Laryngeal Tube Research Articles

Increased rate of anoxic brain damage with laryngeal tube compared to endotracheal intubation in patients with shockable out-of-hospital cardiac arrest – Experience from the HAnnover COoling REgistry (HACORE)

BackgroundSupraglottic airway devices such as the laryngeal tube (LT) are recommended in current guidelines for simplified airway management in patients during and immediately after out-of-hospital cardiac arrest (OHCA). Trials evaluating LTs included predominantly OHCA patients with non-shockable rhythms and low survival rates. Hence, LTs are widely used, but their impact on preventing hypoxic brain damage during resuscitation has not been evaluated yet. MethodsWe analysed 452 OHCA-patients with shockable-rhythms from the HAnnover COoling REgistry (HACORE) who had return of spontaneous circulation prior to transport. Of those, 405 patients received primary airway management by endotracheal intubation (ETI) and 47 by LT. Patients were afterwards treated according to the Hannover Cardiac Resuscitation Algorithm (HaCRA) applying a strict post-resuscitation management including therapeutic hypothermia and avoiding routine prognostication. ResultsWhile mortality in this group was moderate with both airway strategies (ETI 29 % vs LT 34 %, p = 0.487), the rate of anoxic brain damage was much higher in the LT compared to the ETI group (38 % vs 21 %, p = 0.011). Survivors in the ETI group were more likely to have good neurological outcome (cerebral performance category 1&2) compared to the LT group (35 % vs 17 %, p = 0.013). Pneumonia was more common in the LT vs ETI group (81 % vs 53 %, p < 0.001). ConclusionsWhile the original prehospital pragmatic trials comparing LT to ETI mostly included patients with non-shockable rhythm in settings with high mortality, our analysis is based on a real-world registry and focuses on successfully resuscitated patients, whose cause of arrest was most probably not due to hypoxia. In this cohort, use of LT was associated with a higher rate of anoxic brain damage and worse functional neurological outcome compared to use of ETI.

Vasopressor or advanced airway first in cardiac arrest?

BackgroundWhile resuscitation guidelines emphasize early vasopressor administration and advanced airway management, their optimal sequence remains unclear. We sought to determine the associations between vasopressor-airway resuscitation sequence and out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART). MethodsWe analyzed data from the PART trial. For each patient we determined times of first vasopressor administration (epinephrine or vasopressin), and successful advanced airway insertion (laryngeal tube or endotracheal tube). We classified each case as vasopressor-first or advanced airway-first. We used Generalized Estimating Equations to determine associations between vasopressor-airway sequence and outcomes (72-hour survival, return of spontaneous circulation (ROSC) on emergency department arrival, survival to hospital discharge, hospital survival with favorable neurologic status) and CPR outside of recommended parameters (chest compression fraction <0.8, chest compression rate <100 or >120 per min, or ventilation rate <8 or >12 breaths/min), adjusting for confounders. ResultsOf 3,004 patients in the parent trial, we analyzed 2,404, including 1,821 vasopressor-first and 583 advanced airway-first. Median intervention times: ALS arrival-to-vasopressor 8 min (IQR 6–11) and ALS arrival-to-airway 11 min (8–15). Compared with airway-first, vasopressor-first sequence was not associated with 72-hour survival (adjusted OR 0.96; 95% CI: 0.71–1.31), ROSC (0.83; 0.66–1.06), hospital survival (1.09; 0.68–1.73), or hospital survival with favorable neurologic status (0.97; 0.53–1.78). Vasopressor-first sequence was not associated with non-compliance with recommended CPR performance parameters. ConclusionsVasopressor-airway resuscitation sequence was not associated with OHCA outcomes or CPR quality.

Laryngeal mask vs. laryngeal tube trial in paediatric patients (LaMaTuPe): a single-blinded, open-label, randomised-controlled trial.

