Adult Airway Management Research Articles

Endotracheal Intubation Versus Supraglottic Airway for Airway Management in Adults with Out-of-hospital Cardiac Arrest: A Systematic Review and Meta-analysis

Endotracheal Intubation Versus Supraglottic Airway for Airway Management in Adults with Out-of-hospital Cardiac Arrest: A Systematic Review and Meta-analysis

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in adults

Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available.

No: 3572 Comparison of direct and indirect images of two different video laryngoscopes in adult airway management

No: 3572 Comparison of direct and indirect images of two different video laryngoscopes in adult airway management

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Difficult Airway Management in Adults With Recessive Dystrophic Epidermolysis Bullosa: A Case Series.

Airway management of adult patients with recessive dystrophic epidermolysis bullosa presents significant challenges associated with tissue fragility and distortion of airway anatomy. This retrospective case series describes 11 adult patients with recessive dystrophic epidermolysis bullosa and difficult airways undergoing 24 general anesthetics in which transnasal humidified rapid-insufflation ventilatory exchange was used for preoxygenation and apneic oxygenation. Despite an average time to intubation of over 6 minutes, transnasal humidified rapid-insufflation ventilatory exchange provided oxygenation before endotracheal intubation without the need for bag-mask ventilation or supraglottic airway ventilation, facilitating smooth and atraumatic flexible scope intubation. There were no major adverse events.

Comparison of the clinical performance of the i-gelTM, LMA SupremeTM, and Ambu AuraGainTM in adult patients during general anesthesia: a prospective and randomized study.

BackgroundSupraglottic airway devices (SADs) are routinely used for securing the airway. In this study, the clinical performance of three SADs in adult patients under general anesthesia was compared.MethodsAmerican Society of Anesthesiologists physical status I–III subjects were randomly assigned to the i-gelTM (I), LMA SupremeTM (L), or Ambu AuraGainTM (A) group (30 per group). The primary objective of this study was to compare insertion times. Additionally, the ease of insertion, number of attempts, oropharyngeal leak pressure (OLP), airway maneuver requirement, difficulty with gastric tube placement, and complications were assessed.ResultsDemographic data did not differ between the groups. Group I (16.9 ± 4.9 s) had a significantly shorter time of insertion than Group L (19.6 ± 5.2 s) and Group A (22.1 ± 5.7 s) (P = 0.001). The OLP for Group A (29.8 ± 3.0 cmH2O) was higher than those for Group L (24.1 ± 6.3 cmH2O) and Group I (9.4 ± 6.1 cmH2O) (P < 0.001). The number of insertion attempts (P = 0.232), ease of insertion (P = 0.630), airway maneuver requirement (P = 0.585), difficulty with gastric tube placement (P = 0.364), and complications (P = 0.873) were not significantly different between the groups.ConclusionsAll three devices are convenient and effective for airway management in adults under general anesthesia. However, the shorter insertion time required for the i-gel may make it more suitable for resuscitation and emergencies, while aspiration risk may be reduced with the Ambu AuraGain, given its high OLP.

Plastic Screen Versus Aerosol Box as a Barrier During Endotracheal Intubation

Abstract Background: The severe acute respiratory syndrome coronavirus-2-2019 pandemic has posed significant challenges and barrier devices such as aerosol/intubation box, intubation tent, and intubation screen have been widely used during endotracheal intubation by the clinicians without any definite proven benefit. The initial experience at our institute with the intubation box posed some difficulties leading to failed intubations. Hence, as an alternative, we switched to a transparent plastic intubation screen that is likely to provide better vision and space during intubation. We evaluated the impact of intubation box and plastic screen on intubations in this simulation-based crossover study. Materials and Methods: Ten anesthesiologists performed 90 intubations in an operating room on a Laerdal® adult airway management trainer. Each participant performed 9 intubations, 3 without any barrier and 3 each with intubation box and plastic screen. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. Results: Intubation time with no barrier was significantly shorter than with the intubation box (median interquartile range [IQR]: 25 [22–28] vs. 40 [30–51] s, P &lt; 0.001) and with the screen (median [IQR] 29 [25–35] s, P = 0.015). The intubation time was significantly lesser with the screen compared to the box (P = 0.023). The first-pass success was 86.66%, 96.66%, and 100% in the box, screen, and no barrier groups, respectively. Conclusion: In comparison to an intubation box, the transparent plastic screen decreases intubation times and has greater operator comfort. These devices require further evaluation for patient safety.

