Comparison of performance and efficacy of air-Q intubating laryngeal airway and flexible laryngeal mask airway in anesthetized and paralyzed infants and children

Difficult Airway Management in Neonates and Infants: Knowledge of Devices and a Device-Oriented Strategy

Difficult airway management (DAM) in neonates and infants requires anesthesiologists and critical care clinicians to respond rapidly with appropriate evaluation of specific situations. Therefore, organizing information regarding DAM devices and device-oriented guidance for neonate and infant DAM treatment will help practitioners select the safest and most effective strategy. Based on DAM device information and reported literature, there are three modern options for DAM in neonates and infants that can be selected according to the anatomical difficulty and device-oriented strategy: (1) video laryngoscope (VLS), (2) supraglottic airway device (SAD), and (3) flexible fiberoptic scope (FOS). Some VLSs are equipped with small blades for infants. Advanced SADs have small sizes for infants, and some effectively function as conduits for endotracheal intubation. The smallest FOS has an outer diameter of 2.2 mm and enables intubation with endotracheal tubes with an inner diameter of 3.0 mm. DAM in neonates and infants can be improved by effectively selecting the appropriate device combination and ensuring that available providers have the necessary skills.

A generalized multistage approach to oral and nasal intubation in infants with Pierre Robin sequence: A retrospective review

BACKGROUND

Airway management in children with Pierre Robin sequence in the infantile period can be challenging and frequently requires specialized approaches.

AIMS

The aim of this study was to review our experience with a multistage approach to oral and nasal intubation in young infants with Pierre Robin sequence.

METHODS

After IRB approval, we reviewed 13 infants with Pierre Robin sequence who underwent a multistage approach to intubation in the operating room for mandibular distractor or gastrostomy tube placement. All patients underwent awake placement of either an LMA-Classic™ #1 or ProSeal™ laryngeal mask airway size #1. General anesthesia was induced with sevoflurane, and patients were relaxed with rocuronium. The laryngeal mask airway was replaced with an air-Q^® 1.0. Children were then intubated through the air-Q^® 1.0 using a flexible fiberoptic bronchoscope. In cases that required a nasotracheal tube, the oral tube was left in place while a flexible fiberoptic bronchoscope loaded with a similar internal diameter nasal Ring-Adair-Elwyn (RAE) tube was introduced into the nares. Once the scope was in proximity to the glottis, the oral tube was removed and the patient was intubated with the nasal RAE over the fiberscope.

RESULTS

All 13 patients with Pierre Robin sequence were successfully intubated. We observed no periods of desaturation during placement and induction with the LMA-Classic™ or ProSeal™ laryngeal mask airway except in one patient who was in extremis in the neonatal intensive care unit and required emergent transport to the operating room with the laryngeal mask airway in place. We observed several brief periods of desaturation during the apneas associated with fiberoptic intubation.

CONCLUSION

In conclusion, we were able to use a ventilation-driven, multistaged approach using the unique properties of different supraglottic airways to facilitate oral and nasal intubation in 13 infants with Pierre Robin sequence.

A network meta-analysis of the clinical properties of various types of supraglottic airway device in children

We conducted both conventional pairwise and Bayesian network meta-analyses to compare the clinical properties of supraglottic airway devices in children. We searched six databases for randomised clinical trials. Our primary end-points were oropharyngeal leak pressure, risk of insertion failure at first attempt, and blood staining risk. The risk of device failure, defined as the abandonment of the supraglottic airway device and replacement with a tracheal tube or another device, was also analysed. Sixty-five randomised clinical trials with 5823 participants were identified, involving 16 types of supraglottic airway device. Network meta-analysis showed that the i-gel™, Cobra perilaryngeal airway™ and Proseal laryngeal mask airway (LMA^® -Proseal) showed statistically significant differences in oropharyngeal leak pressure compared with the LMA^® -Classic, with mean differences (95% credible interval, CrI) of 3.6 (1.9-5.8), 4.6 (1.7-7.6) and 3.4 (2.0-4.8) cmH₂ O, respectively. The i-gel was the only device that significantly reduced the risk of blood staining of the device compared with the LMA-Classic, with an odds ratio (95%CrI) of 0.46 (0.22-0.90). The risk (95%CI) of device failure with the LMA-Classic, LMA^® -Unique and LMA-Proseal was 0.36% (0.14-0.92%), 0.49% (0.13-1.8%) and 0.50% (0.23-1.1%), respectively, whereas the risk (95%CI) of the i-gel and PRO-Breathe was higher, at 3.4% (2.5-4.7%) and 6.0% (2.8-12.5%), respectively. The risk, expressed as odds ratio (95%CrI), of insertion failure at first attempt, was higher in patients weighing < 10 kg at 5.1 (1.6-20.1). We conclude that the LMA-Proseal may be the best supraglottic airway device for children as it has a high oropharyngeal leak pressure and a low risk of insertion. Although the i-gel has a high oropharyngeal leak pressure and low risk of blood staining of the device, the risk of device failure should be evaluated before its routine use can be recommended.