In hypoxemic children with difficult airway, or for minor elective procedures, the use of a supraglottic airway device may be preferred to endotracheal intubation, whether with a laryngeal mask or laryngeal tube. Second-generation laryngeal masks may offer a better safety profile. Whether they should be preferred to laryngeal tubes is unknown. This study aimed to compare the efficacy and safety of second-generation laryngeal masks and laryngeal tubes in children. This randomised-controlled trial was conducted in a single university hospital in children <18 years undergoing elective anaesthesia in urology, minor paediatric surgery and gynaecology. Patients were 1 : 1 randomised to the laryngeal mask or laryngeal tube group. Children were allocated a second-generation laryngeal tube or a second-generation laryngeal mask as the primary airway device. The primary endpoint was insertion time. Secondary endpoints included first-attempt success, overall success and complications, which included hypoxia (SpO2 < 90%), laryngospasm, bronchospasm, aspiration and bleeding. In total, 135 patients were randomised, with 61 allocated to the laryngeal tube and 74 to the laryngeal mask group, with a median age of 5.4 and 4.9 years, respectively. Median insertion time was significantly longer in the laryngeal tube group (37 vs. 31 s; difference of medians: 6.0 s; 95% confidence interval: 0.0-13.0). The laryngeal tube had a significantly lower first-attempt (41.0%) and overall success rate (45.9%) than the laryngeal mask (90.5% and 97.3%, respectively). Those allocated to the laryngeal tube group had a higher ratio of complications (27.8%) compared to the laryngeal mask group (2.7%). This randomised-controlled trial reported that in children undergoing elective anaesthesia, the use of a laryngeal tube was associated with a longer insertion time.

Anaesthetic challenges of carinal resection and reconstruction: A case report.

Carinal resection of tumour involving trachea and carina remains as a challenge for thoracic surgeons and anaesthesiologists. Resection is technically demanding and can be associated with significant morbidity and mortality. In this case report, we describe the successful management of carinal tumour with carinal resection in a 45-year-old female. The tumour was involving lowermost trachea, carina and bilateral primary bronchi causing 60% narrowing of the lower trachea just before carina, more than 90% narrowing of right main bronchus and 50% luminal narrowing of left main bronchus. Carinal resection and reconstruction were successfully performed under general anaesthesia. Patient was managed with conventional orotracheal intubation with Micro laryngeal endotracheal tube and positioned in left principal bronchus railroaded over a paediatric bronchoscope for lung isolation. After thoracotomy, the left main bronchus was intubated directly across the operative field with a sterile flexometallic endotracheal tube. With intermittent ventilation, anastomosis was completed. During anastomosis Micro laryngeal endotracheal tube cuff was damaged twice and we had to reintubate the patient twice in lateral position itself. At the end of anastomoses, flexometallic tube was removed and wound repaired. After confirming no leakage at anastomotic site, Micro laryngeal endotracheal tube was removed and Laryngeal Mask Airway was inserted and bronchial toileting done with adult bronchoscope. Meticulous planning and communication between the anaesthesia and surgical teams are mandatory for the safe and successful anaesthetic management of carinal resection surgeries.

Indications and success rate of endotracheal emergency intubation in clinical acute and emergency medicine

Securing the airway in the emergency department (ED) is ahigh-stakes procedure; however, the primary success and complication rate are largely unknown in Germany. The aim of this study was aretrospective analysis of prospectively collected resuscitation room data for endotracheal intubation (ETI) regarding indications, performance and complications. Between 1 January 2020 and 30 June 2023 all ETIs conducted in the ED (Kliniken Maria Hilf, Moenchengladbach, Germany) were analyzed following approval by the ethics committee (EK 23-369). Primary intubations performed by the anesthesiology department were excluded. The core medical team of the ED underwent asix-week training program including atwo-week anesthesia rotation prior to performing ETI in the ED. There were standard operating procedures (SOP) for both rapid sequence induction (RSI) and airway exchange with aplaced laryngeal tube (LT) utilizing video laryngoscopy (C-Mac, Storz), rocuronium for relaxation and primary intubation with an elastic bougie. The primary success rate, overall success rate and intubation-related complications were analyzed. Additionally, the factor of consultant ED staff and residents was evaluated with respect to the primary success rate. During the study period 499 patients were intubated by the core ED team and 28patients underwent airway exchange from LT to ETI. Primary success could be achieved in 489/499 (98.0%) ETI and in 25/28 (89.3%) LT exchange patients. Surgically achieved securing of the airway was carried out in 5/527 (0.9%) patients in a cannot intubate situation and 11/527(2.2%) patients suffered cardiac arrest minutes after the ETI. The overall first pass success rate of endotracheal tube placement was 514/527 (97.4%). The comparison of the primary success of consultants (168/175; 96.0%) vs. residents 320/325 (98.5%) yielded no significant differences (p = 0.08). In clinical acute and emergency medicine, astandardized approach utilizing video laryngoscopy and a bougie following astructured training concept, can achieve an above-average high primary success rate with simultaneous low severe complications in the high-risk collective of critically ill emergency patients in an intrahospital setting.

