Laryngeal mask airway versus endotracheal tube for percutaneous dilatational tracheostomy in critically ill adults

Intubating Laryngeal Mask Airway for Airway Management and Blind Tracheal Intubation Through It From 360° Around a Supine Patient: A Randomized Controlled Clinical Study in a Simulated Prehospital Emergency Scenario

Introduction In emergency situations, airway management is often given priority over other treatment methods. The preferred technique for airway management of unconscious patients is endotracheal intubation, which has become the standard of care. Intubation of the trachea not only enables controlled ventilation even for extended periods and in any position but also allows for the removal of tracheal secretions. Supraglottic airways have several advantages over endotracheal intubation, including faster insertion, less need for neuromuscular blockade, and less hemodynamic instability. They can also be used as a bridge to intubation or as a rescue device when intubation fails or is contraindicated. The aim of this randomized controlled clinical study is to simulate a prehospital emergency/disaster scenario to evaluate and study the feasibility and effectiveness of the use of intubating laryngeal mask airway (ILMA) for onsite airway management from 360 degrees around the patient's head as in such situations, there may be limited or no access behind the head of the victim. Such a scenario can be extrapolated to disaster conditions where the victims may be trapped under the rubble following a building collapse /earthquake or are trapped in a vehicular road traffic/ train accident. It may take substantial time for extrication and evacuation of such patients to a hospital and hence it may be life-saving to provide prompt and early onsite airway management from wherever access is possible around the victim. We believe that the provision of a steel handle integrated with the airway tube may provide an opportunity for successful insertion of the device from 360 degrees around the patient merely by suitably changing the way the handle is gripped, so as to allow a single-handed smooth arc-like movement of the device for insertion, irrespective of the position of the rescuer relative to the patient's head. Objectives Our objective is to study the ease and time of insertion of ILMA, the number of attempts for successful ILMA insertion, and oropharyngeal leak pressure attained from unconventional positions in a supine patient.  Materials and methods This prospective, randomized, observer-blinded controlled trial included 90 patients undergoing elective surgery under general anesthesia. Patients were randomized using a chit and box system for group allocation. Groups were as follows: Group 1 (n=30) - Investigator standing on the back of the head of the patient (0°); Group 2 (n=30) - Investigator standing on the left side facing the patient (120°); Group 3 (n=30) - Investigator standing on the right side facing the patient (240°). Then ease and time of insertion of ILMA, number of attempts for successful ILMA insertion and oropharyngeal leak pressure were noted, and intergroup comparison was done. Conclusion ILMA has proved to be an effective ventilatory device and a suitable conduit for intubation in patients lying in the supine position from a conventional standard position standing behind the head of the patient, as well as non-conventional position, facing the patient at 120° or 240° from the standard position.

Influence of endotracheal tube and laryngeal mask airway for general anesthesia on perioperative adverse events in patients undergoing laparoscopic hysterectomy: A propensity score-matched analysis

Background

To compare perioperative adverse events between general anesthesia with endotracheal tube (ETT) and general anesthesia with laryngeal mask airway (LMA) in patients undergoing laparoscopic hysterectomy.

Materials and Methods

This was a large sample retrospective, propensity score-matched (PSM) study. We collected the data of 6739 female patients who underwent laparoscopic hysterectomy between January 2016 and June 2021 in our hospital, China. Patients were divided into two groups (ETT group and LMA group) according to different airway management modes. Data on all perioperative adverse events were collected. PSM analysis was performed to control confounding factors and differences in baseline values between the two groups. Finally, 4150 female patients were recruited after PSM.

Results

The total number of patients taking intraoperative vasoactive drugs during surgery was higher in the ETT group than in the LMA group (P = 0.04). The LMA group had a higher incidence of vomiting (51 [2.46%]) and somnolence (165 [7.95]) in the postanesthesia care unit (PACU) than the ETT group (71 [3.42%] and 102 [4.92%], respectively) (P = 0.02 and P < 0.001). Hypothermia was significantly higher in the LMA group (183 [10.36%]) than in the ETT group (173 [8.34%]) in the PACU (P = 0.03). The number of patients with sore throat was significantly higher in the ETT group (434 [20.02%]) than in the LMA group (299 [14.41%]) in the ward (P < 0.001). Other variables such as hypoxemia, moderate to severe pain, abdominal distension, diarrhea, sleep disorders, wound bleeding, and skin itch were not significantly different between the two groups (P > 0.05).

Conclusion

The ETT group had more incidences of vomiting, sore throat, and cough complications and needed more drug treatment than the LMA group. LMA is a better airway management mode and LMA general anesthesia can be safely used in patients undergoing laparoscopic nonemergency hysterectomy.

Comparıson of Laryngeal Mask and Endotracheal Tube Usıng Percutaneous Dılatatıonal Tracheostomy

Aim: It was aimed to compare the results of using endotracheal tube and laryngeal mask for airway safety in percutaneous tracheostomy applications. Methods: The results of using ETT and LMA in percutaneous tracheostomy applications in Adıyaman Training and Research Hospital between 2013 and 2018 were analyzed retrospectively. 170 patients were identified. 4 patients were excluded from the study due to missing information. Results: Of the 166 patients included in the study, 76 were female and 90 were male. It was most frequently performed in patients with a diagnosis of cerebrovascular accident. (44%) Tracheostomy was successful in all patients, minor bleeding was detected in 20 patients and a second attempt was detected in 21 patients. The duration of tracheostomy procedure was found to be significantly shorter in the LMA group (p < 0.05). The length of hospital stay was significantly higher in the ETT group than in the LMA group (p < 0.05). Conclusion: It has been determined that the use of LMA in percutaneous dilatational tracheostomy applications shortens the procedure time, increases the success of the procedure and is associated with fewer complications.

