Airway management in Greece: a nationwide postal survey.

BACKGROUND: The aim of this study was to identify Greek anesthesiologists' difficult airway management practices, as well as the availability of equipment and familiarity with different airway management techniques. METHODS: A questionnaire containing 21 questions was posted to the vast majority of specialist anesthesiologists practicing in Greece (N.=849). Filled copies of the questionnaire were returned anonymously. RESULTS: Response rate was 42% (360/849). Preoperative evaluation was performed by 95% of the respondents, with senior anesthesiologists relying mostly on subjective estimation of the airway. Ninety percent of the respondents had direct access to a difficult airway cart. Laryngeal masks were available in most anesthesia Departments (86%), but expertise was still unsatisfactory, especially in hospitals with a lower workload. Spreading and familiarity with newer airway adjuncts was insufficient, especially in smaller anesthesia Departments. Only 39% of the respondents had a flexible fibrescope readily available. Sixty percent could be considered skilled with laryngeal masks and 11% with fibrescopes. When the occasion for fibrescope use did occur, less senior anesthesiologists opted for laryngeal masks and were clearly less inclined towards surgical intervention. However, for the more senior anesthesiologists surveyed, the application of a face mask with a ''two hands'' technique and more traditional supraglottic airway devices were found to be more common. CONCLUSION: There are shortfalls in various areas of airway management in Greece, in particular with the availability of modern airway devices and training in fibrescopic intubation.

Feasibility of flexible lightwand-guided tracheal intubation with the intubating laryngeal mask during out-of-hospital cardiopulmonary resuscitation by an emergency physician.

BACKGROUND AND OBJECTIVE: We tested the feasibility of using the intubating laryngeal mask airway Fastrach (ILMA) as a ventilatory device and for flexible lightwand-guided tracheal intubation for out-of-hospital cardiopulmonary resuscitation by an emergency physician. METHODS: After completion of a training programme, a single experienced emergency physician used the technique for all patients requiring out-of-hospital tracheal intubation over a 10-month period. If access to the head and neck was limited, the intubating laryngeal mask airway was inserted from below and to the side, otherwise it was inserted from above the head. Data about the time for the ambulance to reach the patient, whether or not access to the head and neck was limited, whether or not circulation was successfully restored, and the insertion and intubation success rates were noted. RESULTS: The mean (range) time for the ambulance to reach the patient was 12 (10-20) min. Access to the head and neck was limited in 8/37 (22%). Circulation was successfully restored in 10/37 (27%). The intubating laryngeal mask airway was successfully inserted at the first attempt in 35/37 (95%) and at the second attempt in 2/37 (5%). The tracheal tube was successfully inserted in 25/37 (67.5%) at the first attempt, 7/37 (19%) at the second attempt and 5/37 (13.5%) at the third attempt. There were no overall failures for intubating laryngeal mask airway insertion or tracheal intubation. There were no differences in success rate between positions. Oesophageal intubation was detected and corrected in 2/37 (5%). CONCLUSION: The intubating laryngeal mask airway has a high success rate as a ventilatory device and as a flexible lightwand-guided airway intubator during out-of-hospital cardiopulmonary resuscitation by a well-trained emergency physician. This technique may be particularly useful when there is limited access to the head and neck.

The intubating laryngeal mask airway Fastrach for emergence after carotid endarterectomy.

