Alternative Airway Management Technique Research Articles

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care.

Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings. We conducted a market review of 25 SGA devices that may meet inclusion into the medics' aid bag. The company's official "Instructions for Use" document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device. Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device's features, indications, and contraindications based on the manufacturer's product information documentation. There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

Emergency Airway Management During Awake Craniotomy: Comparison of 5 Techniques in a Cadaveric Model.

During awake craniotomy, securing the patient's airway might be necessary electively or emergently. The objective of this study was to compare the feasibility of airway management using a laryngeal mask airway (LMA) and 4 alternative airway management techniques in an awake craniotomy simulation. After completing a questionnaire, 9 anesthesia providers attempted airway management in a cadaver positioned to simulate awake craniotomy conditions. Following the simulation, participants rated and ranked the devices in their order of preference. Only 3 approaches resulted in the successful securement of an airway device for 100% of participants: LMA (median; interquartile range time to secure the airway 6 s, 5 to 10 s), fiberoptic bronchoscopy through an LMA (41 s; 23 to 51 s), and video laryngoscopy (49 s; 43 to 127 s). In contrast, the oral and nasal fiberoptic approaches demonstrated only 44.4% (154.5 s; 134.25 to 182 s) and 55.6% (75 s; 50 to 117 s) success rates, respectively. The LMA was the fastest and most reliable primary method to secure the airway (P=0.001). After the simulation, 100% of participants reported that an LMA would be their first choice for emergency airway management, followed by fiberoptic intubation through the LMA (7 of 9 participants) if the LMA failed to properly seat. We demonstrated that an LMA was the fastest and most reliable primary method to secure an airway in a laterally positioned cadaver with 3-pin skull fixation. Fiberoptic and video laryngoscope airway equipment should be readily available during awake craniotomy procedures, and an attempt to visualize the vocal cords through the LMA should be attempted before removing it for alternative techniques.

Comparison of Supreme laryngeal mask airway versus endotracheal intubation for airway management during general anesthesia for cesarean section: a randomized controlled trial

BackgroundThe obstetric airway is a significant cause of maternal morbidity and mortality. Endotracheal intubation is considered the standard of care but the laryngeal mask airway (LMA) has gained acceptance as a rescue airway and has been incorporated into the obstetric airway management guidelines. In this randomized controlled equivalence trial, we compared the Supreme LMA (SLMA) with endotracheal intubation (ETT) in managing the obstetric airway during cesarean section.MethodsParturients who underwent elective cesarean section under general anesthesia were randomized to receive either an SLMA or ETT as their airway device. Our primary outcome was first-attempt insertion success. Successful insertion was defined as adequate bilateral air entry with auscultation and the presence of end-tidal carbon dioxide on the capnogram. The first-attempt insertion success rate was compared using the Chi-Square test. Secondary outcomes included time-to-ventilation, seal pressure, ventilation/hemodynamic parameters, occurrence of clinical aspiration, fetal outcomes, and maternal side effects associated with the airway device.ResultsWe recruited 920 parturients (460 SLMA, 460 ETT) who underwent elective cesarean section under general anesthesia. Patient characteristics were similar between the groups. First attempt success was similar (Odds Ratio--ORSLMA/ETT: 1.00 (95%CI: 0.25, 4.02), p = 1.0000). SLMA was associated with reduced time to effective ventilation (Mean Difference--MD -22.96; 95%CI: − 23.71, − 22.21 s) compared to ETT group (p < 0.0001). Ventilation parameters, maternal and fetal outcomes were similar between the groups, and there was no aspiration.ConclusionsSLMA could be an alternative airway management technique for a carefully selected low-risk obstetric population, with similar insertion success rates, reduced time to ventilation and less hemodynamic changes compared with ETT. Our findings are consistent with the airway guidelines in recommending the second-line use of LMA in the management of the obstetric airway.Trial registrationThe study was registered at http://www.clinicaltrials.gov, identifier: NCT01858467, retrospectively registered. Date of registration: May 21, 2013.

