The newest variation of the i-gel supraglottic airway is a pediatric version.
This study was designed to investigate the usefulness of the size 2 i-gel compared with the ProSeal laryngeal mask airway (PLMA) and classic laryngeal mask airway (cLMA) of the same size in anesthetized, paralyzed children.
Settings and design:
A prospective, randomized, single-blinded study was conducted in a tertiary care teaching hospital.
Ninety ASA grade I–II patients undergoing lower abdominal, inguinal and orthopedic surgery were included in this prospective study. The patients were randomly assigned to the i-gel, PLMA and cLMA groups (30 patients in each group). Size 2 supraglottic airway was inserted according to the assigned group. We assessed ease of insertion, hemodynamic data, oropharyngeal sealing pressure and postoperative complications.
There were no differences in the demographic and hemodynamic data among the three groups. The airway leak pressure of the i-gel group (27.1±2.6 cmH2O) was significantly higher than that of the PLMA group (22.73±1.2 cmH2O) and the cLMA group (23.63±2.3 cmH2O). The success rates for first attempt of insertion were similar among the three devices. There were no differences in the incidence of postoperative airway trauma, sore throat or hoarse cry in the three groups.
Hemodynamic parameters, ease of insertion and postoperative complications were comparable among the i-gel, PLMA and cLMA groups, but airway sealing pressure was significantly higher in the i-gel group.
Classic laryngeal mask airway; i-gel; pediatric patients; ProSeal laryngeal mask airway
Securing the airway is a crucial aspect during reconstructive surgeries of patients with extensive post-burn mentosternal scar contractures; however, the American Society of Anesthesiologists Difficult Airway Management Algorithm recommendation of initial direct laryngoscopy may not be appropriate for these complicated patients. Consequently, there is a significant risk for failure of intubation and airway emergency. We suggest that initial attempts at securing the airway be made with indirect laryngoscopy. Many airway techniques have been effectively used in burn patients, but the role of awake blind or fiberoptic bronchoscopy, although well established in the non-burn population, has yet to be evaluated in burn patients. We report a case series of successful management of difficult airways with fiberoptic bronchoscopy in patients with varying degrees of post-burn head and neck scar contractures.
Burn airway; neck contracture; fiberoptic bronchoscopy; laryngeal mask airway
Negative pressure pulmonary oedema (NPPO) is a life threatening condition, manifested due to upper airway obstruction in a spontaneously breathing patient. Upper airway obstruction caused by classic laryngeal mask airway (cLMA) and ProSeal laryngeal mask airway (PLMA) has been reported, and NPPO has also been reported following the use of cLMA. Search of literature did not confirm NPPO following the use of PLMA. We encountered a female patient of NPPO scheduled for incision and drainage of an abscess who had signs of airway obstruction following PLMA insertion. Multiple attempts were made to get patent airway without success. PLMA was replaced with endotracheal tube following which pink frothy secretion appeared in breathing circuit. Patient was managed successfully with ICU care.
Airway obstruction; negative pressure; negative pressure pulmonary oedema; ProSeal laryngeal mask airway
A case of difficult intubation is described in which the problem was overcome by use of the laryngeal mask airway (LMA). The patient had difficulty in mouth opening due to severe burn scar contracture around the mouth and limited access prevented tracheal intubation. The use of LMA is shown to have obviated the need for tracheal intubation in the case of a patient whose injuries would have made this technique difficult.
Supraglottic devices have changed the face of the airway management. These devices have contributed in a big way in airway management especially, in the difficult airway scenario significantly decreasing the pharyngolaryngeal morbidity. There is a plethora of these devices, which has been well matched by their wider acceptance in clinical practice. ProSeal laryngeal mask airway (PLMA) is one such frequently used device employed for spontaneous as well as controlled ventilation. However, the use of PLMA at times maybe associated with certain problems. Some of the problems related with its use are unique while others are akin to the classic laryngeal mask airway (cLMA). However, expertise is needed for its safe and judicious use, correct placement, recognition and management of its various malpositions and complications. The present article describes the tests employed for proper confirmation of placement to assess the ventilatory and the drain tube functions of the mask, diagnosis of various malpositions and the management of these aspects. All these areas have been highlighted under the heading of troubleshooting PLMA. Many problems can be solved by proper patient and procedure selection, maintaining adequate depth of anaesthesia, diagnosis and management of malpositions. Proper fixation of the device and monitoring cuff pressure intraoperatively may bring down the incidence of airway morbidity.
