Anesthetic management of thyroid carcinoma invading the upper tracheal segment: A case report

INTRODUCTION AND IMPORTANCE

Intratracheal tumors account for approximately 0.2 % of respiratory tumors, including primary and secondary tumors. Secondary tumors of the upper trachea are most commonly derived from advanced thyroid cancer. Surgical resection is currently the general curative modality for thyroid cancer with tracheal invasion. Patients with tracheal tumors invading and protruding into the lumen may have reduced oxygen reserve capacity, leading to a shorter safe window for general anesthesia induction. Establishing an appropriate artificial airway is essential to ensure intraoperative safety for these patients. Here, we report a case of tracheal tumor caused by differentiated papillary thyroid carcinoma invading the upper segment of the trachea and the non-conventional approach used for intraoperative airway management without traditional endotracheal intubation.

PRESENTATION OF CASE

A 59-year-old female presented with bilateral neck masses and hemoptysis. The CT scan revealed suspicious malignant thyroid nodules, and tracheoscopy showed an approximately 50 % obstruction of the tracheal lumen. The patient's physical examination and biochemical examination showed no significant abnormalities. Based on imaging studies and pre-anesthetic assessment, a multidisciplinary team decided against performing endotracheal intubation in the patient due to the risk of tumor bleeding during the procedure. Instead, they opted for a modified endotracheal tube and the insertion of a laryngeal mask airway (LMA). The anesthesia induction and maintenance proceeded smoothly, with stable intraoperative hemodynamics. The tumor was successfully resected and tracheal anastomosis was performed without any complications.

CLINICAL DISCUSSION

The strategy adroitly evades the risk of bleeding and dislodgement due to tumor contact during the intubation process. In this case report, the anesthetic highlight is the employment of a reverse insertion technique for endotracheal intubation, facilitated by a sterile suction catheter and complemented by an innovative modification to the tracheal tube.

CONCLUSION

For patients with thyroid cancer invading the upper segment of the trachea, and in whom rapid induction anesthesia is anticipated not to cause tumor collapse, the use of laryngeal mask airway combined with modified tracheal tube mechanical ventilation is both safe and feasible.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Efficacy and safety of three inflation methods of the laryngeal mask airway Ambu® Auraonce™: a randomized controlled study

The laryngeal mask airway (LMA) is commonly used for airway management. Cuff hyperinflation has been associated with complications, poor ventilation and increased risk of gastric insufflation. This study was designed to determine the best cuff inflation method of AuraOnce™ LMA during bronchoscopy and EBUS (Endobronquial Ultrasound Bronchoscopy) procedure. We designed a Randomized controlled, doble-blind, clinical trial to compare the efficacy and safety of three cuff inflation methods of AuraOnce™ LMA. 210 consenting patients scheduled for EBUS procedure under general anesthesia, using AuraOnce™ LMA were randomized into three groups depending on cuff insufflation: residual volume (RV), half of the maximum volume (MV), unchanged volume (NV). Parameters regarding intracuff pressure (IP), airway leak pressure (OLP), leakage volume (LV) were assessed, as well as postoperative complications (PC). 201 (95.7%) patients completed the study. Mean IP differed between groups (MV: 59.4 ± 32.4 cm H2O; RV: 75.1 ± 21.1 cm H2O; NV: 83.1 ± 25.5 cmH20; P < 0.01). The incidence of IP > 60 cmH2O was lower in the MV group compared to the other two (MV: 20/65(30.8%); RV:47/69 (68.1%); NV 48/67 (71.6%); p < 0.01). The insertion success rate was 89,6% (180/201) at first attempt, with no difference between groups (p = 0.38). No difference between groups was found either for OLP (p = 0.53), LV (p = 0.26) and PC (p = 0.16). When a cuff manometer is not available, a partial inflation of AuraOnce™ LMA cuff using MV method allows to control intracuff pressure, with no significant changes of OLP and LV compared to RV and NV insufflation method.Registration clinical trial: NCT04769791.

Cardiac Agents during Neonatal Cardiopulmonary Resuscitation

BACKGROUND

Epinephrine (adrenaline) is currently the only cardiac agent recommended during neonatal resuscitation. The inability to predict which newborns are at risk of requiring resuscitative efforts at birth has prevented the collection of large, high-quality human data.

SUMMARY

Information on the optimal dosage and route of epinephrine administration is extrapolated from neonatal animal studies and human adult and pediatric studies. Adult resuscitation guidelines have previously recommended vasopressin use; however, neonatal studies needed to create guidelines are lacking. A review of the literature demonstrates conflicting results regarding epinephrine efficacy through various routes of access as well as vasopressin during asystolic cardiac arrest in animal models. Vasopressin appears to improve hemodynamic and post-resuscitation outcomes compared to epinephrine in asystolic cardiac arrest animal models.

KEY MESSAGES

The current neonatal resuscitation guidelines recommend epinephrine be primarily given via the intravenous or intraosseous route, with the endotracheal route as an alternative if these routes are not feasible or unsuccessful. The intravenous or intraosseous dose ranges between 0.01 and 0.03 mg/kg, which should be repeated every 3-5 min during chest compressions. However, the optimal dosing and route of administration of epinephrine remain unknown. There is evidence from adult and pediatric studies that vasopressin might be an alternative to epinephrine; however, the neonatal data are scarce.

Effects of laryngeal mask ventilation on postoperative atelectasis in children undergoing day surgery: a randomized controlled trial

BACKGROUND

To compare the effects of laryngeal mask mechanical ventilation and preserved spontaneous breathing on postoperative atelectasis in children undergoing day surgery.

METHODS

Children aged 3-7 who underwent elective day surgery were randomly divided into a spontaneous breathing group (n = 23) and a mechanical ventilation group (n = 23). All children enrolled in this trial used the same anesthesia induction protocol, the incidence and severity of atelectasis before induction and after operation were collected. In addition, the baseline data, intraoperative vital signs, ventilator parameters and whether there were complications such as reflux and aspiration were also collected. SPSS was used to calculate whether there was a statistical difference between these indicators.

RESULTS

The incidence of atelectasis in the spontaneous breathing group was 91.30%, and 39.13% in the mechanical ventilation group, and the difference was statistically significant (P = 0.001). There was a statistically significant difference in carbon dioxide (P < 0.05), and the severity of postoperative atelectasis in the mechanical ventilation group was lower than that in the spontaneous breathing group (P < 0.05). In addition, there were no significant differences in the vital signs and baseline data of the patients (P > 0.05).

CONCLUSION

Laryngeal mask mechanical ventilation can reduce the incidence and severity of postoperative atelectasis in children undergoing day surgery, and we didn't encounter any complications such as reflux and aspiration in children during the perioperative period, so mechanical ventilation was recommended to be used for airway management.

TRIAL REGISTRATION

The clinical trial was registered retrospectively at the Chinese Clinical Trial Registry. ( https://www.chictr.org.cn . Registration number ChiCTR2300071396, Weiwei Cai, 15 May 2023).

A systematic review and meta-analysis on the efficacy and safety of the Baska mask versus other laryngeal mask airways during general anaesthesia

BACKGROUND

The Baska mask is a supraglottic airway device used during general anaesthesia that combines features from various other devices. This systematic review aims to compare its efficacy and safety with other laryngeal mask airways.

METHODS

Randomised controlled trials were identified by searching PubMed, Scopus, Web of Science and Cochrane Library. RevMan software was used for meta-analysis, with mean difference and risk ratios calculated for continuous and dichotomous data, respectively, along with a 95% confidence interval.

RESULTS

The meta-analysis found that the Baska mask provides a better oropharyngeal seal pressure (mean difference = 7.03; 95% confidence interval = [6.00, 8.07], p < 0.00001) and a higher rate of maximal seal pressure (risk ratio = 18.38; 95% confidence interval = [2.53, 133.47], p = 0.004) compared to other laryngeal mask airways. However, the Baska mask had lower success rates in first-attempt insertion (risk ratio = 0.79; 95% confidence interval = [0.72, 0.86], p < 0.00001) and higher rates of insertion manipulation (risk ratio = 16.64; 95% confidence interval = [5.86, 47.24], p < 0.00001).

CONCLUSION

The Baska mask offers better oropharyngeal seal pressure, but may be more difficult to insert than other laryngeal mask airways, without causing significant delays. The Baska mask appears as safe as other laryngeal mask airways, but larger trials are needed to support these findings.

The effect of intraoperative transnasal humidified rapid-insufflation ventilatory exchange on emergence from general anesthesia in patients undergoing microlaryngeal surgery: a randomized controlled trial

BACKGROUND

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has received extensive attention for its utility in tubeless anesthesia. Still, the effects of its carbon dioxide accumulation on emergence from anesthesia have not been reported. This randomized controlled trial aimed at exploring the impact of THRIVE combined with laryngeal mask (LM) on the quality of emergence in patients undergoing microlaryngeal surgery.

METHODS

After research ethics board approval, 40 eligible patients receiving elective microlaryngeal vocal cord polypectomy were randomly allocated 1:1 to two groups, THRIVE + LM group: intraoperative apneic oxygenation using THRIVE followed by mechanical ventilation through a laryngeal mask in the post-anesthesia care unit (PACU), or MV + ETT group: mechanically ventilated through an endotracheal tube for both intraoperative and post-anesthesia periods. The primary outcome was duration of PACU stay. Other parameters reflecting quality of emergence and carbon dioxide accumulation were also recorded.

