Use Of Supraglottic Airway Devices Research Articles

Evaluation of supraglottic airway device use during inhalation anesthesia in healthy African pygmy hedgehogs (Atelerix albiventris)

ObjectiveTo evaluate a supraglottic airway device (SGAD) designed for rabbits in African pygmy hedgehogs (Atelerix albiventris) during inhalation anesthesia. Study designProspective, randomized, blinded experimental study. AnimalsA total of 12 adult African pygmy hedgehogs (seven male, five female). MethodsHedgehogs were placed in a chamber and anesthesia was induced using isoflurane in oxygen. Oropharyngeal endoscopy was performed and video recorded. The SGAD (v-gel R1) was inserted and connected to a Mapleson D circuit. Capnography, pulse oximetry and physiologic variables were measured during anesthesia, and lung inflation was tested at 10 and 20 cmH2O. With the SGAD temporarily disconnected, anesthetized hedgehogs were randomly positioned into right and left lateral, dorsal and sternal recumbency to evaluate the effect of a change in body position on SGAD placement. Oropharyngeal endoscopy was repeated at the end of anesthesia, and recovery time was recorded. Pre- and post-SGAD placement endoscopy videos were retrospectively reviewed and scored for gross trauma. ResultsThe median [interquartile range (IQR)] time to successful SGAD placement was 38 (16–68) seconds. The time to SGAD placement decreased as the study progressed. SGAD required repositioning in six hedgehogs, median 2.5 (IQR, 1–3.5) adjustments each, to successfully perform lung inflation or maintain capnography readings. Lung inflation at 10 cmH2O was successfully performed without leakage in nine animals, and in the other three animals after adjusting the SGAD at 1–2 time points. Inflation at 20 cmH2O was rarely achieved without an air leak. Changes in heart and respiratory rates during anesthesia were not clinically relevant. Median endoscopic scores were 0 (no lesions) for both pre-and postplacement. Conclusions and clinical relevanceThe SGAD was relatively quickly and easily placed, permitted lung inflation and caused no significant oropharyngeal damage. The SGAD is a practical option for airway management in African pygmy hedgehogs.

Supraglottic airway device versus tracheal intubation and the risk of emergent postoperative intubation after general anaesthesia in adults: a retrospective cohort study

BackgroundWe examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes. MethodsWe included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used. ResultsUse of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64–0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4–4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4–43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99–6.67 vs aOR=1.68, 95% CI, 1.29–2.18 [P<0.001], respectively). ConclusionsIn patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.

Subcutaneous emphysema as a complication of the use of a laryngeal mask in a child

The use of supraglottic airway devices has been increasing in popularity, mostly due to their high success rate and low complications. However, there is very little information available about the potential and group specific concerns regarding their use in children. We present the first description of a child that developed subcutaneous emphysema after the use of a laryngeal mask. We believe that more awareness to the risk of perioperative adverse events with laryngeal mask insertion in the paediatric population is needed.

Prevention of Oxygen Desaturation in Morbidly Obese Patients During Electroconvulsive Therapy: A Narrative Review.

In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.

Current trends in the use of supraglottic airway device – a multicentre survey

Current trends in the use of supraglottic airway device – a multicentre survey

Endotracheal intubation during out-of-hospital cardiac arrest: New insights from recent clinical trials.

Airway management is an important intervention during resuscitation of out‐of‐hospital cardiac arrest (OHCA). Endotracheal intubation is commonly used by emergency medical services paramedics in the advanced airway management of OHCA, but numerous studies question its safety and effectiveness. Furthermore, there is now increasing use of supraglottic airway devices. In this review, we provide an overview of 3 recent randomized clinical trials of advanced airway management (Pragmatic Airway Resuscitation Trial [PART], AIRWAYS‐2, and Cardiac Arrest Airway Management [CAAM]) and highlight new information that is available to guide OHCA airway management practices.

Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D, Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial.

