Successful Airway Management Research Articles

Larynxtubus-D (LT-D) und Larynxmaske (LMA)

In 2005 the European Resuscitation Council (ERC) published a revised version of the guidelines for Advanced Life Support (ALS). One of the aims was to reduce the time without chest compression in the first period of cardiac arrest. We evaluated in a manikin study whether using the single use laryngeal tube (LT-D) instead of single use laryngeal mask (LMA) for emergency airway management could reduce the "No Flow Time" (NFT). The NFT is defined as the time during which no chest compressions take place. Randomised prospective study with 200 volunteers who performed a standardised simulated cardiac arrest management in a manikin following one-day cardiac arrest training (simulation scenario 430 s). Two supraglottic airway devices were compared (LT-D and LMA). Endpoints were the total "no flow time" during the scenario, and the successful airway management with the used airway device. In the present manikin study the use of the LT-D significantly reduced NFT compared with the LMA (104.2 s vs. 124.0 s; p < 0.01). The LT-D was correctly positioned by 98 % of the participants on the first attempt compared to 74 % with the LMA. The LT-D was inserted significantly faster than the LMA (12.4 s vs. 29.1 s, p < 0.01). During the cardiac arrest simulation establishing and performing first ventilation took an average of 40.5 s with the LT-D compared to 47.9 s with LMA. In this manikin study data showed that the LT-D may be a good alternative airway device compared to LMA for providing and maintaining a patent airway during resuscitation.

Congenital cervical spine fusion and airway management: a case series of Klippel-Feil syndrome

Study Objective To determine the ideal airway management modalities in general anesthesia for pediatric patients with Klippel-Feil syndrome, a disorder that is characterized by abnormalities of the cervical spine and craniofacial structures that may impede successful airway management. Design Retrospective review of electronic anesthesia database. Setting University hospital. Measurements The electronic charts of 10 pediatric patients with Klippel-Feil syndrome (KFS) who received treatment at our institution from 2005 to 2007 were reviewed with a focus on diagnosis, level of lesion, comorbid diseases, age, procedure, history of perioperative difficulties, and airway management during general anesthesia. Main Results A total of 10 pediatric patients, 6 girls and 4 boys, underwent 11 procedures from 2005 to 2007. Average age was 11 (range, 4-16 yrs). Six patients were ASA physical status II and 4 were ASA physical status III. Four patients had spinal fusion, 6 underwent magnetic resonance imaging, and one patient underwent removal of halo hardware. Eight patients had undergone previous surgeries; of the 8, one patient had a history of difficult intubation. Six patients underwent tracheal intubations, 4 had a Laryngeal Mask Airway (LMA; Orthovent Intafix, Maidenhead, UK) placed, and one had mask ventilation with an oral airway. Of 6 tracheal intubations, 5 were achieved on the first or second attempt without difficulty. Three had grade 1 laryngoscopic views; only one patient needed fiberoptic intubation. Because the fiberoptic intubation took several attempts, it was noted as a difficult intubation in the chart. All LMAs were placed without difficulty, and the cases were uneventful. Conclusions The airways of individuals with KFS may be successfully managed in a variety of ways, often with little degree of difficulty.

M634: Airway Management for the OMS

Successful airway management is the cornerstone of safe anesthesia practice. The fundamental responsibility of the anesthesia provider is to maintain adequate gas exchange. Morbidity and mortality studies overwhelmingly conclude that respiratory events are the most common emergent anesthetic events and result in the worst outcomes when not properly treated. We will review the airway management tools available to the oral and maxillofacial surgeon. These will include the endotracheal tube, laryngeal mask airway, combitube, and cricothyroidotomy.

Successful Airway Management in a Patient With Giant Internal Carotid Artery Pseudoaneurysm Occupying the Oral Cavity

Successful Airway Management in a Patient With Giant Internal Carotid Artery Pseudoaneurysm Occupying the Oral Cavity

Airway interventions in children with Pierre Robin Sequence

To describe the interventions required for successful airway management in children with Pierre Robin Sequence (PRS). Case series. The records of both a cleft and craniofacial clinic and a pediatric otolaryngology clinic were searched, and all children with PRS were identified. Data concerning feeding interventions, airway interventions, and comorbid conditions were extracted. Seventy-four cases of PRS were identified. Thirty-eight of the 74 children required airway intervention other than prone positioning. Fourteen of these 38 were managed nonsurgically with nasopharyngeal airway and/or short-term endotracheal intubation, whereas the remaining 24 required surgical intervention. Eighteen of the 24 underwent distraction osteogenesis of the mandible, one underwent tracheostomy, and five underwent tracheostomy followed by eventual distraction. In our series, over 50 percent of children with PRS required an airway intervention. These were both nonsurgical and surgical. As otolaryngologists, we must be prepared for the challenges children with PRS may present and the interventions that may be necessary to successfully manage these difficult airways.

