[Fastrach laryngeal mask and difficult intubation]

Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

I-gel Laryngeal Mask Airway Combined with Tracheal Intubation Attenuate Systemic Stress Response in Patients Undergoing Posterior Fossa Surgery

BACKGROUND

The adverse events induced by intubation and extubation may cause intracranial hemorrhage and increase of intracranial pressure, especially in posterior fossa surgery patients. In this study, we proposed that I-gel combined with tracheal intubation could reduce the stress response of posterior fossa surgery patients.

METHODS

Sixty-six posterior fossa surgery patients were randomly allocated to receive either tracheal tube intubation (Group TT) or I-gel facilitated endotracheal tube intubation (Group TI). Hemodynamic and respiratory variables, stress and inflammatory response, oxidative stress, anesthesia recovery parameters, and adverse events during emergence were compared.

RESULTS

Mean arterial pressure and heart rate were lower in Group TI during intubation and extubation (P < 0.05 versus Group TT). Respiratory variables including peak airway pressure and end-tidal carbon dioxide tension were similar intraoperative, while plasma β-endorphin, cortisol, interleukin-6, tumor necrosis factor-alpha, malondialdehyde concentrations, and blood glucose were significantly lower in Group TI during emergence relative to Group TT. Postoperative bucking and serious hypertensions were seen in Group TT but not in Group TI.

CONCLUSION

Utilization of I-gel combined with endotracheal tube in posterior fossa surgery patients is safe which can yield more stable hemodynamic profile during intubation and emergence and lower inflammatory and oxidative response, leading to uneventful recovery.

[Difficult intubation: should follow the recommendations]

Intubation and ventilation impossible mask is a dramatic situation with potentially serious consequences. We report the case of a patient of 43 years, followed for a goiter, which was scheduled for a total thyroidectomy under general anesthesia. Preoperative evaluation is not noted signs of compression or tracheal deviation, and there were no criteria predictive of intubation or difficult mask ventilation. The induction of anesthesia was standard. Mask ventilation was effective allowing paralysis. The standard laryngoscopy showed a score of Cormack and Lehane grade IV. Several attempts at intubation were made leading to a situation of intubation and ventilation impossible mask with deep desaturation. A tracheostomy was done urgently. The patient was operated on, six months later, with a fiber optic intubation. Through this case, the authors draw attention to the difficulty of achieving an emergency tracheotomy in the presence of goiter and emphasize the need for integration of different modes of learning and retention of management skills of the upper airway.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway

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.

The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient

Background

Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.

Methods

Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.

Conclusions

The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.

Mise en place du masque Laryngé-Fastrach™ au sein d'un service médical d'urgence et de réanimation

OBJECTIVES

Assessment of the intubating Laryngeal Mask Airway(trade mark) in a prehospital emergency mobile unit (PEMU).

STUDY DESIGN

Observational study.

METHODS

All the emergency physicians and nurses of the PEMU were trained with the intubating laryngeal mask (ILMA) handling on manikin and a learning curve was carried out. One year after the initial formation, a reassessment of the operators was performed. Following the initial formation, all the vehicles of the PEMU were equipped with ILMA and during 15 months all cases of ILMA use were recorded. The success rate and the difficulties met were analysed.

RESULTS

Initial formation on manikin showed that at least 8 handling of the device were mandatory to achieve a 100% success rate. A significant reduction of tracheal tube insertion delay was observed up to the eight manipulations. One year after the initial formation, a significant loss of performance was observed. Over the clinical study period 20 ILMA were used with adequate ventilation through the mask in all cases and a possible intubation in 80% of the patients.

CONCLUSION

The ILMA is a potential useful device in the prehospital setting. Initial formation and maintenance of the skill acquired with this technique are essential.

Impact du grade de Cormack et Lehane sur l'utilisation du masque laryngé Fastrach™ : étude en chirurgie gynécologique

OBJECTIVE

To evaluate the impact of Cormack and Lehane grade on the Intubating Laryngeal Mask Airway (LMA-Fastrach) using in women.

STUDY DESIGN

Open prospective study.

PATIENTS

The study included 115 scheduled gynaecologic surgery women.

METHODS

An LMA-Fastrach was systematically performed in patients with a Cormack's grade > or =3 or when Arne's score was > or =7 whatever the Cormack. After induction of anaesthesia and neuromuscular blockade, Cormack's grade was assessed and LMA-Fastrach was inserted. Proper insertion was confirmed by the easiness of assisted ventilation and the normal aspect of the capnographic curve. Intubation through the LMA-Fastrach was carried out with the specific kit's endotracheal tube. More than two attempts were considered as a failure of the technique and an alternative method was performed. The following parameters were noted: age, weight, height, clinical predictors for difficult intubation (Arne et al.'s score), number of LMA-Fastrach insertion, ventilation efficiency through LMA-Fastrach, successful intubation with LMA-Fastrach and oesophageal intubation.

RESULTS

Ventilation through the LMA-Fastrach was efficient in 97%. The success rate of intubation was 94.8% (86% on the first attempt). The success rate of ventilation and intubation were not statistically different according to the different Cormack's grades. The obesity (BMI>30) did not change the success rate of ventilation and intubation through the LMA-Fastrach.

CONCLUSION

In women with either predicted or unpredicted difficult intubation, the success rates of ventilation and intubation through the LMA-Fastrach don't seem to be influenced by Cormack grade and obesity.

