Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?

Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.

Rapid and complete occlusion of a heat and moisture exchange filter by pulmonary edema (clinical report).

PURPOSE: A case of near fatal obstruction of a breathing system is described, due to occlusion of a heat and moisture exchange filter in a patient with pulmonary edema. Previous reports have described cases of mechanical obstruction to fresh gas flow due to an accumulation of a bolus of fluid within the filter housing. However, in this case, the cause of occlusion was due to the protein and cell debris contained in a small amount of pulmonary edema fluid interacting with the filter membrane. CLINICAL FEATURES: Obstruction occurred rapidly and without warning, and was difficult to differentiate from the more common diagnoses of bronchospasm or tension pneumothorax. Outwardly the filter appeared normal, and routine protocol for emergency management of suspected breathing system obstruction initially failed to identify the site of occlusion. CONCLUSION: Minimal contamination by proteinaceous fluid may cause rapid and complete occlusion of a breathing system filter. Blockage of the breathing system filter and catheter mount should be considered in cases of unexplained breathing system occlusion. The use of a fresh breathing system without a filter for each patient, as recommended by The American Center for Disease Control and the American Society of Anesthesiologists, would have prevented this scenario from occurring.