Influence of airway management strategy on "no-flow-time" during an "Advanced life support course" for intensive care nurses – A single rescuer resuscitation manikin study

BackgroundIn 1999, the laryngeal tube (VBM Medizintechnik, Sulz, Germany) was introduced as a new supraglottic airway. It was designed to allow either spontaneous breathing or controlled ventilation during anaesthesia; additionally it may serve as an alternative to endotracheal intubation, or bag-mask ventilation during resuscitation. Several variations of this supraglottic airway exist. In our study, we compared ventilation with the laryngeal tube suction for single use (LTS-D) and a bag-mask device. One of the main points of the revised ERC 2005 guidelines is a low no-flow-time (NFT). The NFT is defined as the time during which no chest compression occurs. Traditionally during the first few minutes of resuscitation NFT is very high. We evaluated the hypothesis that utilization of the LTS-D could reduce the NFT compared to bag-mask ventilation (BMV) during simulated cardiac arrest in a single rescuer manikin study.MethodsParticipants were studied during a one day advanced life support (ALS) course. Two scenarios of arrhythmias requiring defibrillation were simulated in a manikin. One scenario required subjects to establish the airway with a LTS-D; alternatively, the second scenario required them to use BMV. The scenario duration was 430 seconds for the LTS-D scenario, and 420 seconds for the BMV scenario, respectively. Experienced ICU nurses were recruited as study subjects. Participants were randomly assigned to one of the two groups first (LTS-D and BMV) to establish the airway. Endpoints were the total NFT during the scenario, the successful airway management using the respective device, and participants' preference of one of the two strategies for airway management.ResultsUtilization of the LTS-D reduced NFT significantly (p < 0.01). Adherence to the time frame of ERC guidelines was 96% in the LTS-D group versus 30% in the BMV group. Two participants in the LTS-D group required more than one attempt to establish the LTS-D correctly. Once established, ventilation was effective in 100%. In a subjective evaluation all participants preferred the LTS-D over BMV to provide ventilation in a cardiac arrest scenario.ConclusionIn our manikin study, NFT was reduced significantly when using LTS-D compared to BMV. During cardiac arrest, the LTS-D might be a good alternative to BMV for providing and maintaining a patent airway. For personnel not experienced in endotracheal intubation it seems to be a safe airway device in a manikin use.

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]

Successful airway management of a patient with a known difficult airway with the Direct Coupler Interface Video Laryngoscope

We present the case of a patient who first presented with unexpected difficult laryngoscopy and intubation after induction of general anesthesia. After multiple failed attempts using direct laryngoscopy, tracheal intubation was successfully performed with the Intubating Laryngeal Mask Airway. He returned to the operating room 5 days later for another surgical procedure, and intubation was performed with the Direct Coupler Interface Video Laryngoscope on the first attempt by the same anesthesiologist.

Airway Management

Successful airway management is the cornerstone of safe anesthesia practice. The fundamental responsibility of the anesthesia provider is to maintain adequate gas exchange. Morbidity and mortality studies overwhelmingly conclude that respiratory events are the most common emergent anesthetic events and result in the worst outcomes when not properly treated. We will review the airway management tools available to the oral and maxillofacial surgeon. These will include the endotracheal tube, laryngeal mask airway, combitube, and cricothyroidotomy. Advantages, contraindications, and instructions for placement will be covered. Tools of early airway management detection and treatment will be reviewed. Emergency treatment of respiratory complications, including foreign body obstruction, laryngospasm, bronchospasm, aspiration, and pulmonary edema will be covered. Finally, the ‘cannot ventilate, cannot intubate’ scenario will be discussed in detail. The goal of the presentation is to help the clinician avoid airway complications and solve airway problems.

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.

