Airway Management Experience Research Articles

Hands-off time during insertion of six airway devices during cardiopulmonary resuscitation: A randomised manikin trial

Introduction Cardiopulmonary resuscitation (CPR) guidelines recommend limiting interruptions of chest compressions because prolonged hands-off (i.e., non-compression) time compromises tissue perfusion. 2010 European Resuscitation Council guidelines suggest that chest compressions should be paused less than 10 s during airway device insertion. Methods With approval of the local ethics committee of the Medical University of Vienna and written informed consent, we recruited 40 voluntary emergency medical technicians, none of whom had advanced airway management experience. After a standardised audio-visual lecture and practical demonstration, technicians performed airway management with each six airway devices (endotracheal tube, Combitube, EasyTube, laryngeal tube, Laryngeal Mask Airway, and I-Gel) during on-going chest compressions in a randomised sequence on a Resusci Anne Advanced Simulator. Data were analysed using a mixed-effects model accounting for the repeated measurements and pair-wise comparisons among the airway devices. Results The hands-off time associated with airway management using an endotracheal tube (including all intubation attempts) was 48 s (95% confidence interval: 43–53). The hands-off time for airway management using a laryngeal tube was 8.4 (3.4–16.4) s, Combitube 10.0 (4.9–15.1) s, EasyTube 11.4 (6.4–16.4) s, LMA 13.3 (8.2–18.3) s and for I-Gel 15.9 (10.8–20.9) s. Hands-off time was significantly longer with the conventional endotracheal tube than with any of the other airway systems. Only a third of the technicians successfully inserted an endotracheal tube whereas all of them successfully positioned each supraglottic device. Conclusion Supraglottic devices appear to be a reasonable emergency airway management strategy, even for inexperienced personnel.

Performance and skill retention of intubation by paramedics using seven different airway devices—A manikin study

Introduction Endotracheal intubation (ETI) is the most widespread method for emergency airway management. Several studies reported that ETI requires considerable skill and experience and if performed incorrectly, may result in serious adverse events. Unrecognized tube misplacement or oesophageal intubation is associated with high prehospital morbidity. This study investigates the usability of supraglottic airway devices compared to ETI and the skill retention of 41 previously inexperienced paramedics following training using a manikin model. Methods 41 paramedics participated in this study. None had prior experience in airway management, apart from bag-valve ventilation. After a standardised audio-visual lecture lasting 45 min, the paramedics participated in a practical demonstration using the advanced patient simulator SimMan ® (Laerdal Medical, Stavanger, Norway). Afterwards, paramedics were instructed to perform airway-management using seven different techniques to secure the airway (ETI, Laryngeal mask unique [LMA], Proseal, Laryngeal tube disposable [LT-D ®], I-Gel ®, Combitube ®, and EasyTube ®) following a randomized sequence. Participants underwent reassessment after 3 months without any further training or practice in airway-management. Results During the initial training session, ETI was successfully performed in 78% of cases, while 3 months later the success rate was 58%. For the supraglottic airway devices, five out of six were successfully used by all paramedics at both time points, the exception being Proseal ®. Our data show successful skill retention (success rate: 100%) after 3 months for five out of six supraglottic airway devices. Time to ventilation (T3) was significantly less for LMA, LT-D ® and I-Gel ® at all time points compared to ETI. Conclusion ETI performed by inexperienced paramedics is associated with a low success rate. In contrast, supraglottic airway devices like LMA, LT-D ®, I-Gel ®, Combitube ® and EasyTube ® are fast, safe and easy-to-use. Within the limitations of a manikin-study, this study suggests that inexperienced medical staff might benefit from using supraglottic airway devices for emergency airway management.