Airway management; Equipment; ProSeal laryngeal mask airway; Classic laryngeal mask airway; Troubleshooting
The laryngeal mask airway (LMA) is a supraglottic airway device designed to seal around the laryngeal inlet. A controlled study was designed to compare the effectiveness and complications in inserting the LMA when the cuff is fully deflated and partially inflated.
Materials and Methods
American Society of Anesthesiologists physical status I or II 172 female patients scheduled for gynecologic procedures were included in this study. Patients were randomly allocated into one of the two groups; fully deflated (n=86) and partially inflated group (n=86). A size #4 LMA was inserted. The number of attempts, time taken for successful insertion, grade of leak, grade of fiberoptic view, and complications were evaluated.
All 172 patients completed the study protocol. The number of attempts, time taken for successful insertion, and grade of leak were not significantly different between the two groups. The grade of fiberoptic view and complications were lower in the fully deflated group.
The fully deflated method is more accurate and safe because of better fiberoptic view and lesser complications than the partially inflated group.
Complication; laryngeal mask airway
A 13 year- old girl presented to the department with sternomental contractures as a result of facial burns from kerosene explosion. Difficult airway was envisaged. Over the period of time she developed sub-mental contracture with keloids; and was scheduled for release of contractures and flap closure.
Anaesthesia was induced with halothane and 100% oxygen. A size 3 laryngeal mask airway (LMA) was inserted and anaesthesia maintained with oxygen/nitrous oxide/halothane/muscle relaxant technique. The successful placement of LMA at 2nd attempt was aided by a surgical incision on the submental contracture. Blood loss was 600 mls and a unit of packed red blood cells was transfused. She made full recovery and was discharged home after 1 month.
Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process.
Materials and Methods:
30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place.
Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15).
In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.
Difficult; equipment; fiberoptic bronchoscope; intubation; laryngeal mask airway; modified oropharyngeal Guedel airway; tracheal
The i-gel™, LMA-Supreme (LMA-S) and Laryngeal Tube Suction-D (LTS-D) are single-use supraglottic airway devices with an inbuilt drainage channel. We compared them with regard to their position in situ as well as to clinical performance data during elective surgery.
Prospective, randomized, comparative study of three groups of 40 elective surgical patients each. Speed of insertion and success rates, leak pressures (LP) at different cuff pressures, dynamic airway compliance, and signs of postoperative airway morbidity were recorded. Fibreoptic evaluation was used to determine the devices’ position in situ.
Leak pressures were similar (i-gel™ 25.9, LMA-S 27.1, LTS-D 24.0 cmH2O; the latter two at 60 cmH2O cuff pressure) as were insertion times (i-gel™ 10, LMA-S 11, LTS-D 14 sec). LP of the LMA-S was higher than that of the LTS-D at lower cuff pressures (p <0.05). Insertion success rates differed significantly: i-gel™ 95%, LMA-S 95%, LTS-D 70% (p <0.05). The fibreoptically assessed position was more frequently suboptimal with the LTS-D but this was not associated with impaired ventilation. Dynamic airway compliance was highest with the i-gel™ and lowest with the LTS-D (p <0.05). Airway morbidity was more pronounced with the LTS-D (p <0.01).
All devices were suitable for ventilating the patients’ lungs during elective surgery.
German Clinical Trial Register DRKS00000760
Laryngeal mask airway; Leak pressure; Laryngeal Tube
The sniffing position is recommended for conventional laryngeal mask airway (LMA) insertion. However, there has been a high success rate of LMA insertion with the head in the neutral position. The effect of a difficult airway on the ease of LMA insertion is not clear. In this study, we compared the ease of LMA ProSeal™ (PLMA) insertion and the fiberoptic scoring according to the head position and the presence of a difficult airway.
After obtaining informed consent from the subjects, we enrolled 144 adult patients (age range: 18-65) with an ASA physical status 1 or 2. After evaluation of the airway, all the patients were grouped into the EA (easy airway) group (n = 68) and the DA (difficult airway) group (n = 76). According to the head position, each group was divided into the EA-SE (extension) group (n = 35), the EA-SN (sniffing) group (n = 33), the DA-SE group (n = 39) and the DA-SN group (n = 37). The success rate and insertion time at the first attempt were evaluated. The position of the PLMA was fiberoptically scored from the mask aperture of the airway tube in the original head position. After the head position was changed to the sniffing and neutral positions in the SE and SN group, respectively, the position of PLMA was re-evaluated fiberoptically.