The use of supraglottic airway devices (SADs) is becoming more widespread. However, there is little evidence to show which device is best in an emergent clinical scenario. We compared both fiberoptic-guided and blind tracheal intubation through the Intubating Laryngeal Tube Suction-Disposal (iLTS-D), the AuraGain™, and the i-gel® in an airway manikin. Thirty residents were included in a randomized trial to perform both fiberoptic-guided and blind tracheal intubation using the iLTS-D, the AuraGain, and the i-gel. The main endpoint was the total time taken to achieve successful fiberoptic intubation through the SAD. Additional endpoints included total time for blind intubation, SAD insertion time, tracheal tube insertion time, intubation success rate, fiberoptic view, and maneuvers performed to achieve tracheal intubation. All participants performed fiberoptic intubation using all three SADs on the first attempt. The total time to fiberoptic tracheal intubation using the i-gel, AuraGain, and iLTS-D was 42s, 56s, and 56s, respectively. The blind tracheal intubation success rate was 80% with the iLTS-D, 43% with the i-gel, and 0% with the AuraGain. The total time for blind tracheal intubation through the i-gel and the iLTS-D was 29s and 40s, respectively. Laryngeal view grades were significantly poorer with the iLTS-D compared to the other devices. The iLTS-D required significantly more maneuvers to achieve successful tracheal intubation. In an airway manikin, the iLTS-D, AuraGain, and i-gel appear to be reliable devices for airway rescue and fiberoptic-guided tracheal intubation. The iLTS-D is recommended for blind tracheal intubation.

Difficult airway management algorithms: a directed review.

The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.

Supraglottic airway devices in difficult airway management: a retrospective cohort study of 658,104 general anaesthetics registered in the Danish Anaesthesia Database.

Indications for using supraglottic airway devices have widened over time and they now hold a prominent role in guidelines for difficult airway management. We aimed to describe the use of supraglottic airway devices in difficult airway management. We included adult patients undergoing general anaesthesia registered in the Danish Anaesthesia Database from 2008 to 2012 whose airway management had been recorded as difficult, defined as: ≥3 tracheal intubation attempts; failed tracheal intubation; or difficult facemask ventilation. In the Danish Anaesthesia Database, a separate difficult airway management module requires the technique used in each successive airway management attempt to be recorded. The primary aim of the study was to describe the use of supraglottic airway devices in cases of difficult airway management. Secondary aims were to examine success rates of supraglottic airway devices in difficult airway management cases, and specifically in the cases of 'cannot intubate, cannot facemask ventilate'. Difficult airway management occurred in 4898 (0.74% (95%CI 0.72-0.76%)) of 658,104 records of general anaesthesia. Supraglottic airway devices were used or use was attempted in 607 cases of difficult airway management (12.4% (95%CI 11.5-13.3%)), and were successful in 395 (65.1% (95%CI 61.2-68.8%)) cases. In 'cannot intubate, cannot facemask ventilate' situations, supraglottic airway devices were used in 86 (18.9% (95%CI 15.6-22.8%)) of 455 records and were successful in 54 (62.8% (95%CI 52.2-72.3%)) cases. We found that supraglottic airway devices are not widely used in the management of the difficult airway despite their prominent role in difficult airway management guidelines.

Dental injury in anaesthesia: a tertiary hospital\u2019s experience

BackgroundDental injury is a common perioperative complication, but there are no country specific data available, especially with the use of supraglottic airway devices (SAD). The aims of our study are to report the incidence, risk factors, and local practices in the management of perioperative dental injuries in Singapore.MethodsWe analyzed data from the departmental database from 2011 to 2014, noting the anticipated difficulty of airway instrumentation, intubation grade, pre-existing dental risk factors, location of dental trauma discovery, position of teeth injured and presence of dental referral. The risk factors for dental trauma were then identified using logistic regression (between 51 dental trauma patients and 55,107 patients without dental trauma).ResultsThe rate of dental injury was 0.092% for general anaesthesia cases. The most significant patient risk factor is the presence of pre-existing dental risk factors (OR 12.55). Anaesthetic risk factors include McGrath MAC usage (OR 2.51) and a Cormack and Lehane grade of 3 or more (OR 7.25). Most of the dental injuries were discovered in the operating theatre. 7 (13.7%) patients had SAD inserted and only 23 (45.1%) cases were referred to dental services.ConclusionVideolaryngoscopy with the McGrath MAC is associated with an increased likelihood of dental injury. This could be either because videolarygoscopes were used when increased risk of dental trauma was anticipated, or due to incorrect technique of laryngoscopy. Future studies should be done to establish the causality. The management of dental injuries could be improved with development of departmental guidelines.