We determine the feasibility of using the intubating laryngeal mask airway Fastrach (ILM) as a ventilatory device during emergence from anesthesia after use as an airway intubator in patients undergoing carotid endarterectomy. Thirty-five patients (ASA 2-3, 53-84 yr) were studied. Induction was with midazolam/fentanyl/etomidate and maintenance was with sevoflurane 1-2% in O2 33-50% and N2O. Neuromuscular blockade was with cisatracurium. Tracheal intubation was with a flexible lightwand via the ILM. After successful intubation, the ILM remained in the pharynx, but with the cuff deflated. After surgery, but before anesthesia was discontinued, baseline cardiovascular variables were recorded. The ILM cuff was then reinflated, the tracheal tube removed, the anesthesia breathing system connected to the ILM and anesthesia discontinued. Any changes in the cardiovascular variables greater than +/- 20% baseline values were noted from cuff reinflation to 1 minute after ILM removal. Any adverse respiratory (laryngospasm, coughing, gagging, stridor, SpO2 <94%, end-tidal carbon dioxide >45 mmHg, regurgitation/aspiration) or electrocardiographic (ST segment or rhythm changes) events were also noted. Patients were questioned about postoperative sore throat at 2 and 24 hr. ILM insertion and intubation through the ILM were successful in all patients. Adequate ventilation was achieved in all patients before intubation and after extubation. The mean (range) time taken from cuff reinflation to ILM removal was 9 (5-21) min. The rate pressure product remained within +/- 20% baseline values in all patients. There were no adverse respiratory or electrocardiographic events. There were no adverse neurological events. The surgical field was satisfactory. Postoperative sore throat occurred in 14% at 2 hr and 0% at 24 hr. We conclude that the ILM can be used as a ventilatory device for emergence from anesthesia after use as an airway intubator for carotid endarterectomy.

A comparison of the PAxpress and face mask plus Guedel airway by inexperienced personnel after mannequin-only training.

UNLABELLED: The PAxpress (PAX) is a new extraglottic airway device consisting of an anatomically curved tube, an inflatable circular cuff in the midsection, a noninflatable gilled conical cuff at the distal end, and an anterior-facing, rectangular hooded vent between the two cuffs. We compared the ability of nurses with no previous airway management experience to ventilate the lungs of 45 ASA physical status I and II anesthetized, paralyzed patients using either the PAX or face mask and Guedel airway (FM/GA) after mannequin-only training. Nurses were asked to ventilate the patient to an expired target tidal volume of 7 mL/kg and then to the maximum tidal volume achievable. The FM/GA was used first and the then the PAX. The target tidal volume was achieved in all patients with both devices. There were no differences in the time taken (PAX, 41 +/- 15 s; FM/GA, 39 +/- 25 s) or the number of insertion attempts to achieve the target tidal volume. There were no differences in the frequency of esophageal leaks at the target (PAX, 9%; FM/GA, 4%) and maximum tidal volume (PAX, 51%; FM/GA, 49%). The maximal tidal volume (1261 +/- 306 versus 958 +/- 220 mL; P < 0.0001) and peak airway pressure (37 +/- 5 versus 28 +/- 6 cm H(2)O; P < 0.0001) was larger for the PAX, but blood was detected more frequently (22% versus 0%; P = 0.001). We conclude that ventilation to a target tidal volume of 7 mL/kg in anesthetized, paralyzed adults is equally successful for the PAX and FM/GA by inexperienced nurses after mannequin-only training. However, the maximal tidal volume and peak airway pressure is larger and airway trauma more common with the PAX. IMPLICATIONS: Ventilation to a target tidal volume of 7 mL/kg in anesthetized, paralyzed adults is equally successful for the PAxpress (PAX) and Face Mask/Guedel Airway by inexperienced nurses after mannequin-only training. However, the maximal tidal volume and peak airway pressure is larger and airway trauma more common with the PAX.

Flexible lightwand-guided intubation using the intubating laryngeal mask airway in the supine, right, and left lateral positions in healthy patients by experienced users.

IMPLICATIONS: Flexible lightwand-guided intubation with the intubating laryngeal mask airway is equally effective in the supine, right, and left lateral positions in healthy patients by experienced users.

Blockade of branches of the ophthalmic nerve in the management of acute attack of migraine.

The aim of this study was the evaluation of the blockade of branches of ophthalmic nerve in the management of the acute attack of migraine headache localized to the ocular region. The study included 70 female patients 23-60 years old who presented to the pain clinic at our hospital with an acute attack of migraine headache localized to the ocular and retro-ocular region. A targeted history and a neurologic examination were performed in all patients to confirm the diagnosis and at the same time to rule out life-threatening neurological dysfunction. The method applied was the blockade of the supraorbital and supratrochlear nerves which are branches of the ophthalmic nerve. By the use of a fine short needle 27G the nerves were sought for until paraesthesia is obtained and then 1 ml of lignocaine 2% with adrenaline 1:200,000 was injected in every one of the three sites of the nerves. The migraine acute attack was relieved in 58/70 patients (82%), while in 12/70 patients (18%) the results were poor. The pain relief started 3-4 min after the injection and was completed in 10-15 min. Our results support that the blockade of the branches of the ophthalmic nerve seems to be a safe and effective technique in the management of the acute attack of migraine localized to the ocular and retro-ocular region.

