge in Seat Pleasant , which carried what was then MD 389 and is now Addison Road across the railroad , was removed ; the junction was regraded as an intersection with the new highway . In 1944 , the War Production Board authorized the replacement of MD 202 's bridge across the abandoned railroad as one of the few non – war @-@ effort highway projects federally funded during World War II . Construction on the new steel @-@ and @-@ concrete bridge began in late 1944 and was completed by 1946 . Access between the grade @-@ separated highways at the MD 202 – MD 704 junction was via a pair of two @-@ way ramps .
MD 704 was named for George N. Palmer , a banker and community leader in Seat Pleasant , by 1951 . John Hanson Highway was constructed from US 301 in Bowie west to MD 704 between 1954 and 1957 . MD 704 was expanded to a divided highway through the highway 's interchange with the freeway as part of the construction . In addition to the current set of ramps , the interchange included loop ramps from westbound MD 704 to the eastbound freeway and from the westbound freeway to westbound MD 704 . By 1958 , the portion of MD 704 south of the freeway was marked as Temporary US 50 . This temporary route extended west into Washington along newly completed East Capitol Street and the pair of Independence Avenue and Constitution Avenue to reconnect with US 50 at 2nd Street in Capitol Hill . US 50 remained along Defense Highway ( now MD 450 ) from Bowie to Bladensburg and on Bladensburg Road and Maryland Avenue within the city until 1962 , when the U.S. Highway was placed along the newly completed John Hanson Highway from Bowie to Washington and Temporary US 50 was removed from MD 704 .
MD 704 was expanded to a divided highway from the District of Columbia boundary to Addison Road in Seat Pleasant in 1962 . The segment of divided highway at the US 50 interchange was extended west to Ardwick Ardmore Road in Glenarden in 1969 . MD 704 's modern cloverleaf interchange with MD 202 was completed in 1971 , the same year the former highway was expanded to a divided highway from Seat Pleasant to just north of the latter highway . The divided highway was extended southwest through Glenarden from Ardwick Ardmore Road to Glenarden Parkway in 1972 and to MD 202 in 1973 . MD 704 was renamed for Martin Luther King , Jr . , in 1987 . The highway 's interchange with US 50 was rebuilt in 1991 in conjunction with the overhaul of the US 50 – Capital Beltway interchange immediately to the west ; two of the interchange 's loop ramps with westbound MD 704 were removed . The MD 704 divided highway was extended east from the US 50 interchange to Forbes Boulevard in 1997 and <unk> Vista Road in 1999 . MD 704 and MD 450 were relocated at their junction to make MD 704 part of the east – west axis of a more orthogonal intersection in 2000 . This project was part of the expansion of the final segment of MD 704 and the adjacent portion of MD 450 to a divided highway .
= = Junction list = =
The entire route is in Prince George 's County .
= = Auxiliary route = =
MD <unk> was the designation for an unnamed 0 @.@ 15 @-@ mile ( 0 @.@ 24 km ) segment of old alignment of MD 704 at its junction with MD 450 . The designation was assigned in 2000 when MD 704 and MD 450 were relocated . The MD <unk> designation and the road itself were removed in 2004 ; the Vista Gardens shopping center now sits on the highway 's general location .
= Geet Ramayan =
Geet Ramayan ( Marathi : <unk> <unk> , English : The Ramayana in Songs ) is a collection of 56 Marathi language songs chronologically describing events from the Indian Hindu epic , the Ramayana . It was broadcast by All India Radio , Pune in 1955 – 1956 , four years before television was introduced in India . Written by G. D. Madgulkar and the songs being composed by Sudhir Phadke , Geet Ramayan was acclaimed for its lyrics , music and singing . It is considered a " milestone of Marathi light music " and the " most popular " Marathi version of Ramayana .