The success rate and insertion time at the first attempt and the fiberoptic score showed no significant difference among the groups. After head position was changed, there were no significant changes in the fiberopitc scores.
A difficult airway and the head position had no influence on the ease of PLMA insertion and the fiberopic score. Therefore, the head position can be selected according to the individual patient's situation.
Diffcult airway; Laryngeal mask airway; Neutral position; Sniffing position
To compare two different supraglottic airway devices, the laryngeal mask airway (LMA) and the I-gel, regarding easiness of insertion of the device, leak pressure, gastric insufflation, end tidal CO2, oxygen saturation, hemodynamic and postoperative complications in anesthetized, spontaneously ventilated adult patients performing different non-emergency surgical procedures.
Materials and Methods:
The study was carried out as a prospective, randomized, clinical trial among 80 patients who underwent different surgical procedures under general anesthesia with spontaneous ventilation in supine position. They were equally randomized into two groups: I-gel and LMA groups. Both the devices were compared with regard to heart rate, arterial BP, SPO2, end-tidal CO2, number and duration of insertion attempts, incidence of gastric insufflation, leak pressure and airway assessment after removal of the device.
No statistically significant difference was reported between both the groups, regarding heart rate, arterial BP, SPO2 and end-tidal CO2. The mean duration of insertion attempts was 15.6±4.9 seconds in the I-gel group, while it was 26.2±17.7 seconds in the LMA group. The difference between both the groups regarding duration of insertion attempts was statistically significant (P=0.0023*), while the number of insertion attempts was statistically insignificant between both the study groups (P>0.05). Leak pressure was (25.6±4.9 vs. 21.2±7.7 cm H2O) significantly higher among studied patients of the I-gel group (P=0.016*) and the incidence of gastric insufflation was significantly more with LMA group 9 (22.5%) vs. I-gel group (5%) (P=0.016).
Both LMA and I-gel do not cause any significant alteration in the hemodynamic status of the patients, end tidal CO2, and SPO2. The postoperative complications were not significantly different except nusea and vomiting was statistically significant higher in LMA group (P=0.032). among both LMA and I-gel patients. Insertion of I-gel was significantly easier and more rapid than insertion of LMA. Leak pressure was significantly higher with I-gel than LMA and thus incidence of gastric insufflation was significantly lower with I-gel.
Classical laryngeal mask airway; I-gel; supraglottic airway devices
The standard recommended insertion technique for LMA Classic™ requires the insertion of index finger into the oral cavity. Several anesthesiologists are reluctant to do this. We conducted this study to evaluate the modified technique of insertion of LMA Classic™ (not requiring insertion of fingers into the patient's mouth) against the standard index finger insertion technique.
Materials and Methods:
This prospective, randomized, comparative study was conducted on 200 consenting patients. Patients suitable for anesthetic with LMA Classic™ were randomized to standard technique group (standard insertion technique) and modified technique group (technique not requiring digital intraoral manipulation). Laryngeal mask airway (LMA) was inserted by five designated anesthesiologists. Anesthetic protocol was standardized. Time taken to achieve an effective airway, ease of insertion, glottic view obtained through LMA, and incidence of sore throat were assessed.
Patient characteristics and duration of surgery were comparable between the groups. Time to achieve an effective airway was comparable [18.5 (8) s with standard technique and 19.7 (10) s with modified technique; data are mean (standard deviation)]. Ease of insertion (92 easy with standard technique and 91 easy with modified technique), success rate (99% in both the groups), glottic view with fiberoptic bronchoscope, and sore throat incidence (six patients with standard technique and eight patients with modified technique) were comparable. The first attempt success rate was significantly higher with the standard technique (98 patients in the standard technique group and 91 patients in the modified technique group).
LMA Classic™ can be inserted successfully without the need to insert index finger into patient's mouth, though the first attempt success rate is higher with the standard technique.
Insertion technique; LMA Classic™ Supraglottic device
To compare insertion characteristics of 2 different supraglottic devices [I-gel and Proseal laryngeal mask airway (PLMA)] and to observe any associated complications.
