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Won D, Kim H, Chang JE, Lee JM, Kim TK, Kim H, Min SW, Hwang JY. Comparison of the effects of paratracheal pressure and cricoid pressure on placement of the i-gel ® supraglottic airway: a randomized clinical trial. Can J Anaesth 2024; 71:996-1003. [PMID: 38507025 PMCID: PMC11266228 DOI: 10.1007/s12630-024-02741-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 03/22/2024] Open
Abstract
PURPOSE Anesthesiologists can use supraglottic airway devices as a rescue technique for failed intubation even in patients with an increased risk of gastric regurgitation. In this randomized study, we aimed to evaluate the effects of cricoid pressure and paratracheal pressure on placement of the i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK). METHODS After induction of anesthesia in 76 adult patients, we inserted the i-gel under paratracheal or cricoid pressure, and assessed the success rate of i-gel insertion, resistance during insertion, time required for insertion, accuracy of the insertion location, tidal volumes, and peak inspiratory pressure with or without each maneuver after i-gel insertion. RESULTS The overall success rate of insertion was significantly higher under paratracheal pressure than under cricoid pressure (36/38 [95%] vs 27/38 [71%], respectively; difference, 24%; 95% confidence interval [CI], 8 to 40; P = 0.006]. Resistance during insertion was significantly lower under paratracheal pressure than under cricoid pressure (P < 0.001). The time required for insertion was significantly shorter under paratracheal pressure than under cricoid pressure (median [interquartile range], 18 [15-23] sec vs 28 [22-38] sec, respectively; difference in medians, -10; 95% CI, -18 to -4; P < 0.001). Fibreoptic examination of the anatomical alignment of the i-gel in the larynx revealed no significant difference in the accuracy of the insertion location between the two maneuvers (P = 0.31). The differences in tidal volume and peak inspiratory pressure with or without the maneuvers were significantly lower with paratracheal pressure than with cricoid pressure (P = 0.003, respectively). CONCLUSIONS Insertion of the i-gel supraglottic airway was significantly more successful, easier, and faster while applying paratracheal pressure than cricoid pressure. STUDY REGISTRATION ClinicalTrials.gov (NCT05377346); first submitted 11 May 2022.
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Affiliation(s)
- Dongwook Won
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Hyerim Kim
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jee-Eun Chang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
- College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
- College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Honghyeon Kim
- Department of Anesthesiology & Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong-Won Min
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
- College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jin-Young Hwang
- College of Medicine, Seoul National University, Seoul, Republic of Korea.
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramae-ro 5, Dongjak-gu, Seoul, 07061, Republic of Korea.
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Liao H, Chen L, Liu M, Chen J. Sealing mechanism study of laryngeal mask airways via 3D modelling and finite element analysis. Sci Rep 2022; 12:2887. [PMID: 35190622 PMCID: PMC8861007 DOI: 10.1038/s41598-022-06908-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/07/2022] [Indexed: 12/03/2022] Open
Abstract
Proper sealing of laryngeal mask airways (LMAs) is critical for airway management in clinical use. Understanding the sealing mechanism can significantly help front-line anaesthetists to reduce the incidence of adverse events. However, anaesthetists, who may not have the most substantial engineering backgrounds, lack intuitive ways to develop an understanding of the LMA sealing mechanism effectively. The paper aims to study the LMA-pharynx sealing mechanisms from the perspective of front-line anaesthetists. We use a computer-aided 3D modelling technique to visualise the LMA—pharynx interactions, which helps anaesthetists identify the critical areas of complications. Furthermore, we conduct a quantitative pressure distribution analysis of the LMA-pharynx contacting surface using the finite element analysis technique, which helps further understand the sealing mechanics in those areas. We present two cases studies based on one male volunteer, aged 50, inserted with a ProSeal LMA. In the first case, a relatively low cuff pressure (CP) was applied to simulate the clinical circumstances in which complications related to air leakage are most likely to happen; in the second case, we increase the CP to a relatively high value to simulate the scenarios with an increased risk of complications related to high mucosal pressure. The experiments suggest the follows: (1) Sore throat complications related to high mucosal pressure is most likely to occur in the hypopharynx with a high CP setting, particularly in the areas where the cricoid cartilage presses the mucosa. (2) The narrow hyoid bone super horn width likely causes LMA insertion difficulties. (3) Insufficient CP will significantly increase the risk of air leakage in the oropharynx. A complete sealing pressure line in the contacting surface will be formed with sufficient CP, thereby preventing the air leakage into the oral.
