Supraglottic Airway Devices Research Articles

A randomized controlled trial comparing gastro-laryngeal tube with endotracheal intubation for airway management in patients undergoing ERCP under general anaesthesia

BackgroundGastro laryngeal tube (GLT) is a newly introduced device. It is an advanced purpose specific design (essentially a modified laryngeal tube) which especially provides a separate wide channel specifically designed for the introduction of a gastroscope for endoscopic retrograde cholangio-pancreatography (ERCP), simultaneously functioning as a supra-glottic airway device for ventilation. MethodsIn a randomized controlled trial on 100 patients undergoing ERCP under GA, GLT was compared with endotracheal tube as an alternative airway device. Device insertion conditions, oxygenation and ventilation parameters were recorded. ResultsGLT was found to be comparable with ETT. Success rate of insertion of GLT was high (92%) and the insertion time of GLT was significantly shorter 42 (20–210)s vs. 206 (176–320)s – median (range). Both the devices were equally effective in normal oxygenation and ventilation. The recovery time was significantly shorter and postoperative complications such as hoarseness and dysphonia were less common in GLT group. Inserting conditions for the duodenoscope were better in GLT group. ConclusionIn this study, likely to be first of its kind, it is concluded that the GLT is a suitable and better alternative to ETT as it allows adequate ventilation and is associated with faster recovery times and minimal extubation-related complications while enhancing operative conditions for gastroenterologists. Its regular use in patients undergoing ERCP is strongly recommended.

The knowledge and attitude of last year medical students towards supraglottic airway devices

The knowledge and attitude of last year medical students towards supraglottic airway devices

Male requires a higher median target effect-site concentration of propofol for I-gel placement when combined with dexmedetomidine

ObjectiveThe supraglottic airway device (SAD) can be used for airway management of spontaneous breathing patients, and propofol is commonly applied for the SAD placement. This study was designed to assess the effect of gender on median target effect-site concentration (Ce50) of propofol for I-gel placement when combined with dexmedetomidine. Material and method19 males and 18 females, aged 18 to 59 and undergoing elective surgery, were enrolled. After intravenous infusion of dexmedetomidine 1.0μg/kg over 10min followed by continuous infusion of 0.4μg/kg/h, target-controlled infusion of propofol under Marsh model was started and the initial Ce of propofol was set at 4.79μg/mL and 4.35μg/mL in the male and female patients, respectively. The I-gel was inserted when the Ce of propofol reached the pre-set concentration and bispectral index value was less than 60. The Ce of propofol required for I-gel placement was determined by the Dixon up-and-down method. ResultsThe Ce50 (95% confidence interval) of propofol required for I-gel placement were 4.082μg/mL (3.798–4.332μg/mL) and 3.509μg/mL (3.266–3.749μg/mL) in male and female patients, respectively, with a significantly higher Ce50 in males. ConclusionWhen combined with dexmedetomidine, males require a higher Ce50 of propofol for I-gel placement compared to females.

Airway Management in Athletes Wearing Lacrosse Equipment

Patient ventilation volume and rate have been found to be compromised due to the inability to seal a pocket mask over the chinstrap of football helmets. The effects of supraglottic airway devices such as the King LT and of lacrosse helmets on these measures have not been studied. To assess the effects of different airway management devices and helmet conditions on producing quality ventilations while performing cardiopulmonary resuscitation on simulation manikins. Crossover study. Simulation laboratory. Thirty-six athletic trainers (12 men, 24 women) completed this study. Airway-management device (pocket mask, oral pharyngeal airway, King LT airway [KA]) and helmet condition (no helmet, Cascade helmet, Schutt helmet, Warrior helmet) served as the independent variables. Participant pairs performed 2 minutes of 2-rescuer cardiopulmonary resuscitation under 12 trial conditions. Ventilation volume (mL), ventilation rate (ventilations/min), rating of perceived difficulty (RPD), and percentage of quality ventilations were the dependent variables. A significant interaction was found between type of airway-management device and helmet condition on ventilation volume and rate ( F12,408 = 2.902, P < .0001). In addition, a significant interaction was noted between airway-management device and helmet condition on RPD scores ( F6,204 = 3.366, P = .003). The no-helmet condition produced a higher percentage of quality ventilations compared with the helmet conditions ( P ≤ .003). Also, the percentage of quality ventilations differed, and the KA outperformed each of the other devices ( P ≤ .029). The helmet chinstrap inhibited quality ventilation (rate and volume) in airway procedures that required the mask to be sealed on the face. However, the KA allowed quality ventilation in patients wearing a helmet with the chinstrap fastened. If a KA is not available, the helmet may need to be removed to provide quality ventilations.