RESULTS

Duration of PACU stay (22.4 ± 6.4 vs. 28.9 ± 8.8 min, p = 0.011) was shorter in the THRIVE + LM group. The incidence of cough (2/20, 10% vs. 19/20, 95%, P < 0.001) was significantly lower in the THRIVE + LM group. Peripheral arterial oxygen saturation and mean arterial pressure during intraoperative and PACU stay, Quality of Recovery Item 40 total score at one day after surgery and Voice Handicap Index-10 score at seven days after surgery were of no difference between two groups.

CONCLUSIONS

The THRIVE + LM strategy could accelerate emergence from anesthesia and reduce the incidence of cough without compromising oxygenation. However, these benefits did not convert to the QoR-40 and VHI-10 scores improvement.

TRIAL REGISTRATION

ChiCTR2000038652.

[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.

RESULTS

The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

Laryngeal mask general anaesthesia versus spinal anaesthesia for promoting early recovery of cervical conisation: A randomised, controlled clinical study

Background

Although both spinal and general anaesthesia provides good anaesthesia for cervical conization, spinal anaesthesia delays the return of lower limb movements and urinary function, whereas general anaesthesia requires the patient to be unconscious. It is unclear which anaesthetic technique is more conducive to early postoperative recovery in patients undergoing cervical conization.

Patients and methods

140 patients undergoing cervical conization underwent either laryngeal mask general anaesthesia (LMA, n = 70) or spinal anaesthesia (SA, n = 70). In the LMA group, an i-gel mask was used for airway management. In the SA group, spinal anaesthesia was received with 0.75% ropivacaine (15 mg) in the L3-4 interval. The quality of recovery score (QoR-15) was the primary endpoint of the study. Secondary endpoints included incidence of adverse 24-h analgesia (NRS>3); return of lower limb activity; first bed activity and feeding; and the number of catheters removed at 6, 12 and 24 h postoperatively.

Result

The LMA group significantly improved QoR-15 scores (136.62 ± 11.02 vs 119.97 ± 12.75; P < 0.001); and reduced the incidence of poor analgesia (NRS >3) within 24 h postoperatively (20% vs 42.8%, P = 0.006); reduced time in bed (15.62 ± 3.83 h vs 18.27 ± 5.57 vs, P = 0.001); improved patient satisfaction (86% vs 27%; P < 0.001); and catheters removal within 24 h (70/70 vs 42/70, P < 0.001).

Conclusion

LMA general anaesthesia can facilitate early postoperative recovery in patients undergoing cervical conization compared with conventional spinal anaesthesia.

Trial registration

Chinese Clinical Trial Registry (ID: ChiCTR1800019384), http://www.chictr.org.cn/listbycreater.aspx (08/11/2018).

Assessing a novel second generation laryngeal mask airway using the 'ADEPT' approach: results from the LMA® Protector™ observational study

To address the problem of lack of clinical evidence for airway devices introduced to the market, the Difficult Airway Society (UK) developed an approach (termed ADEPT; Airway Device Evaluation Project Team) to standardise the model for device evaluation. Under this framework we assessed the LMA Protector, a second generation laryngeal mask airway. A total of 111 sequential adult patients were recruited and the LMA Protector inserted after induction of general anaesthesia. Effective insertion was confirmed by resistance to further distal movement, manual ventilation, and listening for gas leakage at the mouth. The breathing circuit was connected to the airway channel and airway patency confirmed with manual test ventilation at 20 cm H20 (water) pressure for 3 s. Data was collected in relation to the time for placement, intraoperative performance and postoperative performance of the airway device. Additionally, investigators rated the ease of insertion and adequacy of lung ventilation on a 5-point scale. The median (interquartile range [range]) time taken to insertion of the device was 31 (26-40[14-780]) s with the ability to ventilate after device insertion 100 (95% CI 96.7- 100)%. Secondary endpoints included one or more manoeuvres 60.3 (95% CI 50.6-69.5)% cases requiring to assist insertion; a median ease of insertion score of 4 (2-5[3-5]), and a median adequacy of ventilation score of 5 (5-5[4-5]). However, the first time insertion rate failure was 9.9% (95% CI 5.1-17.0%). There were no episodes of patient harm recorded, particularly desaturation. The LMA Protector appears suitable for clinical use, but an accompanying article discusses our reflections on the ADEPT approach to studying airway devices from a strategic perspective.

Retrospective comparison of the effects of laryngeal mask and endotracheal tube on some cardio-respiratory variables in pet rabbits undergoing anaesthesia for elective gonadectomy

BACKGROUND

Endotracheal intubation in rabbits is challenging and supraglottic airway devices, such as laryngeal masks (LMA), represent an alternative as they are easy to insert, and do not stimulate the larynx requiring therefore a lighter plane of anaesthesia for their insertion and positioning than the endotracheal tubes. We investigated whether, compared to an endotracheal tube, the LMA can reduce the negative effects of general anaesthetics on some cardiovascular and respiratory parameters routinely monitored in rabbits anaesthetized for elective gonadectomy. The records of 21 adult mixed breed pet rabbits were collected retrospectively. Rabbits were divided in two groups based on the type of airway device used. A laryngeal mask secured the airway in group LMA (n = 11), and in group ETT (n = 10) an endotracheal tube was used. The amount of propofol used before successful insertion of the airway device was recorded. A pitot-based spirometer was connected and ventilatory variables were measured immediately after insertion. Pulse rate, non-invasive arterial blood pressure, haemoglobin oxygen saturation, respiratory rate, end-tidal carbon dioxide and volatile anaesthetic consumption were also monitored during the surgical procedure; extubation time was noted as well.

RESULTS

The use of LMA required significantly less propofol (0.8 to 4 mg/kg) for insertion than the ETT (1.2 to 5.6 mg/kg), and the difference was statistically significant (P < 0.01). No differences were observed in ventilatory variables measured immediately after airway positioning. Intraoperatively, there were no differences between groups for respiratory and cardiovascular variables, and amount of isoflurane administered. In all rabbits mean and diastolic blood pressure progressively decreased during surgery. Mean extubation time was shorter in group LMA (6 ± 2 min) than group ETT (8 ± 3 min, P < 0.01).

CONCLUSION

The airway device did not clinically affect the cardiovascular and respiratory variables during anaesthesia. Intraoperative hypoventilation was observed in most rabbits regardless of the device being used; therefore ventilatory support may be required. Rabbits with the laryngeal masks were extubated earlier.

AIRWAY MANAGEMENT IN LAPAROSCOPIC CHOLECYSTECTOMY - A COMPARATIVE ANALYSIS

In this study, we aimed to compare supraglottic airway devices (Supreme and i-gel laryngeal mask) with tracheal tube with respect to airway control and efficiency in ventilation and oxygenation. The study included 325 patients of ASA I-II who underwent laparoscopic cholecystectomy. In group 1, the airway was secured using endotracheal intubation (115 patients). In group 2 (103 patients), LMA Supreme was applied, whereas i-gel mask was used for airway management in group 3 (107 patients). Monitoring parameters were recorded and compared using t-test, analysis of variance (ANOVA), Tukey's test and χ2-test. The following parameters were monitored: insertion time, number of attempts for device placement, oropharyngeal seal pressure, etc. Insertion time was longest in group 1 (14.7±1.65 s) as compared to group 2 (15.5±1.05 s) and group 3 (14.1±1.27 s); ANOVA test yielded a statistically significant difference (p<0.01). Insertion success rate was almost identical in all three groups (p=0.907, χ2-test). Comparison of oropharyngeal seal pressure between group 2 (35.95±2.92 cm H2O) and group 3 (36.47±1.43 cm H2O) yielded no statistical difference (p=0.314, t-test). Endotracheal tube, Supreme and i-gel laryngeal masks were shown to be equally efficient in airway management in laparoscopic cholecystectomy. All three devices enabled efficient ventilation and oxygenation despite certain pathophysiological changes associated with laparoscopy.

The efficacy of different alveolar recruitment maneuvers in holmium laser lithotripsy surgery under general anesthesia using a laryngeal mask

Background

Alveolar recruitment maneuvers (ARMs) is an important part of lung-protective ventilation strategies (LPVSs), but the optimal duration and interval Remain unclear.

Methods

Patients:252 patients who underwent holmium laser lithotripsy surgery and meet inclusion criteria were included and randomized into three groups based on the duration and frequency of ARMs (Regular, one 30 s ARM (RARMs); Improved and intermittent, three 10s ARMs (IARMs); and Control (C), no ARMs).Interventions: Groups R and I received ARMs at 20 cmH2O pressures every 30 min. All patients received the same anesthesia and mechanical ventilation. Measurements:Outcomes included heart rate and mean arterial pressure changes during ARMs and postoperative pulmonary complications (PPCs) within the first 7 postoperative days.

Main results

Incidences of PPCs in groups R(7.1%) and I (5.0%)were slightly lower than those in group C (8.9%).This indicated the potential to reduce lung injury. Heart rate and mean arterial pressure fluctuations during ARMs were significantly higher in groups R and I than in group C (P < 0.01). The rate of blood pressure decrease was significantly higher in group R than in group I (P < 0.01).

Conclusions

IARMs can reduce cycle fluctuations than RARMs in patients Undergoing holmium laser lithotripsy surgery with laryngeal mask general anesthesia. Low tidal volume ventilation and low PEEP combined with ARM did not significantly reduce the incidence of PPCs in healthy lung patients, but tended to reduce lung injury.