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Sorbello M, Zdravkovic I. May the force be with you (but elsewhere): time to rethink cricoid pressure? Minerva Anestesiol 2021; 87:1164-1167. [PMID: 34781672 DOI: 10.23736/s0375-9393.21.16159-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Massimiliano Sorbello
- Department of Anesthesia and Intensive Care, Policlinico San Marco University Hospital, Catania, Italy -
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Hur M, Lee K, Min SK, Kim JY. Left paratracheal pressure versus cricoid pressure for successful laryngeal mask airway insertion in adult patients: a randomized, non-inferiority trial. Minerva Anestesiol 2021; 87:1183-1190. [PMID: 34337919 DOI: 10.23736/s0375-9393.21.15779-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cricoid pressure (CP) is used to prevent pulmonary aspiration of regurgitated gastric contents and gastric insufflation during positive-pressure ventilation. However, CP impedes the successful insertion of laryngeal mask airway (LMA). Left paratracheal pressure (LPP), a manoeuvre of applying backward digital force at the lower left paratracheal level, was recently introduced as an alternative to CP. We assessed whether LPP is non-inferior to CP in successful LMA insertion on the first attempt in adult patients undergoing general anaesthesia. METHODS In this non-inferiority randomized controlled trial, 108 patients undergoing general anaesthesia were randomly allocated to receive either LPP or CP during LMA insertion. The primary outcome was the success rate of LMA insertion on the first attempt. The margin of non-inferiority was defined as 15%. RESULTS The success rate of LMA insertion on the first attempt was 68.5% (37/54) in the LPP group and 51.9% (28/54) in the CP group (P=0.077) with between-group difference of 16.7% (two-sided 95% CI, -1.9% to 35.2%). Time for successful device insertion was comparable in the two groups (P=0.355), whereas LMA insertion was easier in the LPP group than in the CP group (P=0.001). There was no significant difference between the two groups for change in antral cross-sectional area measured before and after mask ventilation (P=0.081). No serious complication was evident in any group. CONCLUSIONS This randomized clinical trial demonstrated the non-inferiority of LPP over CP in the success rate of LMA insertion on the first attempt in adult patients undergoing general anaesthesia.
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Affiliation(s)
- Min Hur
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyuhyeok Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sang K Min
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jong Y Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea -
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Naik K, Frerk C. Cricoid force: time to put it to one side. Anaesthesia 2018; 74:6-8. [DOI: 10.1111/anae.14470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2018] [Indexed: 12/23/2022]
Affiliation(s)
- K. Naik
- Department of Anaesthesia; Northampton General Hospital; Northampton UK
| | - C. Frerk
- Department of Anaesthesia; Northampton General Hospital; Northampton UK
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7
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Joshi S, Prakash S, Mullick P, Usha G, Pawar M. Clinical Evaluation of the Cricoid Pressure Effect on Bag Mask Ventilation, ProSeal Laryngeal Mask Airway Placement and Ventilation. Turk J Anaesthesiol Reanim 2018; 46:381-387. [PMID: 30263862 DOI: 10.5152/tjar.2018.37539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 03/20/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Supraglottic airway devices can be life-saving in the 'cannot intubate, cannot oxygenate' situation. The cricoid pressure (CP) is considered critical in the prevention of aspiration. The aim of this self-controlled study was to evaluate the effect of CP on the bag mask ventilation (BMV), and the placement of and the ventilation through, the ProSeal laryngeal mask airway (LMA). Methods In 60 adult patients undergoing elective surgery, after induction of anaesthesia, the effect of bimanual CP (≈30N) on BMV, ventilation through the ProSeal LMA, its anatomic position and airway seal pressures were evaluated. CP was released, the ProSeal LMA was reseated (appropriate position), the above assessments were repeated, and the effect of CP on the tidal volume (TV) and peak inspiratory pressure (PIP) was noted. Results Out of 60 patients, the bag mask ventilation with CP was adequate in 25 (41.7%) patients compared to 59 (98.3%) patients without CP; p<0.001. The ventilation via the ProSeal LMA with CP was excellent, adequate and impossible in 0.0% (0), 49.2% (29) and 50.8% (30) patients, respectively, compared to 93.3% (56), 6.7% (4), 0% (0) patients, respectively, without CP; p<0.001. Releasing CP and advancing the ProSeal LMA to its appropriate position significantly improved the ventilation and anatomic position scores; both p<0.001. Airway seal pressures improved significantly without CP compared to with CP; p<0.001). With the ProSeal LMA in a proper position, the CP application resulted in a significant decrease in the mean expired TV (489.14±91.62 vs. 355.08±104.42 mL) with an increase in PIP (16.72±5.01 vs. 30.71±6.74 cmH2O); both p<0.001. Conclusion The application of bimanual CP (≈30N) interferes with the bag mask ventilation and prevents both the correct placement and ventilation via the ProSeal LMA in adult patients.
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Affiliation(s)
- Shobha Joshi
- Department of Anaesthesia, NDMC Charak Palika Hospital, New Delhi, India
| | - Smita Prakash
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Parul Mullick
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ganapathy Usha
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Mridula Pawar
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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8
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Abstract
Abstract
Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.
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Zeidan AM, Salem MR, Bamadhaj M, Mazoit JX, Sadek H, Houjairy H, Abdulkhaleq K, Bamadhaj N. The Cricoid Force Necessary to Occlude the Esophageal Entrance. Anesth Analg 2017; 124:1168-1173. [DOI: 10.1213/ane.0000000000001631] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115:827-48. [PMID: 26556848 PMCID: PMC4650961 DOI: 10.1093/bja/aev371] [Citation(s) in RCA: 1215] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.