Self-pressurized air-Q® intubating laryngeal airway versus the LMA® Classic™: a randomized clinical trial

The self-pressurized air-Q® (air-Q SP) intubating laryngeal airway is a relatively new supraglottic airway (SGA) device. The intracuff pressure of air-Q dynamically equilibrates with the airway pressure and adjusts to the patient's pharyngeal and periglottic anatomy, potentially providing improved airway fit and seal. The aim of this prospective randomized study was to compare the clinical performance of air-Q to the LMA® Classic™ SGA. Adult patients requiring general anesthesia for elective surgery were prospectively enrolled and randomly assigned to either air-Q SP or the LMA Classic SGA. Oropharyngeal leak pressure (primary endpoint), success rate, insertion features (insertion time, ease of insertion, requirement for device manipulation), sealing function, gastric insufflation, bronchoscopic view, and oropharyngeal complications at device insertion and following its removal (sore throat, dysphagia, dysphonia) were compared. The mean (standard deviation [SD]) oropharyngeal leak pressure just after insertion was similar in the air-Q SP and LMA [16.8 (4.9) vs 18.6 (5.5) cm H2O, respectively; mean difference, 1.8 cm H2O; 95% CI, -0.5 to 4.2; P = 0.13] and did not differ at ten minutes following device insertion. Median [interquartile range (IQR)] peak inspiratory pressure just after insertion was lower in the air-Q SP (11.0 [10.0-13.0] vs 13.0 [11.0-14.0] cmH2O, median difference, 1.0 cm H2O; 95% CI, 0.0 to 2.0; P = 0.03) but no difference was observed at ten minutes. The median [IQR] insertion time was faster with the air-Q SP (15.9 [13.6-20.3] sec vs 24 [21.2-27.1] sec; median difference, 8.1 sec; 95% CI, 5.6 to 9.9; P < 0.001) and improved bronchoscopic viewing grade were seen with the air-Q SP immediately after insertion (P < 0.001). No differences between the groups were observed with respect to the rate of successful insertion at first attempt, overall insertion success rate, ease of insertion, and complications. The air-Q SP had similar leak pressures but a faster insertion time and superior bronchoscopic viewing grade when compared with the LMA Classic. The air-Q SP is a suitable alternative to the LMA Classic in adult patients and may be a superior conduit for tracheal intubation. www.clinicaltrials.gov (NCT02206438). Registered 1 August 2014.

Comparison of clinical performance of size 1.5 Supreme™ LMA and Proseal™ LMA among Asian children: a randomized controlled trial.

To date, most of the studies on safety and efficacy of supraglottic airway devices were done in Caucasian patients, and the results may not be extrapolated to Asian patients due to the different airway anatomy. We conducted this study to compare Supreme™ LMA (SLMA) and Proseal™ LMA (PLMA) size 1.5 in anaesthetized children among an Asian population. This prospective randomized clinical trial was conducted in a tertiary teaching hospital from September 2013 until May 2016. Sixty children, weighing 5-10kg, who were scheduled for elective surgery under general anaesthesia were recruited and completed the study. Patients were randomly assigned to have either SLMA or PLMA as the airway device for general anaesthesia, and standard anaesthesia protocol was followed. The primary outcome measured was the oropharyngeal leak pressure (OLP). The rate of successful insertion, insertion time, fibreoptic view of larynx and airway complications for each device were also assessed. There were no statistically significant differences between SLMA and PLMA size 1.5 in oropharyngeal leak pressure [19.1 (± 5.5) cmH2O vs. 19.8 (± 4.5) cmH2O, p = 0.68]. Secondary outcomes including time to insertion [20.8 (± 8.3) vs. 22.1 (± 8.3) s, p = 0.57], first attempt success rate for device insertion, fibreoptic view of larynx, and airway complications were also comparable between the two devices. We found that all the patients who had a failed device insertion (either PLMA or SLMA) were of a smaller size (5-6.2kg). The oropharyngeal leak pressure of the SLMA 1.5 was comparable with the PLMA 1.5, and both devices were able to maintain an airway effectively without significant clinical complications in anaesthetized children from an Asian population.