EMS-physicians' self reported airway management training and expertise; a descriptive study from the Central Region of Denmark

BackgroundPrehospital advanced airway management, including prehospital endotracheal intubation is challenging and recent papers have addressed the need for proper training, skill maintenance and quality control for emergency medical service personnel. The aim of this study was to provide data regarding airway management-training and expertise from the regional physician-staffed emergency medical service (EMS).MethodsThe EMS in this part of The Central Region of Denmark is a two tiered system. The second tier comprises physician staffed Mobile Emergency Care Units. The medical directors of the programs supplied system data. A questionnaire addressing airway management experience, training and knowledge was sent to the EMS-physicians.ResultsThere are no specific guidelines, standard operating procedures or standardised program for obtaining and maintaining skills regarding prehospital advanced airway management in the schemes covered by this study. 53/67 physicians responded; 98,1% were specialists in anesthesiology, with an average of 17,6 years of experience in anesthesiology, and 7,2 years experience as EMS-physicians. 84,9% reported having attended life support course(s), 64,2% an advanced airway management course. 24,5% fulfilled the curriculum suggested for Danish EMS physicians. 47,2% had encountered a difficult or impossible PHETI, most commonly in a patient in cardiac arrest or a trauma patient. Only 20,8% of the physicians were completely familiar with what back-up devices were available for airway management.ConclusionsIn this, the first Danish study of prehospital advanced airway management, we found a high degree of experience, education and training among the EMS-physicians, but their equipment awareness was limited. Check-outs, guidelines, standard operating procedures and other quality control measures may be needed.

“Mouth to mouth ventilation”: A comparison of the laryngeal mask airway with the Laerdal Pocket Facemask

Ten nurses with basic airway management experience were formally trained to use a classic laryngeal mask airway (LMA) and a Laerdal Pocket Facemask (LPFM) for oxygen enriched expired air ventilation (EEAV). They then used both of these devices for EEAV in a randomised fashion in 100 anaesthetised ASA I/II patients for elective surgery. EEAV was considered successful if the patient's arterial oxygen saturation was maintained above 93% on room air for 3 min. EEAV success rates for the LMA and LPFM were 95% and 51% respectively ( P = 0.03). There was no apparent learning curve for either apparatus. Mean time in seconds (s) for first successful ventilation from picking up the apparatus was 26.8 s and 15.1 s, for the LMA and LPFM respectively ( P < 0.005). Although the LMA took significantly longer time to insert, it proved to be more successful and easier to use than the LPFM for EEAV.

LMA Supreme™ Versus Facemask Ventilation Performed by Novices: A Comparative Study in Morbidly Obese Patients Showing Difficult Ventilation Predictors

We designed a study to compare ventilation characteristics performed in morbidly obese patients by medical students via the facemask to that via the LMA Supreme. This prospective, randomized, crossover study included 31 ASA I-III morbidly patients showing difficult mask ventilation predictors. After induction of anesthesia, ten medical students with no previous clinical experience in airway management, clinically educated to facemask ventilation maneuvers, and theoretically educated to laryngeal mask use were supervised by a senior anesthesiologist during performance of 60 s facemask and LMA Supreme ventilation in a randomly assigned order. Ventilation quality and difficulty were measured using an original score calculated as the sum of seven indicators (0=no ventilation and complications, 12=optimal and safe ventilation) and a visual analog scale (VAS; 0=no difficult-100=impossible), respectively. Values are presented as means (standard deviation) or medians [extremes]. Mean age and body mass index of the patients were 39 years (12 years) and 44 kg m(-2) (7 kg m(-2)), respectively. One patient was excluded because of ventilation difficulty experienced by the senior anesthesiologist. Medical students successfully established ventilation with the LMA Supreme in all the 30 patients after a delay of 21 s (9 s) compared to 34 s (14 s) with the facemask (P<0.05). Failure of ventilation occurred in four patients with the facemask. Ventilation quality score was superior and ventilation difficulty (VAS 0-100) was inferior with the LMA Supreme than with the facemask (11 [10-12] and 9 [0-45] versus 5 [1-12] and 50 [5-100]); both P<0.05, respectively. We showed that the LMA Supreme placed in novice hands systematically promoted easier ventilation of better quality than the facemask in morbidly obese patients showing difficult mask ventilation predictors. Our data suggest that the LMA Supreme could be considered as a standard airway management tool for both elective and rescue airway management of morbidly obese patients.

