Supraglottic Ventilation Research Articles

Transoral flexible laser surgery of the upper aerodigestive tract with blue laser.

The introduction of fiber-guided lasers was a breakthrough in laryngology practice, opening the path for treating different pathologies with minimally invasive procedures, both in the operating room and in the office. The most recent technology in the area is the blue laser, which combines photoangiolytic and cutting properties, characteristics that make this equipment suitable for its use in upper aerodigestive tract surgery. However, there is not enough experience in this area. The authors present a case series of patients with different pharyngeal, laryngeal, and tracheal pathologies who were treated by means of transoral procedures using fiber-guided blue laser. The surgical records of patients with different upper aerodigestive tract pathologies who were treated with fiber-guided blue laser in the operating room, under general anesthesia with jet ventilation or supraglottic ventilation using suspension laryngotracheoscopy techniques between February 2018 and March 2022 were reviewed. A total of 80 surgical interventions in a group of 38 patients were performed. A wide variety of procedures was executed, either using the laser alone or in combination with other techniques to treat different pathologies of the aero-digestive tract safely and effectively, with adequate functional results. Following all necessary precautions, blue laser is a reliable tool to perform minimally invasive surgeries in the operating room using TOFLS techniques. It can be used alone or in combination with other devices to achieve the desired goals.

Ventilatory management in shared airway surgery: current status, challenges, and future directions

A shared airway during anesthesia refers to maintaining the airway and ventilation of the patient by the anesthesiologist as the surgeon performs the procedures in the same anatomic space. Due to the narrow airway space in shared airway surgery, the difficulty lies both in the exposure of surgery field and implementation of the optimized airway management strategy and maintaining the airway safety in clinical practice. In recent years, many new visualized airway management tools and supraglottic ventilation devices have been invented and verified in clinical settings. Especially, the development of tubeless supraglottic oxygenation and ventilation technique provides new insights into the airway management. This review intends to provide a reference for future innovations in airway management tools and ventilation techniques by summarizing previous airway management strategies of shared airway surgery to benefit more patients.

A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists.

The American Society of Anesthesiologists’ (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist’s choice of pathway in the ASA’s Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist’s unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study

BackgroundOut-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate. Conclusions in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA. MethodsThis was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores). ResultsOf 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3–12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25–0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19–0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80–1.65; p = 0.46). ConclusionsThe findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

Efficacy of WEI NASAL JET for supraglottic ventilation before tracheal intubation in patients with tooth loss

Objective To evaluate the efficacy of WEI NASAL JET for supraglottic ventilation before tracheal intubation in the patients with tooth loss. Methods Sixty patients of both sexes with tooth loss (more than 8 teeth missing), aged 67-83 yr, of American Society of Anesthesiologists physical statusⅠ-Ⅲ, with Mallampati classificationⅠ-Ⅲ, with body mass index of 18-25 kg/m2, undergoing surgery with general anesthesia, were divided into 2 groups (n=30 each) using a random number table method: WEI NASAL JET group (S group) and mask group (M group). After the end of anesthesia induction, WEI NASAL JET was inserted via the nasal cavity to perform supraglottic ventilation in group S, and two-hand buckle mask was performed in group M, and the patients were tracheally intubated after 5-min ventilation.At 5-min spontaneous breathing after nitrogen removal by oxygen supply, 1, 2, 3 and 4 min after no spontaneous breathing and immediately after intubation (T5), ultrasound was used to measure the amplitude of diaphragm motion induced by respiratory movement, and blood gas analysis was performed to record the development of pH value<7.30, SpO2<90% and fluctuation in mean arterial pressure and heart rate ≥30% of baseline before operation.The development of ventilation-related complications was also recorded. Results Compared with group M, the amplitude of diaphragm motion induced by respiratory movement was significantly increased at T1-5, PaO2was increased at T2-5, PaCO2 and PETCO2 were decreased at T3-5, the incidence of sore throat and nasal mucosal bleeding was increased, the incidence of gingiva injury and flatulence was decreased (P 0.05). The pH value<7.30 and SpO2<90% were not found in two groups. Conclusion WEI NASAL JET can provide satisfactory supraglottic ventilation efficacy before tracheal intubation with good safety in the patients with tooth loss. Key words: WEI NASAL JET; Teeth missing

Ambu AuraGain versus intubating laryngeal tube suction as a conduit for endotracheal intubation.

