COMPARISON OF TWO SECOND GENERATION SUPRAGLOTTIC AIRWAY DEVICES I-GEL VERSUS LMA PROSEAL IN PATIENTS UNDERGOING ELECTIVE SURGERIES.

INTRODUCTION:Management of airway is one of the primary responsibilities of anesthesiologist1.Supraglottic airway devices have become a standard fixture in airway management, filling aniche between the face mask and tracheal tube in terms of both anatomical position anddegree of invasiveness. They have separate gastric channel to reduce regurgitation &pulmonary aspiration2.Proseal LMA has unique double cuff arrangement, main cuff is inflated to seal the laryngealopening and additional pharyngeal cuff helps to improve the airway seal which make thePLMA ideal for positive pressure ventilation. ‘I-gel’ is a non-inflatable supraglottic airwaydevice designed to avoid compression trauma.Objectives of the study were Quality of insertion, Complications duringinsertion, Quality of airway sealing, Analysis of hemodynamic parameters, Postoperative complications.METHODS: Total 60 patients were divided in 2 groups: A & B. Airway secured with I-gel& PLMA respectively.Ease of insertion of devices, airway sealing quality score, ease & number of attempts ofgastric tube insertion were noted.RESULTS: I-gel is better than PLMA in term of faster & easy insertion requiring lessmanipulation with low incidence of complications during insertion, less hemodynamic stressresponse and lower postoperative complications.CONCLUSION: Among the second generation supraglottic airway device I-gel is a better &safe alternative to PLMA during elective surgeries

Comparison of the performance of CLASSIC LMA Vs AMBU LMA in minor gynecological surgeries

Background : Supraglottic airway devices are quicker airway control devices even in inexperienced personel. It has better hemodynamic control, less complications and better avoids the disadvantages of the ET insertion. In our study, We compare the performance of CLASSIC LMA and AMBU LMA in minor gynecological procedures. Materials & Methods : In a Prospective randomised case control study, 30 patients in each group were enrolled. size 3 or 4 LMA was used in all adult patients under General anaesthesia without muscle relaxant. Results : AMBU LMA has 90% ease of insertion, 93.3% in first attempt, less time taken for insertion (15 seconds), better hemodynamic control in 5 minutes compared to CLASSIC LMA ( 63%,83.3%,24seconds respectively). Complications like sore throat, blood stain in throat is comparable in both LMA. Conclusion : AMBU LMA has superior performance compared to CLASSIC LMA, and has no significance in view of complications like sore throat.

Comparison of Air-QⓇ insertion techniques in pediatric patients with fiber-optic bronchoscopic assessment: a prospective randomized control trial / 대한마취과학회지

BACKGROUND: Air-QⓇ laryngeal mask airway (LMA) is a second-generation supraglottic airway device (SAD) providing adequate airway control despite the unfavorable airway anatomy in children. Several studies have assessed it as a conduit for tracheal intubation and compared its efficacy with that of other SADs, but there are no studies comparing the laryngeal view with midline and rotational insertion techniques of Air-Q. Therefore, this study compared the fiber-optic bronchoscopic (FOB) assessment of the Air-Q position using these two insertion techniques.METHODS: This randomized controlled trial included 80 patients of the American Society of Anesthesiologists physical status I/II of either sex (age group 5–12 years, weight 10–30 kg), who were scheduled for elective surgery in the supine position under general anesthesia. The patients were randomly subjected to rotational and midline technique groups (n = 40, each), and appropriate sized Air-Q, based on the weight of the patient, was inserted using the technique allocated to each patient. Time taken and number of attempts for successful insertion of the devices and any complications after removal of device were studied.RESULTS: FOB grade 1 (ideal position) was seen in 29/40 (72.5%) and 19/40 (47.5%) children subjected to the rotational and classic midline techniques, respectively (P = 0.045). The time taken to successfully insert the Air-Q was significantly lesser in the rotational technique group (7.2 ± 1.5 s) than in the classic midline technique group (10.2 ± 2.1 s) (P < 0.001), whereas complications were similar in both groups.CONCLUSIONS: The rotational technique was associated with better FOB view, and was faster than the classic midline technique of Air-Q insertion in pediatric patients.

A feasibility study of jaw thrust as an indicator assessing adequate depth of anesthesia for insertion of supraglottic airway device in morbidly obese patients / 中华医学杂志(英文版)

Background@#Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inhalational anesthesia induction. This prospective observational study aimed to determine the feasibility and validity of this test when using as an indicator assessing adequate depth of anesthesia for successful insertion of SAD in spontaneously breathing morbidly obese patients receiving sevoflurane inhalational induction.@*Methods@#Thirty morbidly obese patients with a body mass index 40 to 73 kg/m2 undergoing bariatric surgery in Beijing Friendship Hospital from October 2018 to January 2019 were included in this study. After adequate pre-oxygenation, 5% sevoflurane was inhaled and inhalational concentration of sevoflurane was increased by 1% every 2 min. After motor responses to jaw thrust disappeared, a SAD was inserted and insertion conditions were graded. The anatomic position of SAD was assessed using a fiberoptic bronchoscope.@*Results@#The SAD was successfully inserted at the first attempt in all patients. Insertion conditions of SAD were excellent in nine patients (30%) and good in 21 patients (70%), respectively. The fiberoptic views of SAD position were adequate in 28 patients (93%).@*Conclusions@#Jaw thrust test is a reliable indicator determining adequate anesthesia depth of sevoflurane inhalational induction for successful insertion of SAD in spontaneously breathing morbidly obese patients.@*Clinical trial registration@#ChiCTR1800016868; http://www.chictr.org.cn/showproj.aspx?proj=28646.