Success Rate of Orotracheal Intubation via GlideScope®versus Direct Laryngoscopy in Manikin-Only–Trained Medical Personnel

Success Rate of Orotracheal Intubation <i>via</i> GlideScope®<i>versus</i> Direct Laryngoscopy in Manikin-Only–Trained Medical Personnel

Application of three airway devices during emergency medical training by health care providers—a manikin study

Objective The aim of this study was to evaluate the use of the Combitube (Kendall, Neustadt, Germany), Easytube (Rüsch, Kernen, Germany), and Laryngeal tube (VBM, Sulz, Germany) by health care providers with different experience in airway management. Methods This manikin study consisted of 2 sessions. In the first session, each participant received training in the use of the Combitube, Easytube, and Laryngeal tube. In the second session, each participant repeated the initial trial 4 weeks after the first session without further instruction or training. Time until successful insertion, success rate, level of education, and professional experience were recorded. Results The median time for insertion of the Combitube ( P < .001) or the Easytube ( P < .001) was significantly longer than for the Laryngeal tube. Success rate for the Combitube ( P < .001) and the Easytube ( P < .001) was lower than for the Laryngeal tube. There was no correlation between either years of professional experience and median time for successful insertion, or level of education and the number of unsuccessful insertions. Furthermore, there was no significant difference in the time for insertion between the first and the second sessions. Conclusion Regarding the time required for successful placement and success rate, Laryngeal tube seems to be superior compared to Combitube and Easytube in a manikin model. The use of all 3 devices can be easily learned and is independent of previous experience in airway management. The present findings suggest good skill retention for the Laryngeal tube.

P.147 Percutaneous tracheostomy with the Ciaglia Blue Rhino Dilator

To sum up our experience in percutaneous dilatational tracheostomy (PDT) in ICU patient with severe brain injury.Between November 2011 and April 2014, PDTs were performed on 32 severe brain injury patients in ICU by a team of physicians and intensivists. The success rate, efficacy, safety, and complications including stomal infection and bleeding, paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, as well as clinically significant tracheal stenosis were carefully monitored and recorded respectively.The operations took 4-15 minutes (mean 9.1 minutes±4.2 minutes). Totally 4 cases suffered from complications in the operations: 3 cases of stomal bleeding, and 1 case of intratracheal bloody secretion, but none required intervention. Paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis were not found in PDT patients. There was no procedure-related death occurring during or after PDT.Our study demonstrats that PDT is a safe, highly effective, and minimally invasive procedure. The appropriate sedation and airway management perioperatively help to reduce complication rates. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and also an intensivist with experience in difficult airway management.

Airway Experience of Anaesthetic Registrars

Education and expertise in airway skills are central components of anaesthesia training, yet there is no formal monitoring of the airway experience or level of competence that registrars actually obtain. An audit was performed in two phases to prospectively document the airway management experience of registrars in one teaching hospital department. Novices were studied for three months and subsequently, the whole registrar group for one month. Novice registrars performed a mean of two facemask anaesthetics, 19 laryngeal mask airways and 20 endotracheal intubations per month in their first three months of anaesthetic practice. The overall registrar group performed a mean of 18 laryngeal mask airways and 19 endotracheal intubations in the study month. Our findings indicate that the airway experience of anaesthesia trainees may be inadequate and therefore warrants further investigation.

Clinical experience of airway management and tracheal intubation under general anesthesia in patients with scar contracture of the neck

Because patients with scar contracture of the neck are at a high risk of loss of the airway control after anesthesia induction, awake intubation is usually recommended. This retrospective clinical study was designed to evaluate the possibility, safety and efficacy of airway management and tracheal intubation under general anesthesia in such patients. This retrospective study included 1683 patients from January 1994 to December 2006 with scar contracture of the neck, aged 1.5 - 67.0 years, who were scheduled for elective plastic surgery under general anesthesia in Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. Based on the results of the preoperative airway assessment, the patients were classified into group 1 (including 1375 patients with the atlanto-occipital extension of > 20 degrees and the Mallampatti's grade I or II) and group 2 (containing 308 patients with the atlanto-occipital extension of < 20 degrees and the Mallampatti's grade III or IV. In group 1, the intravenous induction and maintenance of anesthesia and succinylcholine for muscle relaxation were used. The intubation was done using a modified Macintosh technique. In group 2, the total intravenous anesthesia (TIVA) or the sevoflurane inhalation anesthesia was chosen and the spontaneous breathing was reserved during anesthesia. The intubation was performed by a fiberoptic stylet laryngoscope (FOSL). The number of intubation attempts, intubation time and relative complications were observed and recorded in all patients. In group 1, the intubation was accomplished during the first attempt in 1279 cases (93%) and the intubation time was < 3 minutes in 1304 cases (95%). In group 2, the intubation was completed by the first attempt in 114 patients (37%) and 123 patients had an intubation time of < 3 minutes (40%). Tracheal intubation was successful by the second or third attempt in 96 patients in group 1 and 156 patients in group 2. Thirty-eight patients required four or more attempts which only occurred in group 2. The incidence of traumatic complication was 2.6% and 9.7% with one intubation attempt in groups 1 and 2, respectively, 12.5% and 17.0% with multiple intubation attempts (one vs multiple attempts in both groups, P < 0.001). All non-traumatic complications occurred in group 2 and laryngospasm and hypoxemia were more common in patients using the TIVA compared to those using the sevoflurane inhalational anesthesia (P < 0.001). This study demonstrated that with a precise airway evaluation, an adequate preoperative preparation and a pre-planned failed intubation strategy, the anesthetist who was experienced in the difficult airway management could safely perform airway control and tracheal intubation under general anesthesia in patients with scar contracture of the neck. We believe that this technique may be very valuable for the management of a known difficult airway because it is comfortable for the patient and saves time for the anesthetist.