Temporal Trends in End-Tidal Capnography and Outcomes in Out-of-Hospital Cardiac Arrest

While widely measured, the time-varying association between exhaled end-tidal carbon dioxide (EtCO2) and out-of-hospital cardiac arrest (OHCA) outcomes is unclear. To evaluate temporal associations between EtCO2 and return of spontaneous circulation (ROSC) in the Pragmatic Airway Resuscitation Trial (PART). This study was a secondary analysis of a cluster randomized trial performed at multicenter emergency medical services agencies from the Resuscitation Outcomes Consortium. PART enrolled 3004 adults (aged ≥18 years) with nontraumatic OHCA from December 1, 2015, to November 4, 2017. EtCO2 was available in 1172 cases for this analysis performed in June 2023. PART evaluated the effect of laryngeal tube vs endotracheal intubation on 72-hour survival. Emergency medical services agencies collected continuous EtCO2 recordings using standard monitors, and this secondary analysis identified maximal EtCO2 values per ventilation and determined mean EtCO2 in 1-minute epochs using previously validated automated signal processing. All advanced airway cases with greater than 50% interpretable EtCO2 signal were included, and the slope of EtCO2 change over resuscitation was calculated. The primary outcome was ROSC determined by prehospital or emergency department palpable pulses. EtCO2 values were compared at discrete time points using Mann-Whitney test, and temporal trends in EtCO2 were compared using Cochran-Armitage test of trend. Multivariable logistic regression was performed, adjusting for Utstein criteria and EtCO2 slope. Among 1113 patients included in the study, 694 (62.4%) were male; 285 (25.6%) were Black or African American, 592 (53.2%) were White, and 236 (21.2%) were another race; and the median (IQR) age was 64 (52-75) years. Cardiac arrest was most commonly unwitnessed (n = 579 [52.0%]), nonshockable (n = 941 [84.6%]), and nonpublic (n = 999 [89.8%]). There were 198 patients (17.8%) with ROSC and 915 (82.2%) without ROSC. Median EtCO2 values between ROSC and non-ROSC cases were significantly different at 10 minutes (39.8 [IQR, 27.1-56.4] mm Hg vs 26.1 [IQR, 14.9-39.0] mm Hg; P < .001) and 5 minutes (43.0 [IQR, 28.1-55.8] mm Hg vs 25.0 [IQR, 13.3-37.4] mm Hg; P < .001) prior to end of resuscitation. In ROSC cases, median EtCO2 increased from 30.5 (IQR, 22.4-54.2) mm HG to 43.0 (IQR, 28.1-55.8) mm Hg (P for trend < .001). In non-ROSC cases, EtCO2 declined from 30.8 (IQR, 18.2-43.8) mm Hg to 22.5 (IQR, 12.8-35.4) mm Hg (P for trend < .001). Using adjusted multivariable logistic regression with slope of EtCO2, the temporal change in EtCO2 was associated with ROSC (odds ratio, 1.45 [95% CI, 1.31-1.61]). In this secondary analysis of the PART trial, temporal increases in EtCO2 were associated with increased odds of ROSC. These results suggest value in leveraging continuous waveform capnography during OHCA resuscitation. ClinicalTrials.gov Identifier: NCT02419573.

Linking the impact of aspiration to host variables using the BOLUS framework: support from a rapid review.