Emergency Airway Management in a Simulation of Highly Contagious Isolated Patients: Both Isolation Strategy and Device Type Matter.

OBJECTIVE To compare 6 airway-management devices in 3 isolation scenarios regarding their effect on airway management: portable isolation unit (PIU), personal protective equipment (PPE), and standard protection measures METHODS In total, 30 anesthesiologists working in emergency medical services performed airway management on mannequins in 3 isolation settings using 6 different airway management devices (in random order): (1) standard Macintosh laryngoscope; (2) Airtraq SP-video-laryngoscope; (3) i-gel; (4) LMA-Fastrach; (5) Ambu fiberoptic-aScope; and (6) Melker cricothyrotomy-set. Each was assessed regarding time-to-ventilate (primary outcome) and rating of difficulty handling the device. RESULTS In 86% (standard protection) and 85% (PPE) of attempts, airway management was achieved in <60 seconds, irrespective of the device used. In the PIU setting, only 69% of attempts succeeded within this time frame (P<.05). Median time-to-ventilate was shorter for standard protection (23 seconds) and PPE (25 seconds) compared to the PIU (38 seconds; P<.001). In the PIU setting, the fiberscope took the longest (median, 170 seconds), while i-gel was the quickest (median, 13 seconds). The rating of difficulty (visual analogue scale [VAS], 0-100) differed significantly between the isolation scenarios: Airway management was most difficult with PIU (VAS, 76), followed by PPE (VAS, 35), and standard protection (VAS, 9) (P<.01). CONCLUSION Wearing PPE produced similar times-to-ventilate as standard protection among anesthesiologists, but it was subjectively rated more difficult. The portable isolation unit permitted acceptable times-to-ventilate when excluding fiberscope and cricothyrotomy. Supraglottic airway devices allowed the fastest airway management in all isolation scenarios, thus being highly recommendable if a portable isolation unit is used and emergency airway management becomes necessary. Infect Control Hosp Epidemiol 2018;39:145-151.

Out-of-hospital airway management during manual compression or automated chest compression devices : Aregistry-based analysis.

Airway management during resuscitation is pivotal for treating hypoxia and inducing reoxygenation. This German Resuscitation Registry (GRR) analysis investigated the influence of the type of airway used in patients treated with manual chest compression (mCC) and automated chest compression devices (ACCD) after out-of-hospital cardiac arrest (OHCA). Out of 42,977 patients (1 January 2010-30 June 2016) information on outcome, airway management and method of chest compressions were available for 27,544 patients. Hospital admission under cardiopulmonary resuscitation (CPR), hospital admission with return of spontaneous circulation (ROSC), hospital discharge and discharge with cerebral performance categories1 and2 (CPC1,2) were used to compare outcome in patients treated with mCC vs. ACCD, and classified by endotracheal intubation (ETI), initial supraglottic airway device (SAD) changed into ETI, and only SAD use. Outcomes for hospital admission under ongoing CPR, hospital admission with ROSC, hospital discharge and neurologically intact survival (CPC1,2) for mCC (84.8%) vs. ACCD (15.2%) groups were: 8.4/38.6%, 39.2/27.2%, 10.6/6.8%, 7.9/4.7% (p< 0.001), respectively. Only mCC with SAD/ETI for ever ROSC (OR1.466, 95% CI:1.353-1.588, p< 0.001) and mCC group with SAD/ETI for hospital admission with ROSC showed better outcomes (odds ratio [OR]1.277, 95% confidence interval [CI]:1.179-1.384, p< 0.001) in comparison to mCC treated with ETI. Compared to mCC/ETI, all other groups were associated with adecrease in neurologically intact survival. Better outcomes were found for mCC in comparison to ACCD and ETI showed better outcomes in comparison to SAD only. This observational registry study raised the hypothesis that SAD only should be avoided or SAD should be changed into ETI, independent of whether mCC or ACCD is used.