Clinical evaluation of submental intubation as an alternative airway management technique in midface osteotomy

BackgroundThe conventional endonasal intubation would not allow precise intra-operative assessment of the changes to the nasolabial soft tissue complex. Submental intubation allows accurate measurement of nasolabial soft tissue complex with no interference with the occlusion. MethodologyA clinical prospective study was carried on 20 patients visiting the Oral and Maxillofacial Surgery department diagnosed of dentofacial deformity requiring orthognathic surgery. The patient were intubated by the submental route of anaesthesia. Intraoperatively time taken to perform intubation and bleeding during the surgery was noted. Post-operatively infection, presence or absence of any complications were noted along with the measurement of scar by Vancouver scar scale. ResultsOut of 20 patients 17 patients required only maxillary osteotomies whereas 3 patients required bimaxillary osteotomy. The mean time taken for intubation was 5.68 ± 1.257 minutes. In all the cases the scar was measured as minimum. 2 patients showed infection at the site of submental intubation after 7th day while after 14th day there was no infection present. No other complication was noted. 19 out of 20 cases showed no interference during the procedure whereas in 1 case mild interference during mandibular movement. ConclusionThe submental intubation is a very good alternative to nasotracheal intubation in the patients undergoing bimaxillary surgeries or maxillary surgeries. Submental intubation can be chosen whenever possible, as it is easy, takes little time and follow-up is simple, does not result in bleeding or other complications and more importantly does not result in any unaesthetic scar after 3rd month follow up.

Bilateral mandibular nerve injury following mask ventilation: a case report

Nerve injury following mask ventilation is a rare but serious anesthetic complication. The majority of reported cases are associated with excessive pressure applied to the face mask, long duration of mask ventilation, excessive digital pressure behind the mandible to relieve airway obstruction and pressure exerted by the plastic oropharyngeal airway. We present a case of bilateral mandibular nerve injury following mask ventilation with short duration, most likely due to a semi-silicone facemask with an over-inflated cushion. An over-inflated sealing cushion of a facemask may trigger difficult mask ventilation leading to mandibular nerve injury following mask ventilation. Alternative airway management techniques such as laryngeal mask airway should be considered when airway maintenance can only be achieved with strong pressure applied to the facemask and/or mandible.

The Association Between Obesity and Difficult Prehospital Tracheal Intubation

Nonphysician advanced life support (ALS) providers often perform tracheal intubation (TI) for cardiac arrest or other life-threatening indications in the prehospital setting, where airway assessment and airway management tools are limited. However, the frequency of difficult TI in obese patients in this setting is unclear. In this study we determined factors associated with TI success, and determined TI difficulty as a function of body mass index (BMI) in a system of ALS providers experienced in TI, to guide future prehospital education efforts. A retrospective review was performed of all patients ≥15 years of age who underwent prehospital TI by paramedics in the Seattle Medic One system over a 4-year period, and were transported to the regional level 1 trauma center (Harborview Medical Center). Data were abstracted from a prospectively collected prehospital airway management database and from the hospital medical records, including demographic information, number of TI attempts, TI success or failure, and body weight/height (BMI). Descriptive statistics and multivariable logistic regression were calculated, with the primary end point being difficult TI (defined as ≥4 TI attempts or the need to use an alternative airway management technique). Of 80,501 patient contacts in whom 4114 TIs were attempted during the 4-year study period, 823 met study entry criteria (including a calculable BMI). The overall TI success rate in the study population was 98.5% (811 out of 823), with 6.8% (56 out of 823) meeting the predetermined definition for difficult TI. There was no significant association between difficult TI and patient age, gender, use of succinylcholine, or medical diagnosis (trauma vs. nontrauma). In comparison with the lean patient subgroup (BMI <30 kg/m(2)), patients with class III obesity (BMI >40 kg/m(2)) had a significant association with difficult TI (odds ratio 3.68; confidence interval [CI] 1.27-10.59), whereas those with class I/II obesity (BMI ≥30 kg/m(2) and <40 kg/m(2)) did not (odds ratio 0.98; CI 0.46 -2.07). Among prehospital ALS providers with previously documented and published successful TI performance, increased difficulty with TI was observed in patients with extreme obesity, but not in patients with lesser degrees of obesity. Because extreme obesity is an easily identifiable patient characteristic, didactic and clinical (e.g., operating room) airway management education for such providers should emphasize airway management challenges and strategies associated with obesity, including specific equipment, patient positioning, and practice recommendations that may facilitate both TI and alternative airway management techniques in this population.

