[Blind tracheal intubation through two supraglottic devices: i-gel versus Fastrach intubating laryngeal mask airway (ILMA)]

Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document

Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.

Comparative evaluation of Ambu Aura-i and Fastrach™ intubating laryngeal mask airway for tracheal intubation: A randomized controlled trial

Background and aims:

Ambu Aura-i was compared with Fastrach™ (FT)-laryngeal mask airway (LMA) as a conduit for tracheal intubation.

Material and Methods:

A hundred consenting patients were randomly allocated into two groups of 50 patients each in a prospective randomized study. Standard anesthesia technique was used for all patients and FT-LMA or Ambu Aura-i was selected. After insertion of airway device, the cuff was inflated and ventilation was attempted. Once satisfactory ventilation was achieved, with or without maneuvers, a fiberoptic scoring for glottis view was noted. A polyvinylchloride (PVC) tracheal tube of appropriate size was inserted through the airway device as per procedure. If no resistance was felt while advancing the tracheal tube, it was fully inserted into the device and tracheal tube cuff was inflated. The device was removed and tracheal tube was left in situ. If the first attempt failed during tracheal tube insertion, the recommended maneuvers were used. A maximum of three attempts were allowed for intubation. First attempt for tracheal intubation attempt was a blind, second attempt was made with maneuver. If second attempt of intubation was unsuccessful, fiberoptic-guided intubation was performed as a third attempt. When tracheal intubation was unsuccessful, it was performed by direct laryngoscopy and considered as failed intubation. Rest of the anesthesia management was as per the discretion of attending anesthesiologists. The success rate of device insertion, fiberoptic score of glottis view, tracheal intubation via FT-LMA or Aura-i and time were recorded.

Results:

Both FT-LMA and Aura-i were successfully placed within two attempts. The success rate of blind intubation was 92% in FT-LMA and 76% in Aura-i (P < 0.01). Time taken for tracheal intubation at first attempt was lesser in group FT-LMA and Aura-i, respectively (P < 0.01). Fiberoptic-guided intubation success rate was higher with Aura-i than with FT-LMA.

Conclusions:

FT-LMA had a higher success rate in facilitating blind tracheal intubation compared with Ambu Aura-i.

Supraglottic airway devices as a strategy for unassisted tracheal intubation: A network meta-analysis

We aimed to compare the effectiveness of supraglottic airway devices as a strategy for unassisted tracheal intubation. Accordingly, we searched the OVID-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, KoreaMed, and Google Scholar databases to identify all relevant randomized controlled trials (RCTs) on supraglottic airway devices as a strategy for tracheal intubation published until May 2017. The primary outcome was the overall success rate of intubation by the intention to treat (ITT) strategy. The secondary outcomes of the study were the overall success rate of tracheal intubation by the per protocol (PP) strategy and the success rate of tracheal intubation at first attempt by ITT and PP. We conducted a network meta-analysis with a mixed-treatment comparison method to combine direct and indirect comparisons among supraglottic airway devices. Of 1396 identified references, 16 RCTs (2014 patients) evaluated unassisted intubation with supraglottic airway devices. Patients were grouped according to the type of device used: LMA-CTrach, LMA-Fastrach, Air-Q, i-gel, CobraPLA, Ambu-Aura, or single-use LMA devices. Based on the surface under the cumulative ranking curve, the three best supraglottic airway devices for use as a strategy for unassisted tracheal intubation were LMA-CTrach (which included video-assisted tracheal tube guidance), single-use LMA-Fastrach, and LMA-Fastrach. LMA-Fastrach showed a higher success rate of intubation than did i-gel, CobraPLA, Air-Q, and Ambu-Aura. However, this study was limited by the small number of eligible RCTs. Therefore, well-designed RCTs performed on large patient populations are required to increase the confidence of the results.

Endotracheal intubation using i-gel® and lightwand in a patient with difficult airway: a case report

This case report involves tracheal intubation using i-gel® in combination with a lightwand in a patient with a difficult airway, classified as Cormack-Lehane grade 3. I-gel® was used during anesthesia induction to properly maintain ventilation. The authors have previously reported successful tracheal intubation on a patient with a difficult airway through the use of i-gel® and a fiberoptic bronchoscope. However, if the use of a fiberoptic bronchoscope is not immediately available in a patient with a difficult airway, tracheal intubation may be performed by using i-gel® and a lightwand in a patient with difficult airway, allowing the safe induction of anesthesia.

Comparison of 4 supraglotttic devices used by paramedics during simulated CPR : a randomized controlled crossover trial

BACKGROUND

Ensuring an open airway during cardiopulmonary resuscitation is fundamental. The aim of this study was to determine the success rate of blind intubation during simulated cardiopulmonary resuscitation by untrained personnel.

METHODS

Four devices were compared in a simulated resuscitation scenario: ILMA (Intavent Direct Ltd, Buckinghamshire, United Kingdom), Cobra PLA (Engineered Medical Systems Inc, Indianapolis, IN), Supraglottic Airway Laryngopharyngeal Tube (SALT) (ECOLAB, St. Paul, MN), and Air-Q (Mercury Medical, Clearwater, FL). A group of 210 paramedics intubated a manikin with continuous chest compressions.

RESULTS

The mean times to intubation were 40.46 ± 4.64, 33.96 ± 6.23, 17.2 ± 4.63, and 49.23 ± 13.19 seconds (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05). The success ratios of blind intubation for the devices were 86.7%, 85.7%, 100%, and 71.4% (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05).