Airway management and endotracheal intubation by paramedics for cardiac arrest

Paramedics are trained to perform endotracheal intubation (ETI), though a step-wise airway management approach has led to the use of supraglottic airway devices (SGAs), often in place of ETI. The current article considers airway management by paramedics during cardiopulmonary resuscitation (CPR). A case-note review relating to adult out-of-hospital cardiac arrests was carried out, with the collection of data over the period of a year, in one region of the UK. The results indicate that airway management is inconsistent during CPR, though simple adjuncts are used successfully. In a cohort of 2779 patients, in resuscitated cardiac arrest, attempts to intubate were made in less than half of the patients. Less than a third of patients were successfully intubated. Reasons for not attempting intubation need further investigation, alongside reasons for unsuccessful attempts.

An Audit of Use of Supraglottic Airway Devices in Pediatric Patients

An Audit of Use of Supraglottic Airway Devices in Pediatric Patients

In-hospital airway management training for non-anesthesiologist EMS physicians: a descriptive quality control study

BackgroundPre-hospital airway management is a major challenge for emergency medical service (EMS) personnel. Despite convincing evidence that the rescuer’s qualifications determine efficacy of tracheal intubation, in-hospital airway management training is not mandatory in Austria, and often neglected. Thus we sought to prove that airway management competence of EMS physicians can be established and maintained by a tailored training program.MethodsIn this descriptive quality control study we retrospectively evaluated all in- and pre-hospital airway cases managed by EMS physicians who underwent a structured in-hospital training program in anesthesia at General Hospital Wiener Neustadt. Data was obtained from electronic anesthesia and EMS documentation systems.ResultsFrom 2006 to 2016, 32 EMS physicians with 3-year post-graduate education, but without any prior experience in anesthesia were trained. Airway management proficiency was imparted in three steps: initial training, followed by an ongoing practice schedule in the operating room (OR). Median and interquartile range of number of in-hospital tracheal intubations (TIs) vs. use of supra-glottic airway devices (SGA) were 33.5 (27.5–42.5) vs. 19.0 (15.0–27.0) during initial training; 62.0 (41.8–86.5) vs. 33.5 (18.0–54.5) during the first, and 64.0 (34.5–93.8) vs. 27 (12.5–56.0) during the second year. Pre-hospitaly, every physician performed 9.0 (5.0–14.8) TIs vs. 0.0 (0.0–0.0) SGA cases during the first, and 9.0 (7.0–13.8) TIs vs. 0.0 (0.0–0.3) SGA during the second year. Use of an SGA was mandatory when TI failed after the second attempt, thus accounting for a total of 33 cases. In 8 cases, both TI and SGA failed, but bag mask ventilation was successfully performed. No critical events related to airway management were noted and overall success rate for TI with a max of 2 attempts was 95.3%.DiscussionNumber of TIs per EMS physician is low in the pre-hospital setting. A training concept that assures an additional 60+ TIs per year appears to minimize failure rates. Thus, a fixed amount of working days in anesthesia seems crucial to maintain proficiency.ConclusionsIn-hospital training programs are mandatory for non-anesthetist EMS physicians to gain competence in airway management and emergency anesthesia.Our results might be helpful when discussing the need for regulation and financing with the authorities.