Trial registration

The study was registered on the Chinese Clinical Trial Registry.

(ChiCTR2000030815,15/03/2020). This study was approved by the ethics committee of Chengdu Fifth People’s Hospital with approval number(2020–005(Study)-1).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01664-y.

Respiratory monitoring during neonatal resuscitation using a supraglottic airway device vs. a face mask

OBJECTIVE

To evaluate the respiratory function of asphyxiated infants resuscitated with i-gel supraglottic airway (SGA) vs. face mask (FM) in a low-resource setting.

METHODS

In this sub-study from the NeoSupra trial, respiratory function during the first 60 inflations was evaluated in 46 neonates (23 with SGA and 23 with FM) at the Mulago National Referral Hospital, Uganda. The primary outcome was the mask leak (%). The secondary outcomes included inspired (VTi) and expired (VTe) tidal volumes, and heart rate response to ventilation.

RESULTS

Median mask leak was 40% (IQR 22-52) with SGA and 39% (IQR 26-62) with FM (p = 0.38). Median VTe was 7.8 ml/kg (IQR 5.6-10.2) with SGA and 7.3 ml/kg (IQR 4.8-11.9) with FM (p = 0.84), while median VTi was 15.4 ml/kg (IQR 11-4-17.6) with SGA and 15.9 ml/kg (IQR 9.0-22.6) with FM (p = 0.68). A shorter time was needed to achieve heart rate > 100 bpm in SGA (median 13 s IQR 9-15) with respect to FM arm (median 61, IQR 33-140) (p = 0.0002).

CONCLUSION

Respiratory function was not statistically different between neonates resuscitated with SGA vs. FM. SGA was associated with faster heart rate recovery compared to FM in the subgroup of neonates with bradycardia. Further research is needed to investigate possible advantages of SGA on respiratory function at birth.

Laryngeal mask airway protector generates higher oropharyngeal leak pressures compared to the laryngeal mask airway supreme: A randomized clinical trial in the ambulatory surgery unit

Background and Aims

The Laryngeal Mask Airway (LMA) Protector™ is one of the latest introduced supraglottic airway devices. It provides access and functional separation of the respiratory and digestive tracts. Compared to the LMA Supreme™, it has two digestive ports, one to provide suction in the pharyngeal region and one for gastric tube insertion. High oropharyngeal leak pressure is a marker for safe ventilation when using LMA devices. We hypothesized that oropharyngeal leak pressure of the LMA Protector™ is 5 cm H₂O higher than the oropharyngeal leak pressure of the LMA Supreme™ at various cuff volumes. Secondary outcome measures were ease of insertion of both masks, fiberoptic confirmation of correct positioning, failures of insertion, presence of blood staining, sore throat, presence of air leak and insertion time.

Material and Methods

American Society of Anesthesiologists (ASA) I-III patients aged >18 years, scheduled for elective minor ambulatory surgery under general anesthesia with a LMA were included. Patients were randomized in the LMA Protector™ or LMA Supreme™ group based on a computer-generated random sequence table. After general anesthesia induction, oropharyngeal leak pressures were measured.

Results

Oropharyngeal leak pressures were significantly higher (P < 0.0001) for LMA Protector™ compared to LMA Supreme™ at different cuff volumes and a cuff pressure of 65 cm H₂O. Insertion time was significantly higher for the LMA Protector™ (29 sec) [interquartile range (IQR) 23, 35] compared to the LMA Supreme™ (19 sec) (IQR 16, 22) (P < 0.0001). There were no statistically significant differences in ease of insertion (number of attempts for succesful positioning), failures of insertion, presence of blood staining, sore throat or presence of air leak.

Conclusion

Oropharyngeal leak pressures were consistently higher (>5 cm H₂O) for LMA Protector™ compared to LMA Supreme™. LMA Protector™, therefore, allows effective ventilation at higher airway pressures than LMA Supreme™.

Trial Registration

http://clinicaltrials.gov.NCT03462550.

Use of second generation supraglottic airway device for endovascular treatment of unruptured intracranial aneurysms: a retrospective cohort

Background

We aimed to assess the feasibility of using supraglottic devices as an alternative to orotracheal intubation for airway management during anesthesia for endovascular treatment of unruptured intracranial aneurisms in our department over a nine-year period.

Methods

Retrospective single center analysis of cases (2010–2018). Primary outcomes: airway management (supraglottic device repositioning, need for switch to orotracheal intubation, airway complications). Secondary outcomes: aneurysm complexity, history of subarachnoid hemorrhage, hemodynamic monitoring, and perioperative complications.

Results

We included 187 patients in two groups: supraglottic device 130 (69.5%) and orotracheal intubation 57 (30.5%). No adverse incidents were recorded in 97% of the cases. Three supraglottic device patients required supraglottic device repositioning and 1 supraglottic device patient required orotracheal intubation due to inadequate ventilation. Three orotracheal intubation patients had a bronchospasm or laryngospasm during awakening. Forty-five patients (24.1%) had complex aneurysms or a history of subarachnoid hemorrhage. Thirty-three of them (73.3%) required orotracheal intubation compared to 24 of the 142 (16.9%) with non-complex aneurysms. Two patients in each group died during early postoperative recovery. Two in each group also had intraoperative bleeding. A post-hoc analysis showed that orotracheal intubation was used in 55 patients (44%) in 2010 through 2014 and 2 (3.2%) in 2015 through 2018, parallel to a trend toward less invasive blood pressure monitoring from the earlier to the later period from 34 (27.2%) cases to 5 (8.2%).

Conclusion

Supraglottic device, like other less invasiveness protocols, can be considered a feasible alternative airway management approach in selected patients proposed for endovascular treatment of unruptured intracranial aneurisms.

Effectiveness of different supralottic airways during resuscitation manoeuvres. A systematic review

INTRODUCTION

Supraglottic airways, which are easily inserted and minimize interruptions in cardiopulmonary resuscitation manoeuvres, are now widely used in pre- and in-hospital emergencies. However, most studies in these devices do not specify whether they ensure good ventilation during CPR. This systematic review aims to determine whether there is evidence that supraglotic airways enable effective ventilation during resuscitation.

METHODS

The MEDLINE and COCHRANE databases were searched for studies published in English up to 30 November 2018. Eligible studies were all those that objectively evaluated tidal volume during resuscitation maneuvers in patients over 18 years of age using various supraglottic airways.

RESULTS

A total of 3734 articles were identified, of which 252 were duplicates. Only 1 objectively evaluated ventilation during resuscitation maneuvers and presented data relevant to this review. The study included 470 patients, 51 of which underwent spirometry. Only 4.48% of patients survived to hospital discharge; however, the correlation with ventilation effectiveness was not assessed.

CONCLUSION

There is no scientific evidence that supraglottic airways provide effective ventilation during resuscitation maneuvers. Evaluation by spirometry, chest impedance and ultrasound may help to determine the ventilatory efficacy of supraglottic airways during CPR, and clarify whether this factor contributes to the difficulties experienced in reversing cardiorespiratory arrest.

Correlation and variation of cuff inflating volumes and pressures in different adult models of laryngeal mask: a prospective randomized trial

BACKGROUND

Hyperinflation of laryngeal mask cuffs may carry the risk of airway complications. The manufacturer recommends inflating cuff until the intracuff pressure reaches 60 cmH2O, or inflate with the volume of air to not exceed the maximum recommended volume. We prospectively assessed the correlation of cuff inflating volumes and pressures, and the appropriated the cuff inflating volumes to generate an intracuff pressure of 60 cmH2O in the adult laryngeal masks from different manufacturers.

METHODS

Two groups of 80 patients requiring laryngeal mask size 3 and 4 during general anesthesia were randomized into 4 subgroups for each size of the laryngeal mask: Soft Seal® (Portex®), AuraOnce™ (Ambu®), LMA-Classic™ (Teleflex®) and LMA-ProSeal™ (Teleflex®). After insertion, the cuff was inflated with 5-ml increments of air up to the maximum recommended volume. After each 5-ml intracuff pressure was measured, the volume of air that generated the intracuff pressure of 60 cmH2O was recorded.

RESULTS

Mean (SD) volume of air required to achieve the intracuff pressure of 60 cmH2O in Soft Seal®, AuraOnce™, LMA-Classic™, LMA-ProSeal™ laryngeal mask size 3 were 11.80(1.88), 9.20(1.88), 8.95(1.50) and 13.50(2.48) ml, respectively, and these volumes in laryngeal mask size 4 were 14.45(4.12), 12.55(1.85), 11.30(1.95) and 18.20(3.47) ml, respectively. The maximum recommended volume resulted in high intracuff pressures (> 60 cmH2O) in all laryngeal mask types and sizes studied.

CONCLUSION

Pressure-volume curves of adult laryngeal masks are all in sigmoidal shape. Cuff designs and materials can effect pressure and volume correlation. Approximately half of the maximum recommended volume is required to achieve the intracuff pressure of 60 cmH2O except LMA-ProSeal™ which required two-thirds of the maximum recommended volume.

TRIAL REGISTRATION

Thai Clinical Trials Registry, TCTR20150602001, May 28, 2015.