Standalone use of Laryngeal mask airway supreme for primary airway management in adults undergoing laparoscopic surgeries: A prospective observational study

Background: Laryngeal mask airway (LMA) does not provide definitive airway protection from pulmonary aspiration of potential regurgitated gastric contents. LMA supreme, a recent supraglottic (extraglottic) airway device, shows promising results. Thus, aim of study to evaluate the role of supreme laryngeal mask airway (SLMA) in airway management of patients operated with laparoscopic procedures under general Anaesthesia. Methods: The prospective observational study comprised of 274 patients of ASA grade 1 and 2 scheduled for short elective laparoscopic procedures (&lt;1hr.30min) who provided consent. Patients were anaesthetised according to standard protocol, appropriate size of SLMA was chosen and inserted; and complications were noted. Post SLMA removal, recovery and trauma of throat were noted. Postoperative complications such as nausea, vomiting, and throat pain were noted. Binary logistic regression model and Chi-square test of association was performed to analyse data (P&lt;0.05). Results: Most participants were female (n=260) with mean age of 31.42±7.24 years. Mean duration of surgery and recovery time was 37.3±5.84 min and 5.85±1.93 min respectively. SLMA size 3 was commonly used (n=245) and majority of insertions were successful in the first attempt (n=244). Post insertion, SLMA had adequate length (n=208) Throat pain (n=37) and vomiting (n=38) were common post-operative complications observed in the patients. A significant association was observed between operative procedure and complication (P=0.0004) and number of attempts (P=0.0004) with trauma being significant (P=0.0039). Trauma was associated with gender (P=0.08) and body weight (P=0.006). Conclusion: SLMA can be used as a standalone supraglottic (extraglottic) airway device for airway management in laparoscopic surgeries.

Anesthesiologists' airway management expertise: Identifying subjective and objective knowledge gaps.

Failure in airway management continues to cause preventable patient harm, and the recommended continuing education is challenged by anesthesiologists' unknown knowledge gaps. This study aimed to identify anesthesiologists' subjective and objective knowledge gaps as well as areas where anesthesiologists are incorrect and unaware. An adaptive E-learning program with 103 questions on adult airway management was used for subjective and objective assessment of anesthesiologists' knowledge. All anesthesiologists in the Capital Region of Denmark were invited to participate. The response rate was 67% (191/285). For preoperative planning, participants stated low confidence (subjective assessment) regarding predictors of difficult airway management in particular (69.1%-79.1%). Test scores (objective assessment) were lowest for obstructive sleep apnea as a predictor of difficult airway management (28.8% correct), with participants being incorrect and unaware in 33.5% of the answers. For optimization of basic techniques, the lowest confidence ratings related to patient positioning and prediction of difficulties (57.4%-83.2%), which agreed with the lowest test scores. Concerning advanced techniques, videolaryngoscopy prompted the lowest confidence (72.4%-85.9%), while emergency cricothyrotomy resulted in the lowest test scores (47.4%-67.8%). Subjective and objective assessments correlated and lower confidence was associated with lower test scores: preoperative planning [r=-.58, P<.001], optimization of basic techniques [r=-.58, P=.002], and advanced techniques [r=-.71, P<.001]. We identified knowledge gaps in important areas of adult airway management with differing findings from the subjective and objective assessments. This underlines the importance of objective assessment to guide continuing education.