Supraglottic airway devices: current and future uses.

Supraglottic airway devices have increasingly been used in anaesthesia since their invention in 1982. Now over half of general anaesthetic cases in the UK use them, and they have vital roles in difficult airway algorithms, pre-hospital use and emergency medicine. This article presents the current evidence regarding the complications of these devices, and compares these devices and endotracheal intubation. The technology of the newer generation devices has improved the safety profile, and they may be considered a better choice than endotracheal tubes in some cases. There may be a case for using these devices in a wider range of surgical and non-surgical cases.

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.

Direct and indirect low skill fibre-optic intubation: A randomised crossover manikin study of six supraglottic airway devices.

Background and Aims:Fibre-optic intubation (FOI) through supraglottic airway devices (SADs) is useful in the management of the difficult airway. We compared two methods of FOI through seven SADs in a randomised crossover manikin study to assess each device's performance and discuss implications on SAD selection.Methods:Thirty anaesthetsiologists, 15 seniors and 15 juniors, each performed low skill FOI (LSFOI) with seven SADs using both 'direct' and 'indirect' methods. The order of method and device used were randomised. The primary end point was success rate of intubation; secondary end points were time taken for intubation, incidence of difficulties with direct and indirect LSFOI and operator device preference. Statistical analysis was with univariable analysis and comparison of proportions.Results:Data from six devices were analysed due to a protocol breach with one SAD. There was no difference in intubation success rate across all SADs and intubation methods. Intubation time was significantly shorter in AmbuAuragain than other SADs and shorter with the direct method of LSFOI than the indirect method (mean difference of 6.9 s, P = 0.027). Ambu Auragain had the least SAD and bronchoscope-related difficulties. Seniors had significantly shorter mean intubation times than juniors by 11.6 s (P = 0.0392). The most preferred SAD for both methods was AmbuAuragain.Conclusion:Low skill FOI consistently achieves a high intubation success rate regardless of experience, choice of method, or SAD used. SAD design features may significantly affect the performance of low skill FOI.

Comparison of Clinical Performance of Supraglottic Airway Devices I– gel vs LMA-Proseal in Paediatric Elective Surgeries

Comparison of Clinical Performance of Supraglottic Airway Devices I– gel vs LMA-Proseal in Paediatric Elective Surgeries

Current practice patterns of supraglottic airway device usage in paediatric patients amongst anaesthesiologists: A nationwide survey.

Background and Aims:Supraglottic airway devices (SGADs) are increasingly being used for airway management in paediatric patients undergoing general anaesthesia. This survey was designed to assess the nationwide practice patterns of SGAD usage in paediatric patients.Methods:A questionnaire of 28 questions was circulated amongst 16,532 members of the Indian Society of Anaesthesiologists through online survey engine Google Forms® and served manually to 500 delegates attending the Asian Society of Paediatric Anaesthesiologists conference 2017. Percentage, mean and standard deviation were calculated using Microsoft Excel 2016 (Redmond, WA, USA).Results:Four hundred and five (2.3%) valid responses were obtained. The most commonly used device was i-gel© (60.74%). Three hundred and four (75.06%) respondents had access to second-generation SGADs. Second-generation devices (60.74%) were more commonly used than first-generation devices (39.26%). Anaesthesiologists utilised SGADs in various challenging scenarios such as in the difficult airway (53.33%), remote locations (55.47%), ophthalmologic (38.77%) and long-duration surgeries (17.53%). Sixty per cent respondents did not use SGADs in laparoscopic surgery. Disposable SGADs were reused by 77.28% respondents. Oropharyngeal seal and intracuff pressures were not measured by 86.91% and 56.92% respondents, respectively. Difficulty in size selection (84.19%), securing position (82.22%) and maintaining unobstructed ventilation (78.76%) were common problems encountered while using SGADs.Conclusion:Although there is a widespread use of second-generation SGADs in Indian paediatric anaesthesia, safe practices such as using capnography, measurement of oropharyngeal seal pressure, cuff pressure and appropriate disinfection are lacking.