Use of a lighted flexible catheter as a detector for accidental oesophageal intubation through the intubating laryngeal mask: a preliminary study.

We have evaluated the use of a prototype lighted flexible catheter using the transillumination of the light through the soft tissues of the neck, as a detector of the accidental oesophageal intubation during the tracheal intubation through the intubating laryngeal mask. Two hundred patients undergoing general anaesthesia were studied. Accidental oesophageal intubation occurred in 12 patients (6%) during the first intubating attempt and was diagnosed by noting absence of glow on the neck during the tracheal tube advancement and was confirmed by capnography. However, 11/12 (92%) of the above patients were finally intubated successfully, using the lighted flexible catheter. In one patient persistent accidental oesophageal intubation occurred and was classified as failure.

Detection and correction of accidental oesophageal intubation during flexible lightwand-guided intubation via the intubating laryngeal mask.

In the following two-part study, we determined the efficacy of observation of the light glow to detect correct placement of the tracheal tube after lightwand-guided tracheal intubation via the intubating laryngeal mask (ILM). We also determined the efficacy of a protocol to correct oesophageal intubation in this situation. In study 1, 80 ASA 1-3, anaesthetized, paralysed patients were randomly assigned to have a tracheal tube, preloaded with a flexible lightwand, placed into either the trachea (n=40) or oesophagus (n=40) under laryngoscope guidance. A blinded observer experienced with the lightwand technique determined whether oesophageal or tracheal intubation had occurred by observation of the light glow. In study 2, 1,000 patients, 400 of whom were included in a previous study, underwent flexible lightwand-guided intubation via the ILM. Placement of the tracheal tube in oesophagus or trachea was determined by observation of the glow and verified by capnography. Oesophageal intubation was corrected by adjusting the ILM position using a protocol comprising two adjusting manoeuvres. Observation, verification and correction were by experienced anaesthetists conducting the case. In study 1, oesophageal and tracheal intubation was correctly detected in 38/40 (95%) and 37/40 (92.5%) patients respectively. In study 2, oesophageal and tracheal intubation was correctly detected in 55/55 (100%) and 945/945 (100%) patients respectively. In 40/55 (73%) patients, tracheal intubation was successful at the second attempt and in 13/55 (24%) at the third or fourth attempt. In 2/55 (4%) patients, persistent oesophageal intubation occurred. The sensitivity, specificity and positive predictive value were 95%, 92.5% and 92.7% respectively in study 1, and were all 100% in study 2.

Light-guided intubation via the intubating laryngeal mask using a prototype illuminated flexible catheter. Clinical experience in 400 patients.

BACKGROUND: The transillumination of the soft tissues of the neck using lighted stylets has been used as an aid for tracheal intubation. We evaluated the efficacy and safety of a prototype illuminated flexible catheter to facilitate light-guided intubation through the intubating laryngeal mask. METHODS: The illuminated flexible catheter consists of a completely flexible thin plastic catheter with a bulb attached to its distal end. The device was placed into a silicone tracheal tube in such a way that the bulb was adjusted at the distal end of the tracheal tube. The tracheal tube preloaded with the device was inserted through the intubating laryngeal mask and, by observing the glow on the neck, was advanced into the trachea. We report our experience with light-guided intubation through the intubating laryngeal mask in 400 ASA grade 1-3 patients undergoing general anaesthesia. RESULTS: The intubating laryngeal mask was inserted successfully in all patients. The overall intubating success rate was 99.8% (399/400); in 367 (91.8%) cases at the first attempt, in 28 (7%) at the second, in 4 (1%) at the third and in one case (0.2%) at the fifth attempt. There were 27 patients with potentially difficult airways. All these cases were intubated successfully; in 23 of 27 (85.2%) at the first attempt, in 3 of 27 (11.1%) at the second and one of 27 patients (3.7%) at the third attempt. CONCLUSION: We conclude that the use of the illuminated flexible catheter facilitates the intubation through the intubating laryngeal mask. The suggested light-guided intubating method proved to be a simple, safe and effective technique.

