Simulation analysis of three intubating supraglottic devices during infant chest compression.

Current guidelines for pediatric cardiopulmonary resuscitation suggest that supraglottic devices are alternatives for tracheal intubation with minimal interruption of chest compression. We examined the utility of three intubating supraglottic devices, air-Q® (air-Q), Ambu® aura-i (aura-i), and i-gel® (i-gel), utilizing manikin simulation. Twenty-two novice physicians performed securing of airway on an infant manikin with the three devices. We measured the rate of success on ventilation and the insertion time with or without chest compression. Successful ventilation rate did not significantly decrease with chest compression in the three devices (without chest compression: air-Q, 21/22; aura-i, 20/22; i-gel, 20/22, during chest compression: air-Q, 20/22; aura-i, 20/22; i-gel, 18/22). The insertion time with air-Q and aura-i did not extend significantly for chest compression. In contrast, the insertion time with i-gel was significantly extended in chest compression (P < 0.05). Air-Q and aura-i are more useful for airway management during chest compression than i-gel.

Comparison of the Miller Laryngoscope and Videolaryngoscope for Tracheal Intubation by Novice Doctors during Neonatal Cardiopulmonary Resuscitation: A Randomized Crossover Simulation Trial.

OBJECTIVE: Recent guidelines for neonatal cardiopulmonary resuscitation emphasize the importance of adequate ventilation. In cases of failed resuscitation with positive pressure ventilation, tracheal intubation and chest compressions are recommended. The present study compared the utility of the Miller laryngoscope (Mil) and the videolaryngoscope Pentax-AWS Airway Scope (AWS; Hoya, Tokyo, Japan) with an infant or neonatal-sized Intlock (AWS-N; Pentax) during chest compressions on a neonatal manikin. STUDY DESIGN: A total of 23 novice doctors performed tracheal intubation on a neonatal manikin using the Mil and AWS-N, with or without chest compressions. RESULTS: In the Mil trials, all participants secured the airway without chest compressions, but nine failed with compressions (p < 0.001). In AWS-N trials, all participants succeeded regardless of whether chest compressions were performed or not. Intubation time was significantly longer with chest compressions with the Mil (p < 0.001), but not with the AWS-N. Laryngoscopy difficulty, as assessed by a visual analog scale (VAS), increased significantly with chest compressions with the Mil, but not with the AWS-N, while the VAS for tube passage through the glottis increased with compressions with the Mil, but not with the AWS-N. CONCLUSION: The AWS-N is an effective device for endotracheal intubation during chest compressions in neonatal simulations performed by novice doctors.

Simulation study of nasotracheal and orotracheal fiberoptic intubation with the Aintree Intubation Catheter.

Aim: Fiber-optic tracheal intubation is an essential technique to secure the airway for difficult airway and cervical cord injury victims. However, there is an anxiety about the vocal cord passage of tracheal tubes because of the potential of collision with the surroundings of the vocal cords. This study aimed to examine the utility of the Aintree Intubation Catheter in nasotracheal and orotracheal intubation. Methods: Participants were 21 anesthesiologists with more than 2 years of experience in clinical anesthesia. Participants attempted fiber-optic tracheal intubation through the oral or nasal cavity with or without the Aintree Intubation Catheter in random order. The success rate of tracheal intubation, intubation time, and collision with the glottis were recorded. Participants also evaluated the subjective difficulty of the entire intubation process and passing the tracheal tube through the glottis using a Visual Analogue Scale. Results: There were no significant differences in intubation time or Visual Analogue Scale scores for passing the tracheal tube through the glottis between nasal and oral intubation, regardless of the use of the Aintree Intubation Catheter. However, the catheter significantly reduced the number of collisions with the glottis in both routes (nasal, P = 0.026; oral, P = 0.017). Conclusion: Our findings that the Aintree Intubation Catheter is effective in reducing collisions with the glottis during nasal and oral fiber-optic intubation suggest that Aintree Intubation Catheter use may reduce the risk of mechanical injury related to airway obstruction.

Comparison of insertion of the modified i-gel airway for oral surgery with the LMA Flexible: a manikin study.

