[Management of difficult airway with inhalation induction in a patient with Lennox-Gastaut syndrome and neck injury]

Lennox-Gastaut syndrome is a childhood epileptic encephalopathy, and is characterized by frequent and difficult to treat seizures associated with mental retardation. The case is presented of a 21 year-old male with Lennox-Gastaut syndrome, with bilateral cervical facet joint dislocation fracture at C6-C7 and spinal canal compression as a result of a fall during a seizure. In this case the management of the difficult airway expected in an awake and uncooperative patient, with cervical spinal cord injury is described. An airway management strategy was proposed, that allowed a rapid and safe airway control with the best possible tolerance and maintaining the neck immobilised, so as not to increase neurological injury. Within this strategy, plan A was defined as inhalation induction with sevoflurane to maintain spontaneous breathing and tracheal intubation with Airtraq®. We believe that the Airtraq® video laryngoscope with inhalational induction with sevoflurane is a valid and effective alternative in the management of expected difficult airway.

Use of capnographs to assess quality of pediatric ventilation with 3 different airway modalities

OBJECTIVES

Prehospital pediatric airway management is difficult and controversial. Options include bag-mask ventilation (BMV), endotracheal tube (ETT), and laryngeal mask airway (LMA). Emergency Medical Services personnel report difficulty assessing adequacy of BMV during transport. Capnography, and capnograph tracings in particular, provide a measure of real-time ventilation currently used in prehospital medicine but have not been well studied in pediatric patients or with BMV. Our objective was to compare pediatric capnographs created with 3 airway modalities.

METHODS

This was a prospective study of pediatric patients requiring ETT or LMA ventilation during elective surgical procedures. Data were collected during BMV using 2 bag types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag type repeated. Ten- to 14-second capnographs were reviewed by 2 blinded anesthesiologists who were asked to assess ventilation and identify the airway and bag type used. Descriptive statistics, κ, and risk ratios were calculated.

RESULTS

Twenty-nine patients were enrolled. Median age was 4.4 years (2 months to 16.8 years). One hundred sixteen capnographs were reviewed. Reviewers were unable to differentiate between airway modalities and agreed on adequacy of ventilation 77% of the time (κ = 0.6, P < .001). Bag-mask ventilation was rated inadequate more frequently than ETT or LMA ventilation. There were no difference between ETT and LMA ventilation and no difference between the 2 bag types.

CONCLUSION

Capnographs are generated during BMV and are virtually identical to those produced with ETT or LMA ventilation. Attention to capnographs could improve outcomes during emergency treatment and transport of critically ill pediatric patients requiring ventilation with any of these airway modalities.

Comparison of five 2nd-generation supraglottic airway devices for airway management performed by novice military operators

OBJECTIVES

Five different second-generation supraglottic airway devices, ProSeal LMA, Supreme LMA, i-gel, SLIPA, and Laryngeal Tube Suction-D, were studied. Operators were inexperienced users with a military background, combat lifesavers, nurses, and physicians.

METHODS

This was a prospective, randomized, single-blinded study. Devices were inserted in the operating room in low light conditions after induction of general anesthesia. Primary outcome was successful insertion on the first attempt while secondary aims were insertion time, number of attempts, oropharyngeal seal pressure, ease of insertion, fibre optic position of device, efficacy of ventilation, and intraoperative trauma or regurgitation of gastric contents.

RESULTS

In total, 505 patients were studied. First-attempt insertion success rate was higher in the Supreme LMA (96%), i-gel (87.9%), and ProSeal LMA (85.9%) groups than in the Laryngeal Tube Suction-D (80.6%) and SLIPA (69.4%) groups. Insertion time was shortest in the Supreme LMA (70.4 ± 32.5 s) and i-gel (74.4 ± 41.1 s) groups (p < 0.001). Oropharyngeal seal pressures were higher in the Laryngeal Tube Suction-D and ProSeal LMA groups than in other three devices.

CONCLUSIONS

Most study parameters for the Supreme LMA and i-gel were found to be superior to the other three tested supraglottic airway devices when inserted by novice military operators.

Evaluation of training program for surgical trauma teams in Botswana

BACKGROUND

Trauma represents a challenge to healthcare systems worldwide, particularly in low-and middle-income countries. Positive effects can be achieved by improving trauma care at the scene of the accident and throughout hospitalization and rehabilitation. Therefore, we assessed the long-term effects of national implementation of a training program for multidisciplinary trauma teams in a southern African country.

METHODS

From 2007 to 2009, an educational program for trauma, "Better and Systematic Team Training," (BEST) was implemented at all government hospitals in Botswana. The effects were assessed through interviews, a structured questionnaire, and physical inspections using the World Health Organization's "Guidelines for Essential Trauma Care." Data on human and physical resources, infrastructure, trauma administrative functions, and quality-improvement activities before and at 2-year follow-up were compared for all 27 government hospitals.