Using the Intubating Laryngeal Mask Airway for Ventilation and Endotracheal Intubation in Anesthetized and Unparalyzed Acromegalic Patients

Airway management may be difficult in acromegalic patients. The purpose of the study was to evaluate the intubating laryngeal mask airway (ILMA) as a primary tool for ventilation and intubation in acromegalic patients. Twenty-three consenting consecutive adult acromegalic patients presenting for transsphenoidal resection of pituitary adenoma were enrolled in the study. Anesthesia was induced using propofol (1.5 mg/kg followed by 0.5-mg/kg increments); the ILMA was inserted when the bispectral index fell below 50. The ILMA was successful as a primary airway for oxygenation and ventilation at the first attempt for 21 (91%) patients, while 2 (9%) patients required a second attempt. Patient movement was noticed in five (21.7%) of the patients during ILMA insertion. An attempt at tracheal intubation through the ILMA was performed following administration of a mean 395 +/- 168-mg dose of propofol. Overall success rates for tracheal intubation were 82% (19 patients). The first-attempt success rate for tracheal intubation was 52.6% (10 patients), second- and third-attempt success rates were 42.1% (8 patients) and 5.3% (1 patient), respectively. Coughing or movement during intubation was observed in 12 (63.2%) of the patients. Direct laryngoscopy permitted intubation in three cases and blind intubation using a bougie in the fourth case. ILMA can be used as a primary airway for oxygenation in acromegalic patients (manual bag ventilation), but the rate of failed blind intubation through the ILMA precludes its use as a first choice for elective airway management.

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction

PURPOSE

To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction.

CLINICAL FEATURES

A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature.

CONCLUSION

Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.

Initial experience of emergency physicians using the intubating laryngeal mask airway: a case series

OBJECTIVE

Although the intubating laryngeal mask airway (ILMA) is widely available, its use by emergency physicians (EPs) has not been reported. The authors report the initial experience of EPs using the ILMA. A review of their experience and the relevant anesthesia literature provides a basis for EPs to use the ILMA more confidently and effectively.

METHODS

Between January 2000 and January 2001, the ILMA was used on a convenience sample of emergency department (ED) patients undergoing "routine" intubations, and "rescue" situations, after failed rapid-sequence intubation (RSI). Patients were identified from the ED resuscitation case database. Chart review and intubating physician interviews focused on success of the device, complications encountered, and "pearls" of the device's use as perceived by the intubating physician.

RESULTS

Ventilation with the appropriate-size ILMA occurred in less than 15 seconds in all "routine" intubations; tracheal intubation was subsequently accomplished in less than 1 minute. Eight of nine "routine" patients had blind tracheal intubation through the ILMA. One patient required fiberoptic bronchoscopy to guide the endotracheal tube into the trachea. Of the "rescue" intubations, all patients (n = 7) were successfully ventilated and five were successfully intubated using the ILMA.

CONCLUSIONS

In this case series, the ILMA was easy to use in acute resuscitations, and proved to be invaluable in cases of failed RSI.

The intubating laryngeal mask airway: suggestions for use in the emergency department

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.

Blind orotracheal intubation with the intubating laryngeal mask versus fibreoptic guided orotracheal intubation with the Ovassapian airway. A pilot study of awake patients

In a randomized, prospective pilot study, we compared awake blind orotracheal intubation using the intubating laryngeal mask airway (blind-ILM) with awake fibreoptic-guided orotracheal intubation using an Ovassapian airway (FOS-OA). Fifty-four patients (ASA 1 to 3, aged 18 to 85 years) requiring awake intubation for elective surgery were randomly allocated by coin toss into two groups: 31 patients were intubated blindly through the ILM (blind-ILM) and 23 were intubated using fibreoptic guidance through the Ovassapian airway (FOS-OA). Sedation to a target clinical end-point (spontaneous eye-closing, but responsive to verbal command) was obtained with fentanyl/midazolam and a cricothyroid puncture was performed with 3 ml lignocaine 4%. The oropharynx was then topicalized until tolerance of a Guedel airway was achieved. The number of failed attempts (maximum of three allowed), overall success rates, the time from insertion of the airway to capnographic (blind-ILM) or fibreoptic (FOS-OA) confirmation of intubation or until three failed attempts, and cardiovascular responses before and during intubation, were recorded. The first time (blind-ILM, 25/31 [81%]; FOS-OA, 20/23 [87%], P = 0.6) and overall (blind-ILM, 26/31 [84%]; FOS-OA, 22/23 [96%], P = 0.2) intubation success rates were similar. The mean +/- SD time to intubation was shorter for the blind-ILM group (104 +/- 65 vs 158 +/- 115 sec, P = 0.05). There were no clinically significant differences in blood pressure or heart rate between groups. Compared with baseline values, there was no cardiovascular response to intubation in either group. We conclude that the blind-ILM and FOS-OA techniques have similar success rates and cardiovascular responses, but intubation is slightly quicker with the blind-ILM technique.

New equipment and techniques for airway management in trauma

A patent, unobstructed airway is fundamental in the care of the trauma patient, and is most often obtained by placing a cuffed tube in the trachea. The presence of shock, respiratory distress, a full stomach, maxillofacial trauma, neck hematoma, laryngeal disruption, cervical spine instability, and head injury all combine to increase tracheal intubation difficulty in the trauma patient. Complications resulting from intubation difficulties include brain injury, aspiration, trauma to the airway, and death. The use of devices such as the gum-elastic bougie, McCoy laryngoscope, flexible and rigid fiberscopes, intubating laryngeal mask, light wand, and techniques such as rapid-sequence intubation, manual in-line axial stabilization, retrograde intubation, and cricothyroidotomy, enhance the ability to obtain a definitive airway safely. The management of the failed airway includes calling for assistance, optimal two-person bag-mask ventilation, and the use of the laryngeal mask airway, Combitube, or surgical airway. The simulation of airway management using realistic simulator tools (e.g. full-scale simulators, virtual reality airway simulators) is a promising modality for teaching physicians and advanced life support personnel emergency airway management skills.