The purpose of this rapid review was to identify the level of evidence for a previously proposed theoretical framework to assess risks associated with prandial aspiration using the host as a central theme. Covidence software was used to search two databases (PubMed and Web of Science). PEDro scale was utilized to determine the quality of individual studies. Data points were evaluated for level of support and determined to be either conclusive, suggestive, unclear, or not supportive. Within each component of the framework, data points were clustered to determine the level of evidence as strong, moderate, insufficient, or negative. The rapid review process resulted in a limited number of publications investigating host variables impact on outcomes for patients with swallowing disorders. Overall, it yielded 937 articles, of which, upon review, 16 articles were selected for data extraction. There was a strong level of evidence to support that (a) as viscosity and density of aspirate increased, so did the likelihood of general medical complications, (b) poor oral care and oral health increase the risk of a pulmonary or general medical complication, and (c) the presence of oropharyngeal or laryngeal tubes increases the risk of a pulmonary consequence. There was moderate evidence to support the impact of amount and frequency of aspiration on outcomes. There was insufficient evidence to determine relationships for all other aspects of the BOLUS framework. Additional evidence to support the BOLUS framework was obtained; however, the number of studies was limited. A more thorough review such as a systematic review should be employed.

Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)-A Prospective, Randomised Controlled Study.

The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios. After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min. In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02). The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial.

Abstract 432: Temporal Trends in End Tidal Capnography and Outcomes in Out of Hospital Cardiac Arrest

Background: While widely measured and used to direct resuscitation, the time-varying relationship between exhaled end-tidal CO2 (ETCO2) and out-of-hospital cardiac arrest (OHCA) outcomes is unclear. We sought to determine the association between temporal trends in ETCO2 and return of spontaneous circulation (ROSC) in the Pragmatic Airway Resuscitation Trial (PART). Methods: We analyzed data from the PART Trial, which tested endotracheal intubation or laryngeal tube strategies in OHCA resuscitation. Emergency medical services collected continuous ETCO2 recordings using defibrillator monitors. We identified maximal ETCO2 values for each ventilation using previously validated automated signal processing. We determined mean ETCO2 in one-minute(min) epochs from advanced airway insertion through ROSC or end of event. We included all cases with interpretable ETCO2 signal in at least one of the epochs. We compared discrete time points between ROSC and non-ROSC using one way Mann-Whitney and determined the association between temporal trends in ETCO2 comparing the slopes of ETCO2 over time. Results: We included 1147 of 3004 patients with available ETCO2 data. There were 225(20%) ROSC and 923(80%) non-ROSC cases. Mean duration of resuscitation was 16 and 27 minutes for ROSC and non-ROSC cases, respectively. In ROSC cases, ETCO2 increased from 26.8 to 48.9 mmHg over 20-min prior to ROSC. In non-ROSC cases, ETCO2 declined from 30.6 to 21.7 mmHg over the 20-min. Mean ETCO 2 between ROSC and non-ROSC cases did not differ at t-10 (30.6 mmHg vs 26.1 mmHg, p=0.07) or t-20 min (26.8 mmHg vs 30.6 mmHg, p=0.71). However, ETCO 2 changes over time differed between ROSC and non-ROSC (p&lt;0.01, figure 1). Conclusions: Upward temporal increases in ETCO 2 are associated with ROSC. Dynamic time-varying changes in ETCO2 may indicate OHCA outcomes.

Thermal imaging and velocity measurements of the exhaled airflow in total laryngectomized patients during COVID-19 pandemic.

In patients after total laryngectomies, the trachea and the lung can be easily infected by SARS-CoV-2 because the respiration happens through the tracheostoma. The aim of our study was to examine whether patients with LaryTube™ can distribute aerosols to a greater extent than without LaryTube™, and to observe whether the surface of different protective instruments can be examined using the thermal camera in total laryngectomees. An important objective was also to confirm the assumption that the use of HME (heat and moisture exchanger) alone does not provide protection during COVID-19 pandemic. Finally, during our tests, we tried to get an answer to our assumption that the sample taken from the inner surface of the HME can be tested for SARS-CoV-2. A total of 23 patients who underwent total laryngectomies were analyzed by velocity measurements and thermal imaging with and without HMEs and laryngeal tubes, using different types of PPEs. COVID-19 PCR testing was performed on patient tracheas and the inner surfaces of the HMEs. Male patients with laryngeal tubes without HMEs demonstrated an increase in exhaled airflow velocity of more than 43% compared to male patients without laryngeal tubes; in female patients, the same value was more than 39%. Thermal imaging results confirmed that the lowest surface temperature was measured on FFP2 masks. The sent samples can be tested for SARS-CoV-2 using PCR, the presence of the virus was not detected. Laryngectomized patients without laryngeal tubes pose a lower risk for spreading viral aerosols due to the reduced velocity of the exhaled airflow caused by the absence of the tube as the narrowing factor. Patients with laryngeal tubes who undergo total laryngectomies during the COVID-19 pandemic should use HMEs with viral filter, if possible, also changing the laryngeal tubes to dermal adhesives for fitting their HMEs seems to be the best option. The surface of the used protective equipment can also be examined with thermal camera in the case of total laryngectomees. COVID-19 PCR testing of the tracheal secretion from the inner HME surfaces should become a routine in clinical practice if deemed necessary. Orv Hetil. 2023; 164(34): 1327-1336.