Is HFJV a better alternative ventilation technique for percutaneous dilatational tracheostomy? A randomised trial

BACKGROUND

High-Frequency Jet Ventilation (HFJV) has been used for the treatment of tracheal lesions, airway surgery, and treatment of secondary lesions after tracheostomy for many years however, reports on the use of HFJV during PDT are limited. This study compares the use of traditional method, ventilation with LMA, and HFJV through ETT with respect to the duration of PDT procedure and complications.

METHODS

Seventy-five patients were randomized into one of the three groups with computergenerated random numbers: Group ETT (n_25), group LMA (n=25), and group HFJV (n=25). Demographic data, duration of PDT, complications such as ETT cuff puncture and tube transaction, accidental extubation, difficult cannula insertion, bleeding, desaturation during the procedure, arterial blood gases immediately before and after the procedure have been recorded.

RESULTS

Mean time for successful PDT in group ETT was 5.9±1.35 minutes, in group LMA 4.96±0.78 minutes, and 3.88±0.78 minutes in group HFJV. PDT duration was shorter in the LMA group than in the ETT group (p<0.05). In the HFJV group, the PDT duration was shorter than the LMA group (p<0.05) and the ETT group (p<0.001). In terms of the total number of complications, significantly fewer complications were observed in the HFJV group compared with group ETT and group LMA.

CONCLUSIONS

HFJV may be a more effective alternative method for airway management during PDT, facilitating and reducing the duration of the intervention.

Size selection of the Ambu AuraOnce laryngeal mask in Chinese men weighing >70 kg: a pilot study

OBJECTIVE

To collect computed tomography data of the laryngeal anatomy of Chinese men and to determine the feasibility of using the size 4 Ambu AuraOnce laryngeal mask (Ambu A/S, Copenhagen, Denmark) in Chinese men weighing >70 kg.

METHODS

This prospective study involved men who underwent surgery from May 2018 to January 2019 at Jinshan Hospital. Pharyngeal and laryngeal parameters were measured by computed tomography. The laryngeal mask insertion success rate, requirement for tracheal tube insertion, laryngeal mask insertion time, fiberoptic bronchoscopy grading, air leakage pressure, and pharyngeal complications were analyzed.

RESULTS

In a comparison of the size 4 and 5 Ambu AuraOnce devices, the first insertion success rate was 100% and 87% and the three-times insertion success rate was 100% and 93%, respectively, with no significant differences. However, the insertion time was significantly different at 19.6 ± 5.9 versus 31.1 ± 11.2 s, respectively, and the proportions of fiberoptic grading levels were also significantly different. There were no significant differences in the air leakage pressure or pharyngeal complications.

CONCLUSION

The size 4 Ambu AuraOnce is more adequate than the size 5 for Chinese men weighing >70 kg, with a shorter insertion time and higher fiberoptic bronchoscopic grading.

Respiratory acidosis during bronchoscopy-guided percutaneous dilatational tracheostomy: impact of ventilator settings and endotracheal tube size

Background

The current study investigates the effect of bronchoscopy-guided percutaneous dilatational tracheostomy (PDT) on the evolution of respiratory acidosis depending on endotracheal tube (ET) sizes. In addition, the impact of increasing tidal volumes during the intervention was investigated.

Methods

Two groups of ICU-patients undergoing bronchoscopy-guided PDT with varying tidal volumes and tube sizes were consecutively investigated: 6 ml/kg (N = 29, mean age 57.4 ± 14.5 years) and 12 ml/kg predicted body weight (N = 34, mean age 59.5 ± 12.8 years).

Results

The mean intervention time during all procedures was 10 ± 3 min. The combination of low tidal volumes and ETs of 7.5 mm internal diameter resulted in the most profound increase in PaCO₂ (32.2 ± 11.6 mmHg) and decrease in pH-value (− 0.18 ± 0.05). In contrast, the combination of high tidal volumes and ETs of 8.5 mm internal diameter resulted in the least profound increase in PaCO₂ (8.8 ± 9.0 mmHg) and decrease of pH (− 0.05 ± 0.04). The intervention-related increase in PaCO₂ was significantly lower when using higher tidal volumes for larger ET: internal diameter 7.5, 8.0 and 8.5: P > 0.05, =0.006 and = 0.002, respectively. Transcutaneous PCO₂ monitoring revealed steadily worsening hypercapnia during the intervention with a high correlation of 0.87 and a low bias of 0.7 ± 9.4 mmHg according to the Bland-Altman analysis when compared to PaCO₂ measurements.

Conclusions

Profound respiratory acidosis following bronchoscopy-guided PDT evolves in a rapid and dynamic process. Increasing the tidal volume from 6 to 12 ml/kg PBW was capable of attenuating the evolution of respiratory acidosis, but this effect was only evident when using larger ETs.

Trial registration

DRKS00011004. Registered 20th September 2016.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0824-5) contains supplementary material, which is available to authorized users.