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Affiliation(s)
- C Frerk
- Department of Anaesthesia, Northampton General Hospital, Billing Road, Northampton NN1 5BD, UK
| | - V S Mitchell
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Crewe Road South, Edinburgh EH4 2XU, UK
| | - C Mendonca
- Department of Anaesthesia, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health, West Smithfield, London EC1A 7BE, UK
| | - A Patel
- Department of Anaesthesia, The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road, London WC1X 8DA, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, PO Box 580, James's Street, Dublin 8, Ireland
| | - N M Woodall
- Department of Anaesthesia, The Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
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Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev 2015; 2015:CD011656. [PMID: 26578526 PMCID: PMC9338414 DOI: 10.1002/14651858.cd011656.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Rapid sequence induction (RSI) for endotracheal intubation is a technique widely used in anaesthesia, emergency and intensive care medicine to secure an airway in patients deemed at risk of pulmonary aspiration. Cricoid pressure is conceptually used to reduce the risk of aspiration by compressing the oesophagus. OBJECTIVES To identify and evaluate all randomized controlled trials (RCTs) involving participants undergoing elective or emergency airway management via RSI and compare participants who have cricoid pressure administered with participants who do not have cricoid pressure administered. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 4), MEDLINE via OvidSP (1946 to May 2015), EMBASE via OvidSP (1980 to May 2015), ISI Web of Science (from 1940 to May 2015) and CINAHL via EBSCOhost (1982 to May 2015). SELECTION CRITERIA We included all RCTs comparing people undergoing RSI who have cricoid pressure applied, either intermittently or continuously, with people undergoing RSI who do not have cricoid pressure applied in the context of endotracheal intubation using a direct laryngoscopic technique. We included both elective and emergency cases. We included studies of blinded and unblinded participants. Participants (male or female) were involved in any type of procedure where general anaesthetic utilizing RSI or emergency airway management utilizing RSI and endotracheal intubation was undertaken. We expected the control arm to be the absence of cricoid pressure at any stage during RSI. The primary outcome of interest was the reported event rate or prevalence of aspiration determined by a) documented gastric aspiration determined by visual inspection of aspirated stomach contents on laryngoscopy; b) pepsin detection in tracheal aspirate using the Ufberg method; c) post-anaesthetic radiographic changes suggestive of aspiration pneumonitis or d) any combination of a to c. Secondary outcomes of interest included documented impaired visualization of the airway by a treating laryngoscopist, force applied during cricoid pressure, the direction of application of force of applied cricoid pressure, independent risk factors for aspiration and whether the person applying cricoid pressure had previously done so in an emergency airway context. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of all the studies obtained from the search using recognition of words such as 'cricoid pressure', 'rapid sequence intubation', 'emergency airway management' and 'aspiration'. Two authors independently determined the study inclusion by using a study eligibility form that we developed for the purpose of this review. We also reported the decisions regarding inclusion and exclusion in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. We assumed that studies that did not describe the use of RSI in their title, abstract or methodology used an alternative method of anaesthetic induction or emergency airway management and thus we excluded them. Data extracted from included studies comprised study characteristics, participant demographics, intervention and comparison details plus outcome measures and results. We contacted primary authors of studies with missing or unreported but potentially relevant data to obtain missing data. MAIN RESULTS Of 493 records that we identified from databases as a result of the search (excluding duplicates), we regarded 70 abstracts/titles as potentially relevant studies. Independent scrutiny of these 70 titles and abstracts identified 29 potentially relevant studies. Of the 29 potentially relevant studies, one study met the criteria for inclusion. This study was a RCT that compared participants undergoing RSI and endotracheal intubation in the context of elective surgery requiring a general anaesthetic. Forty participants were recruited, 20 of whom had cricoid pressure applied and 20 of whom had cricoid pressure simulated. The main outcomes reported were systolic arterial pressure and heart rate after laryngoscopy and tracheal intubation. We did not consider these outcomes relevant for the purposes of this systematic review. The search also identified one study that could potentially be included in an updated systematic review in the future, but was at the time of the search a proposal for a trial only and had no reported outcomes at this time. AUTHORS' CONCLUSIONS There is currently no information available from published RCTs on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI in the context of endotracheal intubation. On the basis of the findings of non-RCT literature, however, cricoid pressure may not be necessary to undertake RSI safely, and therefore well-designed and conducted RCTs should nonetheless be encouraged to properly assess the safety and effectiveness of cricoid pressure.