Effects of Peak Inspiratory Pressure-Guided Setting of Intracuff Pressure for Laryngeal Mask Airway Supreme™ Use during Laparoscopic Cholecystectomy: A Randomized Controlled Trial

PURPOSE

To determine the effects of peak inspiratory pressure (PIP)-guided intracuff pressure (ICP) modulation of laryngeal mask airway (LMA) Supreme™ during laparoscopic cholecystectomy.

METHODS

Totally 120 patients were randomly divided using computer-generated numbers into a control group (n = 60; ICP, 60 cmH₂O) and a PIP group (n = 60), in which ICP was increased with 5 cmH₂O each time from PIP level until no air leaks from the oropharynx. PIP, ICP, cuff volume (CV), oropharyngeal leak pressure (OLP) and leak fraction (LF) were recorded before and after pneumoperitoneum establishment. Postoperative pharyngolaryngeal complications (sore throat, dysphagia, pharyngeal hematoma, and dysphonia) were also recorded.

RESULTS

Demographic data were similar in the two groups. The CV and ICP before and after pneumoperitoneum were significantly lower in the PIP group (CV: 15.6 ± 2.3 mL and 21.0 ± 2.6 mL; ICP: 14.3 ± 2.9 cmH₂O and 20.5 ± 3.4 cmH₂O) than in the control group (CV: 33.0 ± 2.8 mL and 32.8 ± 1.9 mL; ICP: 60.0 ± 0.1 cmH₂O and 60.0 ± 0.1 cmH₂O) (P < 0.05). Although OLP was lower in the PIP group (P < 0.05), the LF was similar in the two groups (P > 0.05). There were fewer postoperative pharyngolaryngeal complications in the PIP group (P < 0.05).

CONCLUSIONS

Compared with a fixed ICP of 60 cmH₂O, PIP-guided ICP modulation during LMA Supreme™ use provided effective airway sealing at a lower CV and ICP, and produced fewer postoperative pharyngolaryngeal complications in patients undergoing laparoscopic cholecystectomy.

The median effective dose (ED50) of cis-Atracurium for laryngeal mask airway insertion during general Anaesthesia for patients undergoing urinary surgery

Background

In clinical practice, the laryngeal mask airway is an easy-to-use supraglottic airway device. However, the cis-atracurium dosage for laryngeal mask insertion has not been standardised. We aimed to determine the optimal dose of cis-atracurium using a sequential method for successful laryngeal mask insertion.

Methods

The cohort study protocol is registered at clinicaltrial.gov (NCT-03668262). Twenty-three patients undergoing elective urinary surgery were sequentially administered cis-atracurium doses as follows: 150, 100, 70, 50, 30, and 20 μg·kg^− 1. The main outcome involved the determination of the response to laryngeal mask airway insertion: ≥16 points and < 16 points indicated “satisfactory” and “unsatisfactory” responses, respectively. The median effective dose was estimated using the mean of the seven crossovers from “satisfactory” and “unsatisfactory” responses. The primary outcome involved the determination of the median effective dose (ED50) of cis-atracurium for laryngeal mask airway insertion.

Results

The median effective dose of cis-atracurium was 26.5 μg·kg^− 1 (95% CI 23.6–29.8) using the sequential method. Heart rate was decreased in the 50 μg·kg^− 1 group compared to that in the 30 μg·kg^− 1 group at timepoints T7, T8, and T10 (P = 0.0482, P = 0.0460, and P = 0.0236, respectively), but no difference was observed in the 20 μg·kg^− 1 group. Systolic blood pressure was decreased in the 50 μg·kg^− 1 group compared to that in the 20 μg·kg^− 1 group at timepoints T2, T3, and T4 (P = 0.0159, P = 0.0233, and P = 0.0428, respectively). The train-of-four value was significantly lower in the 50 μg·kg^− 1 group than in the 30 μg·kg^− 1 group at timepoint T3 (P = 0.0326).

Conclusions

The ED50 of cis-atracurium was 26.5 μg·kg^− 1 for laryngeal mask airway insertion.

Trial registration

Clinicaltrial.gov Registry, NCT03668262, Registered on 11 September 2018.

[Effect of different training methods on the use of the i-gel laryngeal mask by lay persons on a manikin]

BACKGROUND

Several studies have described the successful application of extraglottic airways by lay people to a phantom.

OBJECTIVES

This study examined the influence of the training method on the success of the application.

METHODS

A total of 150 visitors of a shopping mall were asked to place an i‑gel laryngeal mask (Intersurgical GmbH, Sankt Augustin, Germany) on a manikin. The short instruction was randomized and performed either as a practical demonstration or through the self-study of an illustrated manual.

RESULTS

Application success in the first attempt was 95.8 % for the practical demonstration group and 78.5 % for the written instruction group (p = 0.001). Placement times were also significantly different (median 11.5 s vs. 22.5 s, p < 0.001).

CONCLUSIONS

Learning success can be achieved with both training methods. Initially, a hands-on training should be carried out with a practical demonstration.

Comparative study of the Ambu® AuraOnce™ laryngeal mask and endotracheal intubation in anesthesia airway management during neurosurgery

Objective

To investigate the feasibility and efficacy of the Ambu® AuraOnce™ laryngeal mask (LMA) compared with endotracheal intubation (ETI) during supratentorial tumor resection in the right lateral decubitus position.

Methods

This was a randomized controlled trial of LMA compared with ETI in patients who were scheduled to undergo supratentorial tumor resection in the right lateral decubitus position. The patients were randomized to the LMA (n = 40) and ETI groups (n = 40). The hemodynamic parameters (primary outcome) and mechanical ventilation parameters, anesthetic dose, and complications as well as quality of anesthesia recovery (secondary outcomes) were compared.

Results

Patients in the LMA group exhibited lower mean arterial pressure (MAP) and heart rate (HR) compared with ETI. Nine and two patients received esmolol during intubation and extubation, respectively. The airway pressure (AP) in the LMA group was higher compared with the ETI group 60 minutes after the start of surgery. Compared with the ETI group, the sufentanil dose was lower by 24% and the anesthesia recovery rate was better in the LMA group.

Conclusions

LMA can improve hemodynamic stability in patients undergoing supratentorial tumor resection in the right lateral decubitus position. If there is a clinical need and no contraindication, LMA could replace ETI.

Voice and Vocal Fold Condition Following Short-Term General Anesthesia: A Prospective Study

BACKGROUND

Dysphonia, with or without laryngeal changes, has been reported as a complication following prolonged intubation. In contrast, it is unknown if laryngeal changes also occur following short-term airway instrumentation. The objectives of this study were to determine the prevalence of laryngeal changes in patients undergoing short-term routine general anesthesia using an endotracheal tube (ETT) or supraglottic airway (SGA), and to identify predictors to these changes.

METHODS

Standardized voice assessments were performed preoperatively, postoperatively, and at follow-up on adults undergoing general anesthesia for an elective procedure of less than three hours requiring an ETT or a SGA. The standardized voice assessment protocol comprised a rigid videolaryngostroboscopy, the Voice Handicap Index (VHI), and acoustic voice analysis. The effects of demographic and anesthetic characteristics and type of airway instrumentation on the videolaryngostroboscopic variables were studied using multilevel logistic regression. Multilevel linear regression was used to reveal preoperative versus postoperative changes in VHI and acoustic voice scores.

RESULTS

Overall, the prevalence of postoperative laryngeal changes was low. Significant postoperative laryngeal changes were found for the variables right-sided vocal fold redness in the ETT group (P = 0.048) and right-sided vocal fold blood vessels in both groups (ETT versus SGA). However, after adjustment for all demographic and anesthetic characteristics in the regression model, the effect of the type of airway instrumentation (ETT versus SGA) on the variable right-sided vocal fold redness was no longer significant.

CONCLUSIONS

ETT and SGA short-term airway instrumentation are vocal fold function sparing techniques with negligible laryngeal changes.

Laryngeal mask versus facemask in the respiratory management during catheter ablation

BACKGROUND

The purpose of this study is to investigate if a laryngeal mask could improve respiratory condition during radiofrequency catheter ablation (RFCA).

METHODS

Twenty-four consecutive patients who underwent RFCA for atrial fibrillation were divided into two groups (Facemask group; n = 10, Laryngeal mask group; n = 14). All patients were completely sedated under intravenous anesthesia and fitted with artificial respirators during the RFCA. The capnography waveforms and their differential coefficients were analyzed to evaluate the changes of end-tidal CO₂ (ETCO₂) values, respiratory intervals, expiratory durations, and inspiratory durations.

RESULTS

During the RFCA, ETCO₂ values of the laryngeal mask group were higher than those of the facemask group (36.0 vs. 29.2 mmHg, p = 0.005). The respiratory interval was significantly longer in the laryngeal mask group than those in the facemask group (4.28 s vs.5.25 s, p < 0.001). In both expiratory and inspiratory phases, the mean of the maximum and minimum values of CO₂ was significantly higher when using a laryngeal mask than when using a facemask. The inspiratory-expiratory ratio of the laryngeal mask group was significantly larger than that of the facemask group (1.59 vs. 1.27, p < 0.001). The total procedure duration, fluoroscopic duration and the ablation energy were significantly lower in the laryngeal mask group than in the facemask group. The ETCO₂ value is the most influential parameter on the fluoroscopic duration during the RFCA procedure (β = - 0.477, p = 0.029).

CONCLUSIONS

The use of a laryngeal mask could stabilize respiration during intravenous anesthesia, which could improve the efficiency of RFCA.