Efetividade de técnicas de suporte ventilatório em cenários simulados de emergências e desastres químicos, biológicos, radiológicos e nucleares: metanálise / Effectiveness of ventilatory support techniques in simulated scenarios of chemical, biological, radiological and nuclear emergencies and disasters: meta-analysis

Introdução: certas situações de emergências e desastres são desencadeadas pelo uso acidental ou intencional de agentes químicos, biológicos, radiológicos ou nucleares (QBRN), o que pode resultar em quadros clínicos de insuficiência respiratória às vítimas. Técnicas de suporte ventilatório avançado, tais como inserção de dispositivos supraglóticos e intubação orotraqueal, são fundamentais neste contexto, pois tendem a garantir a sobrevida das vítimas contaminadas por agentes QBRN. Em tais situações recomenda-se, pelo menos, a utilização de equipamento de proteção individual (EPI) nível C, que é composto basicamente por um macacão com gorro impermeável, luvas, botas, proteção ocular e máscara. A efetividade do emprego dessas técncias carece de análise em termos de tempo de execução e de êxito na primeira tentativa, uma vez que possibilidades de ações retardatárias devem ser minoradas na resposta assistencial a situações de emergência e desastres. Objetivo: comparar o tempo médio e o êxito na primeira tentativa de inserção de dispositivos supraglóticos em relação ao tubo orotraqueal, considerando a paramentação de profissionais de saúde com equipamento de proteção individual nível C na resposta assistencial a quadros de insuficiência respirtatória, em situações de emergências e desastres. Metodologia: foram acessadas as bases de dados LILACS, MEDLINE, CINAHL, COCHRANE, SCOPUS, WEB OF SCIENCE e, complementarmente, o Google Acadêmico, no período de 08 de março a 30 de agosto de 2019. A estratégia de busca utilizou a seleção de termos MeSH e estabelecimento de interseções com eles; a pesquisa na lista de artigos relacionados a cada artigo incluído na plataforma PubMed; e a pesquisa manual na lista de referências dos artigos selecionados. A seleção estudos ocorreu por dois pesquisadores independentes (coeficiente Kappa = 0,74). As metanálises foram desenvolvidas no software RevMan 5.3 da Cochrane. Resultados: a Revisão Sistemática (RS) contou com nove estudos para as metanálises. Para o desfecho 'redução de tempo' em cada procedimento, obteve-se o resultado heterogêneo -22,11 [IC 95% : -27,43; -16,79]; (P < 0,00001); I2= 97%, favorecendo os dispositivos supraglóticos. Sequencialmente, subgrupos foram criados os quais mostraram menor ou nenhum grau de heterogeneidade. No subgrupo 'dispositivos supraglóticos de 1a geração', obteve-se o resultado de -28,31 [IC 95% : -37,99; -18,64]; (P < 0,00001); I2= 98%). O subgrupo 'ILMA' resultou em -10,99 [IC 95% : -16,08; -5,90]; (P < 0,00001); I2= 74%. O subgrupo 'dispositivos supraglóticos de 2a geração' gerou o resultado -15,42 [IC 95% : -16,77; -14,06]; (P < 0,00001); I2 = 0%. O subgrupo dos 'emergencistas' resultou em -12,96 [IC 95% : -16,10; -9,82]; (P < 0,00001); I 2= 64%; e subgrupo dos 'anestesistas' apresentou o resultado de - 14,94 [IC 95% : -18,44; -11,45]; (P < 0,00001); I 2= 71%. Nos subgrupos de 'metodologia reprodutível', os estudos de Castle et al (2009 e 2010) tiveram como resultado -39,29 [IC 95% : -41,88; -36,70]; (P < 0,00001); I2 = 12%. No subgrupo 'dispositivos supraglóticos' de Ophir et al (2014) resultou em -15,70 [IC 95% : -17,04; -14,37]; (P < 0,00001); I2 = 0%. No subgrupo 'dispositivos supraglóticos' de Plazikowski et al (2018), obteve-se o resultado - 14,55 [IC 95% : -16,45; -12,64]; (P < 0,00001); I2 = 0%. Concernente ao desfecho 'êxito na primeira tentativa', o resultado foi de 0,06 [IC 95% : 0,03; 0,10]; (P= 0,0008); I2 = 52%. Conclusão: em cenários simulados de emergências e desastres, com risco de contaminação por agentes QBRN, a inserção de dispositivos supraglóticos em comparação à intubação endotraqueal demonstrou ser mais rápida e com maior chance de acerto em manequins, inclusive em seres humanos, com nível de evidência moderado. Registro PROSPERO (CRD42019136139).