Background and Aims:Newly developed supraglottic airway devices (SGAs) are designed to be used both for ventilation and as conduits for endotracheal intubation with standard endotracheal tubes (ETTs). We compared the efficacy of the Ambu AuraGain (AAG) and the newly developed intubating laryngeal tube suction disposable (ILTS-D) as conduits for blind and fiber-optically guided endotracheal intubation in an airway mannequin.Material and Methods:This is a prospective, randomized, crossover study in an airway mannequin, with two arms: blind ETT insertion by medical students and fiber-optically guided ETT insertion by anesthesiologists. The primary outcome variable was the time to achieve an effective airway through an ETT using AAG and ILTS-D as conduits. Secondary outcome variables were the time to achieve effective supraglottic ventilation and successful exchange with an ETT, and the success rates for blind endotracheal intubation and fiber-optically guided intubation techniques for both SGAs.Results:Forty participants were recruited to each group. All participants were able to insert both devices successfully on the first attempt. For blind intubation, the success rate for establishing a definitive airway with an ETT using the SGA as a conduit was significantly higher with ILTS-D (82.5%) compared with AAG (20.0%) (P < 0.001). None of the participants were able to successfully complete the exchange of the SGA for the ETT with the AAG. In the fiber optic guided intubation group, the rate of successful exchange was significantly higher with ILTS-D (84.6%) compared with AAG (61.5%) (P = 0.041).Conclusion:The ILTS-D successfully performs in an airway mannequin with higher success rate and shorter time for blindly establishing an airway with an ETT using the SGA as a conduit, compared with AAG. Further clinical trials are warranted.

First aid cardiopulmonary resuscitation at the exit of capsule and strategy coping with the "Shenzhou 11" spacecraft

Objective To summarize the medical security experience in first-aid and resuscitation for astronauts at the exit of capsule after the spacecraft returns to the main landing site in the process of human spaceflight in China, and thus to provide a powerful security measures for Chinese aerospace medicine. Methods The medical support experiences were summarized in human spaceflight from Shenzhou V to Shenzhou X, relevant reports on emergency rescue and resuscitation were consulted in in-orbit process and after emergency return and landing for domestic and foreign astronauts, astronauts’ physiological changes in cardiopulmonary resuscitation were analyzed during emergency return, and then, corresponding strategies were proposed and tested in practice (actual combat) by combining with the flight characteristics of the spacecraft Shenzhou XI. Results On the basis of the original emergency treatment, the countermeasures for the cardiopulmonary resuscitation were proposed after the spacecraft returned to the main landing site in human spaceflight, the emergency equipment was adjusted, the emergency procedures were optimized, and anti-fog glidescopes were added, laryngeal masks were introduced to perform supraglottic ventilation as the quickest and most effective airway opening measure on site. In addition, ultrasound examination was applied in practice as an important treatment and assessment method for basic life support and advanced life support. All these could ensure the rescuing ability on cardiopulmonary resuscitation during their stay in space for the medium-term and after their return to the main landing site. Conclusions During the return of the astronauts of the spacecraft Shenzhou XI to the main landing site, the first aid and support program had been improved specifically and the process had been optimized to ensure the successful completion of medical security mission of China's human spaceflight. Key words: Asronuats; First aid; Cold weather; Medical security; Ultrasound; Airway; Cardiopulmonary resuscitation; Strategy