This prospective, randomized study was conducted in 80 patients [Group I - I-gel insertion (n = 40) and Group P - LMA Proseal insertion (n =40)] of ASA grades I/II, of either sex in the age group 18-65 years. Both groups were compared with respect to ease of insertion, insertion attempts, fiberoptic assessment, airway sealing pressure, ease of gastric tube placement, and other complications.
Materials and Methods:
All patients were asked to fast overnight. Patients were given alprazolam 0.25 mg orally at 10 p.m. the night before surgery and again 2 hours prior to surgery with 1-2 sips of water. Glycopyrrolate 0.2 mg, metoclopramide 10 mg, and ranitidine 50 mg were administered intravenously to the patients 45 minutes prior to the surgery. Once adequate depth of anesthesia was achieved either of the 2 devices, selected using a random computerized table, was inserted by an experienced anesthesiologist. In group I, I-gel was inserted and in patients of group P, PLMA was inserted.
Student t-test and Mann-Whitney test were employed to compare the means; for categorical variables, Chi-square test was used.
Mean insertion time for the I-gel (11.12 ± 1.814 sec) was significantly lower than that of the PLMA (15.13 ± 2.91 sec) (P = 0.001). I-gel was easier to insert with a better anatomic fit. Mean airway sealing pressure in the PLMA group (29.55 ± 3.53 cm H2O) was significantly higher than in the I-gel group (26.73 ± 2.52 cm H2O; P = 0.001). Ease of gastric tube insertion was significantly higher in the I-gel group (P = 0.001). Incidence of blood staining of the device, sore throat and dysphagia were observed more in PLMA group. No other complications were observed in either of the groups.
Airway sealing; cuff pressure; fiberoptic; I-gel; insertion; leak; proseal laryngeal mask airway
Modern anaesthesia practice in children was made possible by the invention of the endotracheal tube (ET), which made lengthy and complex surgical procedures feasible without the disastrous complications of airway obstruction, aspiration of gastric contents or asphyxia. For decades, endotracheal intubation or bag-and-mask ventilation were the mainstays of airway management. In 1983, this changed with the invention of the laryngeal mask airway (LMA), the first supraglottic airway device that blended features of the facemask with those of the ET, providing ease of placement and hands-free maintenance along with a relatively secure airway. The invention and development of the LMA by Dr. Archie Brain has had a significant impact on the practice of anaesthesia, management of the difficult airway and cardiopulmonary resuscitation in children and neonates. This review article will be a brief about the clinical applications of supraglottic airways in children.
Difficult airway; laryngeal mask airway; paediatric airway; proseal laryngeal mask airway; supraglottic airways
The I-gel™ is a single-use supraglottic airway device introduced in 2007 which features a non-inflatable cuff and allows passage of a tracheal tube owing to its large diameter and short length of the airway tube. In this case, the authors experienced a difficult airway management on a 4-year-old boy with underlying Goldenhar syndrome who underwent a tonsillectomy. Intubation using a laryngoscope was unsuccessful at the first attempt. In the following attempt, we used the I-gel™ supraglottic airway for ventilation and were able to achieve successful intubation with a cuffed tube by using fiberoptic bronchoscope through the I-gel™ supraglottic airway. The authors suggest that I-gel™ is a useful device for ventilation and it has many advantages for tracheal intubation in pediatric patients with difficult airway.
Airway management; Fiberoptic bronchoscope; Goldenhar syndrome; Laryngeal mask airway; Pediatric
Background and Aim:
Exchanging endotracheal tube (ETT) with classic laryngeal mask airway™ (CLMA™) prior to emergence from anaesthesia is a safe technique to prevent the coughing and haemodynamic changes during extubation. We had compared CLMA™ and AMBU laryngeal mask™ (ALM™) during ETT/laryngeal mask (LM) for haemodynamic changes and other parameters.
A total of 100 American Society of Anesthesiologist Grade I and II adult female patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were selected and randomly divided into two groups of 50 patients each. In Group I, CLMA™ and in Group II, ALM™ was placed prior to tracheal extubation. Haemodynamic parameters were recorded during ETT/LM exchange. Glottic view was seen through the LM using flexible fibrescope. Coughing/bucking during removal of LM, ease of placement and post-operative sore throat for both groups were graded and recorded.