Comparison of plasma propofol concentration for apnea, response to mechanical ventilation, and airway device between endotracheal tube and supraglottic airway device in Beagles.

The relationships between propofol plasma concentrations and the pharmacodynamic endpoints may differ according to a type of airway device. To clarify these relationships in different airway devices would be useful to avoid the complication such as apnea and intraoperative awareness. The aim of this study was to investigate the influence of difference of airway device on propofol requirement during maintenance of anesthesia in dogs. We compared the influence of airway devices on the plasma propofol concentrations for apnea, response to mechanical ventilation, and response to airway device between endotracheal tube (ETT) and supraglottic airway device (SGAD) in Beagles. The pharmacodynamic effects were repeatedly assessed at varying propofol concentrations. The plasma concentrations (mean ± SD) of propofol in the ETT and SGAD groups were 10.2 ± 1.8 and 10.9 ± 2.4 µg/ml for apnea (P=0.438), 7.9 ± 1.2 and 7.4 ± 1.5 µg/ml for response to mechanical ventilation (P=0.268), and 5.2 ± 0.7 and 5.4 ± 1.5 µg/ml for response to airway device (P=0.580), respectively. Required propofol concentration during maintenance of anesthesia may be similar between ETT and SGAD. Without moderate to strong stimuli such as airway device insertion or painful stimulation during surgery, the type of airway device may have little impact on required propofol concentration during maintenance of anesthesia in dogs.

Advanced Airway Management for Traffic Accident Patients

This study aims to identify advantages in the speed and success rates of intubation with a supraglottic airway device and tracheal intubation into a simulated trauma patient in an automobile accident. Forty-two EMT-Paramedics (21 in LTS group, 21, in VL group) from Region “K” in Korea performed either laryngeal tube suction (LTS) using a supraglottic airway device (SAD) or tracheal intubation using a video laryngoscope (VL) on a manikin simulating a trauma patient in an overturned automobile, noting the success rate and speed. Among the two methods for advanced airway management used in the experiment, LTS using the SAD was found to have the fastest deployment speed; LTS was also found to have a higher degree of accuracy (p<.001). According to the study, the use of faster and more precise LTS is more effective for the airway management of emergency patients in an overturned vehicle.

Comparison of the Laryngeal Mask Airways: Laryngeal Mask Airway-classic and Laryngeal Mask Airway-proseal in Children.

Introduction:In the past 25 years with the development of various supraglottic airway devices, the armamentarium for airway management has increased. In our study, the laryngeal mask airway (LMA)-ProSeal is compared with the LMA-Classic with respect to as follows: (a) Ease of insertion and number of insertion attempts, (b) Device positional stability and possible oropharyngeal leak, (c) Airway trauma, and (d) Hemodynamic changes; in children aged 3–15 years undergoing elective surgery under general anesthesia, hypothesizing that these would be different.Materials and Methods:Sixty consecutive American Society of Anesthesiologists Physical Status Classes I and II children aged 3–15 years and weighing 5–45 kg undergoing elective surgery in the supine position were randomized for airway management with the LMA-Classic or LMA-ProSeal.Results:Size of the LMA used in both LMA-Classic and LMA-ProSeal was 1.5, 2, and 2.5 and was statistically nonsignificant. There was no difference between LMA-Classic and LMA-ProSeal with regard to ease of insertion, number of attempts for insertion, device positional stability, airway trauma and hemodynamic changes.Conclusions:The complications of usage of the LMA are minimal and similar in both the devices. The LMA-ProSeal has advantages over LMA-classic such as the placement of gastric tube, adequate ventilation, and oxygenation without any gastric distension.

