Alternative management techniques for the difficult airway: esophageal-tracheal Combitube

Comparison of i-gel™ and laryngeal mask airway in anesthetized paralyzed patients

BACKGROUND

The i-gel™ is a new device introduced recently. It differs from other supraglottic airway devices. It has a non-inflatable, gel-made cuff. Previously used devices, have some disadvantages which are claimed to be absent in i-gel™. In this study we aimed to compare the performance of the laryngeal mask airway (LMA)-Classic™ and i-gel™ during anesthesia in paralyzed patients.

MATERIALS AND METHODS

A total of 64 anaesthetized patients with paralysis were enrolled in a single-blind, randomized control trial to be intubated with one of the devices. We compared the device insertion parameters, some ventilatory parameters, and adverse effects after device insertion.

RESULTS

Vital signs were not significantly different between groups. Regarding duration of insertion attempts, the difference between groups was significant (P < 0.05); while the number of insertion attempts was insignificant (P = 0.265). There was no significant difference between both groups regarding postoperative complications (cough, sore throat, and blood on the cuff) (P > 0.05). Airway leak was assessed in both groups and data showed no significant difference (P = 0.662). Additionally, end-tidal CO2 change regarding the baseline value was significantly different after 10 and 15 min of anesthesia (P < 0.05).

CONCLUSIONS

Successful insertion time was shorter significantly for i-gel™. As i-gel™ has easy application, it is advantageous to be used during cardiopulmonary resuscitation by non-anesthetists in which time is very important. We concluded that i-gel™ can be an alternative to LMA-Classic™ for controlled ventilation during anesthesia as it is easier to be placed.

A novel rescue technique for difficult intubation and difficult ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit. Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation. A 13 year old patient was taken to the operating room for incision and drainage of a neck abscess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

Management of the difficult airway

The oral and maxillofacial surgeon frequently encounters and manages difficult airways. Knowledge of and calm progression by practitioner and staff through different means to ventilate and manage a difficult airway are crucial. Practitioners should become comfortable with different types of alternative or rescue airways in order to intervene quickly in case of emergent or unanticipated airway compromise.

Retrograde intubation

Airway management in the emergency department is a critical skill that must be mastered by emergency physicians. When rapid-sequence induction with oral-tracheal intubation performed by way of direct laryngoscopy is difficult or impossible due to a variety of circumstances, an alternative method or device must be used for a rescue airway. Retrograde intubation requires little equipment and has few contraindications. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.