RESULTS

A majority of hospitals had formed local trauma organizations; half were performing multidisciplinary trauma simulations and some had organized multidisciplinary trauma teams with alarm criteria. A number of hospitals had developed local trauma guidelines and local trauma registries. More equipment for advanced airway management and stiff cervical collars were available after 2 years. There were also improvements in the skills necessary for airway and breathing management. The most changes were seen in the northern region of Botswana.

CONCLUSIONS

Implementation of BEST in Botswana hospitals was associated with several positive changes at 2-year follow-up, particularly for trauma administrative functions and quality-improvement activities. The effects on obtaining technical equipment and skills were moderate and related mostly to airway and breathing management.

Randomized controlled pilot trial of the rigid and flexing laryngoscope versus the fiberoptic bronchoscope for intubation of potentially difficult airway

BACKGROUND

The flexible fiberoptic bronchoscope (FOB) is viewed as the gold standard device for awake intubation in the difficult airway. The newer rigid flexible laryngoscope (RIFL) was developed for similar indications. In this study we compare these two devices for management of potentially difficult airways after induction of general anesthesia.

METHODS

Adult surgical patients requiring endotracheal intubation and having a predicted difficult airway based on airway examination, BMI≥35, and/or history of prior difficult intubation were randomized to undergo endotracheal intubation with either the RIFL or FOB. Induction was performed in usual manner, and intubation was performed by providers proficient with both airway devices after induction of general anesthesia. The primary outcomes measured were intubation success, time to intubation, number of attempts, and the need for airway assist maneuvers. The lowest observed oxygen saturation and airway trauma were also recorded.

RESULTS

A total of 41 patients were enrolled, with 20 randomized to each group and 1 withdrawal. Intubation was successful in all patients with both devices. The median time for successful intubation was significantly shorter in the RIFL group compared to the FOB group (49 vs. 64 seconds; P=0.048). Airway assist maneuvers were required in 2 (10%) intubations with the RIFL compared to 16 (80%) intubations with the FOB (P<0.001). There were no significant differences in lowest oxygen saturation or airway trauma.

CONCLUSION

The RIFL required significantly less time and fewer airway assist maneuvers for successful endotracheal intubation compared to FOB when used by experienced providers in patients with anticipated difficult airways.

[Laryngeal Tube Position Shift after Chest Compression: Comparison of Fixation Methods Using Durapore Tape, Multipore Tape, or a Neck Tape]

BACKGROUND

The laryngeal tube (LT ; Smiths Medical, Minnesota, U. S. A) is an inflatable supraglottic device for emergency airway management such as during chest compression, the instability after insertion remains a problem.

METHODS

We investigated the effectiveness of three fixation methods of LT using a manikin and automated chest compressor.

RESULTS

After 10-minute chest compression, LT without fixation was shifted by 0.4 ± 0.1 cm, which was greater than with Durapore tape (0.2 ± 0.1 cm), Multipore tape (0.2 ± 0.1 cm), or a neck tape (0.1 ± 0.1 cm). The shift of the position was smaller with neck tape fixation compared to Durapore or Multipore tape fixation.

CONCLUSIONS

A fixation neck tape may be useful in stabilizing the inserted position of LT during cardiopulmonary resuscitation.

Can the ETView VivaSight SL Rival Conventional Intubation Using the Macintosh Laryngoscope During Adult Resuscitation by Novice Physicians?: A Randomized Crossover Manikin Study

The aim of this study was to assess the performance of the ETView VivaSight SL (ETView) single-lumen airway tube with an integrated high-resolution imaging camera in a manikin-simulated cardiopulmonary resuscitation scenario with and without chest compression. This was a randomized crossover manikin trial. Following a brief training session, 107 volunteer novice physicians who were inexperienced with airway management attempted to intubate a manikin using a Macintosh laryngoscope (MAC) and an ETView, with and without chest compressions. The participants were instructed to make 3 attempts in each scenario. In this trial, we compared intubation time, intubation success rates, and glottic visibility using a Cormack & Lehane Grade. Dental compression and ease of use of each device were also assessed. Median intubation times for the ETView and MAC without chest compressions were 17 (IQR, 15-19) s and 27 (IQR, 25-33) s, respectively (P < 0.001). The ETView proved more successful on the first intubation attempt than the MAC, regardless of compressions. Continuation of compressions caused an increase in intubation times for both the ETView (P = 0.27) and the MAC (P < 0.005). The ETView VivaSight SL is an effective tool for endotracheal intubation when used by novice physicians in a manikin-simulated cardiac arrest, both with and without chest compressions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02295618.

Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

BACKGROUND

Most airway problems in children are identified in advance; however, unanticipated difficulties can arise and may result in serious complications. Training for these sporadic events can be difficult. We identified the need for a structured guideline to improve clinical decision making in the acute situation and also to provide a guide for teaching.

OBJECTIVE

Guidelines for airway management in adults are widely used; however, none have been previously devised for national use in children. We aimed to develop guidelines for the management of the unanticipated difficult pediatric airway for use by anesthetists working in the nonspecialist pediatric setting.

METHOD

We reviewed available guidelines used in individual hospitals. We also reviewed research into airway management in children and graded papers for the level of evidence according to agreed criteria. A Delphi panel comprising 27 independent consultant anesthetists considered the steps of the acute airway management guidelines to reach consensus on the best interventions to use and the order in which to use them. If following the literature review and Delphi feedback, there was insufficient evidence or lack of consensus, regarding inclusion of a particular point; this was reviewed by a Second Specialist Group comprising 10 pediatric anesthetists.

RESULTS

Using the Delphi group's deliberations and feedback from the Second Specialist Group, we developed three guidelines for the acute airway management of children aged 1-8 years.

CONCLUSIONS

This paper provides the background, available evidence base, and justification for each step in the resultant guidelines and gives a rationale for their use.

The Feeding Tube- a Simple Yet Handy Aid to Intubate an Unanticipated Difficult Pediatric Airway

Pediatric intubation requires certain unique set of additional skills compared to intubating adults. The challenges of successfully intubation of a child increases as the age and size of the child decrease and are compounded when airway difficulties arise for various reasons. Often in the rural setting, such procedures may have to be carried out by health care personnel who get trained on-the-job, and in the absence of adequate technological back-up. This leads to an increased incidence of failed intubations which can have devastating complications, especially in the pediatric age group. We describe a simple technique which helped us while intubate a 40-day old infant, without any major catastrophes.

Use of GlideScope® in adults: an overview

This paper is an overview of the literature concerning the "know how" of the GlideScope® use in adults. We summarized the main evidences of the last 10 years with particular attention to experts' suggestions about clinical practice of the GlideScope®, noticing matters still debated on GlideScope® use. We used PubMed to search publications from January 2003 to June 2013 using the search terms "GlideScope", "video laryngoscope" and "videolaryngoscopy". These publications were searched manually or references to further publication not identified using PubMed. All works that made a point worth including were cited in the discussion. Our research confirms the value of GlideScope® use in airway management and highlights the debate about the use of videolaryngoscopes in routine cases and the operators who may use them in clinical practice.

Does prewarming the i-gel supraglottic airway device fit the larynx better compared to keeping it at room temperature for non-paralysed, sedated patients: a randomised controlled trial

OBJECTIVE

This study aimed to test the hypothesis that the i-gel supraglottic airway device would fit the larynx and provide better sealing pressure if prewarmed to 42°C relative to the device kept at room temperature in non-paralysed, sedated patients.

METHODS

A total of 74 adult patients were assigned to the warm (i-gel prewarmed to 42°C; W group; 37 patients) or the control (i-gel kept at room temperature; C group; 37 patients) groups. Anaesthesia was induced with propofol and fentanyl. The i-gel was prewarmed to 42°C for 30 min before insertion in the W group, but kept at room temperature (approximately 23°C) for the C group. The number of attempts made until successful insertion and sealing pressure were compared between the two groups.

RESULTS

Insertion was successful with one attempt in 35 cases each for the W and C groups. Two attempts were needed in two cases for the W group and one case for the C group. There was one failed attempt in the C group, but none in the W group. None of the differences between the two groups were significant (p=0.51). Sealing pressure was slightly, but not significantly, higher in the W group than in the C group (W group 22.6±6.1 cm H2O; C group 20.7±6.1 cm H2O; p=0.15).

CONCLUSIONS

Prewarming of the i-gel to 42°C did not increase the success rate of insertion, nor did it significantly increase sealing pressure in anaesthetised, non-paralysed patients. Our data suggest that we can keep the i-gel at room temperature for emergency airway management for non-paralysed, sedated patients.

TRIAL REGISTRATION NUMBER

University Medical Information Network, Japan 000012287.

What do we need for airway management of adult casualties on the Primary Casualty Receiving Facility? A review of airway management on Role 3 Afloat

The Primary Casualty Receiving Facility (PCRF) of the Royal Navy (RN) is currently based on Royal Fleet Auxiliary (RFA) ARGUS and provides a functioning hospital with surgical teams and a CT scanner (Role 3) within the maritime environment. The case mix could include complex trauma, critically ill patients returning to theatre several times, as well as non-battle injury procedures. This paper describes how we have used national guidelines, evidence from recent military experience, and the Clinical Guidelines for Operations (CGOs) to review and rationalise the airway equipment that is available and that would be required for the PCRF in its current configuration, whilst maintaining capability in a deployed setting.