Laryngeal Mask Airway Protector™ for intubation and extubation in thyroid surgeries: A case report.

The laryngeal mask airway (LMA) Protector™ has recently made its way into clinical practice. As little is reported on this novel supraglottic airway device, we describe our experiences through intubation and Bailey manoeuvre using the LMA Protector™, and the assessment of vocal cord mobility using a flexible bronchoscope through it in three patients undergoing hemithyroidectomies.

Use of Butorphanol, Fentanyl, and Ketamine as Co-Induction Agents with Propofol for Laryngeal Mask Airway Insertion: A Comparative Study.

Background:Management of airway is of great importance in the practice of anesthesia. Supraglottic airway devices, such as laryngeal mask airway (LMA), have greatly revolutionized the management of airway both in terms of ease and degree of invasiveness. Propofol, by its inherent property of decreasing airway reflexes, is used to aid in LMA insertion. In this study, we have evaluated the LMA insertion conditions and hemodynamic stability, comparing butorphanol, fentanyl, and ketamine as co-induction agents with propofol.Materials and Methods:A total of 90 female patients planned to undergo minor gynecological procedures were randomly allocated to one of the three study groups. Patients in Group B received butorphanol 20 μg/kg, patients in Group F received fentanyl 1 μg/kg, and patients in Group K received ketamine 0.5 mg/kg intravenously before injection of propofol 2.5 mg/kg. LMA insertion conditions were graded according to the modified scheme of Lund and Stovner, and hemodynamic parameters were recorded. The results were analyzed statistically.Results:The patients in all the three groups were comparable in their demographic characteristics. The mean total dose of propofol used in Group B was 136.50 mg (standard deviation [SD] 27.70), in Group F was 139.33 mg (SD 28.52), and in Group K was 156.33 mg (SD 38.64). Excellent insertion conditions were observed in 25 (83.3%) patients in Group B, 25 (83.3%) patients in Group F, and 15 (50%) patients in Group K. Group B and Group K showed a more stable hemodynamic profile than Group F.Conclusion:It is concluded that the use of butorphanol as a co-induction agent with propofol provides excellent insertion conditions and stable hemodynamics compared to fentanyl or ketamine.

I-gel as a first-line airway device in the emergencyroom for patients with out-of-hospital cardiac arrest

Aim. The optimal method for advanced airway management during cardiac arrest remains controversial. Most patients with out-of-hospital cardiac arrest (OHCA) in Korea are managed with a bag-valve mask by paramedics, while physicians perform advanced airway management in emer-gency departments (ED). Endotracheal intubation (ETI) has a risk of failure at the first attempt. By contrast, I-gel, a supraglot-tic airway device, is easier to insert than an endotracheal tube and shows a higher first-attempt success rate than ETI in out-of-hospital settings by paramedics in the United States. We reviewed the use of ETI and I-gel by ED physicians to assess the first attempt success rate in a hospital setting. Methods. We conducted a retrospective chart review of patients with non-traumatic OHCA who were managed with either ETI using a Macintosh laryngoscope, or I-gel in the ED of Korean hospital from January 2012 to January 2014. Results. Of 322 adult patients with non-traumatic OHCA, 160 received I-gel and 162 received ETI. The first-attempt success rate was higher in the I-gel group (96.9%) than in the ETI group (84.6%, p < 0.001). The time from arrival to obtaining ad-vanced airway management was shorter in the I-gel group than in the ETI group. Conclusions. I-gel showed a better first-attempt success rate and shorter insertion time compared with ETI when performed by physicians in a hospital setting.

Airway Complications in an Obese Patient following Anaesthesia for Upper Airway Disease: Perioperative Considerations; Supraglottic Airways (SGAs) as a Rescue Device

Septoplasty with or without endoscopic sinus surgery (ESS) for chronic sinusitus are routine procedures done for upper airway obstruction. Obesity remains a risk factor for anaesthesia. Problems relate not only to airway management but to all major systems and is a major factor contributing to morbidity and mortality. Clinical indices in predicting difficult airways are helpful and supraglottic airway devices (SGAs) useful as rescue in the event of a difficult or failed intubation.