Instructor-based Real-time Multimedia Medical Simulation to Update Concepts of Difficult Airway Management for Experienced Airway Practitioners

BackgroundWe integrated lecture, real-time multimedia display and medical simulation into a new renewal airway management training protocol for experienced nurse anesthetists.MethodsTrainees of the Taiwan Association of Nurse Anesthetists from northern Taiwan and junior residents from our department were enrolled into the training program. A 4-hour renewal curriculum in the management of airway emergen-cies was developed, which consisted of a 2-hour general lecture (including 4 divided sections) and a 2-hour instructor-based real-time multimedia medical simulation of 4 specific techniques. After detailed explanation of each specific instrument at the beginning of each simulation, the instructors demonstrated accurate and successful management of 4 airway crises from clinical experience by using a standardized human patient simulator situated on the stage of the conference room. Meanwhile, real-time display of instructors’ performance, responsive physical parameters and images from specific instruments were conducted by video camera and video processor, and projected on a 3-frame screen. Brief summary and feedback were performed after each simulation. Trainees completed a questionnaire 6 months after they participated in the training program.ResultsTwo hundred and forty-two nurse anesthetists and 13 young residents were trained with this protocol. The questionnaire revealed that the renewal training program was useful. Participants updated their knowledge of difficult airway management, gained more confidence, improved performance, and provided effective assistance in handling airway crises.ConclusionRenewing practice guidelines and teaching airway management skills, especially for difficult airway crises and protection of personnel, continues to be an important issue. Instructor-based real-time multimedia simulation is a fast, useful and systematic renewal educational method for many participants with extensive experience of airway management to update their knowledge about difficult airway management, and acquire improved decision-making and communication capabilities, skills of specific airway management. [J Chin Med Assoc 2008;71(4):174–179]

Cook® Airway Exchange Catheter Used During Microlaryngeal Surgery

Anesthesia during laryngeal surgery presents the anesthesiologist with a number of potential challenges. It requires cooperation between the surgeon and anesthesiologist in order to maximize exposure for the surgeon and allow for adequate ventilation of the patient. Many anesthetic techniques have been used such as jet ventilation (subglottic or supraglottic) and endotracheal intubation (intermittently or continuously), with a variety of tubes. We present our experience of successful airway management with the assistance of the Cook® airway exchange catheter during microlaryngeal surgery. [ Tzu Chi Med J 2008;20(1):73–75]

A comparison of direct and indirect laryngoscopes and the ILMA in novice users: a manikin study

Direct laryngoscopic tracheal intubation using the Macintosh laryngoscope is taught to many healthcare professionals as it is a potentially life-saving procedure. However, it is a difficult skill to acquire and maintain. Several alternative intubation devices exist that may provide a better view of the glottis and require less skill to use. We conducted a prospective, randomised trial of four different laryngoscopes and the ILMA in 30 medical students who had no prior airway management experience. The devices were tested in both normal and cervical immobilisation laryngoscopy scenarios. Following brief didactic instruction, each participant took turns performing laryngoscopy and intubation using each device under direct supervision. Each student was allowed up to three intubation attempts with each device, in each scenario. The Airtraq, McCoy, and the ILMA each demonstrated advantages over the Macintosh laryngoscope. In both the easy and difficult airway scenarios, the Airtraq, McCoy, and the ILMA reduced the number of intubation attempts, and reduced the number of optimisation manoeuvres required. The Airtraq and ILMA reduced the severity of dental trauma in both scenarios. The performance of the other devices studied was more variable. Overall, participants found that only the Airtraq was less difficult to use and they were more confident using it compared to the Macinosh laryngoscope.