Data within the groups was analysed using paired t-test while between the groups was analysed using unpaired t-test. Chi-square test was used to analyse grades of glottic view, coughing, and post-operative sore throat.
In Group I, there was a significant rise in systolic blood pressure and heart rate in contrast to insignificant rise in Group II. Glottis view was significantly better in Group II. Incidence of coughing, ease of placement and post-operative sore throat was identical between both groups.
ALM™ is superior to CLMA™ for exchange of ETT before extubation due to greater haemodynamic stability during exchange phase and is better positioned.
Ambu laryngeal mask™; classic laryngeal mask airway™; endotracheal tube; extubation
The laryngeal mask airway (LMA) is a supraglottic airway management device. The LMA is preferred for airway management in paediatric patients for short duration surgical procedures. The recently introduced ProSeal (PLMA), a modification of Classic LMA, has a gastric drainage tube placed lateral to main airway tube which allows the regurgitated gastric contents to bypass the glottis and prevents the pulmonary aspiration. This study was done to compare the efficacy of ProSeal LMA with an endotracheal tube in paediatric patients with respect to number of attempts for placement of devices, haemodynamic responses and perioperative respiratory complications. Sixty children, ASA I and II, weighing 10-20 kg between 2 and 8 years of age group of either sex undergoing elective ophthalmological and lower abdominal surgeries of 30-60 min duration, randomly divided into two groups of 30 patients each were studied. The number of attempts for endotracheal intubation was less than the placement of PLMA. Haemodynamic responses were significantly higher (P<0.05) after endotracheal intubation as compared to the placement of PLMA. There were no significant differences in mean SpO2 (%) and EtCO2 levels recorded at different time intervals between the two groups. The incidence of post-operative respiratory complications cough and bronchospasm was higher after extubation than after removal of PLMA. The incidence of soft tissue trauma was noted to be higher for PLMA after its removal. There were no incidences of aspiration and hoarseness/sore throat in either group. It is concluded that ProSeal LMA can be safely considered as a suitable and effective alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.
ET tube; haemodynamic response; PLMA
ProSeal Laryngeal Mask Airway (PLMA) is extensively being used in pediatric anesthesia.
To evaluate the efficacy of PLMA as compared to Classic Laryngeal Mask Airway (CLMA) for airway maintenance in pediatric patients.
Settings and Design:
A prospective, randomized, Single-blinded study was conducted in a tertiary care teaching hospital.
Materials and Methods:
Sixty ASA I and II children were included. Patients were randomized to either size 2 PLMA or size 2 CLMA groups. Parameters noted were time for insertion, number of attempts, airway sealing pressure, blood pressures (systolic, diastolic, and mean), pulse rate, end-tidal carbon dioxide (EtCO2), peripheral oxygen saturation (SpO2), and postoperative change in abdominal circumference, and airway trauma.
Statistical analysis used:
Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the chi-square (χ2) test. Unless otherwise stated, data are presented as mean (SD). Significance was taken as P < 0.05.
There was no statistical difference between the two groups for the success rates at the first attempt of insertion, airway sealing pressure, hemodynamic responses, SpO2, EtCO2 and postoperative changes in abdominal circumference. Patients in the PLMA group had longer time of insertion and higher incidence of airway trauma.
The PLMA and the CLMA were comparable for hemodynamic and ventilatory parameters and change in abdominal circumference; however, the time taken for insertion and airway trauma was more with PLMA.
Classic laryngeal mask airway; pediatric patients; ProSeal laryngeal mask airway
Supraglottic airway devices have frequently been shown to facilitate airway management and are implemented in the ILCOR resuscitation algorithm. Limited data exists concerning laypersons without any medical or paramedical background. We hypothesized that even laymen would be able to operate supraglottic airway devices after a brief training session.
Four different supraglottic airway devices: Laryngeal Mask Classic (LMA), Laryngeal Tube (LT), Intubating Laryngeal Mask (FT) and CobraPLA (Cobra) were tested in 141 volunteers recruited in a technical university cafeteria and in a shopping mall. All volunteers received a brief standardized training session. Primary endpoint was the time required to definitive insertion. In a short questionnaire applicants were asked to assess the devices and to answer some general questions about BLS.
