Performance and skill retention of five supraglottic airway devices for the pediatric difficult airway in a manikin

Supraglottic Airway Devices: Present State and Outlook for 2050

Correct placement of supraglottic airway devices (SGDs) is crucial for patient safety and of prime concern of anesthesiologists who want to provide effective and efficient airway management to their patients undergoing surgery or procedures requiring anesthesia care. In the majority of cases, blind insertion of SGDs results in less-than-optimal anatomical and functional positioning of the airway devices. Malpositioning can cause clinical malfunction and result in interference with gas exchange, loss-of-airway, gastric inflation, and aspiration of gastric contents. A close match is needed between the shape and profile of SGDs and the laryngeal inlet. An adequate first seal (with the respiratory tract) and a good fit at the second seal of the distal cuff and the gastrointestinal tract are most desirable. Vision-guided insertion techniques are ideal and should be the way forward. This article recommends the use of third-generation vision-incorporated-video SGDs, which allow for direct visualization of the insertion process, corrective maneuvers, and, when necessary, insertion of a nasogastric tube (NGT) and/or endotracheal tube (ETT) intubation. A videoscope embedded within the SGD allows a visual check of the glottis opening and position of the epiglottis. This design affords the benefit of confirming and/or correcting a SGD's position in the midline and rotation in the sagittal plane. The first clinically available video laryngeal mask airways (VLMAs) and multiple prototypes are being tested and used in anesthesia. Existing VLMAs are still not perfect, and further improvements are recommended. Additional modifications in multicamera technology, to obtain a panoramic view of the SGD sitting correctly in the hypopharynx and to prove that correct sizes have been used, are in the process of production. Ultimately, any device inserted orally-SGD, ETT, NGT, temperature probe, transesophageal scope, neural integrity monitor (NIM) tubes-could benefit from correct vision-guided positioning. VLMAs also allow for automatic recording, which can be documented in clinical records of patients, and could be valuable during teaching and research, with potential value in case of legal defence (with an airway incident). If difficulties occur with the airway, documentation in the patient's file may help future anesthesiologists to better understand the real-time problems. Both manufacturers and designers of SGDs may learn from optimally positioned SGDs to improve the design of these airway devices.

Evaluation of the New SingularityTM Air versus Ambu® Aura GainTM: A Randomized, Crossover Mannequin Study

Background: This randomised crossover mannequin study aimed to compare the insertion time for the newly developed SingularityTM Air and the Ambu® AuraGainTM. The SingularityTM Air includes a bendable tube in order to allow optimal passform. Methods: Fifty anaesthetists with a minimum of 100 supraglottic airway device insertions were recruited and randomly assigned to start either with the SingularityTM Air or with the Ambu® AuraGainTM. Participants watched a tutorial video the day before the assessment and received a standardized introduction immediately before the assessment. The primary outcome was the time for successful insertion. Secondary parameters were the overall insertion success rate, the numbers of insertion attempts (maximum three), the glottic view through a flexible bronchoscope, and the success rate for gastric tube insertion. Results: Fifty participants were eventually recruited and randomly assigned to insert both devices according to the randomization. The insertion time was 24 s for SingularityTM Air as compared to 20 s for Ambu® AuraGainTM (p < 0.001). Overall insertion rate was 92% for the SingularityTM Air as compared to 100% for the Ambu® AuraGainTM (p could not be derived as one variable is a constant). The primary insertion success rate was better for the Ambu® AuraGainTM than for the SingularityTM Air (94% versus 68%; p: 0.002, respectively). Conclusion: The time for successful insertion and the insertion success rate for the newly developed SingularityTM Air is inferior to that for the Ambu® AuraGainTM.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Supraglottic Airway Devices for Elective Pediatric Anesthesia: I-gel versus Air-Q, Which is the Best?

Objectives:

The objectives of the study were to compare the insertion facility, the effect on hemodynamic parameters, and effective ventilation using I-gel versus Air-Q supraglottic airway devices (SADs) for pediatric patients undergoing short-duration surgical procedures.

Patients and Methods:

One hundred and fifty children aged 3–10 years were randomly divided into two equal groups: Group I received I-gel and Group Q received Air-Q SAD. All patients were anesthetized by sevoflurane inhalation using a face mask without neuromuscular blockade. Study outcomes included SAD insertion success rate (SR), insertion time, anatomic alignment of the SAD to the larynx as judged using fiberoptic bronchoscope (FOB) inserted through the SAD, and tidal volume leak, and incidence of postoperative complications.

Results:

Total and first attempt SRs were 97.3% and 85.3% for I-gel and 94.7% and 82.7% respectively, for Air-Q with nonsignificant differences. However, I-gel insertion time (12.3 ± 3.6 s.) was significantly (P = 0.034) shorter than Air-Q (13.7 ± 4.2 s). FOB grading of laryngeal view through SAD was better with I-gel but without significant difference for patients who had view Grades 1-2. Percentage of tidal volume loss was significantly decreased at 5 min after insertion than immediately after insertion, in all patients, with a nonsignificant difference in favor of I-gel. Intraoperative hemodynamic changes and postoperative complications showed a nonsignificant difference between both the groups.

Conclusion:

Both Air-Q and I-gel SAD provided advantages for pediatric anesthesia during short-duration surgical procedure with nonsignificant differences. However, I-gel SAD required a shorter insertion time and provided a high SR which is satisfactory for trainees and during an emergency. I-gel SAD allowed minimization of tidal volume leak and gastric inflation and is associated with infrequent complications.

Comparing the insertion and ventilation of laryngeal mask airway according to the patient's head position and muscle relaxation use. A prospective clinical trial

OBJECTIVES

To assess the insertion and ventilation of the laryngeal mask airway (LMA) classic while using different head positions with or without muscle relaxant.

METHODS

This is a double-blind randomized clinical trial. Patients scheduled for ureteral calculus surgery at Shanghai General Hospital, Shanghai, China were recruited between November 2017 and November 2018. A total of 132 adults were consecutively selected. Patients were randomly divided into 4 groups according to head positioning and muscle relaxant use. An 8-cm-high pillow was used to achieve the sniffing position. The insertion time, initial peak pressure (Ppeak), mean pressure (Pmean) of the airway during intermittent positive pressure ventilation (primary endpoint) and fiberoptic score of the LMA position (secondary endpoint) were evaluated via electronic bronchoscopy through the mask bar. All adverse events were recorded. Results: Data were analyzed by ANOVA, 2-way ANOVA, Chi-squared, Cochran-Mantel-Haenszel, and Kruskal-Wallis tests. The insertion time required for the first attempt, fiberoptic score, Ppeak and Pmean did not differ among the groups. However, the incidence of adverse events in groups not using muscle relaxant was higher than in those using muscle relaxant. Conclusion: Use of a sniffing position and muscle relaxant slightly eased the insertion of the LMA but did not affect the fiberoptic score or ventilation parameters. Using a muscle relaxant, but not the sniffing position, reduced the incidence of adverse effects.