Novices Ventilate and Intubate Quicker and Safer via Intubating Laryngeal Mask Than by Conventional Bag–Mask Ventilation and Laryngoscopy

Because airway management plays a key role in emergency medical care, methods other than laryngoscopic tracheal intubation (LG-TI) are being sought for inadequately experienced personnel. This study compares success rates for ventilation and intubation via the intubating laryngeal mask (ILMA-V/ILMA-TI) with those via bag-mask ventilation and laryngoscopic intubation (BM-V/LG-TI). In a prospective, randomized, crossover study, 30 final-year medical students, all with no experience in airway management, were requested to manage anesthetized patients who seemed normal on routine airway examination. Each participant was asked to intubate a total of six patients, three with each technique, in a randomly assigned order. A task not completed after two 60-s attempts was recorded as a failure, and the technique was switched. The success rate with ILMA-V was significantly higher (97.8% vs. 85.6%; P < 0.05), and ventilation was established more rapidly with ILMA-V (35.6 +/- 8.0 vs. 44.3 +/- 10.8 s; P < 0.01). Intubation was successful more often with ILMA-TI (92.2% vs. 40.0%; P < 0.01). The time needed to achieve tracheal intubation was significantly shorter with ILMA-TI (45.7 +/- 14.8 vs. 89.1 +/- 23.3 s; P < 0.01). After failed LG-TI, ILMA-V was successful in all patients, and ILMA-TI was successful in 28 of 33 patients. Conversely, after failed ILMA-TI, BM-V was possible in all patients, and LG-TI was possible in 1 of 5 patients. Medical students were more successful with ILMA-V/ILMA-TI than with BM-V/LG-TI. ILMA-TI can be successfully used when LG-TI has failed, but not vice versa. These results suggest that training programs should extend the ILMA to conventional airway management techniques for paramedical and medical personnel with little experience in airway management.

Laryngoscopic versus intubating LMA guided tracheal intubation by novice users—A manikin study

Airway control is a potentially lifesaving procedure but tracheal intubation by direct laryngoscopy is difficult. This pilot study was conducted to determine whether tracheal intubation was more rapid and the success rate higher using an intubating laryngeal mask airway. The success rates of 119 medical students without prior airway management experience in ventilating and then intubating the trachea of a Laerdal Airway Management Trainer with two different methods were compared. The methods were bag-mask ventilation (BM-V) followed by laryngoscopic intubation (LG-TI), and intubating laryngeal mask ventilation (ILMA-V) followed by ILMA-guided tracheal intubation (ILMA-TI). After an introductory lecture and demonstration, each student was allowed three attempts to intubate using each method in random order. All participants were successful with BM-V and ILMA-V on the first attempt. Laryngoscopic tracheal intubation was achieved by 60 (50.4%), 31 (26.1%) and 12 (10.1%) participants on the first, second and third attempt, respectively, while 16 (13.4%) failed in all three attempts. In the ILMA-TI group, 107 (90.0%), 10 (8.4%) and 2 (1.6%) succeeded on the first, second and third attempt, respectively. None failed. The intergroup difference is highly significant (p<0.001). Male participants were more successful with LG-TI than female (p<0.01), but not with ILMA-TI. Laryngoscopic orotracheal intubation is difficult for the untrained, but all participants were successful with ILMA-TI. These data suggest that alternative devices such as the ILMA should be included in the medical school curriculum for airway management.