The longest time to insertion was observed for Cobra (31.9 ± 27.9 s, range: 9-120, p < 0.0001; all means ± standard deviation). There was no significant difference between the insertion times of the other three devices. Fewest insertion attempts were needed for the FT (1.07 ± 0.26), followed by the LMA (1.23 ± 0.52, p > 0.05), the LT (1.36 ± 0.61, p < 0.05) and the Cobra (1.45 ± 0.7, p < 0.0001). Ventilation was achieved on the first attempt significantly more often with the FT (p < 0.001) compared to the other devices. Nearly 90% of the participants were in favor of implementing supraglottic airway devices in first aid algorithms and classes.
Laypersons are able to operate supraglottic airway devices in manikin with minimal instruction. Ventilation was achieved with all devices tested after a reasonable time and with a high success rate of > 95%. The use of supraglottic airway devices in first aid and BLS algorithms should be considered.
Airway management of patients with very limited mouth opening remains a challenge for the anaesthetist. We describe the use of the Bonfils Intubation Fiberscope for awake intubation in two patients with a very limited mouth opening. In the first case, a 60-year-old 80 kg female, scheduled for a right modified radical mastectomy for infiltrating ductal carcinoma (15 mm mouth opening, a short thick neck, limited neck extension, and a Mallampati class 4 airway), the Bonfils was advanced via the retromolar technique. In the second patient, a 34-year-old male, scheduled for a surgical tracheotomy for right tonsillar cancer, due to a neoplastic infiltration of the right temporomandibular joint (7 mm mouth opening and limited neck movement), the Bonfils was advanced using the midline approach. The Bonfils is a reusable, rigid, straight fiberoptic device with a curved tip, is 5 mm in diameter, and has several advantages: it is quick and easy to use, more cost effective than a flexible fiberscope, and is safe in expert hands, thanks to its smaller diameter. Our conclusion is that awake BIF intubation is a reliable, atraumatic, and well-tolerated procedure to secure a safe airway in patients with a limited mouth opening.
Currently, the role of ultrasound (US) in anaesthesia-related airway assessment and procedural interventions is encouraging, though it is still ill defined. US can visualise anatomical structures in the supraglottic, glottic and subglottic regions. The floor of the mouth can be visualised by both transcutaneous view of the neck and also by transoral or sublinguial views. However, imaging the epiglottis can be challenging as it is suspended in air. US may detect signs suggestive of difficult intubation, but the data are limited. Other possible applications in airway management include confirmation of correct endotracheal tube placement, prediction of post-extubation stridor, evaluation of soft tissue masses in the neck prior to intubation, assessment of subglottic diameter for determination of paediatric endotracheal tube size and percutaneous dilatational tracheostomy. With development of better probes, high-resolution imaging, real-time picture and clinical experience, US has become the potential first-line noninvasive airway assessment tool in anaesthesia and intensive care practice.
Airway; ultrasonography; upper respiratory tract
Laryngeal mask airway (LMA) C Trach is a novel device designed to intubate trachea without conventional laryngoscopy. The aim of the study was to evaluate the clinical efficacy of C trach in the simulated scenario of cervical spine injury where conventional laryngoscopy is not desirable.
This prospective pilot study was carried out in 30 consenting adults of either gender, ASAPS I or II, scheduled for surgery requiring endotracheal intubation. An appropriate sized rigid cervical collar was positioned around the patient's neck to restrict the neck movements and simulate the scenario of cervical spine injury. After induction of anesthesia, various technical aspects of C Trach facilitated endotracheal intubation, changes in hemodynamic variables, and complications were recorded.
Mask ventilation was easy in all the patients. Successful insertion of C Trach was achieved in 27 patients at first attempt, while 3 patients required second attempt. Majority of patients required one of the adjusting maneuvers to obtain acceptable view of glottis (POGO score >50%). Intubation success rate was 100% with 26 patients intubated at first attempt and the rest required second attempt. Mean intubation time was 69.8±27.40 sec. With experience, significant decrease in mean intubation time was observed in last 10 patients as compared to first 10 (46±15.77 sec vs. 101.3±22.91 sec). Minor mucosal injury was noted in four patients.
LMA C Trach facilitates endotracheal intubation under direct vision and can be a useful technique in patients with cervical spine injury with cervical collar in situ.