Introduction: Certain emergencies are triggered by malicious or accidental use of chemical, biological, radiological or nuclear (CBRN) agents, sometimes resulting in respiratory failure for victims. For example, the action of nerve agents; viral hemorrhagic fever; and acute radiation syndrome. Advanced ventilatory support techniques such as orotracheal intubation and insertion of supraglottic devices are critical in this context. Considering the victim contaminated by a CBRN agent, health providers should wear at least a level C personal protective equipment (PPE), which means a chemical-resistant splash suit, butyl rubber gloves, boots, and a respirator. Objective: To compare the mean time and success in the first attempt at orotracheal tube insertion as well as supraglottic devices, considering health professionals paired with level C personal protective equipment. Methodology: The checked databases were LILACS, MEDLINE, CINAHL, COCHRANE, SCOPUS, WEB OF SCIENCE and, as complementary resource, the Google Scholar, from 08th March to 30th August 2019. The search strategy used the selection of MeSH terms and establishment of intersections with them; searching the list of related articles to each article included, through the PubMed platform; and hand search on the reference list of the selected articles. The selection took place by two independent researchers (Kappa coefficient = 0.74). The meta- analyzes were developed by Cochrane RevMan 5.3 software. Results: the Systematic Review captured nine studies to make meta-analysis. For the outcome mean time in each procedure, the heterogeneous result was obtained -22.11 [95% CI: -27.43; -16.79]; (P <0.00001); I2 = 97%, in favor of supraglottic airway device. Subsequently, subgroups were created to decrease the degree of heterogeneity. In 1st Generation Supraglottic Devices subgroup, the result was -28.31 [95% CI: -37.99; -18.64]; (P <0.00001); I2 = 98%). The ILMA subgroup resulted in -10.99 [95% CI: -16.08; -5.90]; (P <0.00001); I2 = 74%. The 2nd Generation Supraglottic Devices subgroup generated the result -15.42 [95% CI: -16.77; -14.06]; (P <0.00001); I2 = 0%. The emergency caregivers subgroup resulted in -12.96 [95% CI: -16.10; -9.82]; (P <0.00001); I 2 = 64%. The anesthetists' subgroup presented the result of -14.94 [95% CI: -18.44; -11.45]; (P <0.00001); I 2 = 71%. Concern reproducible methodology subgroups, the studies by Castle et al (2009 and 2010) resulted in -39.29 [95% CI: -41.88; -36.70]; (P <0.00001); I2 = 12%. The subgroup supraglottic devices of Ophir et al (2014) resulted in -15.70 [95% CI: -17.04; - 14.37]; (P <0.00001); I2 = 0%. The subgroup supraglottic devices of Plazikowski et al (2018) resulted -14.55 [95% CI: -16.45; -12.64]; (P <0.00001); I2 = 0%. Concerning the outcome success rate in the first attempt, the result was 0.06 [95% CI: 0.03; 0.10]; (P = 0.0008); I2 = 52%. Conclusion: In the context of an environment with risk of CBRN contamination, insertion of a supraglottic device compared to endotracheal intubation was shown to be faster and more likely to obtain success in manikins and humans with moderate level of evidence. Prosperous Registration (CRD42019136139).