I-Gel is a suitable alternative to endotracheal tubes in the laparoscopic pneumoperitoneum and trendelenburg position

BackgroundThe use of supraglottic airway devices (SADs) in surgeries with laparoscopic pneumoperitoneum and Trendelenburg (LPT) positioning is controversial due to concerns about insufficient pulmonary ventilation and aspiration. In this prospective, randomized-controlled trial, we evaluated whether the i-gel, a new second generation SAD, provides an effective alternative to an endotracheal tube (ETT) by comparing respiratory parameters and perioperative respiratory complications in non-obese patients.MethodsIn a randomized controlled trial, forty anesthetized patients with ASA I-II were divided into equally sized i-gel and ETT groups. We evaluated the respiratory parameters in the supine and LPT position in comparison between the two groups. The leak fraction was our primary outcome, which was defined as the leak volume divided by the inspired tidal volume. The leak volume was the difference between the inspired and expired tidal volumes. We also monitored pulmonary aspiration and respiratory complications during the perioperative period.ResultsIn the LPT position, there were no differences in the leak fraction (median [IQR]) between the i-gel and ETT groups (6.20[3.49] vs 6.38[3.71] %, P = 0.883). In the i-gel group, notably less leakage was observed in the LPT position than in the supine position (median [IQR]: 7.01[3.73] %). This phenomenon was not observed in the ETT group. The rate of postoperative sore throat was also significantly lower in the i-gel group than in the ETT group (3/17 vs 9/11). No vomitus nor any signs associated with aspiration were noted in our patients after extubation in the follow-up prior to discharge.ConclusionsThe i-gel provides a suitable alternative to an ETT for surgeries with LPT positioning in non-obese patients.Trial registrationRegistered at Clinicaltrials.gov NCT02462915, registered on 1 June 2015.

Use of Supraglottic Airway Devices by Paramedics in the Management of Adult Prehospital Cardiac Arrest Patients

Introduction Current best practice for paramedic airway management of prehospital cardiac arrest is being continually reviewed following changes to the emphasis on intubation as a primary intervention within international resuscitation guidelines. Subsequently, there is increased enthusiasm for the use of next generation supraglottic airway devices. This review aimed to identify the current evidence for the safety and effectiveness of supraglottic airways for the management of prehospital cardiac arrest. Methods A search of the electronic databases Medline, PubMed, Science Direct and Cochrane Library was conducted. Papers were excluded if they did not examine airway management in the prehospital cardiac arrest setting, involved the use of sedative or paralysing agents, involved paediatric patients, animals or cadavers. Results Of the 689 articles identified, 22 peer-reviewed articles were included for analysis. All 22 articles were from the following countries: United States of America, United States of America and Canada, Australia, Austria, Finland, Germany, Korea, Japan, The Netherlands, Norway, Taiwan and the United Kingdom. Discussion This review revealed large variances in both device effectiveness and patient outcome, particularly between geographical locations. Second-generation supraglottic airway devices demonstrated considerable improvement in effectiveness over their predecessors. Interestingly, the use of bag-valve mask ventilation reported better outcomes than any other form of advanced airway intervention. Studies also highlighted the diversity of airway management techniques and devices across global EMS systems. Conclusion Despite favourable indications of the effectiveness and safety of the next generation supraglottic airway devices, the paucity of pre-hospital specific research (particularly randomised controlled trials) challenges decision-making regarding pre-hospital airway management best practice.

Use of Supraglottic Airway Devices in the Prone Position

Supraglottic airway devices (SADs) have revolutionized airway management. These advanced devices incorporate specific features to protect against gastric regurgitation and aspiration and also create a high oropharyngeal seal pressure. These developments have broadened indications for SADs, and some anesthetists use SADs with the patient in the prone position. SADs are also used as rescue device in instances of unintentional tracheal extubation. In addition, there is the elective use of SADs in the prone position. However, the use of SADs in the prone position remains controversial. This review aims to examine the published evidence regarding the use of SADs in patients undergoing surgery in the prone position.