A comparative evaluation of LMA® Gastro™ versus Gastro Laryngeal Tube for airway management in patients undergoing endoscopic retrograde cholangiopancreatography under general anesthesia: A randomized control study

BackgroundEndoscopic Retrograde Cholangio-Pancreatography is fraught with anesthetic challenges. Various anesthesia techniques have been studied, ranging from sedation to general anesthesia with tracheal intubation or specialized supra-glottic airway devices. MethodsThis randomized control trial included 70 patients undergoing endoscopic retrograde cholangio-pancreatography under general anesthesia and divided equally into two groups, LMA® Gastro™ or Gastro-Laryngeal tube. The primary objective was to compare the 1st time success rate and the secondary outcomes included, ease of insertion, number of attempts, oropharyngeal leak pressure, occurrence of adverse events; hemodynamic and ventilatory parameters. They were also compared in terms gastroenterologist's feedback about the device. ResultsThe first-time success rate for LMA® Gastro™ group was 88.5% and for Gastro-Laryngeal tube group was 77.1% (p value = 0.10). The mean difference for ease of insertion (p value = 0.001), oropharyngeal leak pressure (p value < 0.0001), peak airway pressure (p value < 0.0001) at different time intervals were significant for LMA® Gastro™ group. Hemodynamic response in terms of mean arterial pressure at 0 min (p value = 0.021) and gastroenterologist's feedback (p value < 0.0001) for Gastro-Laryngeal tube group was shown to be statistically significant. The mean difference between two groups for number of attempts, complications, hemodynamic response, end tidal volume, EtCO2 and recovery time were statistically insignificant (p value > 0.05). There was no desaturation in both the groups. ConclusionTo conclude, LMA® Gastro™ had performed better in terms of an airway device and ventilatory efficiency even in anticipated difficult airway, on the other hand, Gastro-Laryngeal tube is more conducive for the insertion and maneuvering of a gastro-endoscope.

Use of a laryngeal tube for sialolithotomy in a pediatric patient with left vocal cord paralysis: a case report

BackgroundThe laryngeal tube (LT), a closed esophageal supraglottic device comprising pharyngeal and esophageal cuffs, is used for emergency airway management. However, it is not often used in intraoperative airway management.Case presentationA 9-year-old boy was scheduled for a sialolithotomy for sialolithiasis. He had a history of surgery for tetralogy of Fallot and had undergone vocal cord fusion for postoperative left-sided vocal cord paralysis. Following a strong request by the mother to avoid tracheal intubation to reduce the risk of bilateral vocal cord paralysis, management without intubation was initially considered in the preoperative anesthesia plan. Airway management was planned using an LT in case of ventilation failure due to positional abnormalities. Although some leakage was observed during intraoral surgery, it was quickly resolved by adjusting the position of the LT outside the sterile surgical field.ConclusionsThe LT may be a viable option in cases where tracheal intubation is not preferred.

Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present aliterature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine. Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors. The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have agastric drainage possibility. Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of alocal emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

An Approach to an Anticipated Difficult Airway in a Patient with a Periglottic Mass: A Case Report

Rationale: Dealing with patients with periglottic masses is very challenging to anaesthesiologist and there is an overall lack of knowledge and guidelines. Patient concerns: A 79-year-old man with the complaint of hoarseness of voice who presented for micro laryngoscopy and excision of a laryngeal mass under general anaesthesia. He had a preoperative fibreoptic laryngoscopy which revealed a 3-4 cm sized right vocal cord mass. Diagnosis: preoperative fibreoptic laryngoscopy revealed a large vocal cord mass obstructing the laryngeal inlet. Interventions: Intubation was facilitated by glide scope video laryngoscope and micro laryngeal endotracheal tube (MLT). Outcomes: the mass was excised, and the patient was successfully extubated. Lessons: the importance of this case report lies in the unique challenges we faced and the significance of the multidisciplinary team care