Introducción: Ciertas emergencias se desencadenan por el uso intencional o accidental de agentes químicos, biológicos, radiológicos o nucleares (QBRN), que a veces resultan en insuficiencia respiratoria para las víctimas. Se puede citar la acción de los agentes neurotóxicos; fiebre hemorrágica viral; y síndrome de radiación aguda. Las técnicas avanzadas de soporte ventilatorio como la intubación orotraqueal y la inserción de dispositivos supraglóticos son críticas en este contexto. Durante los primeros auxilios de los profesionales de la salud, considerando a la víctima contaminada por un agente QBRN, se recomienda al menos el nivel C de equipo de protección personal (EPP), que consiste en un traje con gorro impermeable, guantes, botas, protección. ocular y máscara. Objetivo:Comparar el tiempo medio y el éxito en el primer intento de inserción del tubo orotraqueal, así como los dispositivos supraglóticos, considerando a los profesionales de la salud emparejados con equipos de protección personal de nivel C. Metodología: Utilizamos las bases de datos LILACS, MEDLINE, CINAHL, COCHRANE, SCOPUS, WEB OF SCIENCE y, además, Google Académica, del 8 de marzo al 30 de agosto de 2019. La estrategia de búsqueda utilizó la selección de términos MeSH y el establecimiento de intersecciones con ellos; buscar en la lista de artículos relacionados con cada artículo incluido en la plataforma PubMed; y búsqueda manual en la lista de referencias de artículos seleccionados. Los estudios de selección fueron realizados por dos investigadores independientes (coeficiente Kappa = 0,74). Los metanálisis se desarrollaron utilizando el software Cochrane RevMan 5.3. Resultados: La Revisión Sistemática capturó nueve estúdios para hacer metanálisis. Para el tiempo de resultado empleado en cada procedimiento, se obtuvo el resultado heterogéneo -22,11 [IC 95%: -27,43; -16,79]; (P <0,00001); I2 = 97%, favoreciendo el dispositivo supraglótico. Posteriormente, se crearon subgrupos donde mostraron menor o ningún grado de heterogeneidad. En el subgrupo de dispositivos supraglóticos de primera generación, el resultado fue -28.31 [95% CI: -37.99; -18.64]; (P <0,00001); I2 = 98%). El subgrupo ILMA resultó en -10.99 [IC 95%: -16.08; -5,90]; (P <0,00001); I2 = 74%. El subgrupo 2 Supr Generation Supraglottic Devices generó el resultado -15.42 [IC 95%: -16.77; -14,06]; (P <0,00001); I2 = 0%. El subgrupo de la sala de emergencias resultó en -12.96 [IC 95%: -16.10; -9,82]; (P <0,00001); I 2 = 64%. El subgrupo de anestesistas presentó el resultado de -14,94 [IC 95%: -18,44; -11,45]; (P <0,00001); I 2 = 71%. En los subgrupos de metodología reproducible, los estudios de Castle et al (2009 y 2010) dieron como resultado -39.29 [IC 95%: -41.88; -36,70]; (P <0,00001); I2 = 12%. En el subgrupo, los dispositivos supraglóticos de Ophir et al (2014) resultaron en -15.70 [IC 95%: -17.04; -14,37]; (P <0,00001); I2 = 0%. En el subgrupo de dispositivos supraglóticos de Plazikowski et al (2018), el resultado fue -14.55 [IC 95%: -16.45; -12,64]; (P <0,00001); I2 = 0%. Con respecto a la tasa de éxito del resultado en el primer intento, el resultado fue 0.06 [IC 95%: 0.03; 0,10]; (P = 0,0008); I2 = 52%. Conclusión: en el contexto de un entorno con riesgo de contaminación QBRN, se demostró que la inserción de un dispositivo supraglótico en comparación con la intubación endotraqueal fue más rápida y más probable que golpee a maniquíes y humanos con un nivel de evidencia moderado. Registro PROSPERO (CRD42019136139).

Comparison of three different insertion techniques with LMA-UniqueTM in adults: results of a randomized trial / Comparação de três técnicas diferentes de inserção com a máscara laríngea LMA-UniqueTM em adultos: resultados de um estudo randômico

Abstract 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-UniqueTM. 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.

Resumo Justificativa A técnica de inserção com a manobra tripla das vias aéreas permitiu a inserção mais rápida da ML. Este estudo comparou três técnicas de inserção da máscara laríngea UniqueTM. Métodos Foram incluídos no estudo 180 pacientes ASA I-II, entre 18-65 anos. Os pacientes foram aleatoriamente designados para grupos de manobra das vias aéreas padrão, rotacional e tripla. No grupo padrão (n = 60), a máscara laríngea (ML) foi inserida com a técnica digital intraoral. No grupo tripla (n = 60), a ML foi inserida com a técnica de manobra tripla das vias aéreas (abertura bucal, extensão da cabeça e elevação da mandíbula). No grupo rotacional (n = 60), a ML foi inserida com a técnica de inserção de trás para frente, como uma cânula de Guedel. Inserção bem-sucedida na primeira tentativa, tempo de inserção bem-sucedida, avaliação por fibra óptica, morbidade das vias aéreas e respostas hemodinâmicas foram avaliados. Resultados O sucesso da inserção na primeira tentativa foi de 88,3% para o grupo padrão, 78,3% para o grupo rotacional e 88,3% para o grupo tripla. A taxa de sucesso global (definida como inserção bem-sucedida na primeira e segunda tentativas) foi de 93% para o grupo padrão, 90% para o grupo rotacional e 95% para o grupo tripla. O tempo de inserção bem-sucedida foi significativamente menor no grupo tripla (média [intervalo] 8,63 [5-19]s), em comparação com o grupo padrão (11,78 [6-24]s) e o grupo rotacional (11,57 [5-31]s). A avaliação por fibra óptica, a morbidade das vias aéreas e as respostas hemodinâmicas foram semelhantes em todos os grupos. Conclusões As técnicas de inserção rotacional e de manobra tripla das vias aéreas são opções aceitáveis. A técnica de manobra tripla das vias aéreas apresenta taxas mais altas de sucesso global e permite um tempo menor de inserção da ML e, portanto, deve ser considerada em situações de emergência.