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Affiliation(s)
- Catherine M Algie
- Western HealthDepartment of Anaesthesia & Pain MedicineGordon Street, Footscray, Locked Bag 2FootscrayVictoriaAustralia3011
| | - Robert K Mahar
- The Royal Children's Hospital, The University of MelbourneDepartment of PaediatricsParkvilleAustralia
- Murdoch Childrens Research Institute, The Royal Children's HospitalData Science CoreParkvilleVictoriaAustralia
| | - Hannah B Tan
- The Alfred HospitalVictorian Adult Burns ServiceCommercial RoadPrahranVictoriaAustralia
| | - Greer Wilson
- The Royal Melbourne HospitalEmergency Department300 Grattan Street, ParkvilleMelbourneAustralia
| | - Patrick D Mahar
- St Vincent's Clinical School, The University of MelbourneDepartment of MedicineFitzroyVictoriaAustralia
- School of Medicine, Deakin UniversityDepartment of SurgeryGeelongVictoriaAustralia
| | - Jason Wasiak
- The Epworth HospitalDepartment of Radiation Oncology89 Bridge RdRichmondAustralia3121
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Abstract
Cardiac arrest is a dynamic disease that tests the multitasking and leadership abilities of emergency physicians. Providers must simultaneously manage the logistics of resuscitation while searching for the cause of cardiac arrest. The astute clinician will also realize that he or she is orchestrating only one portion of a larger series of events, each of which directly affects patient outcomes. Resuscitation science is rapidly evolving, and emergency providers must be familiar with the latest evidence and controversies surrounding resuscitative techniques. This article reviews evidence, discusses controversies, and offers strategies to provide quality cardiac arrest resuscitation.
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Affiliation(s)
- Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan Street Northeast, Suite 420, Grand Rapids, MI 49503, USA.
| | - Adam Frisch
- Department of Emergency Medicine, Albany Medical Center, 47 New Scotland Avenue, MC 139, Albany, NY 12208, USA
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Hashimoto Y, Asai T, Arai T, Okuda Y. Effect of cricoid pressure on placement of the I-gel™ : a randomised study. Anaesthesia 2014; 69:878-82. [PMID: 24866121 DOI: 10.1111/anae.12731] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2014] [Indexed: 11/30/2022]
Abstract
We studied 40 adult patients to see if cricoid pressure affected placement of the I-gel(™). In a randomised crossover design, the i-gel was placed with and without cricoid pressure, and we compared the success rate of adequate ventilation through the i-gel, time to placement and the rate of optimal position of the device between the two circumstances. Cricoid pressure significantly decreased the success rate of adequate ventilation through the i-gel (40 vs 34 patients) (p = 0.041, 95% CI for difference 4-26%), and significantly decreased the rate of the optimal position (39 vs 17 patients) (p < 0.001). The time to achieve adequate ventilation was significantly longer (p < 0.001) with cricoid pressure than without (median difference 8 s; 95% CI for median difference 3-12 s). Cricoid pressure significantly decreases the success rate of ventilation through the i-gel, but the success rate of ventilation through the i-gel is reasonably high.
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Affiliation(s)
- Y Hashimoto
- Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
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Salem MR, Khorasani A, Saatee S, Crystal GJ, El-Orbany M. Gastric tubes and airway management in patients at risk of aspiration: history, current concepts, and proposal of an algorithm. Anesth Analg 2014; 118:569-79. [PMID: 23757470 DOI: 10.1213/ane.0b013e3182917f11] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rapid sequence induction and intubation (RSII) and awake tracheal intubation are commonly used anesthetic techniques in patients at risk of pulmonary aspiration of gastric or esophageal contents. Some of these patients may have a gastric tube (GT) placed preoperatively. Currently, there are no guidelines regarding which patient should have a GT placed before anesthetic induction. Furthermore, clinicians are not in agreement as to whether to keep a GT in situ, or to partially or completely withdraw it before anesthetic induction. In this review we provide a historical perspective of the use of GTs during anesthetic induction in patients at risk of pulmonary aspiration. Before the introduction of cricoid pressure (CP) in 1961, various techniques were used including RSII combined with a head-up tilt. Sellick initially recommended the withdrawal of the GT before anesthetic induction. He hypothesized that a GT increases the risk of regurgitation and interferes with the compression of the upper esophagus during CP. He later modified his view and emphasized the safety of CP in the presence of a GT. Despite subsequent studies supporting the effectiveness of CP in occluding the esophagus around a GT, Sellick's early view has been perpetuated by investigators who recommend partial or complete withdrawal of the GT. On the basis of available information, we have formulated an algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents. The approach in an individual patient depends on: the procedure; type and severity of the underlying pathology; state of consciousness; likelihood of difficult airway; whether or not the GT is in place; contraindications to the use of RSII or CP. The algorithm calls for the preanesthetic use of a large-bore GT to remove undigested food particles and awake intubation in patients with achalasia, and emptying the pouch by external pressure and avoidance of a GT in patients with Zenker diverticulum. It also stipulates that in patients with gastric distension without predictable airway difficulties, a clinical and imaging assessment will determine the need for a GT and in severe cases an attempt to insert a GT should be made. In the latter cases, the success of placement will indicate whether to use RSII or awake intubation. The GT should not be withdrawn and should be connected to suction during induction. Airway management and the use of GTs in the surgical correction of certain gastrointestinal anomalies in infants and children are discussed.
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Affiliation(s)
- M Ramez Salem
- From the *Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois; and †Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Zeidan AM, Salem MR, Mazoit JX, Abdullah MA, Ghattas T, Crystal GJ. The Effectiveness of Cricoid Pressure for Occluding the Esophageal Entrance in Anesthetized and Paralyzed Patients. Anesth Analg 2014; 118:580-6. [DOI: 10.1213/ane.0000000000000068] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT. The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J Anaesth 2013; 60:1119-38. [PMID: 24132408 PMCID: PMC3825645 DOI: 10.1007/s12630-013-0020-x] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 08/13/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.