Cardiac arrest equipment to support airway

Each hospital should have standardised cardiac arrest trolleys equipped with all the instruments and medication needed to deal with an acute adult cardiac arrest. Nurses must know the contents of these trolleys and how to use them to fulfil their common role as first responder. This first article in a two-part series looks at equipment to aid airway management and breathing; part two will focus on circulation.

Cricothyrotomy performed with the Melker™ set or the QuickTrach™ kit: procedure times, learning curves and operators' preference

BACKGROUND

Cricothyroidotomy is a surgical airway technique in which an airway device is inserted into the trachea through an incision made at the cricothyroid membrane. It is used for the management of the "difficult airways" and may be a lifesaving procedure in "can't intubate, can't oxygenate" situations. However, many healthcare professionals working in emergency settings have little of no experience with this procedure. Achievement of theoretical and practical knowledge of different cricothyrotomy techniques is therefore a fundamental prerequisite for those healthcare professionals.

MATERIALS AND METHODS

In this study, 40 volunteers representative of different categories of healthcare professionals were enrolled for the theoretical and practical 1-day training course on cricothyrotomy. Two commercially available device for cricothyrotomy were used during the course, the Melker™ set, which involves the Seldinger technique, and the QuickTrach™ kit, which does not rely on the use of a guide-wire. Each participant performed a series of 5 attempts on a manikin with each kit. Procedure time was recorded, and satisfaction with the course, preference for each cricothyrotomy kit and self-rating of cricothyrotomy skills were assessed by a self-administered questionnaire.

RESULTS

Mean procedure time significantly decreased from the first to the last attempt (48.7±21.9 and 27.8±13.7 seconds, respectively; p<0.0001). The Melker™ set was the most preferred, being rated as "excellent" by 62% of participants. This preference was even more pronounced among anaesthesiologists, that are more familiar with the Seldinger technique. Participants' satisfaction was high: the course was rated as "excellent" by 66.7% of attendees, the theoretical and practical knowledge achieved was rated as "very useful" by 94% of all attendees and by 100% of the anaesthesiologists.

CONCLUSIONS

A systematic approach to teach healthcare professionals in the application of various devices for the management of the socalled "difficult airways" may maximize intubation success and minimize complication. The present study provides evidence for the efficacy of training courses in Emergency Departments aimed at improving theoretical and practical cricothyrotomy skills in emergency situations.

Inconsistent size nomenclature in extraglottic airway devices

BACKGROUND

Extraglottic airway devices (EADs) are frequently used airway devices, yet often they seal poorly, resulting in a functionally unacceptable leak. Optimal size selection of the EAD is therefore critical to the safe and effective use of an EAD. This review is designed to delineate the sizing recommendations of EADs and indicate the differences in order to make the optimal choice for device effectiveness and patient safety.

METHODS

We searched manufacturing' guidelines regarding size recommendations of EADs. Alternative size selection suggestions were obtained through an extensive literature search.

RESULTS

Most manufacturers offer different types and a wide range of (up to 8 different) sizes of EADs. Size ranges offered by manufacturers are most often based on weight, although some manufacturers offer alternative EADs based on a variety of patient variables (age, gender, height). Even 'one-size-fits-all' adult EADs have been introduced into clinical practice. Special formulae and methods are suggested to aid the clinician to find the optimal EAD size, especially for children.

CONCLUSION

Selecting the appropriate size of an EAD is critical to optimal use, although applying the correct size of an EAD has been subject of controversy, as recommendations on sizing differ substantially and are far from a coherent and universal sizing system. Successful use of an EAD depends in part on appropriate size selection, in addition to clinical judgment, as well as patient anatomy and physiology. Standardization in the use of EAD sizes and a consensus about a consistent size systematic of EADs would benefit to promote a safer clinical practice in airway management.

[Role of the i-gel in emergency airway management]

The i-gel is a relatively new supraglottic airway, which has been shown to be useful during general anesthesia, and it may have a potential role during cardiopulmonary resuscitation. In a manikin study, we have found that, compared with laryngeal mask airways, the i-gel was significantly easier and faster to insert, due mainly to no-necessity of cuff inflation. One possible difficulty in using the i-gel during cardiopulmonary resuscitation is that the device cannot be fixed with the Thomas Tube Holder (Laerdal Medical Japan KK, Tokyo, Japan). A specially tailored device for cardiopulmonary resuscitation, recently has become available. The pack includes the i-gel O2 (which has a side port for oxygen delivery), a suction catheter, a sachet containing lubrication jelly, and a fixation strap. We describe the role of the i-gel during emergency airway management.