Cervical spine injury; cervical collar; laryngeal mask airway C Trach
We compared the usefulness of the laryngeal tube (LT) with the intubating laryngeal mask airway (ILMA) in 51 patients whose necks were stabilised by manual in-line traction. After induction of anaesthesia and neuromuscular block, the LT and ILMA were inserted consecutively in a randomised, crossover design. During pressure-controlled ventilation (20 cmH2O inspiratory pressure), we measured insertion attempts, time to establish positive-pressure ventilation, tidal volume, gastric insufflation, and minimum airway pressure at which gas leaked around the cuff. Data were compared using Wilcoxon signed-rank tests; P<0.05 was considered significant. Insertion was more difficult with the LT (successful at first attempt in 16 patients) than with the ILMA (successful at first attempt in 42 patients, P<0.0001). Time required for insertion was longer for the LT (28 [23–35] sec, median [interquartile range]) than the ILMA (20 [15–25] sec, P=0.0009). Tidal volume was less for the LT (440 [290–670] ml) than the ILMA. (630 [440–750] ml, P=0.013). Minimum airway pressure at which gas leak occurred and incidence of gastric insufflation were similar with two devices. In patients whose necks were stabilised with manual in-line traction, insertion of the ILMA was easier and quicker than insertion of the LT and tidal volume was greater with the ILMA than the LT.
Anaesthesia; equipment; airway; intubating laryngeal mask airway; laryngeal tube; cervical spine immobilization
The Laryngeal Mask Airway (LMA) is a frequently-used efficient airway device, yet it sometimes seals poorly, thus reducing the efficacy of positive-pressure ventilation. The Perilaryngeal Airway (CobraPLA) is a novel airway device with a larger pharyngeal cuff (when inflated). We tested the hypothesis that the CobraPLA was superior to LMA with regard to insertion time and airway sealing pressure and comparable to LMA in airway adequacy and recovery characteristics. After midazolam and fentanyl, 81 ASA I-II outpatients having elective surgery were randomized to receive an LMA or CobraPLA. Anesthesia was induced with propofol (2.5 mg/kg, IV), and the airway inserted. We measured 1) insertion time; 2) adequacy of the airway (no leak at 15-cm-H2O peak pressure or tidal volume of 5 ml/kg); 3) airway sealing pressure; 4) number of repositioning attempts; and 5) sealing quality (no leak at tidal volume of 8 ml/kg). At the end of surgery, gastric insufflation, postoperative sore throat, dysphonia, and dysphagia were evaluated. Data were compared with unpaired t-tests, chi-square tests, or Fisher’s Exact tests; P<0.05 was significant. Patient characteristics, insertion times, airway adequacy, number of repositioning attempts, and recovery were similar in each group. Airway sealing pressure was significantly greater with CobraPLA (23±6 cm H2O) than LMA (18±5 cm H2O, P<0.001). The CobraPLA has insertion characteristics similar to LMA, but better airway sealing capabilities.
Airway: Sealing. Cuff Pressure. Insertion. Leak. Pharynx; Equipment: Laryngeal mask airway. Perilaryngeal airway; Ventilation: Controlled. Spontaneous; Anesthesia
The newest variation of i-gel is its pediatric version. This novel supraglottic airway device has the added advantage of a drain tube. In this study, we compared the effectiveness of size 2.5 i-gel with size 2.5 ProSeal LMA.
This study was designed to investigate the usefulness of the size 2.5 i-gel compared with the ProSeal laryngeal mask airway (PLMA) of the same size in anesthetized, paralyzed children.
Materials and Methods:
Sixty ASA grade I – II patients undergoing elective surgery were included in this prospective study and were randomly assigned to the i-gel and PLMA groups (30 patients in each group). A size 2.5 supraglottic airway was inserted according to the assigned group. We assessed the ease of insertion, hemodynamic data, oropharyngeal sealing pressure, and postoperative complications.
There were no differences in the demographic and hemodynamic data, success rates for the first attempt of insertion, or postoperative airway morbidity among the two groups. The airway leak pressure of the i-gel group (27.12 ± 1.69 cm H2O) was significantly higher than that of the PLMA group (22.75 ± 1.46 cm H2O).
Hemodynamic parameters, ease of insertion and postoperative complications were comparable between the i-gel and PLMA, but the nairway sealing pressure was significantly higher in the i-gel group.
I-gel; Pediatric patients; ProSeal laryngeal mask airway