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Affiliation(s)
- J Adam Law
- Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada,
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The role of the supraglottic airway in general anaesthesia for Caesarean section. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Use of cricoid pressure during rapid sequence induction: Facts and fiction. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Habib AS. Is it time to revisit tracheal intubation for Cesarean delivery? Can J Anaesth 2012; 59:642-7. [PMID: 22528169 DOI: 10.1007/s12630-012-9719-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/13/2012] [Indexed: 05/26/2023] Open
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jensen AG, Callesen T, Hagemo JS, Hreinsson K, Lund V, Nordmark J. Scandinavian clinical practice guidelines on general anaesthesia for emergency situations. Acta Anaesthesiol Scand 2010; 54:922-50. [PMID: 20701596 DOI: 10.1111/j.1399-6576.2010.02277.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Emergency patients need special considerations and the number and severity of complications from general anaesthesia can be higher than during scheduled procedures. Guidelines are therefore needed. The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine appointed a working group to develop guidelines based on literature searches to assess evidence, and a consensus meeting was held. Consensus opinion was used in the many topics where high-grade evidence was unavailable. The recommendations include the following: anaesthesia for emergency patients should be given by, or under very close supervision by, experienced anaesthesiologists. Problems with the airway and the circulation must be anticipated. The risk of aspiration must be judged for each patient. Pre-operative gastric emptying is rarely indicated. For pre-oxygenation, either tidal volume breathing for 3 min or eight deep breaths over 60 s and oxygen flow 10 l/min should be used. Pre-oxygenation in the obese patients should be performed in the head-up position. The use of cricoid pressure is not considered mandatory, but can be used on individual judgement. The hypnotic drug has a minor influence on intubation conditions, and should be chosen on other grounds. Ketamine should be considered in haemodynamically compromised patients. Opioids may be used to reduce the stress response following intubation. For optimal intubation conditions, succinylcholine 1-1.5 mg/kg is preferred. Outside the operation room, rapid sequence intubation is also considered the safest method. For all patients, precautions to avoid aspiration and other complications must also be considered at the end of anaesthesia.
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Affiliation(s)
- A G Jensen
- Department of anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
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Lerman J. In Response. Anesth Analg 2010. [DOI: 10.1213/ane.0b013e3181d906c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gerstein NS, Braude DA, Hung O, Sanders JC, Murphy MF. The Fastrach Intubating Laryngeal Mask Airway: an overview and update. Can J Anaesth 2010; 57:588-601. [PMID: 20112078 DOI: 10.1007/s12630-010-9272-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Accepted: 01/12/2010] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To provide an evidence-based overview and update on the use of the Fastrach Intubating Laryngeal Mask Airway (FT-LMA) when used within operative and non-operative settings. PRINCIPAL FINDINGS The FT-LMA is available in three sizes to provide ventilation and the ability to pass an endotracheal tube (ETT) into the trachea blindly, semi-blindly, or with indirect visualization for patients over 30 kg. The Chandy maneuver is recommended routinely; the first maneuver optimizes ventilation, and the second maneuver increases success at endotracheal intubation (ETI). The manufacturer's reinforced tube or a pre-warmed or reversed standard ETT may be utilized. Insertion and ventilation are successful in almost all patients. Blind ETI is highly successful; adjuncts are generally not necessary. The FT-LMA has a proven role in the airway management of anticipated difficult operating room (OR) intubations, unanticipated OR intubations, cervical spine injuries, and limited airway access situations. Literature in the pre-hospital and emergency department settings is limited but favourable. The FT-LMA has compared favourably with fibreoptic intubation, the LMA-Classic, the laryngeal tube, and the CobraPLA. Initially, the more expensive LMA CTrach appeared to be more successful, but overall it is not. The FT-LMA airway seal pressures are excellent; serious complications are uncommon, and the FT-LMA figures prominently in most difficult airway guidelines. CONCLUSIONS The FT-LMA has proven to be a useful difficult airway device both within and outside of the operating room. Effective ventilation is established in nearly all cases, and blind ETI is possible in the vast majority of cases if the optimal techniques described are used. Serious complications are uncommon.
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Affiliation(s)
- Neal S Gerstein
- Department of Anesthesiology, University of New Mexico, Albuquerque, 87131-0001, USA.
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Sood V, Robinson D, Suri I. Difficult intubation during rapid sequence induction in a parturient with Ehlers-Danlos syndrome, hypermobility type. Int J Obstet Anesth 2009; 18:408-12. [DOI: 10.1016/j.ijoa.2009.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 11/24/2008] [Accepted: 03/10/2009] [Indexed: 01/08/2023]
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Takenaka I, Aoyama K, Kinoshita Y, Iwagaki T, Ishimura H, Takenaka Y, Kadoya T. Combination of Airway Scope and bougie for a full-stomach patient with difficult intubation caused by unanticipated anatomical factors and cricoid pressure. J Clin Anesth 2009; 21:64-6. [PMID: 19232945 DOI: 10.1016/j.jclinane.2008.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Revised: 06/15/2008] [Accepted: 06/16/2008] [Indexed: 11/29/2022]
Abstract
The Airway Scope, one of the newest video-laryngoscopes, provides an excellent view of the larynx on a built-in monitor screen. Difficulty in introducing an endotracheal tube into the laryngeal aperture may occur, even though the aperture is visible. The bougie may solve this difficulty because its angulated tip can be controlled in a desired direction. The successful use of the bougie along with the Airway Scope in a full-stomach patient with a difficult airway is presented.