Methodological quality and transparency of clinical practice guidelines for difficult airway management using the appraisal of guidelines research & evaluation II instrument: A systematic review.

Complications arising from airway management represent an important cause of morbidity and mortality. Clinical practice guidelines (CPGs) are systematically created documents that summarise knowledge and assist the delivery of high-quality medical care by identifying evidence that supports best clinical care. Using the Appraisal of Guidelines for Research & Evaluation II instrument, we aimed to evaluate the methodological rigour and transparency of unanticipated difficult airway management CPGs in adults. Using PUBMED without language restrictions, we identified eligible CPGs between 1 January 1996 and 30 June 2019. All versions of a CPG were included as independent guidelines to assess improvements over time or the methodological limitations of each version. CPGs-related obstetrics or paediatrics or the management extubation in cases of difficult airway were excluded. Fourteen CPGs were included. Of the six domains suggested by the Appraisal of Guidelines for Research & Evaluation II instrument, 'applicability' had the lowest score (23%) and 'scope and objectives' had the highest score (88%). The remaining domains (stakeholder involvement, editorial independence, rigour of development and clarity of presentation) had scores ranging between 56 and 81%. Overall, the highest scored CPG was the Difficult Airway Society 2015. Future updates of CPGs for difficult airway management in adults and severely ill patients should consider more emphasis on the applicability of their recommendations to real clinical practice.

The impact of a checklist on the short-term complications of airway management in adults

Introduction: Airway management is an integral part of general anaesthesia, which may lead to severe short- and long-term complications. Aim: We assessed whether the application of a checklist for the steps of airway management reduces the number of complications in our institute. Method: In our observational, prospective, controlled study we made a checklist and a data collection sheet. Each airway management was performed for one month without the checklist and then for one month in the possession of the checklist. We evaluated the outcome of airway maneuvers and the occurrence of related early complications before and after the introduction of the checklist. The primary endpoint was the incidence of unexpected difficult airway. The secondary endpoints were difficult intubation, successful first intubation, aspiration, cardiac arrest, post-induction hypotension and desaturation, soft tissues/teeth injuries. Our results were also corrected for factors that affect the risk of complications (urgency of interventions, medical experience). Results: We did not find any difference in the frequency of acute complications before the introduction of the checklist (n = 439) and during the subsequent period (n = 423). At the primary endpoint (7.29% and 6.14%), there was no substantive difference (1.15%, 95% CI: -2.26%-4.56%, p = 0.5). No differences were found regarding the secondary and other endpoints. Following the correction of risk factors, there was no impact of the checklist on the incidence of complications. Conclusion: The introduction of the checklist in itself did not result in a significant change in the risk of short-term complications of airway management in our institution. Orv Hetil. 2019; 160(26): 1025-1035.

Comparative evaluation of CMAC and Truview picture capture device for endotracheal intubation in neonates and infants undergoing elective surgeries: A prospective randomized control trial.

Videolaryngoscopy has an established role in difficult airway management in adults. However, there is limited literature to support their efficacy in children. The Truview PictureCapture Device has shown promising results for endotracheal intubation in infants in the past. The CMAC videolaryngoscope has launched its novel infant Miller blade, but its performance has not been assessed clinically for routine intubation in infants and neonates. We hypothesized that the CMAC videolaryngoscope would reduce the total time to intubation as compared to the Truview PictureCapture Device in neonates and infants. After parental informed consent, 80 prospective infants posted for surgical procedures under general anesthesia were randomized to undergo intubation with either of the two. The two videolaryngoscopes were also compared in terms of time required for glottis view and intubation (primary outcome), modified Cormack and Lehane grade, first attempt and overall success rate, ease of intubation, number of attempts, and any complications. The CMAC significantly reduced the time required for glottic view [8s (5.25-9) vs 9s (6.5-12); P=0.02] and intubation [22s (18-26) vs 26s (21.5-32); P=0.003]. The median difference (95% CI) for time to tracheal intubation and time to glottic view was 4s (1-7) and 1 (0-4). It also improved the ease of intubation, the Cormack-Lehane grades, and first attempt success rate. Intubation with the CMAC was possible in 100% cases, whereas only 92.5% of patients could be intubated with the Truview. The failed intubations with the Truview could be successfully intubated with the CMAC. The CMAC Miller blade reduced the total time taken for tracheal intubation and intubation difficulty as compared to the Truview PictureCapture Device and may be a better tool for intubation in infants.