Laryngeal tube suction for airway management during in-hospital emergencies

OBJECTIVE: The role of supraglottic airway devices in emergency airway management is highlighted in international airway management guidelines. We evaluated the application of the new generation laryngeal tube suction (LTS-II/LTS-D) in the management of in-hospital unexpected difficult airway and cardiopulmonary resuscitation. METHODS: During a seven-year period, patients treated with a laryngeal tube who received routine anesthesia and had an unexpected difficult airway (Cormack Lehane Grade 3-4), who underwent cardiopulmonary resuscitation, or who underwent cardiopulmonary resuscitation outside the operating room and had a difficult airway were evaluated. Successful placement of the LTS II/LTS-D, sufficient ventilation, time to placement, number of placement attempts, stomach content, peripheral oxygen saturation/end-tidal carbon dioxide development (SpO2/etCO2) over 5 minutes, subjective overall assessment and complications were recorded. RESULTS: In total, 106 adult patients were treated using an LTS-II/LTS-D. The main indication for placement was a difficult airway (75%, n=80), followed by cardiopulmonary resuscitation (25%, n=26) or an overlap between both (18%, n=19). In 94% of patients (n=100), users placed the laryngeal tube during the first attempt. In 93% of patients (n=98), the tube was placed within 30 seconds. A significant increase in SpO2 from 97% (0-100) to 99% (5-100) was observed in the whole population and in cardiopulmonary resuscitation patients. The average initial etCO2 of 39.5 mmHg (0-100 mmHg) decreased significantly to an average of 38.4 mmHg (10-62 mmHg) after 5 minutes. A comparison of cardiopulmonary resuscitation patients with non-cardiopulmonary resuscitation patients regarding gastric contents showed no significant difference. CONCLUSIONS: LTS-D/LTS-II use for in-hospital unexpected difficult airway management provides a secure method for primary airway management until other options such as video laryngoscopy or fiber optic intubation become available.

A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation / Uma comparação de vários dispositivos supraglóticos para intubação traqueal guiada por fibra óptica

Abstract Background: Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. Methods: With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p < 0.05). Results: Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. Conclusion: None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical assisted intubation compared to other devices.

Resumo Justificativa: A intubação guiada por fibra óptica (IGFO) através de dispositivo supraglótico (DSG) tem sido descrita como um procedimento seguro e fácil para o manejo de via aérea difícil. No entanto, a visibilização da abertura da glote é essencial para a IGFO. Vários DSGs diferentes estão comercialmente disponíveis e podem oferecer diferentes condições para a IGFO. O objetivo deste estudo foi comparar a melhor visão obtida da abertura da glote com o uso de diferentes DSGs. Métodos: Com a aprovação do Comitê de Ética local, 52 pacientes adultos submetidos à anestesia eletiva foram randomicamente designados para um dos DSGs: tubo laríngeo (TL), máscara laríngea (ML) I-Gel, ML Unique, ML Supreme, ML AuraOnce. Após a indução padronizada da anestesia, o DSG foi colocado de acordo com as recomendações do fabricante. Após ventilação bem-sucedida, a posição do DSG em relação à abertura da glote foi examinada com um endoscópio flexível. Uma abertura da glote total ou parcialmente visível foi considerada como adequada para a IGFO. A adequação para a IGFO foi comparada entre os grupos (teste-H, teste-U; p < 0,05). Resultados: Os dados demográficos não foram diferentes entre os grupos. A colocação do DSG e a ventilação adequada foram bem-sucedidas em todas as tentativas. A visão da glote adequada para a IGFO diferiu entre os dispositivos, variou de 40% para o TL, 66% para a ML Supreme, 70% para a ML I-Gel e 90% para ambas as máscaras laríngeas Unique e AuraOnce. Conclusão: Nenhum dos DSG usados ofereceu uma visão total ou parcial da glote em todos os casos. Porém, as máscaras laríngeas Unique e AuraOnce pareceram mais adequadas para a IGFO em comparação com os outros dispositivos.

Comparison of the i-gelTM and the Laryngeal Mask Airway ClassicTM in terms of clinical performance / Comparação da máscara laríngea i-gel (i-gelTM) com a máscara laríngea clássica (LMA-ClassicTM) em relação ao desempenho clínico

ABSTRACTPURPOSE: The i-gelTM is one of the second generation supraglottic airway devices. Our study was designed to compare the i-gel and the Laryngeal Mask Airway ClassicTM with respect to the clinical performance.METHODS: We compared the performance of the i-gel with that of the Laryngeal Mask Airway Classic in 120 patients undergoing urologic surgery during general anesthesia without muscle relaxant with respect to the number of attempts for successful insertion, insertion time, peak airway pressure, incidence of regurgitation, fiberoptic glottic view and postoperative complications. Second generation supraglottic airway devices were inserted by the same anesthesiologist, experienced in use of both devices (>200 uses and first time failure rate <5%). Methylene blue method was used to detect gastric regurgitation.RESULTS: There was no statistical difference between the two groups regarding the success of insertion of second generation supraglottic airway device (p = 0.951). The laryngeal mask insertion time for the i-gel group was significantly shorter than that for the Laryngeal Mask Airway Classic group (11.6 ± 2.4 s versus 13.1 ± 1.8 s [p = 0.001]). The fiberoptic glottic view scores for the i-gel group was significantly better than that for the ones for the Laryngeal Mask Airway Classic group (p = 0.001). On fiberoptic view, there was no sign of methylene blue dye at any time point in either group. In addition, there was no difference between the groups in patient response regarding the presence of a sore throat when questioned 24 h after the procedure (p = 0.752).CONCLUSION: Both devices had good performance with low postoperative complications and without occurrence of regurgitation. The i-gel provided a shorter insertion time and a better fiberoptic view than the Laryngeal Mask Airway Classic.