The team of Madgulkar and Phadke presented a new song every week for a year with every song being aired first on a Friday morning and then again on Saturday and Sunday morning , between 8 : 45 AM and 9 : 00 AM IST . The program 's first song " <unk> Lava <unk> <unk> " was aired on 1 April 1955 . Though Geet Ramayan is based on sage Valmiki 's epic Ramayana , Madgulkar chose a different narrative format and was praised for the lyrics , and was called <unk> Valmiki ( the modern Valmiki ) . The Geet Ramayan is considered as " the crescendo of Madgulkar 's literary vigour " . Phadke mainly used ragas of Hindustani classical music to compose the songs . He also selected the raga and the <unk> of a song to suit the time of the incident and the narrative mood . The poet and composer were praised for their contribution to the series .
The series showcased a total of 32 various characters from Ramayana . Rama ( avatar of Vishnu and hero of the Ramayana ) being the lead character of the series was given maximum number of songs ( 10 ) , followed by eight songs for Sita ( Rama 's wife and avatar of the Hindu goddess Lakshmi ) . Madgulkar expressed their various moods , ranging from their divinity to the human weaknesses . Incidentally , the central antagonist of the Ramayana and Geet Ramayan , the demon @-@ king Ravana , was not given any song . The series is narrated by Kusha and Lava , twin sons of Rama and Sita , and the writer of Ramayana ( Valmiki ) was also given one song in the series .
With increasing popularity since its release , Geet Ramayan has been translated into nine other languages : five Hindi translations and one each in Bengali , English , Gujarati , Kannada , Konkani , Sanskrit , Sindhi and Telugu . It has also been transliterated into Braille .
= = Concept = =
Geet Ramayan was conceptualized in 1955 , four years before the introduction of television in India in 1959 . During the early days of All India Radio , Pune ( also known as <unk> Pune ) , station director <unk> Lad wanted to begin a radio programme which would be entertaining and provide moral education . He hence outlined his plan to poet and writer G. D. Madgulkar ( popularly known as " Ga @-@ Di @-@ Ma " ) . Since the Ramayana ( written by Valmiki ) is an Indian epic , Lad and Madgulkar came up with an idea of a version in singable verse . Madgulkar accepted the challenge , enlisting his music @-@ director friend Sudhir Phadke ( popularly known as " <unk> " ) for the collaboration .
The team of Madgulkar and Phadke would present a new song every week for a year . Every song would be aired first on a Friday morning and then again on Saturday and Sunday morning , between 8 : 45 am and 9 : 00am IST . The programme was initially planned for a year ( with 52 songs ) with the concluding song <unk> <unk> <unk> where Rama becomes the King , but 1955 in the Hindu calendar had an extra month ( <unk> ) ; therefore , four songs were added to extend the series to a total of fifty @-@ six . The series ended with the song " Gā Bāḷāno , Shrīrāmāyaṇ " where the part post crown ceremony was added . Apart from the number of songs , Madgulkar and Phadke left music , lyrics and choice of singers ad libitum . Madgulkar was given artistic liberty for the choice of the meters for the song , execution of the story line , and the message he could convey through it .
Initially , the programme was scheduled to begin on the occasion of Gudi Padwa , beginning of the New year according to the lunisolar Hindu calendar but later finalized to be Rama Navami , traditional birthday of Rama . The program 's first song " <unk> Lava <unk> <unk> " was aired on 1 April 1955 at 8 : 45 am IST . Vidya Madgulkar , the poet 's wife , recalled in an interview that Madgulkar wrote the first song and gave it to Phadke the day before the recording ; however , Phadke lost the lyrics . With the broadcast already scheduled , station director <unk> Lad requested Madgulkar to re @-@ write the song which was readily declined by an angered poet . Lad then decided to lock the poet in one of recording rooms equipped with all the required writing material and agreed to unlock the door only when Madgulkar is ready with the lyrics . Madgulkar then rewrote the lyrics from memory in fifteen minutes so Phadke could compose the music .
= = Lyrics = =