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature.

The C-MAC videolaryngoscope is the first Macintosh-typed videolaryngoscope. Since the advent of its original version video Macintosh system in 1999, this device has been modified several times. A unique feature of C-MAC device is its ability to provide the 2 options of direct and video laryngoscopy with the same device. The available evidence shows that in patients with normal airways, C-MAC videolaryngoscope compared with direct laryngoscopy can provide comparable or better laryngeal views and exerts less force on maxillary incisors, but does not offer conclusive benefits with regard to intubation time, intubation success, number of intubation attempts, the use of adjuncts, and hemodynamic responses to intubation. In patients with predicted or known difficult airways, C-MAC videolaryngoscope can achieve a better laryngeal view, a higher intubation success rate and a shorter intubation time than direct laryngoscopy. Furthermore, the option to perform direct and video laryngoscopy with the same device makes C-MAC videolaryngoscope exceptionally useful for emergency intubation. In addition, the C-MAC videolaryngoscope is a very good tool for tracheal intubation teaching. However, tracheal intubation with C-MAC videolaryngoscope may occasionally fail and introduction of C-MAC videolaryngoscope in clinical practice must be accompanied by formal training programs in normal and difficult airway managements.

Laryngeal mask airway ProSeal provides higher oropharyngeal leak pressure than i-gel in adult patients under general anesthesia: a meta-analysis

Study Objectivei-gel is a single-use supraglottic airway device that has a gastric drain tube similar to laryngeal mask airway (LMA) ProSeal. Randomized trials, when compared i-gel with LMA ProSeal, reported a differing results. Primary objective of this study is to compare LMA ProSeal and i-gel in terms of oropharyngeal leak pressure. DesignMeta-analysis of randomized controlled trials where i-gel has been compared to LMA ProSeal in adult airway management during general anesthesia. SettingTeaching institutions. MeasurementsPubMed, PubMed Central, and Cochrane databases were searched with search words “i-gel,” “i-gel laryngeal mask airway,” “i-gel ProSeal,” and “i-gel LMA ProSeal” to find out the randomized controlled trials that compared i-gel with LMA ProSeal in terms of safety and efficacy. A total of 10 prospective randomized trials have been included in this meta-analysis. Main ResultsLMA ProSeal provides higher oropharyngeal leak pressure than i-gel (mean difference, 3.37 cm H2O; 95% confidence interval, 1.80-4.95 cm H2O; P< .0001). Time to insert the device, first insertion success rate, and ease of gastric tube insertion are similar with both the devices, but i-gel may be easier to insert. Although the reported complications are not frequent and not very serious, a significantly higher blood staining on the mask has been noted with LMA ProSeal (odds ratio, 0.27; 95% confidence interval, 0.13-0.56; P= .0004). ConclusionLMA ProSeal may still remain the supraglottic device of choice over i-gel in adult patients during general anesthesia as it provided better seal against leak pressure with comparable device insertion characteristics.

Prehospital Airway Management in Adults: Is Intubation the Best Strategy?