Use of the intubating laryngeal mask for airway management and light-guided tracheal intubation in the lateral position.

Sudden accidental loss of the airway during surgery is potentially hazardous especially when the patient is lying in any position which prevents easy intubation of the trachea. We describe two patients lying in the lateral position who required urgent airway management and endotracheal intubation. In both cases endotracheal intubation was achieved successfully using a light-guided technique--with a prototype illuminated flexible catheter--through an intubating laryngeal mask airway.

Use of an illuminated flexible catheter for light-guided tracheal intubation through the intubating laryngeal mask by nurses.

We evaluated the ability of inexperienced personnel in using a prototype illuminated flexible catheter to assist tracheal intubation through the intubating laryngeal mask in anaesthetised, paralysed patients. The device consists of a completely flexible thin plastic catheter, a bulb attached to its distal end and a 15-mm concentric adapter at its proximal end. The illuminated catheter is placed into a straight silicone tracheal tube in such a way that the bulb is placed at the distal end of the tracheal tube. Six nurses inexperienced in tracheal intubation followed a 2-hr training program by using the device through the intubating laryngeal mask in a mannequin and then intubated 10 patients each, with instruction from an anaesthetist. All patients (n=60) were ASA 1-2, scheduled to undergo general anaesthesia for elective surgery. After fentanyl/propofol induction the intubating laryngeal mask was inserted. When an adequate airway was established, patients received atracurium and the endotracheal tube preloaded with the device was inserted through the intubating laryngeal mask and by observing the glow in the neck was advanced into the trachea. The final outcome and the duration of the procedure were recorded. The intubating laryngeal mask was inserted successfully in all patients. The success rate of intubation was 57/60 (95%); 38 patients at first attempt and 19 after two or three attempts. The mean (+/-SD) duration of the procedure in the first five patients in the series of each nurse was 74+/-40 s while in the last five patients it was diminished to 52+/-23 s (P=0.01). We conclude that the described methodology has the potential for more widespread use of tracheal intubation through the intubating laryngeal mask even by inexperienced personnel.

Comparative evaluation of the prolonged use of the cuffed oropharyngeal airway and the laryngeal mask airway in spontaneously breathing anaesthetized patients.

The cuffed oropharyngeal airway (COPA) was compared with the laryngeal mask airway (LMA) with respect to airway quality and respiratory adverse events in 140 spontaneously breathing patients undergoing procedures of duration more than 1 h. Patients were allocated randomly to receive either a COPA (n = 72) or a LMA (n = 68) for airway management during anaesthesia induced with propofol and maintained with sevoflurane, nitrous oxide and oxygen. Groups were similar when comparing the first-time successful insertion rates (COPA: 94.5%, LMA: 95.6%), but airway manipulations (head tilt, chin lift, jaw thrust) were reported more frequently in the COPA group, 27.8% vs. LMA, 4.4%; P = 0.0005. During the post-induction apnoeic period, all patients were ventilated manually and although, mean (SD) leak pressure was lower in the COPA group (18 (4) cm H2O vs. LMA, 22 (3) cm H2O; P < 0.0001), the tidal volumes achieved did not differ in both groups: COPA, 9.5 (4) mL kg-1 vs. LMA, 10.5 (4.5) mL kg-1. The incidences of intra-operative coughing, gagging, laryngospasm, oxygen desaturation and hypercarbia were similar in both groups. Although both devices are equivalent with respect to the overall respiratory problems during spontaneous breathing anaesthesia of intermediate or prolonged duration, the LMA was associated with fewer airway quality problems, suggesting that it is more efficacious in securing the airway.