Current airway management in craniofacial anomalies

Airway obstruction requiring intervention occurs frequently among children with craniofacial anomalies. The presence of a craniofacial anomaly is a common reason for tracheotomy in the pediatric population. Because of the complications associated with tracheotomy, however, numerous other methods have been proposed to alleviate severe airway obstruction in this patient population. Nonsurgical management of airway obstruction remains the initial treatment option in children with craniofacial abnormalities; however, a significant number of patients fail to respond to this management strategy. Perhaps the most significant recent alternative airway management technique is the use of distraction osteogenesis to advance the mandible and maxilla. This technique has been used both to achieve early decannulation and to avoid a tracheotomy in infants and children with craniofacial anomalies. Multiple options exist for relieving upper airway obstruction in craniofacial patients, and the application of these treatment strategies is dependent on the patient's disease and the philosophy of the treating institution. Future research into the management of airway obstruction in children with craniofacial anomalies will need to focus on predicting which children will benefit from conservative management and which children will need distraction osteogenesis or a tracheotomy.

Use of an emergency sedation protocol to assist intubation in helicopter patient retrieval in Victoria

Abstract Objectives: To review emergency sedation intubation as practised in the Melbourne-based ambulance helicopter. Specifically, to describe patient profiles, drug dosage, difficulties encountered, success rate and patient outcomes. Methods: Retrospective review of all helicopter primary and secondary retrieval patients, who received application of the emergency sedation intubation protocol using morphine and diazepam during a 3 year period (January 1995 to December 1997). Data were collected from an audit of patient care records completed by flight paramedics and from hospital records. Results: Emergency sedation intubation was performed on 128 patients: 103 adults and 25 children. The median dose of drugs required for emergency sedation intubation by adult patients was 20 mg morphine and 20 mg diazepam. The overall success rate for emergency sedation intubation was 94.5%, with 73.6% of these being successful intubations at the first attempt. On intubation, 54.1% of patients were fully relaxed, while a gag reflex was still present in 45.9% of patients during or just after emergency sedation intubation. Twenty-two per cent of patients had a change in blood pressure of more than 20 mmHg. The maximum rise in blood pressure was 60 mmHg and the maximum fall was 80 mmHg. Conclusions: Flight paramedics achieved a high success rate for intubation with the morphine/ diazepam emergency sedation intubation protocol. However, there was still a significant percentage of patients for whom more than one attempt was required to achieve emergency sedation intubation and, in almost half the patients, gag reflexes remained present either during or immediately after intubation. Additionally, some patients experienced blood pressure changes following intubation that may have potential adverse consequences in terms of compromised cerebral perfusion or rises in intracranial pressure. Consideration should be given to revision of the protocol to allow the use of neuromuscular blocking agents and alternative airway management techniques, such as cricothyroidotomy, for specified circumstances in the aeromedical environment.

Emergency Management Of The Airway

When to intervene and control the airway is the critical decision the physician must make. The technical expertise and confidence of each physician determine the particular airway modality chosen. The medications used depend on each clinical setting and can significantly impact the outcome of airway management. To control the airway and breathing and move on to circulation requires a broad knowledge of alternative airway management techniques and the challenging task of placing each into the appropriate clinical setting.