Neonatal resuscitation using a supraglottic airway device for improved mortality and morbidity outcomes in a low-income country: study protocol for a randomized trial

Background

Intrapartum-related death is the third leading cause of under-5 mortality. Effective ventilation during neonatal resuscitation has the potential to reduce 40% of these deaths. Face-mask ventilation performed by midwives is globally the most common method of resuscitating neonates. It requires considerable operator skills and continuous training because of its complexity. The i-gel^® is a cuffless supraglottic airway which is easy to insert and provides an efficient seal that prevents air leakage; it has the potential to enhance performance in neonatal resuscitation. A pilot study in Uganda demonstrated that midwives could safely resuscitate newborns with the i-gel^® after a short training session. The aim of the present trial is to investigate whether the use of a cuffless supraglottic airway device compared with face-mask ventilation during neonatal resuscitation can reduce mortality and morbidity in asphyxiated neonates.

Methods

A randomized phase III open-label superiority controlled clinical trial will be conducted at Mulago Hospital, Kampala, Uganda, in asphyxiated neonates in the delivery units. Prior to the intervention, health staff performing resuscitation will receive training in accordance with the Helping Babies Breathe curriculum with a special module for training on supraglottic airway insertion. A total of 1150 to 1240 babies (depending on cluster size) that need positive pressure ventilation and that have an expected gestational age of more than 34 weeks and an expected birth weight of more than 2000 g will be ventilated by daily unmasked randomization with a supraglottic airway device (i-gel^®) (intervention group) or with a face mask (control group). The primary outcome will be a composite outcome of 7-day mortality and admission to neonatal intensive care unit (NICU) with neonatal encephalopathy.

Discussion

Although indications for the beneficial effect of a supraglottic airway device in the context of neonatal resuscitation exist, so far no large studies powered to assess mortality and morbidity have been carried out. We hypothesize that effective ventilation will be easier to achieve with a supraglottic airway device than with a face mask, decreasing early neonatal mortality and brain injury from neonatal encephalopathy. The findings of this trial will be important for low and middle-resource settings where the majority of intrapartum-related events occur.

Trial registration

ClinicalTrials.gov. Identifier: NCT03133572. Registered April 28, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3455-8) contains supplementary material, which is available to authorized users.

Unilateral hypoglossal nerve palsy after the use of laryngeal mask airway (LMA) Protector

BACKGROUND

The laryngeal mask airway (LMAⓇ) ProtectorTM (Teleflex Medical Co., Ireland) is the latest innovation in the second generation of LMA devices. One distinguishing feature of this device is its integrated, color-coded cuff pressure indicator (Cuff PilotTM technology) which enables continuous cuff pressure monitoring and allows adjustments when necessary; this ensures patient safety due to better monitoring.

CASE

We report a case of postoperative unilateral hypoglossal nerve palsy after uncomplicated use of the LMA Protector. To the best of our knowledge, this could be the second reported case.

CONCLUSIONS

This case demonstrates that anesthetists need to routinely measure cuff pressure and that the Cuff PilotTM technology is not a panacea for potential cranial nerve injury after airway manipulation.

Association of Mallampati scoring on airway outcomes in women undergoing general anesthesia with Supreme™ laryngeal mask airway in cesarean section

Background

Obstetric dfficult airway is a leading cause of maternal morbidity and mortality. The laryngeal mask airway (LMA) is often used as a rescue airway device after failed intubation, however, little is known about predictors of difficult LMA insertion, particularly in obstetrics. Since Mallampati scores of III/IV has been associated with difficult tracheal intubation, our present study aims to investigate if Mallampati score (MP) could predict airway outcomes for LMA use in obstetrics.

Methods

This prospective cohort study was performed at a single-center: Quanzhou Women’s and Children’s Hospital, Fujian Province, China. Five hundred and eighty-four parturients undergoing elective cesarean section under general anesthesia were recruited. The primary outcome was time to effective ventilation, and secondary outcomes included first attempt insertion success, seal pressure, ventilation and hemodynamic parameters, occurrence of clinical aspiration, and maternal and fetal outcomes.

Results

The parturients were classified into two groups based on MP of III/IV (High MP: 61) versus I/II (Low MP: 523). BMI was higher in the High MP group than in the Low MP group (mean (SD) 29.3 (7.0) vs 26.8 (3.1), p <  0.0001). There was no difference in maternal age, ASA status and gestational age. There was similar time to effective ventilation (mean (SD) High MP: 14.9 (4.5) vs Low MP: 15.7 (4.4) seconds, p = 0.2172), and first attempt success rate, seal pressure, and peak airway pressure. No clinical aspiration was noted. The incidence of blood on SLMA was higher in the High MP group than in Low MP (4 (6.6%) vs 4 (0.8%), p = 0.001). There was no difference in sore throat, voice hoarseness, maternal satisfaction and fetal outcomes.

Conclusion

High MP was not associated with reduced SLMA airway outcomes in cesarean section under general anesthesia, but may increase the risk of blood found on SLMA upon removal.

Trial registration

This study was registered at http://www.clinicaltrials.gov, identifier: NCT02026882, retrospectively registered. Date of registration: December 31, 2013.

Recent Recommendations and Emerging Science in Neonatal Resuscitation

The Neonatal Resuscitation Program, initially an expertise- and consensus-based approach, has evolved into an evidence-based algorithm. Ventilation remains the key component of successful resuscitation of neonates. Recent changes in recommendations include management of cord clamping, multiple methods to prevent hypothermia, rescinding of mandatory intubation and suction of the nonvigorous meconium-stained infant, electrocardiographic monitoring, and establishing an airway for ventilation before initiation of chest compressions. Emerging science, including issues such as cord milking, oxygen targeting, and laryngeal mask use, may lead to future program modifications. Technology such as video laryngoscopy and telemedicine will affect the way training and care is delivered.

The impact of laryngeal mask versus other airways on perioperative respiratory adverse events in children: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Increasing studies have shown that the use of laryngeal mask airways (LMAs) improved the perioperative respiratory adverse events (PRAEs) in children. However, the results of some of these studies still remained controversial as their sample sizes were small. A systematic review and meta-analysis was designed to evaluate the impact of LMAs in decreasing PRAEs in children.

METHODS

We searched the Cochrane Library, PubMed, EMBASE and Web of Science up to May 29, 2018 to identify relevant randomized controlled trials (RCTs) which analyzed and evaluated the impact of LMAs in decreasing PRAEs in children. Participants were randomly assigned to receive LMAs (the intervention group) or other airways (the control group). We studied PRAEs which included breath apnea, laryngospasm, desaturation, cough, fever, pulmonary rales and pulmonary infection. Risk ratio (RR) with 95% confidence intervals (CIs) were estimated to compare the outcomes of the groups. We also performed subgroup analysis and sensitivity analysis to evaluate the impact of LMAs on further decreasing PRAEs. Two reviewers assessed the trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in the Review Manager 5.2.

RESULTS

Twelve RCTs (N = 1577 participants) were identified. Comparing with other airways, significant reduction were found in the overall PRAEs (RR 0.52, 95% CI 0.39-0.70; P < 0.0001), major PRAEs (RR 0.47, 95% CI 0.29-0.79; P = 0.004) as well as minor PRAEs (RR 0.57, 95% CI 0.45-0.74; P < 0.0001) in patients managed with LMAs. When compared with endotracheal tubes (ETTs), LMAs also significantly reduced PRAEs. Further analysis also found that LMAs reduced the incidences of postoperative cough (RR 0.44, 95% CI 0.31-0.63; P < 0.00001), pulmonary rales (RR 0.62, 95% CI 0.44-0.87; P = 0.006) and infections (RR 0.28, 95% CI 0.13-0.61; P = 0.001) in children.

CONCLUSIONS

LMAs reduced the incidences of many PRAEs in children and should be used as one of anaesthesia methods for children.

Laryngeal mask airway Unique™ position in paediatric patients undergoing magnetic resonance imaging (MRI): prospective observational study

Background

Laryngeal mask UNIQUE® (LMAU) is supraglottic airway device with good clinical performance and low failure rate. Little is known about the ideal position of the LMAU on the magnetic resonance imaging (MRI) and whether radiological malposition can be associated with clinical performance (audible leak) in children. The primary aim of the study was to evaluate incidence of the radiologic malposition of the LMAU according to size. The secondary outcome was the clinical performance and associated complications (1st attempt success rate, audible leak) in LMAUs in correct position vs. radiologically misplaced LMAUs.

Methods

In prospective observational study, all paediatric patients undergoing MRI of the brain under general anaesthesia with the LMAU were included (1.9.2016–16.5.2017). The radiologically correct position: LMAU in hypopharynx, proximal cuff opposite to the C1 or C2 and distance A (proximal cuff end and aditus laryngis) ≤ distance B (distal cuff end and aditus laryngis). Malposition A: LMAU outside the hypopharynx. Malposition B: proximal cuff outside C1-C2. Malposition C: distance A ≥ distance B. We measured distances on the MRI image. Malposition incidence between LMAU sizes and first attempt success rate in trainees and consultant groups was compared using Fisher exact test, difference in incidence of malpositions using McNemar test and difference in leakage according to radiological position using two-sample binomial test.