Comparison of the performance of the self-pressurized air-Q intubating laryngeal airway with the LMA–ProSeal in pediatric patients under general anesthesia: a randomized controlled trial

Background Self-pressurized air-Q intubating laryngeal airway (air-Q SP) is a supraglottic airway device with a noninflatable cuff that does not need continuous monitoring of the cuff pressure. As the ProSeal laryngeal mask airway (PLMA) is considered the ‘state-of-the-art’ supraglottic device, we conducted this randomized trial to evaluate the safety and efficacy of air-Q SP compared with that of PLMA in pediatric patients. Patients and methods The study included 70 pediatric patients aged from 4 to 15 years undergoing elective surgery under general anesthesia who were randomized to either the air-Q SP group or the PLMA group. The primary outcome parameter in this study was the oropharyngeal leak pressure, and the secondary outcome parameters were ease of insertion, time of insertion, first attempt insertion success rate, number of gastric insufflations, fiberoptic glottic view, and complications related to the supraglottic airway device use. Results There was no significant difference between air-Q SP and PLMA regarding first insertion success rate, ease of insertion, oropharyngeal leak pressure, number of gastric insufflations, number of manipulations required to adjust the airway, and complications. Time to insert the air-Q SP was significantly shorter than that of PLMA (13.2±4.2 vs. 17.5±4.8 s, P=0.03). The fiberoptic view was significantly better with air-Q SP than with PLMA (P=0.018). Conclusion The performance of air-Q SP is comparable to that of PLMA as a primary airway device during general anesthesia in pediatric patients, with a shorter insertion time and better fiberoptic view for air-Q SP.

Randomised Comparison of the Effectiveness of the Laryngeal Mask Airway Supreme, I-Gel and Current Practice in the Initial Airway Management of Out of Hospital Cardiac Arrest

(Abstracted from Br J Anaesth, 116(2):262–268, 2016) Effective ventilation is a crucial component of cardiopulmonary resuscitation (CPR) after cardiac arrest, but what constitutes effective ventilation is unclear. Although tracheal intubation has traditionally been viewed as the best airway management during out-of-hospital cardiac arrest (OHCA), this assumption has been challenged by the use of supraglottic airway devices (SGAs), which are faster and easier to insert.

Obstetric Anaesthetists’ Association and Difficult Airway Society Guidelines for the Management of Difficult and Failed Tracheal Intubation in Obstetrics

(Anaesthesia. 2015;70(11):1286–1306) This paper presents the first national obstetric-specific failed intubation guidelines in the United Kingdom. These guidelines were developed by a working group commissioned by the Obstetric Anaesthetists’ Association and the Difficult Airway Society UK. The guidelines include specific measures to account for the physiological and physical changes of pregnancy, which significantly affect oxygenation and airway management, as well as the need to consider both maternal and fetal status when making decisions regarding management of the difficult airway. They also provide a structure for advance planning in the event that failed intubation were to arise. There is a need for standardizing the approach to obstetric failed intubation as the number of obstetric general anesthetics has been declining over the last 3 decades as regional anesthesia has become more popular. As a result, experience in managing the obstetric airway in general and the specific situation of difficult intubation has declined, especially among anesthesia trainees. In addition, other trends in anesthesia care, such as the increased use of supraglottic airway devices (SADs), has led to a decrease in the use of some specific airway skills, including bag/mask ventilation and tracheal intubation.

Postoperative sore throat: a systematic review.

Postoperative sore throat has a reported incidence of up to 62% following general anaesthesia. In adults undergoing tracheal intubation, female sex, younger age, pre-existing lung disease, prolonged duration of anaesthesia and the presence of a blood-stained tracheal tube on extubation are associated with the greatest risk. Tracheal intubation without neuromuscular blockade, use of double-lumen tubes, as well as high tracheal tube cuff pressures may also increase the risk of postoperative sore throat. The expertise of the anaesthetist performing tracheal intubation appears to have no influence on the incidence in adults, although it may in children. In adults, the i-gel(™) supraglottic airway device results in a lower incidence of postoperative sore throat. Cuffed supraglottic airway devices should be inflated sufficiently to obtain an adequate seal and intracuff pressure should be monitored. Children with respiratory tract disease are at increased risk. The use of supraglottic airway devices, oral, rather than nasal, tracheal intubation and cuffed, rather than uncuffed, tracheal tubes have benefit in reducing the incidence of postoperative sore throat in children. Limiting both tracheal tube and supraglottic airway device cuff pressure may also reduce the incidence.