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Affiliation(s)
- Ichiro Takenaka
- Surgical Center, Nippon Steel Yawata Memorial Hospital, Kitakyushu 805-8508, Japan.
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Ellis DY, Harris T, Zideman D. Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis. Ann Emerg Med 2007; 50:653-65. [PMID: 17681642 DOI: 10.1016/j.annemergmed.2007.05.006] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 05/02/2007] [Accepted: 05/05/2007] [Indexed: 12/20/2022]
Abstract
Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.
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Affiliation(s)
- Daniel Y Ellis
- Department of Emergency Medicine, The Townsville Hospital, Douglas, Queensland, Australia.
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Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anaesth 2007; 54:748-64. [PMID: 17766743 DOI: 10.1007/bf03026872] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The purpose of this structured, evidence-based, clinical update was to determine if rapid sequence induction is a safe or effective technique to decrease the risk of aspiration or other complications of airway management. SOURCE In June 2006 a structured search of MEDLINE from 1966 to present using OVID software was undertaken with the assistance of a reference librarian. Medical subject headings and text words describing rapid sequence induction or intubation (RSI), crash induction or intubation, cricoid pressure and emergency airway intubation were employed. OVID's therapy (sensitivity) algorithm was used to maximize the detection of randomized trials while excluding non-randomized research. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search. PRINCIPAL FINDINGS A total of 184 clinical trials were identified of which 163 were randomized controlled trials (RCTs). Of these clinical trials, 126 evaluated different drug regimens with 114 being RCTs. Only 21 clinical trials evaluated non-pharmacologic aspects of the RSI with 18 RCTs identified. A parallel search found 52 trials evaluating cricoid pressure (outside of the context of an RSI technique) with 44 classified as RCTs. Definitive outcomes such as prevention of aspiration and mortality benefit could not be evaluated from the trials. Likewise, the impact on adverse outcomes of the different components of RSI could not be ascertained. CONCLUSION An absence of evidence from RCTs suggests that the decision to use RSI during management can neither be supported nor discouraged on the basis of quality evidence.
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Affiliation(s)
- David T Neilipovitz
- Department of Anesthesiology, The Ottawa Hospital and the University of Ottawa, Ontario K1Y 4E9, Canada.
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Asai T, Goy RWL, Liu EHC. Cricoid pressure prevents placement of the laryngeal tube and laryngeal tube-suction II. Br J Anaesth 2007; 99:282-5. [PMID: 17573388 DOI: 10.1093/bja/aem159] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The laryngeal tube has a potential role in patients with a difficult airway, but cricoid pressure is required if the patient is at risk of aspiration. The effect of cricoid pressure on insertion of these devices is unknown. METHODS In a randomized cross-over study, the laryngeal tube (25 patients) or the laryngeal tube-suction II (15 patients) was inserted with cricoid pressure applied on one occasion and with sham pressure on the other occasion. Adequacy of ventilation, time to achieve adequate ventilation, and the leak pressure were assessed. RESULTS Ventilation was adequate in all patients when sham pressure was applied. Cricoid pressure significantly reduced the rate of adequate ventilation to 6 of 25 patients for the laryngeal tube [P < 0.001; 95% confidence interval (CI) for difference: 59-93%] and to 5 of 15 patients for the laryngeal tube-suction II (P < 0.05; 95% CI for difference: 43-91%). The median time taken to achieve adequate ventilation for the laryngeal tube was 10 s [inter-quartile range (IQR): 8-15] (range 5-26) for sham pressure and 25 s (15-32) (15-33) for cricoid pressure; the median leak pressure was 30 (IQR: 30-30) (range 20-30) cm H2O for sham pressure and 15.5 (14.3-20.5) (12-22) cm H2O for cricoid pressure. CONCLUSIONS Continuous cricoid pressure prevents correct placement of the laryngeal tube and the laryngeal tube-suction II such that placement and ventilation via these devices are ineffective. The effect of cricoid pressure on ventilation via these devices, after correct placement, remains unknown.