Field Airway Management Disasters

half century ago, a patient with impaired ventilation was at high riskofimminentdeath.Successfulairwaymanagementprofoundlyreducestherisk of morbidity and mortality in a severely injured or ill patient.Unsuccessful airway management kills patients. Studies have questionedthe usefulness of endotracheal intubation by relatively inexperiencedrescuers because of its deadly complications (1,2). The impressive studyfrom Timmermann et al. (3) reveals similarly catastrophic disasters afterintubation in the field, as detected by emergency medical service (EMS)physicians arriving by helicopter and performing laryngoscopy uponarrival at the scene to verify endotracheal tube position. Although briefand rapidly detected esophageal intubation may not cause harm, sevenpatients with spontaneous circulation on initial examination developedasystole after esophageal intubation. This suggests iatrogenic hypoxiaresulting in cardiac arrest. We can only assume that the steps required todetect esophageal intubation were either incorrectly performed or com-pletely omitted in these cases.Unfortunately, these cases from Go¨ttingen, Germany are not isolatedincidents of bad luck. After we published eight cases of catastrophicairway management (4), another five cases quickly surfaced, suggestingthat these potentially deadly problems are common.

Retention of tracheal intubation skills by novice personnel: a comparison of the Airtraq® and Macintosh laryngoscopes*

Direct laryngoscopic tracheal intubation is a potentially lifesaving manoeuvre, but it is a difficult skill to acquire and to maintain. These difficulties are exacerbated if the opportunities to utilise this skill are infrequent, and by the fact that the consequences of poorly performed intubation attempts may be severe. Novice users find the Airtraq laryngoscope easier to use than the conventional Macintosh laryngoscope. We therefore wished to determine whether novice users would have greater retention of intubation skills with the Airtraq rather than the Macintosh laryngoscope. Twenty medical students who had no prior airway management experience participated in this study. Following brief didactic instruction, each took turns performing laryngoscopy and intubation using the Macintosh and Airtraq devices in easy and simulated difficult laryngoscopy scenarios. The degree of success with each device, the time taken to perform intubation and the assistance required, and the potential for complications were then assessed. Six months later, the assessment process was repeated. No didactic instruction or practice attempts were provided on this latter occasion. Tracheal intubation skills declined markedly with both devices. However, the Airtraq continued to provide better intubating conditions, resulting in greater success of intubation, with fewer optimisation manoeuvres required, and reduced potential for dental trauma, particularly in the difficult laryngoscopy scenarios. The substantial decline in direct laryngoscopy skills over time emphasise the need for continued reinforcement of this complex skill.

Tracheal intubation by inexperienced medical residents using the Airtraq and Macintosh laryngoscopes—a manikin study

The Airtraq laryngoscope is a novel intubation device that may possess advantages over conventional direct laryngoscopes for use by personnel that are infrequently required to perform tracheal intubation. We conducted a prospective study in 20 medical residents with little prior airway management experience. After brief didactic instruction, each participant took turns performing laryngoscopy and intubation using the Macintosh (Welch Allyn, Welch Allyn, NY) and Airtraq (Prodol Ltd. Vizcaya, Spain) devices, in 3 laryngoscopy scenarios in a Laerdal Intubation Trainer (Laerdal, Stavanger, Norway) and 1 scenario in a Laerdal SimMan manikin (Laerdal, Kent, UK). They then performed tracheal intubation of the normal airway a second time to characterize the learning curve. In all scenarios tested, the Airtraq decreased the duration of intubation attempts, reduced the number of optimization maneuvers required, and reduced the potential for dental trauma. The residents found the Airtraq easier to use in all scenarios compared with the Macintosh laryngoscope. The Airtraq may constitute a superior device for use by personnel infrequently required to perform tracheal intubation.