The novel video‐assisted intubating laryngeal mask Totaltrack compared to the intubating laryngeal mask Fastrach – a controlled randomized manikin study

The novel Totaltrack combines a supraglottic airway device with video laryngoscopic tracheal intubation. The intubation laryngeal mask Fastrach is an established device without visual control of intubation. We hypothesized that supraglottic ventilation success with Totaltrack would be similar to Fastrach, but intubation would be performed faster due to visual control of the procedure. Fifty-five anaesthesiologists were randomized into one of two study arms: Fastrach Totaltrack. After a standardized introduction, six consecutive attempts of supraglottic ventilation and intubation attempts with each of one of the devices were performed on an airway manikin. The combined primary outcome was: time to supraglottic ventilation and time to ventilation after intubation. Additionally, success rate and learning curves were evaluated. Supraglottic time to ventilation was shorter when using the Fastrach compared to the Totaltrack (median: 7.8s [confidence interval [CI]: 7.0-8.6s] vs. 11s [CI: 7.8-14.2s], P<0.001). Intubation was faster using the Fastrach compared to Totaltrack (median: 12.5s, [CI: 10.1-14.9s] vs. 23.3s [CI: 21.5-25.1s], P<0.001). Success rate for supraglottic ventilation was comparable between Fastrach and Totaltrack (86-96%). Successful intubation via the device was 100% in Fastrach and ranged from 61% to 93% in Totaltrack, with a higher probability of successful intubation after four applications. In this manikin-based study the novel Totaltrack did not prove superior to Fastrach despite a similar design. Video laryngoscopic control of supraglottic ventilation and endotracheal intubation was prolonged using the Totaltrack. Clinical trials are mandatory to evaluate the role of the Totaltrack in airway management.

A novel supraglottic ventilation device:SLIPATM

Regurgitation and aspiration are rare but real risk complications in general anesthetized patients who receive the positive pressure ventilation through the laryngeal mask airway (LMA). SLIPATM, designed by Don Miller, is a novel supraglottic ventilation device. Theoretically, it may greatly reduce the risk of regurgitation and aspiration. SLIPATM has been safely used for the airway management in patients undergoing surgery under general anesthesia. In this review, the SLIPATM about design views, construction features and procedure skills, as well as its clinical uses and prospect was briefly described. Key words: airway management; anesthesia; supraglottic ventilation device; SLIPATM

Use of Preoxygenation with the Laryngeal Mask Airway in Critical Care

Positive pressure ventilation (PPV) greatly benefits critically ill patients, but frequently endotracheal intubation is required. The recent article on rapid-sequence intubation (RSI) preceded by noninvasive ventilation (NIV) by Baillard and colleagues may have a tremendous impact on practice (1). RSI was meant to reduce pulmonary aspiration in surgical patients. As little as 30 ml of gastric fluids predisposes the patient to pulmonary aspiration. Thus, supraglottic ventilation is usually avoided (2). In addition, spontaneous vomiting and regurgitation are common during acute illness as predisposing factors for surgeryrelated aspiration. Even trained anesthesiologists using collapsible flow-filled bags coupled to adjustable pressure relief valves cannot always avoid gastric inflation in healthy patients. Thus, early sealing of the trachea is always warranted. While 1 per 2,000–7,000 adults undergoing general anesthesia aspirates gastric contents, laborious intubations in the critical care setting are associatedwithmuch higher rates of regurgitation and aspiration (3). RSI is not a rigid technique but an evolving concept. Recent modifications have included administration of opioids, use of video devices, and omission of cricoid pressure, but avoidance of PPVwas considered for over five decades as dogma. Although the benefits of PPV are unquestionable, facial mask PPV is not necessarily safe. The data to support delivering pressures of 15 cm H2O were extrapolated from articles citing work with 9 asphyxiated and 4 fresh stillborn babies as well as 60 anesthetized adults (4, 5). An intermediate approach to preoxygenation in many critical care patients would be the laryngeal mask airway (LMA). Its introduction spares laryngoscopy and demands less pharmacological modulation, resulting in a smooth induction. Initially, the classic LMA was an alternative to the face mask, but it has proved to be an excellent protection to the trachea and an instant bridge to cuffed tubes (6). Like others, we have used these versatile devices in trauma and resuscitation, and in critical care patients. The LMA family also excels in the case of accidental extubations and many difficult airway situations. The LMA ProSeal (LMA North America, Inc., San Diego, CA) seals the airway even more effectively than the classic LMA and has an extra lumen to use in gastric suctioning. Using pressures of up to 20 to 30 cmH2O, this model helps to overcome low compliance lungs. Future studies should define the safety profile of PPV RSI in critical care patients. A recent audit on perioperative pulmonary aspiration disclosed both lowmorbidity (1/16, 573) andmortality (1/99, 441) whenPPVRSIwas used (3).Meanwhile, practitioners should keep in mind that the technique proposed is an attractive intervention to ameliorate severe hypoxia in selected patients.