Prehospital endotracheal intubation is performed for adult patients with out-of-hospital cardiac arrest in most U.S. emergency medical systems (EMS),

Comparison of Direct and Video Assisted Views of the Larynx during Routine Intubation in Infants and Children

Purpose: Video assisted laryngoscopy has been rapidly incorporated into the anesthesiologist’s arsenal for challenging adult airway management. The development of pediatric video airway equipment presents an opportunity to expand upon the previous reliance on direct laryngoscopy alone. This study utilized the Storz DCI® Video Laryngoscope which consists of a standard straight 0 and 1 blade combined with a 2.8 mm fiberoptic light bundle built into the left side of the blade. Method: The ease of use, best direct and video-assisted glottic view was documented for 50 infants and children less than 2 years of age. Direct laryngoscopy was performed with the naked eye (direct view). The best views obtained with and without external laryngeal manipulation were graded by the laryngoscopist without looking at the video monitor. The views on the video monitor, located in front of the intubator and to the right of the patient, were simultaneously graded independently by another pediatric anesthesiologist. Results: Fifty infants and children, ages ranging from one day to 22 months, were enrolled in the study. There were 37 males, and 13 females. The average age was 10.5 months. ASA physical status ranged from I to III, with the vast majority of patients being either class I or II. The grade of laryngeal view on the video monitor was significantly improved when compared with that of direct laryngoscopy (p<0.05). Conclusion: In our study the view on the monitor screen was, on average, one grade better than the direct view. In only one instance was the view obtained with the video laryngoscope worse than that obtained under direct vision. The magnified view provided by the video laryngoscope allows for better visualization of airway structures in difficult airways and further help in facilitating securing the airway.

Video‐laryngoscopes in the adult airway management: a topical review of the literature

The aim of the present paper is to review the literature regarding video-laryngoscopes (Storz V-Mac and C-Mac, Glidescope, McGrath, Pentax-Airway Scope, Airtraq and Bullard) and discuss their clinical role in airway management. Video-laryngoscopes are new intubation devices, which provide an indirect view of the upper airway. In difficult airway management, they improve Cormack-Lehane grade and achieve the same or a higher intubation success rate in less time, compared with direct laryngoscopes. Despite the very good visualization of the glottis, the insertion and advancement of the endotracheal tube with video-laryngoscopes may occasionally fail. Each particular device's features may offer advantages or disadvantages, depending on the situation the anaesthesiologist has to deal with. So far, there is inconclusive evidence indicating that video-laryngoscopy should replace direct laryngoscopy in patients with normal or difficult airways.

Spotlight on Research

Tracheal intubation with a cuffed tube is considered the definitive method of airway management in adults, but if the cuff pressure is above 30 cm of water, then the blood flow to the tracheal mucosa can become restricted—causing complications such as ulceration and ischaemia.

Airway Management in Adults After Cervical Spine Trauma

Airway Management in Adults After Cervical Spine Trauma

ERRATUM

The American Society of Anesthesiologists has withdrawn Question #4 from the June 2006 Journal CME (Anesthesiology 2006;104:1359–60). Editorial review of the article by Crosby, entitled “Airway Management in Adults after Cervical Spine Trauma” (Anesthesiology 2006;104:1293–318), did not yield agreement with the answers provided as possible choices. Therefore, the question is eliminated. Subscribers to June 2006 Journal CME will be given credit based on the elimination of Question #4. One credit CME will be awarded for June 2006 Journal CME as modified to six questions.

Airway Management in Adults after Cervical Spine Trauma

Cervical spinal injury occurs in 2% of victims of blunt trauma; the incidence is increased if the Glasgow Coma Scale score is less than 8 or if there is a focal neurologic deficit. Immobilization of the spine after trauma is advocated as a standard of care. A three-view x-ray series supplemented with computed tomography imaging is an effective imaging strategy to rule out cervical spinal injury. Secondary neurologic injury occurs in 2-10% of patients after cervical spinal injury; it seems to be an inevitable consequence of the primary injury in a subpopulation of patients. All airway interventions cause spinal movement; immobilization may have a modest effect in limiting spinal movement during airway maneuvers. Many anesthesiologists state a preference for the fiberoptic bronchoscope to facilitate airway management, although there is considerable, favorable experience with the direct laryngoscope in cervical spinal injury patients. There are no outcome data that would support a recommendation for a particular practice option for airway management; a number of options seem appropriate and acceptable.