The supraglottic airway device as first line of management in anticipated difficult mask ventilation in the morbidly obese

Randomized Clinical Trial Comparing the Success Rate of Blockbuster Intubating Laryngeal Mask Airway Versus Fastrach Intubating Laryngeal Mask Airway During Blind Endotracheal Intubation

Background A new piece of equipment, the Blockbuster (BB) Intubating Laryngeal Mask Airway (ILMA; Tuoren Medical India, Gurugram, India), was created in 2012. Dr. Chandy created the Fastrach (F) ILMA in 1997, which is another supraglottic airway equipment. The primary purpose of this study was to compare the success rate of intubation with BB-ILMA and F-ILMA. Methods In the chosen age category of >20 to <70 years, undergoing general anesthesia for intubation with ILMAs, 55 patients were in the BB-ILMA (group B), and 55 patients were in the F-ILMA (group F). These ILMAs were put in after the induction and checked to see if adequate ventilation was accomplished with either of these devices. Once ventilation had been attained, we proceeded with fiberoptic scope to visualize the glottis, followed by blind intubation. The primary objective was to compare the first pass successful intubation of BB-ILMA and F-ILMA. The secondary objectives were ease of LMA insertion, time taken for intubation, hemodynamic changes, glottis fiberoptic view, and complications. Results The first pass successful intubation of the BB-ILMA and F-ILMA are 94.5% and 87.3%, respectively, whereas the time taken for intubation in BB-ILMA and F-ILMA are 25.02 seconds (s) and 42.77 s with a p-value of 0.0001, indicating a statistically significant relationship. Conclusion When compared to the F-ILMA (group F), the BB-ILMA (group B) has a higher success rate for blind tracheal intubation, with lesser time taken for intubation and fewer complications.

Airway management in patients with obesity

Airway management in patients with obesity remains a complex and evolving topic that is becoming more pertinent given the increasing prevalence of obesity and bariatric surgery worldwide. Obesity is associated with increased morbidity and mortality secondary to anesthetic complications, especially related to airway management. Preoperative assessment is especially vital for the bariatric patient so that potential predictors for a difficult airway can be identified. There are several airway management strategies and techniques for the bariatric population that may help reduce postoperative pulmonary complications. This review aims to discuss assessment of the airway, ideal patient positioning, intubation techniques and devices, apneic oxygenation, optimal ventilation strategies, and extubation and post-anesthesia care.

High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II

BACKGROUND

Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series.

OBJECTIVE

This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department.

DISCUSSION

Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise.

CONCLUSIONS

This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.

Predictors of difficult airway in the obese are closely related to safe apnea time!

Background and Aims:

We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese.

Material and Methods:

We analyzed 834 patients with body mass index (BMI) >35 kg/m² for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from “0” no difficulty to “12” serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters – neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference– were assessed.

Results:

Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m² and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001).

Conclusion:

This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.