Success Rate of Airway Management by Residents in a Pre-hospital Emergency Setting: a Retrospective Study

The objective of this retrospective study over a 5-year period was to assess the success rate of airway management by residents. Criteria of successful airway management were both the adherence to a standardized protocol of pre-hospital airway management and successful endotracheal intubation (ETI) in rescue missions. The minimal level of training time required for residents rotating in the pre-hospital emergency team was either 1 year in our university department of anesthesiology, or 3 years of internal medicine including 20 ETIs under supervision in the operating room. According to a strict protocol detailing indications and drugs to be administered, residents performed rapidsequence intubation (RSI) except in cases of cardiopulmonary arrests where ETI was performed without drugs. Adherence to the protocol of airway management was evaluated according to data provided by the residents. Successful endotracheal tube placement was confirmed only in transported patients with a combination of clinical signs, infrared capnography, and a chest X-ray on hospital admission. A total of 13,537 rescue missions were reviewed. The protocol adherence was 96.1%. ETI was attempted in 753 patients, and successful placement was confirmed in 98.2%. Pre-hospital airway management (protocol adherence and proper endotracheal tube placement) was successful overall in 94.3% of rescue missions. Our results support the efficacy of a pre-hospital emergency rescue system reinforced by residents.

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.

To Distract or Not to Distract: An Algorithm for Airway Management in Isolated Pierre Robin Sequence

Approaches advocated for treatment of airway obstruction among neonates with Pierre Robin sequence include positioning, tongue-lip adhesion, mandibular distraction, and tracheostomy, with no established guidelines regarding which modality is appropriate for a specific patient. This report proposes an algorithm for the management of neonatal upper airway obstruction among patients with isolated Pierre Robin sequence. Data for 21 patients with isolated Pierre Robin sequence who were treated by one surgeon during a 9-year period were reviewed. Eighteen patients presented during the first 1 week of life and three patients presented late, between 12 and 33 months of age. Follow-up periods ranged from 9 to 70 months (median, 33 months). Successful airway management was achieved with positioning alone for 10 patients, with tongue-lip adhesion for seven of nine patients, with tracheostomy for two patients, and with mandibular distraction for three patients. Changes in the maxillary-mandibular discrepancy were significant with natural mandibular growth during the first 1 year of life (p < 0.0001). Oromotor studies performed 3 months or more after tongue-lip adhesion reversal (n = 9) demonstrated no appreciable deficits in tongue function, relative to other children with cleft lips/palates. A multidisciplinary team should evaluate all patients with isolated Pierre Robin sequence, to fully assess the maxillary-mandibular relationship, anatomically define the site of airway obstruction, and identify feeding difficulties. Patients should be evaluated for episodes of desaturation occurring spontaneously, during feeding, or during sleeping. Patients with desaturation should be further evaluated with double endoscopy (nasoendoscopy and bronchoscopy). If the airway obstruction is localized to the tongue base alone and cannot be controlled with positioning, then tongue-lip adhesion is the initial treatment of choice, because such patients demonstrate significant mandibular growth during the first 1 year of life. Mandibular distraction among neonates is reserved for failures of tongue-lip adhesion in which isolated tongue-base airway obstruction is documented. Neither of the patients who experienced failure of tongue-lip adhesion in this series would have been a candidate for distraction with the algorithm presented. Avoiding routine neonatal distraction serves to avoid facial scarring, nerve and tooth bud injury, and potential disturbances of intrinsic mandibular growth. Patients with persistent respiratory difficulties beyond age 9 months require reevaluation for multiple sites of airway obstruction. Mandibular distraction may be one of several modalities required to avoid tracheostomy for such patients.

This Month in ANESTHESIOLOGY

This Month in ANESTHESIOLOGY

Inhalational induction of anaesthesia with 8% sevoflurane in children: conditions for endotracheal intubation and side-effects

Background and objective: This study was designed to assess the conditions for endotracheal intubation or insertion of a laryngeal mask airway following an inhalational induction using 8% sevoflurane and nitrous oxide without the use of muscle relaxants or opioids. Methods: There were two groups: 30 children had endotracheal intubation and 30 children had a laryngeal mask airway inserted. Induction of anaesthesia was accomplished using an inspiratory concentration of sevoflurane 8% in a nitrous oxide and oxygen mixture. After an end-expiratory concentration of sevoflurane of at least 4% had been reached, when the pupils were miotic and centred, the trachea was intubated or a laryngeal mask inserted. The time to loss of consciousness and successful airway management was recorded. Jaw relaxation, movements, visibility, and position of the vocal cords and vital parameters were monitored. Results: Jaw relaxation was complete in all children. The vocal cords were completely visible in all patients of the tracheal intubation group, whereas vocal cord relaxation was incomplete in five children. Nevertheless, all children had an atraumatic intubation or insertion of the laryngeal mask without the use of a muscle relaxant. Vital signs were stable in both groups. There were no cases of restlessness and/or postoperative shivering. Four patients in the endotracheal group (13.3%) were nauseous and three (10%) vomited, while two children (6.6%) in the laryngeal mask group experienced nausea and vomiting. Conclusions: Induction with sevoflurane in nitrous oxide and oxygen leads to fast loss of consciousness and provides ideal conditions for managing the airway without supplemental opioids or muscle relaxants. Furthermore, sevoflurane using this technique was very well tolerated, indicated by high haemodynamic stability and a reduced rate of postoperative restlessness, shivering, nausea and vomiting.