Results

Overall 202 paediatric patients were included. The incidence of radiologically defined malposition was 26.2% (n = 53). Laryngeal mask was successfully inserted on the 1st attempt in 91.1% (n = 184) cases. Audible leak was detected in 3.5% (n = 7) patients. The radiologically defined malposition was present in 42.9% (n = 3) cases with audible leak. The rate of associated complications was 1.5% (n = 3): laryngospasm, desaturation, cough. In 4.0% (n = 8) the LMAU was soiled from blood.

Higher incidence of radiological malposition was in LMAU 1.0, 1.5 and LMAU 3, 4 compared to LMAU 2 or LMAU 2.5 (p < 0.001).

Conclusion

Malposition was not associated with impaired clinical performance (audible leak, complications) of the LMAU or the need for alternative airway management.

Trial registration

Clinicaltrials.gov  (NCT02940652) Registered 18 October 18 2016.

Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis

OBJECTIVES

To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA).

METHODS

A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state.

RESULTS

Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I² = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I² = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I² = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I² = 0%; p < 0.00001).

CONCLUSIONS

The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.

[Impacts of different methods in laryngeal mask airway positioning on the airway management of elderly patients with general anesthesia]

Objective: By observing the clinical effect of ultrasound, fiberoptic bronchoscopy and traditional standard in positioning the general anesthesia of laryngeal mask ventilation in elderly patients, the superiority of laryngeal mask positioning with visualization technique of ultrasound and fiberoptic bronchoscope on airway management in elderly patients with general anesthesia was analyzed. Methods: One hundred and twenty cases of elderly patients with general anesthesia of laryngeal mask ventilation from the People's Hospital of Yuyao city from October 2016 to October 2017 were selected and randomly divided into 3 groups(n=40)according to American Society of Anesthesiologists (ASA) grading criteria Ⅰ-Ⅲ. Group A: traditional standard positioning laryngeal mask group. Group B: fiberoptic bronchoscope positioning laryngeal mask group. Group C: ultrasound positioning laryngeal mask group. The general information of sex ratio of male and female, mass, and height, and operation type, operation duration, anaesthesia duration, and modified Mallampati grade were observed and compared among the three groups. The number of successful laryngeal mask ventilation after laryngeal mask placement in 3 groups was observed, the laryngeal mask placement time (T(0)) and the normal ventilation time after adjustment (T(1)) in each group were recorded, and the first success rate of laryngeal mask placement, the success rate after adjusting the positioning, and the success rate of re-placement were calculated. Moreover, the mean peak airway pressure at 5 min after operation, the minimum intrathecal injection gas for minimum ventilation (V(min)), the minimum laryngeal mask intravesical pressure (ICP(min)), and the lowest air pressure for oral and pharyngeal leakage (OLP(min)) were recorded. The airway seal pressure (OLP(60)) and the volume of gas injection (V(60)) when the intravesical pressure was 60 cmH(2)O (1 cmH(2)O=0.098 kPa) were used to record the incidence of postoperative laryngeal mask bleeding, cough, nausea and vomiting, and the incidence of pharyngalgia, odynophagia, hoarseness and other related complications after 24 hours of the operation. Results: There was no significant difference in general information, airway evaluation and anesthesia operation among the three groups (all P>0.05). The incidence of intraoperative laryngeal mask bleeding in group B and C was 7.9% and 2.6% respectively, the incidence of odynophagia at 24 hours after operation was 5.3% and 0 respectively, and the incidence of pharyngalgia and hoarseness was 18.4% and 7.9% respectively, less than that in group A (24.2%, 12.1% and 36.3%). The difference was statistically significant (χ(2)=8.900, 6.880, 9.000, P<0.05). The success rate of adjustment and positioning after the placement of laryngeal mask was 84.2% and 94.7% respectively in group B and C, higher than that in group A of 72.7%, and the difference was statistically significant (χ(2)=6.500, P<0.05). The lowest laryngeal mask intralaryngeal pressure for ventilation in group B and C was (35.39±4.67) cmH(2)O and (32.61±3.22) cmH(2)O, lower than that in group A of (39.30 ± 5.93) cmH(2)O, the intralaryngeal pressure was 60 cmH(2)O, and the airway seal pressure was (25.82±4.48) cmH(2)O and (28.34±6.99) cmH(2)O, higher than that in group A of (22.45±4.98) cmH(2)O, which was significantly different (F=18.200, 9.720, P<0.05). Conclusions: In elderly patients with general anesthesia, it is feasible to manage the airway by ultrasound or fiberoptic bronchoscopy with laryngeal mask. Ultrasound positioning laryngeal mask improves the accuracy of the intraoperative ventilation, and reduces the incidence of postoperative airway related complications.

Clinical effects of single femoral nerve block in combination with general anesthesia on geriatric patients receiving total knee arthroplasty

Objective:

To evaluate the clinical effects of single femoral nerve block (sFNB) combined with general anesthesia on geriatric patients receiving unilateral total knee arthroplasty (UTKA).

Methods:

Sixty geriatric UTKA patients who were treated in The First People's Hospital of Changzhou from January 2015 to August 2015 were randomly divided into an sFNB + laryngeal mask airway (FLA) group, an sFNB + tracheal intubation (FGA) group and a tracheal intubation (GA) group. Their clinical parameters and indices were recorded. They were scored by the Visual Analogue Scale (VAS).

Results:

All patients completed this study. FLA and FGA groups used less propofol, remifentanil and fentanyl than GA group (P<0.01), with shorter recovery time and extubation time (P<0.05). Compared to GA group, FLA and FGA groups had lower systolic blood pressures at T3, T4 and T5 (P<0.05), and lower heart rates at T5 (P<0.05). FLA and FGA groups had fewer cases of adverse reactions after extubation (P<0.01). FLA group was less prone to irritating cough after extubation and pharyngeal pain than FGA and GA groups (P<0.01). The postoperative six hour and 24 hour VAS scores in resting state as well as the postoperative 24 hour and 48 hour scores in training state of FLA and FGA groups were lower than those of GA group (P<0.05). FLA and FGA groups used significantly lower times and total doses of patient-controlled intravenous analgesia pump.

Conclusion:

sFNB combined with general anesthesia, especially that using laryngeal mask, were superior to general anesthesia alone, which reduced recovery and extubation times, and decreased intraoperative and postoperative drug uses, postoperative early VAS score and adverse reactions.

[Comparison of three different insertion techniques with LMA-Unique™ in adults: results of a randomized trial]

BACKGROUND

The triple airway maneuver insertion technique allowed faster insertion of the LMA. This study compared three different insertion techniques of the laryngeal mask airway-Unique™.

METHODS

One hundred and eighty ASA I-II patients aged 18-65 years were included into the study. Patients were randomly allocated to the standard, rotational and triple airway maneuver (triple) group. In the standard group (n=60), the LMA (Laryngeal Mask Airway) was inserted with digital intraoral manipulation. In the triple group (n=60), the LMA was inserted with triple airway maneuver (mouth opening, head extension and jaw thrust). In the rotational group (n=60), LMA was inserted back-to-front, like a Guedel airway. Successful insertion at first attempt, time for successful insertion, fiber optic assessment, airway morbidity and hemodynamic responses were assessed.

RESULTS

Successful insertion at the first attempt was 88.3% for the standard, 78.3% for the rotational and 88.3% for the triple group. Overall success rate (defined as successful insertion at first and second attempt) was 93% for the standard, 90% for the rotational and 95% for the triple group. Time for successful insertion was significantly shorter in the triple group (mean [range] 8.63 [5-19]s) compared with the standard (11.78 [6-24]s) and rotational group (11.57 [5-31]s). Fiber optic assessment, airway morbidity and hemodynamic responses were similar in all groups.

CONCLUSIONS

Rotational and triple airway maneuver insertion techniques are acceptable alternatives. Triple airway maneuver technique shows higher overall success rates and allows shorter insertion time for LMA insertion and should therefore be kept in mind for emergent situations.

A preliminary assessment of the LMA protector™ in non-paralysed patients

BACKGROUND

The LMA Protector™ is the latest CE marked single use supraglottic airway device. This airway device provides access and functional separation of the respiratory and digestive tracts. There are two ports (male, female ports) to provide suction in the laryngeal region and insertion of the gastric tube. The aim of our study is to assess the ease of use, airway quality, device positioning, airway leak and complications associated with initial clinical experience in LMA Protector™ usage.

METHODS

This is an initial investigation of LMA Protector™ airway device. We conducted a preliminary assessment in the anaesthetised women who underwent minor gynaecological procedures with spontaneous ventilation in order to evaluate the performance of the airway device.

RESULTS

Insertion was successful on first and second attempts in 23 (88.5%) and 3 (11.5%) respectively. Median [IQR (range)] insertion time was 19 [17-21(14-58)] seconds. Airway leak pressure was 25.5 [23-29(21-30] cmH₂O. On fibreoptic examination via the device, vocal cords were visible in all 26 patients. There were no alternative airway use or airway manipulations required during maintenance of anaesthesia. Six patients had sore throat 24 h after procedures and there was no dysphagia or hoarseness.

CONCLUSION

This pilot study of the LMA protector shows that the device is easily inserted with fast insertion time, providing a reliable and adequate airway seal.

TRIAL REGISTRATION

Clinicaltrials.gov Registration NCT02531256 . Retrospectively registered on August 21, 2015.

Pilot manikin study showed that a supraglottic airway device improved simulated neonatal ventilation in a low-resource setting

AIM

We compared the performance of personnel in a low-resource setting when they used the I-gel cuffless neonatal laryngeal mask or a face mask on a neonatal airway management manikin.