We previously modified the i-gel airway to enable its use in the field of oral and maxillofacial surgery and reported its fabrication methods. In general, the standard i-gel airway is quick to insert and has a high success rate, but the modified i-gel airway has yet to be assessed for these attributes. We, therefore, set out to compare the ease of insertion of the modified i-gel airway with the LMA Flexible to investigate the usefulness of the modified i-gel airway. The study participants, who included 20 new interns with no experience using either the LMA Flexible or the modified i-gel airway, inserted each device 3 times into an intubation practice manikin. The variables measured in this study were insertion time and rate of successful insertions. Mean insertion time over 3 attempts was significantly shorter for the modified i-gel™ airway (18.9 ± 4.7 seconds) than the LMA Flexible (24.9 ± 5.1 seconds, P < .001). The rate of successful insertions as a total of all 3 attempts was significantly higher for the modified i-gel airway (56/60 times, 93.3%) than the LMA Flexible (45/60 times, 75%; P = .012). When used by an inexperienced operator, the modified i-gel™ airway is faster and has a higher success rate than the LMA Flexible, suggesting that it can be easily manipulated during insertion.

Significance of debriefing methods in simulation-based sedation training courses for medical safety improvement in Japan.

Based on the American Society of Anesthesiologists' Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists (ASA-SED), a sedation training course aimed at improving medical safety was developed by the Japanese Association for Medical Simulation in 2011. This study evaluated the effect of debriefing on participants' perceptions of the essential points of the ASA-SED. A total of 38 novice doctors participated in the sedation training course during the research period. Of these doctors, 18 participated in the debriefing group, and 20 participated in non-debriefing group. Scoring of participants' guideline perceptions was conducted using an evaluation sheet (nine items, 16 points) created based on the ASA-SED. The debriefing group showed a greater perception of the ASA-SED, as reflected in the significantly higher scores on the evaluation sheet (median, 16 points) than the control group (median, 13 points; p < 0.05). No significant differences were identified before or during sedation, but the difference after sedation was significant (p < 0.05). Debriefing after sedation training courses may contribute to better perception of the ASA-SED, and may lead to enhanced attitudes toward medical safety during sedation and analgesia.

[Verification of complete blood cell count (CBC) data from heparinized blood gas samples].

Complete blood cell count (CBC) data from heparinized blood gas (H-Gas) samples were verified with primary focus on the platelet count (PLT). When a part of H-Gas sample was taken to a separation tube from the blood collection syringe and CBC of the sample in the separation tube was repeatedly measured (Procedure 1), the PLT from 5 samples relative to that obtained immediately after the separation was gradually reduced to 72.6-94.2% during serial measurements (every 5 minutes, up to 30 minutes). The change in the scattergram pattern suggested that this PLT decrease was due to the formation of platelet clumps. The white blood cell count (WBC), red blood cell count (RBC), hemoglobin (Hb) and hematocrit (Ht) values did not significantly change during the repeated measurements. On the other hand, PLT was significantly improved to 96.8-99.8% when the H-Gas sample was kept in the blood collection syringe so as to minimizing the exposure to the air, and the sample for the measurement from H-Gas was taken every time to separation tube from the syringe, followed by CBC measurement without delay (Procedure 2). In addition, while there were significant variations (CV: 11.8-18.2%) in PLT reproducibility among H-Gas samples by Procedure 1, measurements utilizing the Procedure 2 resulted in much smaller variations (CV: 2.2-3.7%). Thus the CBC data obtained from H-Gas samples were equivalent to those from EDTA samples when the Procedure 2 was applied. These data suggest that H-Gas samples can be used for the accurate CBC measurement, including PLT, by applying the Procedure 2.

[Refinement of the simulation-based sedation training course based on sedation and analgesia guidelines for non-anesthesiologists by American Society of Anesthesiologists].

We report the refinement of the simulation-based sedation training course (SEDTC) hosted by the Japanese Association of Medical Simulation, and the drafting and development of an learning goal and instructor course. In basic airway management training, we highlighted the importance of the "call for help" and oxygen supply. In card-based simulation training sessions, we posted a picture detailing recommended amounts of oxygen and the duration of its use. We set the time of preplanning of sedation strategy in the simulation-training. Twenty-seven SEDTCs were conducted between August 2011 and March 2013 at several locations in Japan. A total of 395 medical staffs affiliated with various medical departments participated in the courses. SEDTCs may serve as a vehicle to improve the safety of sedation and analgesia.

Evaluation of chest compression effect on airway management with air-Q, aura-i, i-gel, and Fastrack intubating supraglottic devices by novice physicians: a randomized crossover simulation study.