Use of Preoxygenation with the Laryngeal Mask Airway in Critical Care

Positive pressure ventilation (PPV) greatly benefits critically ill patients, but frequently endotracheal intubation is required. The recent article on rapid-sequence intubation (RSI) preceded by noninvasive ventilation (NIV) by Baillard and colleagues may have a tremendous impact on practice (1). RSI was meant to reduce pulmonary aspiration in surgical patients. As little as 30 ml of gastric fluids predisposes the patient to pulmonary aspiration. Thus, supraglottic ventilation is usually avoided (2). In addition, spontaneous vomiting and regurgitation are common during acute illness as predisposing factors for surgeryrelated aspiration. Even trained anesthesiologists using collapsible flow-filled bags coupled to adjustable pressure relief valves cannot always avoid gastric inflation in healthy patients. Thus, early sealing of the trachea is always warranted. While 1 per 2,000–7,000 adults undergoing general anesthesia aspirates gastric contents, laborious intubations in the critical care setting are associatedwithmuch higher rates of regurgitation and aspiration (3). RSI is not a rigid technique but an evolving concept. Recent modifications have included administration of opioids, use of video devices, and omission of cricoid pressure, but avoidance of PPVwas considered for over five decades as dogma. Although the benefits of PPV are unquestionable, facial mask PPV is not necessarily safe. The data to support delivering pressures of 15 cm H2O were extrapolated from articles citing work with 9 asphyxiated and 4 fresh stillborn babies as well as 60 anesthetized adults (4, 5). An intermediate approach to preoxygenation in many critical care patients would be the laryngeal mask airway (LMA). Its introduction spares laryngoscopy and demands less pharmacological modulation, resulting in a smooth induction. Initially, the classic LMA was an alternative to the face mask, but it has proved to be an excellent protection to the trachea and an instant bridge to cuffed tubes (6). Like others, we have used these versatile devices in trauma and resuscitation, and in critical care patients. The LMA family also excels in the case of accidental extubations and many difficult airway situations. The LMA ProSeal (LMA North America, Inc., San Diego, CA) seals the airway even more effectively than the classic LMA and has an extra lumen to use in gastric suctioning. Using pressures of up to 20 to 30 cmH2O, this model helps to overcome low compliance lungs. Future studies should define the safety profile of PPV RSI in critical care patients. A recent audit on perioperative pulmonary aspiration disclosed both lowmorbidity (1/16, 573) andmortality (1/99, 441) whenPPVRSIwas used (3).Meanwhile, practitioners should keep in mind that the technique proposed is an attractive intervention to ameliorate severe hypoxia in selected patients.