A two-stage approach to induction and intubation of two infants with Pierre Robin Sequence using a LMA Classic™ and Air-Q®: two cases report

The laryngeal mask airway (LMA) Classic™ and Air-Q® are supralaryngeal devices used for airway management in routine and difficult pediatric airways. We describe a novel two-stage technique of insertion of the LMA Classic™ awake prior to induction of anesthesia, to assure oxygenation and ventilation, and after induction removal and placement of the Air-Q® for intubation using the flexible fiberoptic bronchoscope. The LMA Classic's™ pliable design and relatively small size allow it to be easily placed in awake infants. In contrast, the Air-Q® is an excellent device for intubation because of its larger internal diameter and removable 9 mm adapter. Our goal was to reduce unpredictability and potentially increase the safety of induction of anesthesia and intubation in infants with Pierre Robin sequence. By using these devices in a two-stage approach we created a technique for consistent oxygenation, ventilation, and intubation in these infants.

Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis

Air-Q® (air-Q) is a supraglottic airway device which can be used as a guidance of intubation in pediatric as well as in adult patients. We evaluated the efficacy and safety of air-Q compared to other airway devices during general anesthesia in pediatric patients by conducting a systematic review and meta-analysis. A total of 10 studies including 789 patients were included in the final analysis. Compared with other supraglottic airway devices, air-Q showed no evidence for a difference in leakage pressure and insertion time. The ease of insertion was significantly lower than other supraglottic airway devices. The success rate of intubation was significantly lower than other airway devices. However, fiberoptic view was better through the air-Q than other supraglottic airway devices. Therefore, air-Q could be a safe substitute for other airway devices and may provide better fiberoptic bronchoscopic view.

Comparison of air-Q and Ambu Aura-i for controlled ventilation in infants: a randomized controlled trial

BACKGROUND

The air-Q is a new supraglottic airway device (SAD) and has been increasingly used as a primary airway device and as a conduit for tracheal intubation in children as well as in adults. This device has either performed equally or better than other SADs in children. The Ambu Aura-i is a commonly used SAD in children undergoing various short surgical procedures. However, limited literature is available evaluating the safety and efficacy of the air-Q and the Ambu Aura-i in small children. We, therefore, conducted this study to compare the clinical performance of these two airway devices in infants weighing up to 10 kg. Our hypothesis is that air-Q, due to its improved and larger cuff design will yield better airway seal pressures as compared with the Ambu Aura-i.

METHODS

Sixty-four ASA I-II infants weighing <10 kg undergoing elective ophthalmic surgery were randomly assigned to receive either an air-Q or the Ambu Aura-i. After induction of general anesthesia (GA) and muscle relaxation, we measured oropharyngeal leak pressure (OLP) as the primary outcome. The secondary end points measured were time to insert, first insertion success rate, fiberoptic grade (FO) of laryngeal view and any other airway complications like trauma, laryngospasm, and desaturation.

RESULTS

The air-Q ILA provided significantly higher OLP as compared with the Ambu Aura-i [20.2 ± 4.6 cm H2 O, CI 18.55-21.88; vs 16.2 ± 5.6 cmH2 O, CI 14.27-18.25, P = 0.003; mean difference 4 ± 1.29 cm H2 O, CI 1.41-6.58]. However, the Ambu Aura-i required significantly less time for its insertion (14.6 ± 2.8 s, CI 13.66-15.70; vs 16.3 ± 1.5 s, CI 15.75-16.86, P = 0.005; mean difference 1.625 ±  0.56 s, CI 0.48-2.76). There were no differences in first insertion success rate, FO view, and postoperative complications.

CONCLUSION

We conclude that air-Q may be considered superior to Ambu Aura-i in infants for controlled ventilation as it provides higher airway sealing pressures.

An update on newer pediatric supraglottic airways with recommendations for clinical use

Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

A randomized comparison of the i-gel with the self-pressurized air-Q intubating laryngeal airway in children

BACKGROUND

Supraglottic airway devices with noninflatable cuff have advantages in omitting the cuff pressure monitoring and reducing potential pharyngolaryngeal complications. Typical devices without cuff inflation available in children are the i-gel and the self-pressurized air-Q intubating laryngeal airway (air-Q SP). To date, there is no comparative study between these devices in pediatric patients.

AIM

The purpose of this randomized study was to compare the i-gel(™) and the self-pressurized air-Q(™) intubating laryngeal airway (air-Q SP) in children undergoing general anesthesia.

METHODS

Eighty children, 1-108 months of age, 7-30 kg of weight, and scheduled for elective surgery in which supraglottic airway devices would be suitable for airway management, were randomly assigned to either the i-gel or the air-Q SP. Oropharyngeal leak pressure and fiberoptic view were assessed three times as follows: after insertion and fixation of the device, 10 min after initial assessment, and after completion of surgery. We also assessed insertion parameters and complications.

RESULTS

Insertion of the i-gel was regarded as significantly easier compared to the air-Q SP (P = 0.04). Compared to the air-Q SP group, the i-gel group had significantly higher oropharyngeal leak pressures at all measurement points and significantly lower frequencies of gastric insufflation at 10 min after initial assessment and completion of surgery. The air-Q SP group had better fiberoptic views than the i-gel group at all measurement points.

CONCLUSION

Our results showed that the i-gel had easier insertion and better sealing function, and the air-Q SP provided improved fiberoptic views in children requiring general anesthesia.