A retrospective comparison of the King Laryngeal Tube and iGel supraglottic airway devices: A study for the CARES surveillance group

ObjectiveSupraglottic airway devices are increasingly used during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients in the United States and worldwide. In this study, we aimed to compare the neurologic outcomes of OHCA patients managed with the King Laryngeal Tube (King LT) to the neurologic outcomes of patients managed with the iGel. MethodsWe used the Cardiac Arrest Registry to Enhance Survival (CARES) public use research dataset for our analysis. Non-traumatic OHCA cases with attempted EMS resuscitation enrolled from 2013-2021 were included. We used two-level mixed effects multivariable logistic regression analyses with treating EMS agency as the random effect to determine the association between supraglottic airway device and outcome. The primary outcome was survival with a Cerebral Performance Category (CPC) score of 1 or 2 at discharge. Secondary outcomes included survival to hospital admission and survival to hospital discharge. Age, sex, calendar year of OHCA, initial ECG rhythm, witnessed status (unwitnessed, bystander witnessed, 9-1-1 responder witnessed), bystander CPR, response interval, and OHCA location (private/home, public, institutional) were used as covariables. ResultsIn comparison to use of the King LT, use of the iGel was associated with greater neurologically favorable survival (aOR: 1.45 [1.33, 1.58]). In addition, use of the iGel was associated with greater survival to hospital admission (1.07 [1.02, 1.12]) and survival to hospital discharge (1.35 [1.26, 1.46]). ConclusionsThis study adds to the body of literature suggesting that use of the iGel during OHCA resuscitation is associated with better outcomes than use of the King LT.

Dose Response Curves of Plasma Concentration 50 of Propofol Target-Controlled Infusion for Supraglottic Airway Devices: A Randomized Controlled Trial

Objective: We aimed to determine the plasma concentration 50 (CP50) of propofol target controlled infusion (TCI) for successful insertion of four types of supraglottic airway devices (SGD). Material and Methods: This prospective parallel randomized controlled, double blinded, superiority trial was conducted in June 2012 following approval by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University, Thailand. Effect-site concentrations (Ce) of propofol TCI were determined by the modified Dixon’s up-and-down method. After equilibration was established between the plasma and effect-site concentrations, a SupremeTM, ProSealTM(control groups), I-gelTM or Laryngeal Tube Suction IITM devices were inserted. The CP50 was determined by dose response logistic curves presented as means and 95% confidence intervals (CI). The General Estimating Equation was used to determine factors associated with hemodynamic changes. Results: The Ces of TCI propofol requirements in the SupremeTM, ProSealTM, I-gelTM and Laryngeal Tube Suction IITM groups were 5.8, 4.8, 5.6, and 5.8 μg/ml, respectively (effect size [95% CI]: 0.22 [0.06, 0.51], p-value 0.036). The CP50 [95% CIs] in the SupremeTM, ProSealTM, I-gelTM and Laryngeal Tube Suction IITM groups were 5.8 [-0.01, 11.6], 4.9 [3.3, 6.5], 5.7 [5.0, 6.3] and 5.5 [4.7, 6.4] μg/ml, respectively. Heart rates and systolic blood pressure were significantly higher in the Laryngeal Tube Suction IITM group than in the ProSealTM (p-value&lt;0.01) and I-gelTMgroups (p-value&lt;0.01 Conclusion: The ProSealTM and I-gelTM are preferred over the SupremeTM and Laryngeal Tube Suction IITM devices due to the lower CP50 and hemodynamic changes.