Initial anatomic investigations of the I‐gel airway: a novel supraglottic airway without inflatable cuff*

The I-gel airway is a novel supraglottic airway that uses an anatomically designed mask made of a gel-like thermoplastic elastomer. We studied the positioning and mechanics of this new device in 65 non-embalmed cadavers with 73 endoscopies (eight had repeat insertion), 16 neck dissections, and six neck radiographs. A full view of the glottis (percentage of glottic opening score 100%) occurred in 44/73 insertions, whereas only 3/73 insertions had epiglottis-only views. Including the eight repeat insertions with a different size, a glottic opening score of > 50% was obtained in all 65 cadavers. The mean percentage of glottic opening score for the 73 insertions was 82% (95% confidence interval 75-89%). In each of the neck dissections and radiographs the bowl of the device covered the laryngeal inlet. We found that the I-gel effectively conformed to the perilaryngeal anatomy despite the lack of an inflatable cuff and it consistently achieved proper positioning for supraglottic ventilation.

The EasyTube for Airway Management in Emergencies

Background. The EasyTube (EzT) is a new sterile, disposable airway device approved by the European Union in February 2003 andby the U.S. Food andDrug Administration in January 2005. The two-lumen design of the EzT enables it to be used as an endotracheal tube or as a supraglottic emergency airway. Objective. To report the preliminary experiences with the EzT airway device in prehospital andin-hospital emergency airway management procedures. Methods. All airway management procedures involving the EzT were recorded for a period of 18 months. Results. The EzT was successfully used to intubate 15 patients with unanticipated airway difficulties during either anesthesia induction or prehospital airway management. In all patients, the EzT was positioned successfully in the first attempt, within a median time of 31 seconds until start of ventilation. Effective supraglottic ventilation andoxygenation was achieved within 25 to 40 seconds. In three patients, the EzT needed one additional repositioning maneuver. On removal of the EzT, no blood was observed on the surface of the device, as a sign of absence of potential mucosal lesion. No injuries were observed in the mouth, pharynx, or esophagus. Conclusions. The first experiences with the use of the EzT are promising. In emergency airway management procedures presenting problems, the device successfully established sufficient ventilation andoxygenation. Further studies are needed to compare its value with those of other supraglottic devices.

Preoperative planning of airway management in critical care patients.

The aim of this article is to review aspects of airway evaluation that may affect the care of the critical care patient whose airway is to be managed. This information must then be incorporated into the decision-making process of the "airway manager." Literature review. Historically used indexes of airway evaluation suffer from low sensitivity and only modest specificity in identifying the difficult-to-intubate patient. Using each index in isolation of others contributes to their poor predictive power. An understanding of anatomical relationships that these indexes measure should help the clinician in evaluating the airway. The clinician's impression of the airway, as well as the likelihood of trouble with supraglottic ventilation, the patient's inability to take food orally, and the patient's general condition can be used to formulate a management plan. This plan should be consistent with the American Society of Anesthesiologist's difficult airway algorithm. Rote decision making on airway management, based on commonly used indexes, is not adequate. The vital role of airway in anesthetic management of the critical care patient demands thoughtful consideration. Patient conditions including the need for airway control, the likelihood of difficult laryngoscopy or supraglottic ventilation, the patient's inability to take food orally, and the medical state of the patient must be incorporated.

Laryngeal mask airway and high-frequency jet ventilation for the resection of a high-grade upper tracheal stenosis

The surgical resection of a high-grade tracheal stenosis presents a special case of a difficult airway. A 20-year-old male was treated for a 45-mm long tracheal stenosis with 60% reduction of the patent airway area beginning 25 mm below the glottis. To avoid manipulations of the affected segment before surgical exposure of the trachea was established, strictly supraglottic ventilation via a laryngeal mask airway was performed. During removal of the stenosis and creation of the anastomosis, transglottic high-frequency jet ventilation (HFJV) is a convenient technique that enables optimal access to the operation field. Changing from HFJV to conventional ventilation after completion of the anastomosis is not necessary, and the jet catheter can be left in place until the end of the anesthesia.