PURPOSE: In the 2010 American Heart Association guidelines, supraglottic devices (SGDs) such as the laryngeal mask are proposed as alternatives to tracheal intubation for cardiopulmonary resuscitation. Some SGDs can also serve as a means for tracheal intubation after successful ventilation. The purpose of this study was to evaluate the effect of chest compression on airway management with four intubating SGDs, aura-i (aura-i), air-Q (air-Q), i-gel (i-gel), and Fastrack (Fastrack), during cardiopulmonary resuscitation using a manikin. METHODS: Twenty novice physicians inserted the four intubating SGDs into a manikin with or without chest compression. Insertion time and successful ventilation rate were measured. For cases of successful ventilation, blind tracheal intubation via the intubating SGD was performed with chest compression and success or failure within 30 s was recorded. RESULTS: Chest compression did not decrease the ventilation success rate of the four intubating SGDs (without chest compression (success/total): air-Q, 19/20; aura-i, 19/20; i-gel, 18/20; Fastrack, 19/20; with chest compression: air-Q, 19/20; aura-i, 19/20; i-gel, 16/20; Fastrack, 18/20). Insertion time was significantly lengthened by chest compression in the i-gel trial (P < 0.05), but not with the other three devices. The blind intubation success rate with chest compression was the highest in the air-Q trial (air-Q, 15/19; aura-i, 14/19; i-gel, 12/16; Fastrack, 10/18). CONCLUSIONS: This simulation study revealed the utility of intubating SGDs for airway management during chest compression.

Effects of a simulation-based sedation training course on non-anesthesiologists' attitudes toward sedation and analgesia.

The purpose of this study was to conduct a survey of emergency or complication during sedation and change of attitude toward sedation by simulation-based sedation training course (SEDTC) hosted by the Japanese Association of Medical Simulation. We used a questionnaire survey to non-anesthesiologists who participated in the 1st to 13th SEDTCs from 2011 to 2012. Survey contents included emergencies or complications during sedation and impressions of the Sedation and Analgesia guidelines for non-anesthesia doctors developed by the American Society of Anesthesiologists. Of 84 non-anesthesiologists, 81 have encountered patient respiratory suppression. More than 70% non-anesthesiologists have encountered patient respiratory arrest. All non-anesthesiologists have encountered patient cardiac suppression; 20-30% of non-anesthesiologists have encountered patient anaphylaxis, asthma attack, and cardiac arrest; and all non-anesthesiologists have encountered patient vomiting and about 80% aspiration. Non-anesthesiologists largely accepted the guidelines. SEDTC attendance improved significantly 13 points of 18 important suggestions. As non-anesthesiologists experience several complications during sedation, SEDTC may be useful for the improvement of their attitude toward the safety management of sedation.

Utility of the Aintree Intubation Catheter in fiberoptic tracheal intubation through the three types of intubating supraglottic airways: a manikin simulation study.

PURPOSE: The purpose of this study was to examine the utility of the Aintree Intubation Catheter (AIC) with three types of supraglottic airway devices for tracheal intubation (ISGAs) using a manikin. METHODS: Participants were 21 anesthesiologists with more than 2 years of experience in clinical anesthesia. Three types of ISGAs were passed through the glottis: Fastrack-Single Use (FSU; size 4), air-Q (size 3.5), and i-gel (size 4). Participants attempted fiberoptic tracheal intubation with the ISGAs in random order. Success rate of tracheal intubation, intubation time, and collision with the glottis were recorded. Participants also evaluated the subjective difficulty of the entire intubation process and passing the tracheal tube through the glottis using a Visual Analogue Scale. RESULTS: The FSU required a significantly longer time for intubation compared with the other two ISGAs (p < 0.05). AIC use did not significantly improve the success rate of intubation or shorten intubation times for any of the ISGAs. However, there were significantly more collisions with the glottis without AIC use for the FSU and air-Q compared to when they were used with the AIC (FSU, p = 0.015; air-Q, p = 0.025). CONCLUSION: Among the ISGAs tested, intubation took longer with the FSU, and the FSU had a higher failure rate than the other ISGAs. AIC significantly decreased the number of collisions with the FSU and air-Q. These findings suggest that the AIC is effective in reducing collisions with the tracheal tube and thus will reduce the risk of mechanical injury to the airway.

[Application of air-Q laryngeal airway and gum elastic bougie in a case of anticipated difficult. Mask ventilation and tracheal intubation in a man with morbid obesity].