RESUMOJUSTIFICATIVA E OBJETIVO: A i-gel é um dos dispositivos supraglóticos de segunda geração para o manejo das vias aéreas. Nosso estudo foi projetado para comparar a i-gelTM e a máscara laríngea clássica (Laryngeal Mask Airway ClassicTM, LMA-C) em relação ao desempenho clínico.MÉTODOS: Avaliamos os desempenhos de i-gel e LMA-C em 120 pacientes submetidos à cirurgia urológica sob anestesia geral sem relaxante muscular. Comparamos o número de tentativas de inserção bem-sucedidas, o tempo de inserção, a pressão de pico das vias aéreas, a incidência de regurgitação, a visibilidade da glote com o uso de fibra óptica e as complicações no pós-operatório. Os dispositivos supraglóticos de segunda geração foram inseridos pelo mesmo anestesiologista com experiência na aplicação de ambos os dispositivos (> 200 aplicações e taxa de falha na primeira tentativa < 5%). O corante azul de metileno foi usado para detectar regurgitação gástrica.RESULTADOS: Não houve diferença estatística entre os dois grupos em relação ao sucesso da inserção do dispositivo supraglótico de segunda geração (p = 0,951). O tempo de inserção da máscara laríngea no grupo i-gel foi significativamente menor do que no grupo LMA-C (11,6 ± 2,4 segundos vs. 13,1 ± 1,8 segundos, p = 0,001). O escore de visibilidade da glote via fibra óptica do grupo i-gel foi significativamente melhor do que o do grupo LMA-C (p = 0,001). Na visão via fibra ótica, sinais do corante azul de metileno não foram observados em qualquer momento em ambos os grupos. Além disso, não houve diferença entre as respostas dos grupos quando perguntados sobre a presença de dor de garganta 24 horas após o procedimento (p = 0,752).CONCLUSÃO: Ambos os dispositivos apresentaram bom desempenho, com poucas complicações no pós-operatório e sem ocorrência de regurgitação. A máscara laríngea i-gel proporcionou um tempo de inserção mais curto e uma visão via fibra óptica melhor do que a LMA-C.

A Comparative Study Evaluating I-gel and Air-Q LMA for Ventilation in Anaesthetised and Paralysed Patients.

Background: The aim of study is to compare I-gel and Air-Q supraglottic airways in terms of - success rate of device insertion, number of attempts taken, haemodynamic parameters before and after device insertion, incidence of trauma and postoperative sore throat, dysphagia. Methods: This randomised single blind study was conducted on 90 patients of age 18-60 years, undergoing elective surgery requiring general anaesthesia. Patients were randomly allocated in two groups- Group I: I-gel (n= 45), Group II: Air-Q (n=45). After preoxygenation, induction and muscle relaxation appropriate size I-gel or Air-Q was inserted and all parameters were noted by an independent observer. For statistical analysis, Student t-test was employed to compare the means and Chi-square test was used for categorical variables. Complications were compared using Fisher’s exact test. Results: The demographic profile of patients in both groups was similar. In all patients supraglottic airway device was inserted within 3 attempts. Mean insertion time in first attempt for I-gel (25.85 ±1.7 sec) was found to be significantly lower than Air-Q (26.73±1.51 sec) [P=0.0128]. Conclusion: We conclude that I-gel is easier and safer than Air- Q when ventilation through LMA is intended during surgery.

Safety and clinical usefulness of supraglottic airway device

Supraglottic airway devices (SADs) are used to keep the upper airway open and provide adequate ventilation and oxygenation. Their use is increasing, and various kinds of SADs have been introduced to routine clinical practice. This review describes the characteristics and illustrates the use of those SADs that have been introduced to and/or are available in Korea. Particular attention is paid to the use of SADs in special clinical settings such as a difficult airway, prehospital care, resuscitation, and intubation. There has been a paradigm shift in the emphasis of difficult airway management from endotracheal intubation to adequate ventilation and oxygenation. SADs have proven to be useful alternatives to tracheal intubation; however, they also have potential disadvantages such as the risk of regurgitation of gastric contents and pulmonary aspiration. Advances in SAD design such as drainage tubes or double cuffs, which lessen the possibility of harmful events and complications, are discussed. The evolution and widespread use of SADs have changed the clinical theory and practice of airway management. Clinicians should be aware of the strengths and limitation of each SAD and understand the limited evidence currently available for guidance.