METHODS

At Mulago Hospital, Uganda, 25 doctors, nurses and midwives involved in neonatal resuscitation were given brief training with the I-gel and face mask. Then, every participant was observed positioning both devices on three consecutive occasions. The success rate and insertion times leading to effective positive pressure ventilation (PPV) were recorded. Participants rated the perceived efficiency of the devices using a five-point Likert scale.

RESULTS

The I-gel achieved a 100% success rate on all three occasions, but the face mask was significantly less effective in achieving effective PPV and the failure rates at the first, second and third attempts were 28%, 8% and 20%, respectively. The perceived efficiency of the devices was significantly superior for the I-gel (4.7 ± 0.4) than the face mask (3.3 ± 0.8).

CONCLUSION

The I-gel was more effective than the face mask in establishing PPV in the manikin, and user satisfaction was higher. These encouraging manikin data could be a stepping stone for clinical research on the use of the I-gel for neonatal resuscitation in low-resource settings.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence.

RESULTS

The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

Removal of foreign bodies from the respiratory tract of young children: Treatment outcomes using newly developed foreign-body grasping forceps

BACKGROUND

Although a foreign body in the airway of children constitutes a medical emergency, most available therapeutic tools are insufficient, and treatment can be difficult. Herein, we evaluated the outcomes of various treatment methods of foreign body removal from the respiratory tract.

METHODS

We retrospectively analyzed 24 children (13 boys, 11 girls; median age, 18months [range, 9-60months]) treated for airway foreign bodies from January 1994 to December 2013 by examining their preoperative diagnoses and anesthesia and surgical methods.

RESULTS

The foreign body was a peanut, green soybean, almond, chestnut, dental prosthesis, and bead in 15, 3, 3, 1, 1, and 1 cases, respectively. General anesthesia was used in all cases, and flexible bronchoscopy was performed under airway maintenance using a laryngeal mask in 23 cases. The mean operation time was 51±32min. Grasping forceps, basket forceps, and a Fogarty catheter were used in 14, 7, and 2 cases, respectively. In July 2003, 3-pronged foreign-body grasping forceps with a 2.0-mm diameter designed for use with a thin bronchoscope were introduced. Of 16 treated cases, 9 were successfully treated with only forceps. The mean operation time was significantly shortened to 38±24min (range, 7-91min) compared to the traditional operation time of 82±42min (range, 23-147min) (p=0.01).

CONCLUSIONS

These novel forceps are useful for reducing the operation time and are suitable for removing airway foreign bodies from children with a narrow tracheobronchial caliber.

Laparoscopic Nissen fundoplication with Baska Mask® laryngeal mask

Tracheal intubation has historically been considered the ideal technique to handle the airway in laparoscopic surgical procedures. The introduction of such procedures in ambulatory surgery requires the use of anesthetic techniques that offer optimal and early postoperative recovery under strict security conditions. Laryngeal mask is proposed as a suitable alternative to tracheal intubation, even in high risk patients due to new devices which have been modified to improve their characteristics, becoming great alternatives in the overall management of the airway. We report the first case of laparoscopic Nissen fundoplication performed with a laryngeal Baska Mask in patient with high risk of regurgitation due to its gastroesophageal reflux.

Awake intubating laryngeal mask airway placement in a morbidly obese patient with ankylosing spondylitis and unstable thoracic spine

Intubating laryngeal mask airways can be used to provide continuous ventilation throughout intubation. This is a case of a morbidly obese (body mass index = 58) 65-year-old woman with T10 and T11 compression fractures. Optimal positioning for airway management was hindered by her unstable spine, minimal neck range of motion, and extreme pain with any movement. An intubating laryngeal mask airway was placed in the awake, topically anesthetized patient, and the laryngeal mask airway and endotracheal tube combination was left in place throughout surgery.

Comparison of Laryngeal Mask Airway Supreme(TM) Versus Unique(TM) in Edentulous Geriatric Patients

OBJECTIVE

It is more difficult to perform bag-mask ventilation in edentulous patients than in patients with intact dentition. The laryngeal mask airway (LMA) provides a better alternative to the standard face mask if the facial contours of the patient are not suited for the standard face mask. We aimed to compare these two different LMAs in edentulous geriatric patients.

METHODS

Edentulous patients aged ≥65 years of American Society of Anesthesiologists physical status I-III were included in the study. They were randomly assigned to Supreme group (n=30) and Unique group (n=30). Success of first insertion attempt, ease and time of insertion and oropharyngeal leak pressure were recorded.

RESULTS

The success rate of the first insertion attempt was higher in the Supreme group than in the Unique group (86.6 and 73.3%, respectively; p=0.04). Time of insertion was similar (10.04 s and 11.87 s, respectively) and insertion was easy in 90% and 100% of patients, respectively. Oropharyngeal leak pressures were measured as 20.56-cm H2O and 17.10-cm H2O for LMA Supreme™ and LMA Unique™, respectively.

CONCLUSION

The efficacy and safety in both groups were comparable in edentulous geriatric patients during short surgical procedures. Even the success rate of insertion with both was lower than that mentioned in the literature; the success of insertion at the first attempt was superior with the LMA Supreme™ in our edentulous study group.

Challenge to pediatric anatomical variation : Can we draw the ideal line on the pediatric I-gel?

OBJECTIVE

I-gel is a noncuff type of laryngeal airway mask. No horizontal line has yet been determined as an ideal position for pediatric sizes because of the variability in length of the oropharyngeal-laryngeal arch in children. We investigated whether there is a correlation between insertion length and patient body weight or height for the pediatric I-gel sizes from 1.5 to 2.5.

METHODS

With parental informed consent, we planned to maintain the airway of 130 children aged from 7 months to 13 years by using the I-gel device under general anesthesia. The following two parameters were evaluated: (1) distance between the teeth and the connector wing; (2) insertion length (distance from the distal end of the gastric tube to the teeth). Size selection was determined on the basis of patients' body weight. We identified the relationship between each parameter and height or weight.

RESULTS

Average insertion length became gradually longer with increasing height and weight. Spearman's R between insertion length and height or weight was 0.8. There was more correlation with height than with weight in pediatric size 2.5.

CONCLUSION

Results suggested that it is possible to draw an ideal line on the I-gel with sizes 1.5 and 2 only.

Establishing a definitive airway in the trauma patient by novice intubators: A randomised crossover simulation study

BACKGROUND

Establishing a definitive airway, defined as a tube placed in the trachea with cuff inflated below the vocal cords, is standard of care in pre-hospital airway management of the trauma patient. However, in this setting, and using manual in-line stabilisation of the neck, success rate of intubation by inexperience providers is suboptimal. The use of supraglottic airway devices that allow blind tracheal intubation has been suggested as an alternative method by the Advanced Trauma Life Support (ATLS) programme of the American College of Surgeons. We aimed to compare intubation with the standard intubation technique (direct laryngoscopy [DL]) with blind intubation through an intubating-laryngeal mask airway (I-LMA) during manual in-line stabilisation of the neck.

MATERIALS AND METHODS

A randomised, crossover manikin study was performed with 29 emergency medical technicians undergoing training for paramedic status. Outcome measures were success rate in one intubation attempt, duration of intubation, and assessment of ease-of-use.

RESULTS

Study subjects had a higher success rate of tracheal intubation with I-LMA than with DL (27/29 vs. 18/29, p<0.025), and I-LMA was assessed as easier to use (4 vs. 3, p<0.0001). Longer duration of intubation was found with I-LMA compared to DL (54.2 vs. 42.8s, p<0.002). Success rate of correct placement of I-LMA within the airway was 28/29 (96.5%). Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL (26.9 vs. 42.8s, p<0.0001).

CONCLUSIONS

Novice intubators had a higher success rate of intubation with I-LMA than with DL, but duration of intubation was longer with I-LMA. Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL. Findings of this simulation study suggest that in the presence of manual in-line stabilisation of the neck, I-LMA-guided intubation is the preferred technique for novice intubators.

Comparison of Four Different Supraglottic Airway Devices in Terms of Efficacy, Intra-ocular Pressure and Haemodynamic Parameters in Children Undergoing Ophthalmic Surgery

OBJECTIVE

The aim of this study was to compare insertion parameters of four different types of supraglottic airway devices (SGAD) (Classic LMA, I-gel LMA, Proseal LMA, Cobra PLA) in children undergoing ophthalmic surgery and to determine the effect on intra-ocular pressure (IOP) and haemodynamic responses during insertion.

METHODS

Sixty American society of Anesthesiologists (ASA) I-II children aged 1-10 years undergoing extra-ocular ophthalmic surgery were randomly divided into four groups (Group LMA, Group I-gel LMA, Group PLMA and Group CPLA) in this prospective, randomised study. Anaesthesia was induced with decreasing sevoflurane concentrations (8%-2%) in a mixture of 50% N2O-O2. All SGADs were inserted under deep anaesthesia. The characteristics of insertion (number of attempts, ease and time), oropharyngeal leak pressure (OLP) and complications were recorded. IOP in both eyes, heart rate (HR), mean arterial pressure (MAP) and EtCO2 were measured before and 2 and 5 min after insertion of the SGADs.