A 46-year-old man was diagnosed with descending colon cancer and was planned to undergo left hemicolectomy under general anesthesia. His body mass index was 42.6 and due to his small mouth and jaw, we anticipated difficult mask ventilation and tracheal intubation. To avoid 'can't ventilate, can't intubate', we first inserted a size 3.5 air-Q laryngeal airway under moderate sedation, maintaining spontaneous ventilation. After confirming sufficient assisted ventilation, we used a bronchofiberscope to visualize placement of a gum elastic bougie in the trachea via the air-Q. Then, we replaced the air-Q with an outside diameter 8.5 mm tracheal tube. This case was a successful use of the air-Q under moderate sedation for airway management in the setting of anticipated difficult mask ventilation and tracheal intubation.

Utility of the Pentax-AWS Airwayscope and Macintosh laryngoscope for airway management during chest compressions in 27° left-lateral tilt: a manikin simulation study of maternal cardiopulmonary resuscitation.

PURPOSE: American Heart Association (AHA) 2010 cardiopulmonary resuscitation guidelines recommend high-quality chest compressions (minimum interruption, a pace >100 compressions/min, and a depth more than 5 cm). They propose minor changes for pregnant women: manual left deviation of the uterus or a left-lateral incline of 27°-30° to alleviate pressure on the inferior vena cava. We examined the performance of the Pentax-AWS Airwayscope (AWS) and Macintosh laryngoscope (McL) for airway management during chest compressions on a 27° left-lateral tilt (27 LLT) operating table. METHODS: The study included 18 novice doctors in our anesthesia department. They performed tracheal intubation on a manikin positioned on a 27 LLT operating table using the AWS or McL with or without chest compressions. We measured the intubation time and success rate for tracheal intubation. RESULTS: Intubation success rate with the McL decreased with chest compressions compared to without chest compressions (12/18 vs. 18/18, P < 0.05). Intubation time with the McL was lengthened with chest compressions compared to without chest compressions (18.9 ± 4.0 s vs. 11.1 ± 1.0 s, P < 0.05). Intubation success rate was the same for the AWS with and without chest compressions (18/18 in both cases), and intubation time did not increase significantly without compressions compared to with compressions (11.6 ± 1.4 s vs. 12.6 ± 1.2 s, NS). CONCLUSIONS: The AWS is an effective tool for airway management during chest compressions in 27 LLT in a manikin, suggesting that the AWS may be a useful device for airway management during maternal resuscitation.

Comparison of Pentax-AWS Airwayscope, Airtraq and Miller laryngoscope for tracheal intubation by novice doctors during infant cardiopulmonary resuscitation simulation: a randomized crossover trial.

Recent guidelines for infant cardiopulmonary resuscitation emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Pentax-AWS Airway Scope (AWS) with an infant-sized Intlock (AWS-I), Airtraq laryngoscope (ATQ) and Miller laryngoscope during chest compressions on an infant manikin. Twenty-three novice doctors performed tracheal intubation on an infant manikin using the AWS-I, ATQ and Miller laryngoscope, with or without chest compressions. In Miller laryngoscope trials, one participant failed to secure the airway without chest compressions, while nine failed with compressions (P < 0.05). In ATQ trials, none of the participants failed without compressions, while six failed with compressions (P < 0.05). In AWS-I trials, all participants succeeded regardless of chest compressions. Intubation time was significantly longer with chest compressions with the Miller laryngoscope and ATQ, but not with the AWS-I. The AWS-I is an effective device for endotracheal intubation during chest compressions in infant simulations managed by novice doctors.

[A case of awake intubation using the Pentax-AWS airwayscope in a patient with a difficult airway combined with severe hemorrhagic shock].

We report a case of awake intubation in a patient with a difficult airway combined with severe hemorrhagic shock using the Pentax-AWS Airwayscope (AWS). A 65-year-old man experienced severe hemorrhagic shock due to diaphragmatic hernia after extrapleural pneumonectomy and was scheduled for emergent exploratory thoracotomy under general anesthesia. Blood pressure was maintained with dopamine-noradrenaline support, and rapid transfusion. We anticipated difficult ventilation due to a swollen face and tongue. The patient underwent awake intubation with the AWS under dexmedetomidine sedation and lidocaine spray for laryngotracheal anesthesia. The patient did not buck during intubation and hemodynamic changes were minimal.

[Use of the air-Q intubating laryngeal airway for tracheal intubation in predicted difficult airway management in a pediatric patient].