A clinical evaluation of i-gel(TM) during general anesthesia in children

BACKGROUND: The i-gel(TM) (i-gel) is a new single-use supraglottic airway device with a non-inflatable cuff. This study investigated the safety and efficacy of the i-gel during general anesthesia in children. METHODS: Ninety-eight children at ASA physical status I-II who underwent general anesthesia were included in this prospective observatory study. The size of the i-gel was selected based on patient's body weight. We evaluated success rates, insertion time, airway leak pressure, fiberoptic examination, airway manipulation, airway quality, and postoperative complications. RESULTS: The first-attempt success rate was 96.9% with overall success rate of 98.0%. The insertion time was 15.6 +/- 4.7 seconds. The airway leak pressure was 28.2 +/- 5.9 cmH2O. The maximal peak inspiratory pressure was 15.4 +/- 3.0 cmH2O. On fiberoptic examination, vocal cords were visible in 86.5% of patients. During maintenance of anesthesia, manipulations of i-gel were required for 32 (33.3%) children to maintain airway. Controlled ventilation was possible in all cases, although excess leak transiently occurred in three children. Postoperative complications including blood-staining on device, cough, and sore throat were infrequent. CONCLUSIONS: The i-gel size at 1.5-2.5 provided a satisfactory airway and ventilation during anesthesia in children. However, i-gel required a number of manipulations to maintain patency of airway during general anesthesia.

Use of supraglottic airway devices in children

Supraglottic airway devices (SADs) have become prevalent in children because they avoid many of the adverse effects associated with endotracheal intubation. The laryngeal mask airway (LMA) Classic and the LMA Proseal have proven safe and efficacious for routine cases in pediatric patients. The LMA Proseal provides a better airway seal and protection against aspiration than the LMA Classic in children. Most SADs are designed for airway maintenance during routine anesthesia, but other roles include rescue airway after failed intubation, conduit to facilitate difficult intubation and as an adjunct device for special situations in or outside the hospital (e.g., neonatal resuscitation). Recently developed second-generation SADs, the i-gel and the LMA Supreme may be a suitable alternative for airway management when a single-use device with gastric access is needed in children. The Air-Q intubating laryngeal airway may be feasible as a conduit for tracheal intubation for pediatric patients with a difficult airway. This review article discusses the safety and efficacy of SADs in children.

A comparative study of tracheal intubation through i-gel® and Intubating Laryngeal Mask Airway ( ILMA®).

In this prospective randomized study, success rate of blind tracheal intubation through two different supraglottic airway devices viz. i-gel ® and the intubating laryngeal mask airway (ILMA)® was compared a using conventional polyvinylchloride endotracheal tubes. Eighty patients undergoing elective surgery under general anaesthesia were randomized in two groups comprising of 40 patients each to tracheal intubation using either i-gel or ILMA. After induction of anesthesia, supraglottic airway device(SAD) was inserted and on achieving adequate ventilation with the device, the fibrescopic view of the larynx was obtained through the SAD for laryngeal grading. Then fiberscope was removed and blind tracheal intubation was attempted through the SAD. Success at first attempt and overall tracheal intubation success rates were evaluated and tracheal intubation time was measured.There was no difference in the incidence of adequate ventilation with either of the SAD. The glottic view ( Laryngeal grading ) was better in i-gel group. The grade 1 laryngeal grading was obtained in 82.5% cases in i-gel group as compared to 75% cases in ILMA group. The success rate in first attempt was 65% in i-gel group and 52.55% in ILMA group, while overall success rate was 77.5% in i-gel group as compared to 62.5% in ILMA group. Time taken for successful tracheal intubation through i-gel was lesser (20.4 sec.) as compared to ILMA (30.68 sec.) and the difference was statistically significant (p <0.001). Both the SADs were proved to be useful alternative to conventional laryngoscope for tracheal intubation. In the present study, i-gel had better success rate in tracheal intubation as compared to ILMA.

Comparison between the Use of LMA™ and SLIPA™ in Patients Undergoing Minor Surgeries

Supraglottic airway devices have been used as safe alternatives to endotracheal intubation in appropriate types of surgery. This was a prospective, randomised, single blind study comparing the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and occurrence of adverse effects (e.g. blood stains on the device upon removal and sore throat). A total of 62 ASA I or II patients, aged between 18 to 70 years were recruited for this study. Patients were randomised into two groups; LMA™ and SLIPA™ group. Following induction of anaesthesia, an appropriate sized LMA™ or SLIPA™ was inserted after ensuring adequate depth of anaesthesia. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. The ease of insertion was graded and haemodynamic changes were recorded at 2 minute intervals up to 10 minutes after insertion of the airway devices. The presence of blood stains upon airway device removal at the end of surgery and incidence of sore throat was also recorded. No difficult insertion was experienced in either of these devices. Insertion was either easy [LMA™ 87.1% versus SLIPA™ 80.6% (p = 0.49)] or moderate [LMA™ 12.9% versus SLIPA™ 19.4% (p = 0.16)]. Throughout the study period, the haemodynamic changes that occurred in both groups were not statistically different. Traces of blood were noted on the surface of the device in 9.7% of patients in the SLIPA™ group versus 6.5% of patients in the LMA™ group. The incidence of sore throat was recorded in 12.9% versus 19.4% of patients in the SLIPA™ and the LMA™ groups respectively. These findings were not statistically significant. In conclusion, this study showed no significant differences between the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and adverse effects in patients undergoing minor surgical procedures.