A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation

Introduction While various supraglottic airway devices are available for use during out-of-hospital cardiac arrest (OHCA) resuscitation, comparisons of patient outcomes by device are limited. In this study, we aimed to compare outcomes of OHCA patients who had airway management by emergency medical services (EMS) with the iGel or King-LT. Methods We used the 2018-2021 ESO Data Collaborative public use research datasets for this retrospective study. All patients with non-traumatic OHCA who had iGels or King-LTs inserted by EMS were included. Our primary outcome was survival to discharge to home, and secondary outcomes included first-pass success, return of spontaneous circulation (ROSC), and prehospital rearrest. We examined the association between airway device and each outcome using two-level mixed effects logistic regression with EMS agency as the random effect, adjusted for standard Utstein variables and failed intubation prior to supraglottic airway insertion. Average treatment effects were calculated through propensity score matching. Results A total of 286,192 OHCA patients were screened, resulting in 93,866 patients eligible for inclusion in this analysis. A total of 9,456 transported patients (59.8% iGel) had associated hospital disposition data. Use of the iGel was associated with greater survival to discharge to home (aOR:1.36 [1.06, 1.76]; ATE: 2.2%[+0.5, +3.8]; n = 7,576), first pass airway success (aOR:1.94 [1.79, 2.09]; n = 73,658), and ROSC (aOR:1.19 [1.13, 1.26]; n = 73,207) in comparison to airway management with the King-LT. iGel use was associated with lower odds of experiencing a rearrest (aOR:0.73 [0.67, 0.79]; n = 20,776). Among patients who received a supraglottic device as a primary airway, use of the iGel was not associated with significantly greater survival to discharge to home (aOR:1.26 [0.95, 1.68]). Among patients who received a supraglottic device as a rescue airway following failed intubation, use of the iGel was associated with greater odds of survival to discharge to home (aOR:2.16 [1.15, 4.04]). Conclusion In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.

Laryngeal Suction tube: A Novel Technique for Tracheal Ventilation in an Obstructed Airway in a Child with Respiratory Papillomatosis.

Airway obstruction in a child requires expedite management in addition to comprehensive discussion between the Otolaryngology and Anaesthesiology team to formulate a treatment plan to ensure safe airway. Juvenile-onset recurrent respiratory papillomatosis (JORRP) is an exophytic benign laryngeal lesion which poses a great challenge when presented with respiratory distress. This paper presents a novel, safe and cost-effective approach to temporary tracheal ventilation of the obstructed airway in a child with juvenile-onset recurrent respiratory papillomatosis using the laryngeal suction tube connected to general anaesthetic (GA) machine. Rigid laryngeal suction tube is placed through the side-port of Lindholm laryngoscope and connected to breathing circuit of GA machine. Manual bagging ventilation with 100% FiO2 achieved good oxygenation throughout the debulking of the papilloma without hindering the surgical field. Our technique utilizes the readily available equipment whilst enabling safe anaesthesia and providing good surgical field during excision of obstructive papillomatous airway lesion.

Military Standard Testing of Commercially Available Supraglottic Airway Devices for Use in a Military Combat Setting.

Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing. We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3. The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered. Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.

Comparison of two techniques of airway anaesthesia for awake fibreoptic nasotracheal intubation in patients with anticipated difficult airway

Introduction: The success of awake fibreoptic assisted intubation often depends on the adequacy of anaesthesia of the airway and patient comfort for the procedure. Aim: To compare the standard technique (nerve block) of airway anaesthesia with simple aspiration of lignocaine. Methods: Thirty patients in whom difficult airway was anticipated were randomly allocated into either Group A (Aspiration) and Group B (Nerve block). In Group A, 0.2 mL/kg of 1.5% lignocaine was trickled on to the dorsum of the tongue while the patient was encouraged to breathe through the mouth. In Group B, superior laryngeal nerve block and intratracheal injection of lignocaine was used. Fibreoptic bronchoscopy was then carried out by a consultant anaesthesiologist, who was blinded to the local anaesthetic technique used. The patient responses to instrumentation of pharynx, glottis and trachea, and tolerance of the endotracheal tube were noted. Results: Two cases were excluded from the study because of bleeding resulting in subsequent loss of visualisation of glottis through bronchoscope. There was no statistical or clinical difference in the patient responses between the two groups (P &gt; 0.05) due to fibreoptic bronchoscope in the pharynx, larynx and endotracheal tube in the trachea or with regard to the use of rescue medications. Conclusions: Aspiration of 1.5% lignocaine (0.2 mL/kg) provides clinically comparable conditions for intubation as the nerve block technique for awake fibreoptic nasotracheal intubation in patients with anticipated difficult airway.