RESULTS

There was no difference between the groups in terms of the characteristics of insertion. The mean IOP did not increase significantly in all groups. MAP and HR changes were similar among the groups during follow-up. In all groups, HR increased 2 min after insertion (statistically insignificant) and returned to the baseline value 5 min after insertion. A statistically significant correlation was seen between HR increase and IOP values before and after insertion of the SGADs (p=0.006, correlation coefficient=0.352). Desaturation was seen in one patient in Groups LMA, PLMA and CPLA, and laryngospasm was seen in two patients in Group CPLA and in one patient in Group LMA.

CONCLUSION

It was seen that during insertion of Classic LMA, I-gel LMA, Proseal LMA and Cobra PLA, IOP did not increase and haemodynamic stability was maintained in children undergoing extra-ocular ophthalmic surgery.

Efficacy of laryngeal mask airway I-gel for airway management in patients undergoing laparoscopic cholecystectomy

AIM: To evaluate the efficacy of laryngeal mask airway I-gel for airway management in patients who underwent insertion of a nasogastric tube before laparoscopic cholecystectomy.

METHODS: Eighty-seven patients who would undergo laparoscopic surgery were randomly divided into three groups: Ⅰ, Ⅱ and Ⅲ (n = 29 each). Group Ⅰ underwent insertion of a nasogastric tube through the drain tube of laryngeal mask airway I-gel; group Ⅱ underwent insertion of a nasogastric tube through the nostril before surgery, retained the nasogastric tube during surgery, and then underwent insertion of a nasogastric tube not through the drain tube after placing laryngeal mask airway I-gel; group Ⅲ underwent insertion of a nasogastric tube through the nostril before surgery, retained the nasogastric tube during surgery, and then underwent insertion of a nasogastric tube through the drain tube after placing laryngeal mask airway I-gel. The anesthesia time, operative time, recovery time, laryngeal mask airway placement time, success rate of laryngeal mask airway placement at the first attempt, depth of placement, the time to laryngeal mask airway removal, bloodstains, gastroesophageal reflux and adverse reactions within 24 h after surgery were recorded. The fiberoptic laryngoscopy score, airway sealing pressure, and pH values at the tip of laryngeal mask airway and on the dorsal and ventral sides of the body of laryngeal mask airway were assessed after successful laryngeal mask airway placement.

RESULTS: The laryngeal mask airway placement time, depth of placement, success rate of laryngeal mask airway placement at the first attempt, airway sealing pressure, peak airway pressure, the time to laryngeal mask airway removal, and leakage of laryngeal mask airway showed no significant differences among the three groups (P > 0.05). The peak airway pressures in group Ⅰ (25.3 cmH₂O± 4.7 cmH₂Ovs 28.1 cmH₂O± 5.6 cmH₂O), group Ⅱ (24.6 cmH₂O± 3.8 cmH₂Ovs 29.2 cmH₂O± 5.8 cmH₂O), and group Ⅲ (24.3 cmH₂O± 3.1 cmH₂Ovs 30.4 cmH₂O± 6.2 cmH₂O) were significantly lower than airway sealing pressure (P < 0.05). There were no differences in mean arterial pressure, saturation of pulse oximetry or heart rate before and after placing laryngeal mask airway among the three groups (P > 0.05). The scores of fiberoptic laryngoscopy among the three groups did not differ significantly (P > 0.05). The rates of bloodstains, gastroesophageal reflux, pharyngalgia, and hoarseness among the three groups also showed no significant differences (P > 0.05). The pH values at the tip of laryngeal mask airway and on the dorsal and ventral sides of the body of laryngeal mask airway among the three groups also showed no significant differences (P > 0.05).

CONCLUSION: When patients undergo insertion of a nasogastric tube before laparoscopic cholecystectomy, insertion of laryngeal mask airway I-gel is easy, and laryngeal mask airway I-gel can assure a good airway sealing and adequate ventilation. The airway management using laryngeal mask airway I-gel is secure and efficient.

Clinical evaluation of the Baska Mask laryngeal mask in adult patients in ambulatory surgery

OBJECTIVE

To evaluate the clinical performance of the Baska Mask, a new second-generation supraglottic airway device with a self-inflating cuff and two side suction channels for continuous aspiration.

MATERIAL AND METHODS

Eighty adult patients without difficult airways were prospectively included. Ease of insertion and number of attempts needed, quality of ventilation, airway seal pressure, fibreoptic view, ease of gastric access, and complications were assessed. Sizes 3, 4, 5 were analyzed and compared.

RESULTS

First attempt insertion success rate was 88% and the overall rate was 100%, although additional maneuvers were necessary in 44% of the cases. The ventilation was adequate in 96%, with 39% of them requiring adjusting maneuvers. Size 3 needed significantly less adjustments, and achieved a higher seal pressure than sizes 4 and 5 combined. The airway seal pressure was 33 ± 7 cm H2O. Complete or partial vocal cords were visible in 90% of the 66 cases assessed. Partial obstruction, caused by distortion of the cuff-free border, was seen in 5%, and no glottic structures were identified in 5%. Gastric access was easy in all cases. Complications were mild and transient.

CONCLUSIONS

The Baska Mask achieves a high seal pressure, effective ventilation, and a quick access to drain gastric contents. However, additional adjustment maneuvers are frequently required to insert the mask and to optimize ventilation.

Anaesthesia Management During Interventional Bronchoscopic Procedures: Laryngeal Mask Airway or Rigid Bronchoscope

OBJECTIVE

Interventional bronchoscopy procedures are novel and effective modes of diagnosing and treating airway lesions. Airway management and ventilation are a major concern, especially when considering the fire hazard of ventilating during endobronchial thermal therapies. The aim of this study was to evaluate the usage of laryngeal mask airway (LMA) compared to rigid bronchoscopy for the ventilation of patients undergoing diagnostic or therapeutic interventional bronchoscopy procedures.

METHODS

During this prospective randomised clinical trial study, patients were randomly allocated to two groups for ventilation: LMA and rigid bronchoscopy. Vital signs, including blood pressure, heart rate and percentage of blood O2 saturation before and during the procedure, degree of sore throat after recovery and physician's satisfaction, were recorded.

RESULTS

A total of 83 patients, including 45 in the "LMA" and 38 in the "rigid" groups, were enrolled in this study. Their mean age was 51±17 years, and 59 (71%) were male. There was a statically significant difference between "rigid" and "LMA" categories regarding the decrease in O2 during the procedure in proportion to baseline figures (p=0.028). Haemodynamic parameters were better maintained using LMA compared to rigid bronchoscopy.

CONCLUSION

Laryngeal mask ventilation maintains better oxygenation and haemodynamic stability and ensures physicians' and patients' satisfaction regarding ease of use, airway access and fewer complications compared to rigid bronchoscopy. Therefore, LMA can be introduced as a reliable alternative for ventilation during interventional airway procedures.

[About laryngeal mask: is the lowest price material the better cost-efficacy choice?]

OBJECTIVE

The main goal of this study was to achieve a medico-economic comparison between four disposable laryngeal masks (LM) (LMA-Unique™, Ambu AuraOnce™, I-Gel™ and LMA-Suprême™).

STUDY DESIGN

A prospective, randomized, monocentre study.

MATERIAL AND METHODS

In a center, using routinely LMA-Unique masks, scheduled breast surgery patients were allocated into four groups according to the LM model. After the induction, the modalities of use were collected, as well as the intraoperative events that required additional anesthetic equipment. The real cost of each model was calculated (cost of the mask+extra cost related to complications). Using the LMA-Unique as a reference, we performed a cost-efficacy analysis. We realized a cost-efficiency analysis putting in parallel the impact on the cost and the incidence of the events.

RESULTS

A total of 178 patients were included. According to the cost-efficacy analysis, the dominant model was the Ambu AuraOnce™ (Δreal cost: -34.2%, Δevents: -30.6%). The LMA-Unique™ was dominated because of a high morbidity rate. The I-Gel™ and LMA-Suprême™ models were more efficient but more expensive (Δreal cost: +16% and +22.5% respectively). To compensate for additional costs, it would be necessary to apply a price reduction of at least 50%.

CONCLUSIONS

Despite their better efficiency and safety, the latest generation laryngeal masks are still expensive in spite of a low rate of complication. These results do not take into account very rare and severe complications not met in this study in the limited size; then the economic and medical impact can influence the choice beyond the simple analysis cost-efficiency.

[Survey national professional practice on the use of the laryngeal mask]

BACKGROUND

This survey aimed to describe the current use of laryngeal mask (LM) and to define the difference of use according to a group defined like experts.

METHODS

A self-questionnaire available on Internet was sent by e-mail to French anesthesiologists. Results were compared by a Chi(2) test between anesthesiologists according to their expertise defined by a >750 LM use.

RESULTS

Nine hundred and fifty-three anesthesiologists answered to the survey. Only 19 reported never using LM and 37% of responders were defined as expert. More than half of the MAR used the ideal weight to set the size of the MLA to use. Pressure leak was sought by less than one-third of the MAR. In case of leakage, a mobilization of the ML or the patient's head was performed first. In second intention, nearly a quarter of MAR changed technique for the benefit of oral intubation. Only 50% of responders used LM as a rescue technique in case of difficult intubation and ventilation. Experts had less insertion failure and laryngospasm. Complications and medico-legal suites are few.

CONCLUSIONS

Variability of practice may be explained by low-grade recommendations in the literature. LM insertion in case of difficult intubation/ventilation to provide adequate oxygenation and should be formally reminded to clinicians.