Continuous ventilation during intubation through a supraglottic airway device guided by fiberoptic bronchoscopy: a observational assessment

AuraGain™ versus i-gel™ for bronchoscopic intubation under continuous oxygenation: A randomised controlled trial

INTRODUCTION

After failed mask ventilation and tracheal intubation, guidelines issued by the Difficult Airway Society recommend placing a second generation supraglottic airway device to secure oxygenation. Ultimately, a secure airway can be obtained by tracheal intubation through the supraglottic airway device using a bronchoscope. In this randomised trial, we compared the AuraGain™ with the i-gel™ as conduit for bronchoscopic intubation under continuous oxygenation performed by a group of anaesthesiologists with variable experience in a general population of patients.

METHOD

We randomised one hundred patients who were equally allocated to flexible bronchoscopic intubation through the i-gel™ or the AuraGain™. In a random order, 25 anaesthesiologists each performed four intubations, two using the i-gel™ and two using the AuraGain™. Our primary outcome was 'total time for airway management'; i.e. total time from manually reaching the SAD to successful FBI confirmed at the end of the first inspiratory downstroke on the capnography curve.

RESULTS

In total, 87% (95% CI, 79%-92%) of the patients were successfully intubated through the allocated supraglottic airway device. There was no difference in total time for airway management between the i-gel™ and the AuraGain™ (199 vs. 227 s, p = .076). However, there was a difference in time for placement of the i-gel™, compared to the AuraGain™, (37 vs. 54 s, p < .001). There were nine failed intubations in the AuraGain™ group compared to four in the i-gel™ group (p = .147).

CONCLUSION

We found no difference in total time for airway management between using the i-gel™ and using the AuraGain™.

The changes on anesthetic practice for non-intubated bronchoscopic interventions during Covid-19 pandemic

Bronchoscopic interventions (BIs) and airway management for bronchoscopy are exceptionally high-risk procedures not only for anesthesiologists, pulmonologists, but also for nursing staff because they expose nurses to COVID-19-containing droplets. However, perioperative changes can be made to the anesthetic management for nonintubated BIs to minimize the spread of COVID-19.

Comprehensive evaluation of manikin-based airway training with second generation supraglottic airway devices

Background

Supraglottic airway devices (SADs) are an essential second line tool during difficult airway management after failed tracheal intubation. Particularly for such challenging situations the handling of an SAD requires sufficient training. We hypothesized that the feasibility of manikin-based airway management with second generation SADs depends on the type of manikin.

Methods

Two airway manikins (TruCorp AirSim^® and Laerdal Resusci Anne^® Airway Trainer™) were evaluated by 80 experienced anesthesia providers using 5 different second generation SADs (LMA^® Supreme™ [LMA], Ambu^® AuraGain™, i-gel^®, KOO™-SGA and LTS-D™). The primary outcome of the study was feasibility of ventilation measured by assessment of the manikins' lung distention. As secondary outcome measures, oropharyngeal leakage pressure (OLP), ease of gastric tube insertion the insertion time, position and subjective assessments were evaluated.

Results

Ventilation was feasible with all combinations of SAD and manikin. By contrast, an OLP exceeding 10 cm H₂O could be reached with most of the SADs in the TruCorp but with the LTS-D only in the Laerdal manikin. Gastric tube insertion was successful in above 90% in the Laerdal vs 87% in the TruCorp manikin (P<0.009). Insertion times differed significantly between manikins. The SAD positions were better in the Laerdal manikin for LMA, Ambu, i-gel and LTS-D. Participant's assessments were superior in the Laerdal manikin for LMA, Ambu, i-gel and KOO-SGA.

Conclusions

Ventilation is possible with all combinations. However, manikins are variable in their ability to adequately represent additional functions of second generation SADs. In order to achieve the best performance during training, the airway manikin should be chosen depending on the SAD in question.

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy

PURPOSE

Interventional pulmonology is a growing subspecialty of pulmonary medicine with flexible and rigid bronchoscopies increasingly used by interventional pulmonologists for advanced diagnostic and therapeutic purposes. This review discusses different technical aspects of anesthesia for interventional pulmonary procedures with an emphasis placed on pharmacologic combinations, airway management, ventilation techniques, and common complications.

SOURCE

Relevant medical literature was identified by searching the PubMed and Google Scholar databases for publications on different anesthesia topics applicable to interventional pulmonary procedures. Cited literature included case reports, original research articles, review articles, meta-analyses, guidelines, and official society statements.

PRINCIPAL FINDINGS

Interventional pulmonology is a rapidly growing area of medicine. Anesthesiologists need to be familiar with different considerations required for every procedure, particularly as airway access is a shared responsibility with pulmonologists. Depending on the individual case characteristics, a different selection of airway method, ventilation mode, and pharmacologic combination may be required. Most commonly, airways are managed with supraglottic devices or endotracheal tubes. Nevertheless, patients with central airway obstruction or tracheal stenosis may require rigid bronchoscopy and jet ventilation. Although anesthetic approaches may vary depending on factors such as the length, complexity, and acuity of the procedure, the majority of patients are anesthetized using a total intravenous anesthetic technique.

CONCLUSIONS

It is fundamental for the anesthesia provider to be updated on interventional pulmonology procedures in this rapidly growing area of medicine.

The optimum sevoflurane concentration for supraglottic airway device Blockbuster™ insertion with spontaneous breathing in obese patients: a prospective observational study

BACKGROUND

Airway management of the obese patient presenting for surgery is more likely to be a challenging problem. Supraglottic airway device has been adopted as a bridge to connect ventilation and tracheal intubation in obese patients who would be suffered with difficult intubation. The optimum sevoflurane concentration for supraglottic airway device insertion allowing spontaneous breathing in 50% of obese patients (ED₅₀) is not known. The purpose of this study was to determine the ED₅₀ of sevoflurane for supraglottic airway device Blockbuster™ insertion with spontaneous breathing in obese patients requiring general anesthesia.

METHODS

Thirty elective obese patients (body mass index 30-50 kg/m²) undergoing bariatric surgery were recruited in this study. The predetermined target sevoflurane concentration (initiating at 2.5% with 0.5% as a step size) was sustained for >5 min using a modified Dixon's up-and-down method, and then the supraglottic airway device Blockbuster™ was inserted. The patient's response to supraglottic airway device insertion was classified as either 'movement' or 'no-movement'. The ED₅₀ of sevoflurane were determined by calculating the midpoint concentration of crossover point from 'movement' or 'no-movement' response.

RESULTS

The ED₅₀ of sevoflurane for supraglottic airway device Blockbuster™ insertion in obese patients calculated using up-and-down method were 2.50 ± 0.60%. The ED₅₀ and ED₉₅ (95% confidence interval) obtained by probit regression analysis were 2.35 (1.28-3.42) % and 4.03 (3.16-17.83) % for supraglottic airway device Blockbuster™ insertion, respectively.

CONCLUSION

We conclude that the optimum end-tidal sevoflurane concentration required for the supraglottic airway device Blockbuster™ insertion allowing spontaneous breathing in 50% of obese patients (ED₅₀) is 2.5 ± 0.6%.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-16009071 , Registered on 24 August 2016.