Airway management of a patient with weill-marchesani syndrome

Weill-Marchesani syndrome is a genetically determined rare systemic connective tissue disorder consisting of brachymorphy, brachydactyly, aortic stenosis, and ophthalmologic abnormalities, such as ectopia lentis, microspherophakia, and secondary glaucoma. The primary lesion is fibrous tissue hyperplasia. Airway control and intubation may be difficult in patients with WMS because of stiff joints, poorly aligned teeth, and maxillary hypoplasia with a narrow palate. We describe the successful airway management of a patient with WMS and laryngeal stenosis, using an intubating laryngeal mask following failed conventional laryngoscopic intubation.

Airway Management of the Severely Retrognathic Child: Use of the Laryngeal Mask Airway

Successful airway management of an infant or child with moderate to severe retrognathia first requires recognition of a potential problem. If the child cannot be intubated in a standard fashion, the use of a laryngeal mask airway (LMA) should be considered. We describe two cases wherein a toddler and an infant with severe retrognathia failed multiple attempts at traditional intubation. Both had an anterior larynx and hypoplasia of the mandible. In both cases, a subsequent LMA was successfully placed. The severely retrognathic newborn or child presents to the physician a unique challenge in airway management. Techniques to manage this difficult pediatric airway are different from those used in the adult. Otolaryngologists should be aware of this intubation technique and include it in their armamentarium of airway-management strategies. The LMA is not recommended as the technique of choice for securing a difficult airway, but it is an effective alternative when indicated, and it might be life-saving.

Measurement of laryngeal dimensions in neonates.

Intimate knowledge of laryngeal anatomy and various laryngeal dimensions is crucial for successful airway management. Selection of a proper endotracheal tube is also a critical factor. Subglottic dimension is the most important measurement of larynx because of it being the narrowest part of the infant larynx. Data about various infantile laryngeal dimensions in Indian population is sparse. In this article, we present various laryngeal dimensions using 30 infantile laryngeal autopsy specimens and review of literature.

International Trauma Anesthesia and Critical Care Society (ITACCS).

International Trauma Anesthesia and Critical Care Society (ITACCS).

Emergency airway management in penetrating neck injury

Study objectives: Airway management in the context of penetrating neck injury is a challenging scenario. Management decisionmaking has not been well studied and the initial airway approach remains controversial. We examined various initial emergency airway techniques and their success in the setting of penetrating neck trauma. Methods: A retrospective study was conducted of emergency department intubations in penetrating neck injury from January 1, 1993, to December 31, 1996, at a Level I trauma center. Cases of out-of-hospital traumatic arrest or out-of-hospital intubation were excluded. Successful airway management was defined as endotracheal tube placement confirmed by clinical evaluation, pulse oximetry, chest radiography, and end-tidal CO 2 detection. Results: During the study period, 748 consecutive patients with penetrating neck injury were evaluated in the ED. Of these, 82 (11%) were deemed to require immediate airway management. Twenty-four of the 82 were excluded because of out-of-hospital traumatic arrest or out-of-hospital intubation, resulting in a study population of 58 patients. Of these 58 patients, 39 had initial rapid sequence intubation using succinylcholine with a 100% success rate. Five comatose patients had successful orotracheal intubation without paralysis, and 2 patients underwent successful emergency tracheostomy. The remaining 12 patients had initial fiberoptic intubation by otolaryngology clinicians, which was unsuccessful in 3 patients. All 3 of these patients were subsequently successfully orotracheally intubated using the rapid sequence intubation technique. Therefore, oral endotracheal intubation was the definitive method of airway management in 47 (81%) of the 58 patients and was successful in all cases. Conclusion: Rapid sequence intubation was the most commonly performed initial technique by emergency physicians and was safe and effective in all cases attempted. Furthermore, rapid sequence intubation methodology resulted in successful intubation of the fiberoptic intubation failures. Physicians with airway expertise should consider using rapid sequence intubation as an initial airway technique in managing patients with penetrating neck injury who require airway control. [Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med . March 2000;35:221-225.]