A comparative study of tracheal intubation using an intubating laryngeal mask (Fastrach) alone or together with a lightwand (Trachlight)

Overinflation of a King LT Extraglottic Airway Device Mimicking Ludwig's Angina

In this report, we describe the case of a young female with Down syndrome who presented to the anesthesia service after pulseless electrical activity arrest with a King LT(S)-D extraglottic airway device in situ. She had multiple predictors of difficult intubation, including what appeared to be a submental mass consistent with Ludwig's angina. She went on to receive an urgent tracheotomy because of those predictors but had full resolution of the submental mass on removal of the extraglottic airway device, which had been overinflated at the time of insertion. We outline the various techniques to establish a definitive airway with an extraglottic device in place.

Laryngoscope and a new tracheal tube assist lightwand intubation in difficult airways due to unstable cervical spine

PURPOSE

The WEI Jet Endotracheal Tube (WEI JET) is a new tracheal tube that facilitates both oxygenation and ventilation during the process of intubation and assists tracheal intubation in patients with difficult airway. We evaluated the effectiveness and usefulness of the WEI JET in combination with lightwand under direct laryngoscopy in difficult tracheal intubation due to unstable cervical spine.

METHODS

Ninety patients with unstable cervical spine disorders (ASA I-III) with general anaesthesia were included and randomly assigned to three groups, based on the device used for intubation: lightwand only, lightwand under direct laryngoscopy, lightwand with WEI JET under direct laryngoscopy.

RESULTS

No statistically significant differences were detected among three groups with respect to demographic characteristics and C/L grade. There were statistically significant differences between three groups for overall intubation success rate (p = 0.015) and first attempt success rate (p = 0.000). The intubation time was significantly longer in the WEI group (110.8±18.3 s) than in the LW group (63.3±27.5 s, p = 0.000) and DL group (66.7±29.4 s, p = 0.000), but the lowest SpO2 in WEI group was significantly higher than other two groups (p<0.01). The WEI JET significantly reduced successful tracheal intubation attempts compared to the LW group (p = 0.043). The severity of sore throat was similar in three groups (p = 0.185).

CONCLUSIONS

The combined use of WEI JET under direct laryngoscopy helps to assist tracheal intubation and improves oxygenation during intubation in patients with difficult airway secondary to unstable spine disorders.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-TRC-14005141.

Tracheal intubation through the I-gel™ supraglottic airway versus the LMA Fastrach™: a randomized controlled trial

BACKGROUND

The i-gel™ is a supraglottic airway device not requiring inflation of a cuff for lung ventilation. Its design allows for unobstructed passage of a tracheal tube and previous studies have demonstrated a favorable alignment with the glottic inlet. In this prospective randomized study, we compared the success rate of blind tracheal intubation using the i-gel and the laryngeal mask airway (LMA) Fastrach™.

METHODS

One hundred sixty patients requiring general anesthesia and airway management were randomized to tracheal intubation using the i-gel or the LMA Fastrach. After induction of general anesthesia, the allocated device was inserted and adequate lung ventilation was confirmed. Blind tracheal intubation was then attempted. First attempt and overall tracheal intubation success rates were evaluated and tracheal intubation times were measured.

RESULTS

Eighty patients were recruited in each study group. Successful tracheal intubation was obtained on the first attempt in 69% of patients with the i-gel and 74% of patients with the LMA Fastrach (95% confidence interval [CI] of difference, -9% to 19%, P = 0.60). The overall intubation success rate was lower using the i-gel than it was using the LMA Fastrach (73% vs 91%, 95% CI of difference, 7% to 31%, P < 0.0001).

CONCLUSIONS

On first attempts, successful blind tracheal intubation was obtained at comparable rates using the i-gel and the LMA Fastrach. However, when the first attempt was unsuccessful, subsequent attempts through the i-gel did not significantly increase tracheal intubation success rate. The LMA Fastrach yielded a higher overall intubation success rate.

Equipment to manage a difficult airway during anaesthesia

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

The Fastrach Intubating Laryngeal Mask Airway: an overview and update

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.

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review

BACKGROUND

Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals.

OBJECTIVES

To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation.

SEARCH STRATEGY AND METHODOLOGY

Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.

A comparison of the intubating laryngeal mask airway and the Bonfils intubation fibrescope in patients with predicted difficult airways*

Tracheal intubation with the intubating laryngeal mask airway or the Bonfils intubation fibrescope was performed in 80 patients with predicted difficult airways. Mallampati score, thyromental distance, mouth opening and mobility of the atlanto-occipital joint were used to predict difficult airways. The overall success rate, time to the first adequate lung ventilation and time taken for the successful placement of the tracheal tube were recorded, as well as a subjective assessment of the handling of the device and the incidence of postoperative sore throat and hoarseness. The median [range] time to the first adequate ventilation was significantly shorter with the intubating laryngeal mask airway than with the Bonfils intubation fibrescope (28 [6-85] s vs. 40 [23-77] s, p < 0.005). Tracheal intubation was significantly slower with the intubating laryngeal mask airway than with the Bonfils intubation fibrescope (76 [45-155] s vs. 40 [23-77] s, p < 0.0001. Patients in the Bonfils group suffered less sore throat and hoarseness than those in the other group.

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.

Intubating laryngeal mask airway

The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in "routine" cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting. Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence. The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.