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Affiliation(s)
- T Asai
- Department of Anesthesiology, Kansai Medical University, Osaka, Japan
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Li CW, Xue FS, Xu YC, Liu Y, Mao P, Liu KP, Yang QY, Zhang GH, Sun HT. Cricoid pressure impedes insertion of, and ventilation through, the ProSeal laryngeal mask airway in anesthetized, paralyzed patients. Anesth Analg 2007; 104:1195-8, tables of contents. [PMID: 17456674 DOI: 10.1213/01.ane.0000260798.85824.3d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We designed this prospective self-controlled study to assess whether cricoid pressure hampers placement of and ventilation through the ProSeal laryngeal mask airway (ProSeal LMA) in anesthetized, paralyzed adult patients. METHODS After induction of anesthesia, the ProSeal LMA was inserted using the introducer tool with cricoid pressure advanced as far as possible, and the cuff pressure was set at 60 cm H2O. Ventilation adequacy and anatomic position were scored using measures previously described for ProSeal LMA assessment. Airway seal pressure was recorded. Cricoid pressure was then released, the ProSeal LMA further advanced and reseated, and the assessment repeated. RESULTS Lung ventilation scores, anatomic position scores, and airway seal pressure were significantly better after release of cricoid pressure and reseating of the ProSeal LMA than in the first position, where the ProSeal LMA was seated with cricoid pressure (P < 0.05). Expiratory tidal volume during intermittent positive pressure ventilation was similar with and without cricoid pressure, but peak inspiratory pressure decreased from 28 cm H(2)O with cricoid pressure to 14 cm H(2)O without cricoid pressure (P < 0.05). CONCLUSIONS Cricoid pressure applied before insertion hampered proper placement of the ProSeal LMA. Temporary cricoid pressure release during insertion allowed the device to be advanced to the proper position. After correct placement of the ProSeal LMA, application of cricoid pressure did not change tidal volume, but produced a significant increase in peak inspiratory pressure.
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Affiliation(s)
- Cheng W Li
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shi-Jing-Shan District, Beijing, People's Republic of China
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Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med 2006; 47:548-55. [PMID: 16713784 DOI: 10.1016/j.annemergmed.2006.01.013] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Revised: 12/06/2005] [Accepted: 01/03/2006] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view. METHODS This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure. RESULTS A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24). Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP. CONCLUSION Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.
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Affiliation(s)
- Richard M Levitan
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Abstract
OBJECTIVES To provide a current review of the literature regarding airway problems in pregnancy and management. BACKGROUND Obstetrical anesthesia is considered to be a high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of a parturient is a challenge because it involves simultaneous care of both mother and baby. Failure to appropriately manage a difficult or failed intubation increases the risk of hypoxemic cardiopulmonary arrest and/or pulmonary aspiration, resulting in a high probability of maternal morbidity and mortality. DATA Anesthesia is the seventh leading cause of maternal mortality in the United States. Anatomic and physiologic changes during pregnancy place the parturient at increased risk for airway management problems. It is essential to perform a thorough preanesthetic evaluation and identify the factors predictive of difficult intubation. Airway devices such as the laryngeal mask airway, ProSeal, intubating laryngeal mask airway, Combitube, and laryngeal tube are described and have been used during failed intubation in pregnant patients. CONCLUSION Teamwork between an anesthesiologist and an obstetrician is absolutely essential for the safety of both the mother and baby. Most of us tend to agree that airway emergencies have a way of occurring at the worst possible times. It is essential that all anesthesia care practitioners must have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.
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Affiliation(s)
- Uma Munnur
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA.
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39
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Abstract
Pulmonary aspiration is a cause of anesthesia-related morbidity and mortality, with little change in incidence over the past 20 years. Rapid sequence induction is a common procedure in obese patients, who appear to be more at risk for both pulmonary gastric aspiration and difficult airways, and is required in obese and sleep apnea syndrome patients with symptomatic gastroesophageal reflux or other predisposing conditions. In the elective obese or sleep apnea patient with no other risk factors for pulmonary aspiration, the risks and benefits of rapid sequence induction and cricoid pressure should be weighed. If rapid sequence induction is required, succinylcholine remains the neuromuscular blocking agent of choice, if there are no contraindications.
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Affiliation(s)
- Eugene B Freid
- Department of Anesthesiology, Nemours Children's Clinics, 807 Children's Way, Jacksonville, FL 32207, USA.
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41
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Abstract
Obstetric anesthesia is considered to be a difficult, high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of parturient patients is a challenge, as it involves simultaneous care of two lives. The anesthesia practitioner has a duty to provide safe anesthetic care, including effective airway management when providing regional or general anesthesia. The potential need to manipulate the airway is perhaps the leading cause of concern among obstetric anesthesiologists.
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Affiliation(s)
- Uma Munnur
- Department of Anesthesiology, Baylor College of Medicine, 6550 Fannin, Smith Tower, Suite 1003, Houston, TX 77030, USA.
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42
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Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-94. [PMID: 15200543 DOI: 10.1111/j.1365-2044.2004.03831.x] [Citation(s) in RCA: 786] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. DISCLAIMER It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.
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Affiliation(s)
- J J Henderson
- Anaesthetic Department, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 0YN, UK.
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43
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Mercier L, Derrode N, Debaene B. [What is the proper use of Sellick's maneuver?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:679-82. [PMID: 12946507 DOI: 10.1016/s0750-7658(03)00212-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
- L Mercier
- Département d'anesthésie-réanimation, CHU de Poitiers, rue de la Milétrie, BP 577, 86021 Poitiers, France.
