Effect of head position on the success rate of blind intubation using intubating supraglottic airway devices

Tracheal intubation using intubating laryngeal tube iLTS-D™ and LMA Fastrach™ in 99 adult patients: A prospective multicentric randomised non-inferiority study

STUDY OBJECTIVE

This study aimed to investigate the overall success of tracheal intubation using the intubating Laryngeal Tube Suction-Disposable (iLTS-D™, VBM, Sulz a. N., Germany) compared to the Laryngeal Mask Airway (LMA) Fastrach™ (Teleflex, Athlone, Ireland). We hypothesised that the iLTS-D™ would be non-inferior to the LMA Fastrach™ for tracheal intubation and ventilation.

DESIGN

Multicentric, non-inferiority, randomised controlled study.

SETTING

Operating rooms from two tertiary and one secondary centre in Switzerland from January 2017 to July 2019. The investigators were trained anaesthetists with extensive experience with laryngeal masks but limited to laryngeal tubes. The study was discontinued after the planned interim analysis.

PATIENTS

Ninety-nine adult patients were included after randomisation. The inclusion criteria were American Society of Anesthesiologists physical status 1 to 3 in patients scheduled for elective surgery requiring tracheal intubation. Patients with a history of difficult intubation were excluded.

INTERVENTION(S)

After anaesthesia induction and once neuromuscular blockade was obtained, ventilation was initiated, and tracheal intubation was performed through the randomised device with the flexible endoscope tip placed proximally to the tip of the tracheal tube (visualised blind intubation).

MEASUREMENTS

The primary outcome was the intubation success rate after two attempts. The secondary outcomes were time to intubation, successful ventilation rate, time to achieve ventilation, and gastric access success rate.

MAIN RESULTS

The overall intubation success rate was significantly higher in the Fastrach™ group than in the iLTS-D™ group (91.8% vs 70.0%, p = 0.006). No difference was found in the ventilation success rate (94% for iLTS-D™ and 100% for LMA Fastrach™ [p = 0.829]). The time to achieve ventilation and intubation were similar between the groups. No major airway complications were noted.

CONCLUSIONS

Although both supraglottic devices provided the same effective ventilation rate, the LMA Fastrach™ was superior to the iLTS-D™ as a conduit for intubation in 99 adult patients without a known difficult intubation. These preliminary results need to be confirmed in studies that include a larger population.

TRIAL REGISTRATION

Clinicaltrials.gov, 21.09.2016, Identification Number NCT02922595.

Intubating Through Supraglottic Airway Devices: A Narrative Review

Implication Statement: Despite the increasing popularity of video laryngoscopes, the supraglottic airway device (SAD) remains a critical airway rescue tool. The SAD provides a conduit for tracheal intubation in failed laryngoscopy. This article aims to help the operator: (1) select an intubating SAD with consistent performance; (2) inform the appropriate SAD-endotracheal tube pairings; and (3) explain various SAD and endotracheal tube maneuvers available to increase chances of successful intubation. Objectives: The first supraglottic airway device (SAD) was introduced more than thirty years ago. Since then, SADs have undergone multiple iterations and improvements. The SAD remains an airway rescue device for ventilation and an intubation conduit on difficult airway algorithms. Data Sources: Several SADs are specifically designed to facilitate tracheal intubation, i.e., “intubating SADs,” while most are “non-intubating SADs.” The two most commonly reported tracheal intubation methods via the SADs are the blind and visualized passage of the endotracheal tube (ETT) preloaded on a fiberoptic scope. Fiberoptic guided tracheal intubation (FOI) via an intubating SAD generally has higher success rates than blind intubations and is thus preferred. However, fiberscopes might not always be readily available, and anesthesiologists should be skilled to successfully intubate blindly through a SAD. Summery: This narrative review describes intubating SAD with consistent performance, appropriate SAD-ETT pairings, and various SAD and ETT maneuvers to increase successful intubation chances.

Comparison of the Success Rate of Intubation Between the LMA Fastrach and AirQ-ILA Methods in Patients Undergoing Elective Surgery During General Anaesthesia

Background

Rapid placement of a reliable airway is the most important task in anesthesia practice. Airway management is a critical skill to provide safe anesthesia since morbidity. In addition, mortality due to anesthesia could be linked to difficulty or failure in airway management. In this study, intubation success was compared between two methods, AirQ-ILA and LMAfastrach, among candidates for elective surgery under general anesthesia.

Methods

In this clinical trial, patients, who were candidates for elective surgery under general anesthesia at Firoozgar and Rasoul Akram Hospitals, were randomly divided into LMAfastrach and AirQ-ILA groups. Heart rate before and after induction and intubation, diastolic blood pressure, systolic blood pressure, duration of device insertion, intubation time, number of attempts until successful device insertion and trachea intubation, and success or failure in the insertion of the device and the tube were recorded; as for statistical analysis, SPSS version 21 was considered.

Results

In comparison with the LMAfastrach group, the device insertion time and intubation time were significantly longer in the AirQ-ILA group (P < 0.05). However, the groups showed no significant difference regarding the number of device and tube insertion attempts (P > 0.05). Moreover, no significant difference was observed in the success of device insertion and intubation in either LMAfastrach or AirQ-ILA group (P > 0.05).

Conclusions

The LMAfastrach and AirQ-ILA methods were not significantly different regarding the success of airway instrument application and intubation, while the device insertion time and intubation time were significantly longer in the AirQ-ILA group in comparison with the LMAfastrach group.

Pre-hospital i-gel blind intubation for trauma: a simulation study

Objective

This study aimed to evaluate the efficacy of i-gel blind intubation (IGI) as a rescue device for definitive airway management in ground intubation for pre-hospital trauma patients.

Methods

A prospective randomized crossover study was conducted with 18 paramedics to examine intubation performance of two blind intubation techniques through a supraglottic airway devices (IGI and laryngeal mask airway Fastrach), compared with use of a Macintosh laryngoscope (MCL). Each intubation was conducted at two levels of patient positions (ground- and stretcher-level). Primary outcomes were the intubation time and the success rate for intubation.

Results

The intubation time (sec) of each intubation technique was not significantly different between the two positions. In both patient positions, the intubation time of IGI was shortest among the three intubation techniques (17.9±5.2 at the ground-level and 16.9±3.8 at the stretcher-level). In the analysis of cumulative success rate and intubation time, IGI was the fastest to reach 100% success among the three intubation techniques regardless of patient position (all P<0.017). The success of intubation was only affected by the intubation technique, and IGI achieved more success than MCL (odds ratio, 3.6; 95% confidence interval, 1.1 to 11.6; P=0.03).

Conclusion

The patient position did not affect intubation performance. Additionally, the intubation time with blind intubation through supraglottic airway devices, especially with IGI, was significantly shorter than that with MCL.