Endotracheal intubation using i-gel and a flexible fiber optic bronchoscope: A case report

Most anesthesiologists, at one point or another, are faced with a difficult airway. We came upon an unexpected difficult airway and a failed intubation using a direct laryngoscope and lightwand. At this point, we decided to insert an i-gel which is quick and simple. This allowed us to maintain oxygenation and ventilation. After checking for the location of the laryngeal inlet with a flexible fiber optic bronchoscope, a 5.5 mm internal diameter endotracheal tube was inserted into the trachea over the flexible fiber optic bronchoscope. Finally, a suitable a 7.0 mm internal diameter endotracheal tube was inserted using an exchange catheter technique. With respect to this case, we conclused that the i-gel is a very helpful device for endotracheal intubation in patients with difficult airways.

The clinical effectiveness of the streamlined liner of pharyngeal airway (SLIPA(TM)) compared with the laryngeal mask airway ProSeal(TM) during general anesthesia / 대한마취과학회지

BACKGROUND: The aim of this study was to compare the streamlined liner of the pharynx airway (SLIPA), a new supraglottic airway device (SGA), with the laryngeal mask airway ProSeal(TM) (PLMA) during general anesthesia. METHODS: Sixty patients were randomly allocated to two groups; a PLMA group (n = 30) or a SLIPA group (n = 30). Ease of use, first insertion success rate, hemodynamic responses to insertion, ventilatory efficiency and positioning confirmed by fiberoptic bronchoscopy were assessed. Lung mechanics data were collected with side stream spirometry at 10 minutes after insertion. We also compared the incidence of blood stain, incidence and severity of postoperative sore throat and other complications. RESULTS: First attempt success rates were 93.3% and 73.3%, and mean insertion time was 7.3 sec and 10.5 sec in PLMA and SLIPA. There was a significant rise in all of hemodynamic response from the pre-insertion value at one minute following insertion of SLIPA. But, insertion of PLMA was no significant rise in hemodynamic response. There was no statistically significant difference in the mean maximum sealing pressure, gas leakage, lung mechanics data, gastric distension, postoperative sore throat and other complication between the two groups. Blood stain were noted on the surface of the device in 40% (n = 12) in the SLIPA vs. 6.7% (n = 2) in the PLMA. CONCLUSIONS: The SLIPA is a useful alternative to the PLMA and have comparable efficacy and complication rates. If we acquire the skill to use, SLIPA may be considered as primary SGA devices during surgery under general anesthesia.

Airway Management

Airway management is still perceived as the greatest patient safety issue and the key task that anesthesiologists perform. Management includes mask ventilation, use of a laryngoscope, and the endotracheal intubation and extubation of the patient. Difficulty can be encountered at any of these stages, and can be a major cause of anesthesia-related morbidity and mortality. Competence in airway management requires knowledge of the anatomy and physiology of the airway, ability to access the patient's airway for the anatomic features that correlate with difficulties in airway management, skill with the many devices used in airway management, including a variety of recently-introduced airway tools, and the appropriate application of the sophisticated algorithm for difficult airway management. Development and clinical distribution of supraglottic airway devices and their enhancement, as well as the broad acceptance of awake fiber-optic intubation, has led to profound changes in the strategy for managing a difficult airway. Including the American Society of Anesthesiologists, many countries have developed their own airway management algorithm these days. Nevertheless, massive national and international deficits still exist in implementing these guidelines into practice as well as the implicated structural requirements with respect to education, reflection, team building and equipment concerning each individual institution. In regard to this situation, it is the recommendation of the author that our country develop and institute such a standardized system of airway management.

Clinical Effectiveness of Laryngeal Mask Airway ProSeal(TM), Laryngeal Tube and PAxpressTM as a Supraglottic Airway / 대한마취과학회지

BACKGROUND: Supraglottic airway devices can be used to maintain stable hemodynamics during intubation, to secure a difficult airway and to administer muscle relaxants at reduced levels for brief operation. We investigated the insertion success rates, hemodynamic stabilities after insertion, intraoperative ventilatory parameters, and postoperative laryngopharyngeal discomforts of three supraglottic airway devices: the ProSealTM laryngeal mask airway (PLMA), the laryngeal tube (LT), and the PAxpressTM (PAX). METHODS: After induction with thiopental 5 mg/kg with fentanyl 1microgram/kg and rocuronuim 0.6 mg/kg as muscle relaxants, manual control ventilation was done with N2O : O2 (1 : 1) and sevoflurane 5-6 vol% for 2 minutes. The supraglottic airway devices were inserted into 94 adult ASA physical status I and II patients. Unblinded observers collected the intraoperative data, and blinded observers collected the postoperative data. RESULTS: The success rates of first-attempts were similar (PLMA: 96.9%, LT: 93.1%, PAX: 96.8%). The time to achieve effective ventilation was shorten for PLMA. Peak inspiratory pressure (PIP) was significant higher for PAX than PLMA. Cuff pressure significantly increased in LT at 60 and 90 minutes after insertion. LT provided the tightest seal for positive ventilation. The incidence of blood-tinged and sore throat was highest for PAX. CONCLUSIONS: These three supraglottic airway devices can be used successfully and effectively without gastric insufflation. We suspected that the incidences of airway complications were proportional to PIP and cuff pressure and that they are dependent upon insertion skill.