Reply

EDITOR: Dr Kotsev's comments seem to stem from an archaic attitude towards airway management and a failure to grasp the importance of bougie-guided insertion of the ProSeal laryngeal mask airway for airway rescue [1,2]. We will address each of his points in turn. First, this patient was reviewed both by a second anaesthetist and a clinical psychologist who found that he had a rational fear of awake intubation: his brother had undergone a rather gruesome awake intubation for an elective cholecystectomy (on the basis of having buck teeth and a beard) which left him with a vocal cord injury. Second, spontaneous breathing was not lost after induction. We took over the patient's ventilation to allow better gas exchange and to deepen anaesthesia. Having established successful ventilation, we felt it was safe to administer a muscle relaxant. It is debatable as to whether suxamethonium would have been a better choice than atracurium. Third, the principle that ‘the natural airway is better maintained when the patient remains breathing spontaneously’ makes little sense and is almost certainly wrong. The natural airway is usually lost once the patient is anaesthetised and gas exchange is usually worse with spontaneous rather than positive pressure ventilation. Other than providing information about depth of anaesthesia and perhaps reducing the frequency of gastric insufflation and barotrauma, spontaneous breathing under anaesthesia is neither natural nor beneficial. Fourth, the concept that inhalational anaesthesia is best if airway problems are anticipated is entrenched in anaesthesia teaching, yet few clinicians adhere to it and it remains (and probably always will be) unproven. The primary benefit of inhalational induction is that if problems arise they occur slowly and can easily be reversed – but is this true? More importantly, can these problems be reversed more rapidly than after an intravenous induction with modern short acting agents? There is no answer. Certainly, most of us have experienced horrendous gas inductions in adults. Fifth, it took less than 20 s to work through the section of the algorithm which relates to guided insertion techniques, and a further 10 s to remove the ProSeal laryngeal mask airway and railroad the tracheal tube into position. Thus we wasted no time in securing the patients airway. The minimal SPO2 was 94%. Our algorithm is not particularly complex: it certainly has fewer steps than the American Society of Anesthesiologists difficult airway algorithm. Sixth, we do not consider that there are compelling reasons to perform awake tracheal intubation in a patient with a history of difficult tracheal intubation if other forms of airway management have proved to be easy. In this case, face mask ventilation was known to be easy (admittedly it required a Guedel airway) and there were no signs that laryngeal mask airway insertion/function would be difficult. Certainly, if both face mask ventilation and laryngeal mask airway insertion are predicted to be easy, it is difficult to justify awake tracheal intubation, especially against a patient's wishes. Finally, all anaesthesiologists should familiarise themselves with the bougie-guided technique for insertion of the ProSeal laryngeal mask airway. It is a powerful yet simple new concept in airway management: using a tube that is easily accessible (the oesophagus) to secure access to a tube that is not easily accessible (the trachea). The combination of the best extraglottic device with this new technique for placement results in remarkably high insertion success rates. In our experience of over 15 000 uses, it has a failure rate of 0.5% falling to 0.1% after the application of the algorithm. We recently found that even personnel with no experience of airway management have exceptionally high success rates (100 out of 100 patients) following brief manikin-only training [3]. In our view, it is one of the most successful airway management techniques in anaesthesia practice today and our algorithm further increases its success.

Guided Insertion of the ProSeal Laryngeal Mask Airway Is Superior to Conventional Tracheal Intubation by First-Month Anesthesia Residents After Brief Manikin-Only Training

In the following pilot study, we compared conventional laryngoscope-guided tracheal intubation (tracheal intubation) and laryngoscope-guided, gum elastic bougie-guided ProSeal laryngeal mask airway insertion (guided ProSeal) for airway management by first-month anesthesia residents after brief manikin-only training. Five first-month residents with no practical experience of airway management were observed performing these techniques in 200 ASA I-II anesthetized, paralyzed adults. Each resident managed 40 patients, 20 in each group, in random order. The number of insertion attempts, effective airway time, ventilatory capability during pressure-controlled ventilation set at 15 cm H2O, airway trauma, and skill acquisition were studied. Data were collected by unblinded observers. Insertion was more frequently successful (100% versus 65%) and effective airway time was shorter (41 +/- 24 s versus 89 +/- 62 s) in the guided ProSeal group (both P < 0.0001). Expired tidal volume was larger (730 +/- 170 mL versus 560 +/- 140 mL) and end-tidal CO(2) lower (33 +/- 4 mm Hg versus 37 +/- 5 mm Hg) in the guided ProSeal group during pressure controlled ventilation (both P < 0.0001). Blood staining was more frequent on the laryngoscope (24% versus 2%; P < 0.0001) in the tracheal intubation group. There was evidence for skill acquisition in both groups. We conclude that laryngoscope-guided, gum elastic bougie-guided insertion of the ProSeal laryngeal mask airway is superior to conventional laryngoscope-guided tracheal intubation for airway management in terms of insertion success, expired tidal volume, and airway trauma by first-month anesthesia residents after brief manikin-only training. The guided ProSeal technique has potential for cardiopulmonary resuscitation by novices when conventional intubation fails.