The intubating laryngeal airway, air-Q ILA, was recently introduced in Japan. It has been used in adult patients for difficult airway management; however, there are few reports available on its use in pediatric patients. We report the use of the air-Q ILA in predicted difficult airway management in a 16-month-old patient with Apert syndrome characterized by acrocephalosyndactyly undergoing a syndactyly operation. It was somewhat difficult to keep his airway with a facemask, and an air-Q ILA was inserted. Following the ventilation via air-Q ILA, tracheal intubation guided by a tracheal fiberscope was attempted through the air-Q ILA. Five months after this operation, the patient again underwent the same operation. We managed his airway in the same way as previously, and the tracheal was intubated. This case shows that the air-Q ILA can be an alternative device in pediatric difficult airway management.

[Use of the air-Q laryngeal airway and tube exchanger in a case of difficult tracheal extubation after maxillectomy].

A 79-year-old man was diagnosed with maxillary cancer and underwent total maxillectomy under general anesthesia. The oropharyngeal airway was needed for efficient mask ventilation during anesthesia induction. The maxilla was totally resected and reconstructed with skin from a femoral flap. Tracheal extubation was considered to be difficult given that mask ventilation was contraindicated due to reconstruction of the maxilla. After inserting a tube exchanger (TE) into the trachea, the tracheal tube was exchanged with an air-Q laryngeal airway through the TE. After confirming effective ventilation with the air-Q mask, the patient was awakened from anesthesia. We confirmed sufficient spontaneous breathing and no active bleeding in the pharynx. After re-inserting the TE thorough air-Q, the air-Q was removed, followed by removal of the TE. These findings suggest that the air-Q and TE were effective in a case of difficult extubation after maxillectomy.

Addition of a video camera system improves the ease of Airtraq(®) tracheal intubation during chest compression.

Recent resuscitation guidelines for cardiopulmonary resuscitation emphasize that rescuers should perform tracheal intubation with minimal interruption of chest compressions. We evaluated the use of video guidance to facilitate tracheal intubation with the Airtraq (ATQ) laryngoscope during chest compression. Eighteen novice physicians in our anesthesia department performed tracheal intubation on a manikin using the ATQ with a video camera system (ATQ-V) or with no video guidance (ATQ-N) during chest compression. All participants were able to intubate the manikin using the ATQ-N without chest compression, but five failed during chest compression (P < 0.05). In contrast, all participants successfully secured the airway with the ATQ-V, with or without chest compression. Concurrent chest compression increased the time required for intubation with the ATQ-N (without chest compression 14.8 ± 4.5 s; with chest compression, 28.2 ± 10.6 s; P < 0.05), but not with the ATQ-V (without chest compression, 15.9 ± 5.8 s; with chest compression, 17.3 ± 5.3 s; P > 0.05). The ATQ video camera system improves the ease of tracheal intubation during chest compressions.

Comparison of air-Q(®) and Soft Seal(®) laryngeal mask for airway management by novice doctors during infant chest compression: a manikin study.

BACKGROUND: Recent resuscitation guidelines for infant cardiopulmonary resuscitation (CPR) emphasise that rescuers should minimise the interruption of chest compressions. To that end, supraglottic devices such as laryngeal mask airways (LMAs) are suggested as a backup for airway management during infant CPR. We therefore compared the utility of the air-Q(®) LMA (air-Q) with that of the Soft Seal(®) LMA (Soft Seal) for infant CPR in an infant manikin. METHODS: Twenty-four novice doctors in the anaesthesia department performed insertion and ventilation with air-Q and Soft Seal on an infant manikin with or without chest compression. RESULTS: Two doctors failed to insert the Soft Seal without chest compression, while nine failed during chest compression (P<0.05). However, only one doctor failed to insert the air-Q without chest compression, and two doctors failed during chest compression. Insertion time was not significantly increased with chest compression using either device. Insertion time during chest compression was significantly shorter for the air-Q than for the Soft Seal (P<0.05). The visual analogue scale (VAS) was used to evaluate difficulty of use (0mm (extremely easy) to 100mm (extremely difficult)). VAS scores did not change significantly by the addition of chest compression with either device; however, VAS scores during chest compression were significantly higher with Soft Seal than with the air-Q device. CONCLUSION: We conclude that novice doctors find the air-Q easier to use than Soft Seal for emergency airway management during chest compression in infants, in an infant manikin.