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44
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Abstract
Cervical spine injuries occur in 2-5% of blunt trauma patients, and 1-5% of these injuries are initially missed. Data from the large National Emergency X-Radiography Utilisation Study have helped to define the problem in some detail. There is a consensus on how to clear the cervical spine in patients who are alert, but in patients with altered mental status the choice of strategy for spinal clearance is more controversial. Despite obtaining extensive radiological studies, some clinicians will not clear the patient's cervical spine until full recovery of consciousness. As long as manual in-line neck stabilization is applied, rapid sequence induction of anaesthesia, followed by direct laryngoscopy and oral intubation appears to be safe in the patient with a cervical spine injury. If intubation is not urgent, an awake fibreoptic technique is a useful option. If intubation of the patient with a potential cervical spine injury fails, or appropriate experienced personnel are unavailable, the laryngeal mask airway or one of its various modifications are useful alternatives.
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45
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Abstract
General anesthesia may predispose patients to aspiration of gastroesophageal contents because of depression of protective reflexes during loss of consciousness. In addition, some patients may be at increased risk of pulmonary aspiration because of retention of gastric contents caused by pain, inadequate starvation, or gastrointestinal pathology resulting in reduced gastric emptying and gastroesophageal reflux. Despite increasing knowledge of the problems associated with aspiration, the relatively small incidence and associated mortality rates in the perioperative period do not appear to have changed markedly over the last few decades. In this review article, the physiological factors associated with an increased risk of gastroesophageal reflux and aspiration are considered together with some of the methods that are used to prevent aspiration. In particular, preoperative starvation, the use of drugs designed to increase gastric pH, recent developments in airway devices, and appropriate application of cricoid pressure are critically appraised.
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Affiliation(s)
- A Ng
- University Department of Anaesthesia, Critical Care and Pain Management, Leicester Royal Infirmary, Leicester LE1 5WW, England
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46
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47
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Reardon RF, Martel M. The intubating laryngeal mask airway: suggestions for use in the emergency department. Acad Emerg Med 2001; 8:833-8. [PMID: 11483462 DOI: 10.1111/j.1553-2712.2001.tb00217.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.
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Affiliation(s)
- R F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA.
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48
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Ho AM, Wong W, Ling E, Chung DC, Tay BA. Airway difficulties caused by improperly applied cricoid pressure. J Emerg Med 2001; 20:29-31. [PMID: 11165834 DOI: 10.1016/s0736-4679(00)00285-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cricoid pressure, when properly applied, may prevent gastric regurgitation and may improve the view of laryngoscopy. When improperly applied, however, it can impede laryngoscopy and mask-ventilation. When faced with a "cannot intubate" or "cannot mask-ventilate" situation, clinicians should reevaluate the manner with which the assistant is applying cricoid pressure and must be prepared to adjust or even to release it.
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Affiliation(s)
- A M Ho
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital and Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
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49
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Asai T, Murao K, Shingu K. Cricoid pressure applied after placement of laryngeal mask impedes subsequent fibreoptic tracheal intubation through mask. Br J Anaesth 2000; 85:256-61. [PMID: 10992835 DOI: 10.1093/bja/85.2.256] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We studied 70 patients to see if cricoid pressure applied after insertion of the laryngeal mask altered the success rate of tracheal intubation through the mask. After induction of anaesthesia and neuromuscular blockade, patients were randomly allocated to have either cricoid pressure (Group C) or sham pressure (Group S). The view of the glottis through the laryngeal mask was assessed before and after the test pressure, and tracheal intubation through the mask was attempted using a fibreoptic bronchoscope. The test pressure did not alter the view of the glottis in any patient in group S, whereas it narrowed the glottic aperture in 16 out of 35 patients in group C. The fibrescope was inserted into the trachea in all patients in group S and in 25 patients in group C. The success rate of tracheal intubation in group S (31 patients) was significantly higher than in group C (21 patients, P << 0.001; 95% CI for difference: 9-48%). The time for insertion of the fibrescope in group S (median (95% CI): 12 (11-12) s) was significantly faster than in group C (16 (14-17) s, P << 0.001; 95% CI for difference: 3-6 s), and the time for tracheal intubation in group S (16 (15-18) s) was significantly faster than in group C (22 (19-24) s, P < 0.0005; 95% CI for difference: 3-7 s). Cricoid pressure after insertion of the laryngeal mask makes tracheal intubation through the mask significantly more difficult.
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Affiliation(s)
- T Asai
- Department of Anaesthesiology, Kansai Medical University, Osaka, Japan
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50
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Foley LJ, Ochroch EA. Bridges to establish an emergency airway and alternate intubating techniques. Crit Care Clin 2000; 16:429-44, vi. [PMID: 10941582 DOI: 10.1016/s0749-0704(05)70121-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this article, a number of alternatives to direct laryngoscopy are examined. These alternatives include the laryngeal mask airway (LMA; LMA North America, San Diego, CA), cuffed oropharyngeal airway (COPA; Mallinckrodt, St. Louis, MO), and Combitube (Kendall-Sheridan, Mansfield, MA), that have been designed to act as bridges to establish an airway. Other devices, such as rigid stylets, the lightwand (a blind technique) and indirect fiberoptic rigid stylets, such as the Bullard scope, Upsher scope, and Wu scope are also briefly discussed.
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Affiliation(s)
- L J Foley
- Department of Anesthesia, Winchester Hospital, Massachusetts, USA
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