CONCLUSION

The study showed that the most efficient device with the shortest blind intubation time was the SALT device.

To assess the efficacy of i-gel for ventilation, blind tracheal intubation and nasogastric tube insertion

Background:

The i-gel is a novel supraglottic airway device with a soft and non-inflatable cuff. In our study we attempted to evaluate the performance of i-gel as a ventilatory device, as a conduit to blind tracheal intubation using conventional polyvinyl chloride tracheal tube and gastric tube insertion through it.

Materials and Methods:

A total of 180 patients of American Society of Anesthesiologist (ASA) physical status I/II undergoing elective surgery under general anesthesia were included in this study. After induction of anesthesia, i-gel was inserted and the following parameters were recorded: Time taken for successful i-gel insertion, airway leak pressures, ease of gastric tube insertion and laryngeal view using fiberscope. Following this blind tracheal intubation was attempted. First attempt and overall success rate in blind tracheal intubation and gastric tube insertion were evaluated and tracheal intubation time was measured. Also presence of any side effects or complication following removal was recorded.

Results:

We achieved a 100% success rate in insertion of i-gel and in 171 out of 180 patients; i-gel was inserted in the 1^st attempt itself. We also were able to achieve an overall success rate for blind endotracheal intubation via i-gel in 78.33% cases, and successful gastric tube placement was possible in 92.22%. In our study we also achieved a leak pressure of 25.52 (±2.33) cm of H₂O.

Conclusion:

I-gel may be effectively used for ventilation, nasogastric tube insertion and as a conduit to blind endotracheal intubation with minimal complication and acceptable airway sealing pressures.

Comparison of supraglottic devices i-gel(®) and LMA Fastrach(®) as conduit for endotracheal intubation

Background and Aims:

i-gel^®, a recently introduced supraglottic airway device (SAD) has been claimed to be an efficient supraglottic airway. It can also be used as a conduit for endotracheal intubation. However, LMA Fastrach^® frequently used for this purpose; hence in this randomized study, success rate of blind tracheal intubation through two different SADs i-gel^® and LMA Fastrach^® was evaluated. The complications if any were also studied.

Methods:

A total of 100 patients undergoing elective surgery under general anaesthesia were randomised in two groups comprising of 50 patients each to tracheal intubation using either i-gel (I group) or LMA Fastrach (F group). After induction of anaesthesia SAD was inserted and on achieving adequate ventilation with the device, blind tracheal intubation was attempted through the SAD. Success at first-attempt and overall tracheal intubation success rates were evaluated, and tracheal intubation time was measured. Data were analysed using IBM SPSS Statistics 20.0 software (Statistical Package for Social Sciences by International Business Machines Corporation). P < 0.05 was considered as statistically significant.

Results:

There was no difference in the incidence of adequate ventilation with either of the SAD. The success rate of tracheal intubation in first attempt was 66% in Group I and 74% in Group F, while overall success rate of tracheal intubation was 82% in Group I when compared to 96% in Group F. Time taken for successful tracheal intubation through LMA Fastrach was lesser (20.96 s) when compared to i-gel (24.04 s). Complication rates were statistically similar in both the groups.

Conclusion:

i-gel^® is a better device for rescue ventilation due to its quick insertion but an inferior intubating device in comparison to LMA Fastrach^®.

[Blind tracheal intubation with the air-Q(®) (ILA-Cookgas) mask. A comparison with the ILMA-Fastrach™ laryngeal intubation mask]

BACKGROUND AND OBJECTIVES

Supraglottic airway devices are increasingly used in anesthesia and emergency medicine as a rescue for intubation and ventilation. This study was designed to investigate the air-Q(®) supralaryngeal device and compare it with the ILMA-Fastrach™ for airway rescue and intubation.

PATIENTS AND METHODS

The devices were inserted in 80 patients (40 patients in each group) according to manufacturer' instructions. An inspiration pressure of 20cmH2O was applied through a ventilator for checking air leaks. If no air leak was detected, the glottis status was checked using a pediatric fiberoptic bronchoscope, followed by introducing an endotracheal tube through the supraglottic device. If the first attempt was unsuccessful, the device was removed and a second attempt was made in the same way. The primary outcome was the overall success rate for intubation. Other measurements were: successful ventilation, fiberoptic glottis view and adverse events.

RESULTS

Successful first-attempt ventilation was better with the Fastrach™ than with the air-Q(®) (90 vs. 60%, P=.0019) and overall ventilation success (first plus second attempts) was also better with ILMA-Fastrach™ (95 vs. 80%, P=.04). View of the glottis,according to Brimacombe scale, was better with air-Q(®) (84.62 vs. 37.50%, P=.0017) at the second, but not at the first, attempt. There were no differences in the percentage of successful intubations between the 2 devices. The incidence of sore throat was similar with both devices. Two patients in the air-Q(®) group suffered hoarseness and arterial desaturation, but the difference was not statistically significant.

CONCLUSIONS

Both the ILMA-Fastrach™ and the air-Q(®) provided a similar rate of successful intubation, but ILMA-Fastrach™ was better for ventilation. The rate of adverse events was similar with both devices. Because no additional maneuver was used to facilitated intubation, there needs to be further studies to confirm these findings.