Flexible bronchoscopic intubation through a supraglottic airway device: An evaluation of consultant anaesthetist performance.

BACKGROUND: Few clinical studies investigate technical skill performance in experienced clinicians. METHODS: We undertook a prospective observational study evaluating procedural skill competence in consultant anaesthetists who performed flexible bronchoscopic intubation (FBI) under continuous ventilation through a second-generation supraglottic airway device (SAD). Airway management was recorded on video and performance evaluated independently by three external assessors. We included 100 adult patients undergoing airway management by 25 anaesthetist specialists, each performing four intubations. We used an Objective Structured Assessment of Technical Skills-inspired global rating scale as primary outcome. Further, we assessed the overall pass rate (proportion of cases where the average of assessors' evaluation for every domain scored ≥3); the progression in the global rating scale score; time to intubation; self-reported procedural confidence; and pass rate from the first to the fourth airway procedure. RESULTS: Overall median global rating scale score was 29.7 (interquartile range 26.0-32.7 [range 16.7-37.7]. At least one global rating scale domain was deemed 'not competent' (one or more domains in the evaluation was scored <3) in 30% of cases of airway management, thus the pass rate was 70% (95% CI 60%-78%). After adjusting for multiple testing, we found a statistically significant difference between the first and fourth case of airway management regarding time to intubation (p = .006), but no difference in global rating scale score (p = .018); self-reported confidence before the procedure (p = .014); or pass rate (p = .109). CONCLUSION: Consultant anaesthetists had a median global rating scale score of 29.7 when using a SAD as conduit for FBI. However, despite reporting high procedural confidence, at least one global rating scale domain was deemed 'not competent' in 30% of cases, which indicates a clear potential for improvement of skill competence among professionals.

Minimal alveolar concentration of sevoflurane in combination with remimazolam in adults during laryngeal mask insertion: an up-down sequential allocation study.

BACKGROUND: Remimazolam is a novel ultrashort-acting intravenous benzodiazepine sedative-hypnotic. The combination of remimazolam and sevoflurane does not increase respiratory sensitivity, produce bronchospasm, or cause other adverse conditions. We aimed to observe the effects of different remimazolam doses on the minimum alveolar concentration (MAC) of sevoflurane at end-expiration during laryngeal mask insertion and evaluate the effect of sex on the efficacy of the combination of remimazolam on the suppression of laryngeal mask insertion in adult patients. METHODS: We included 240 patients undergoing laparoscopic surgery under general anesthesia with elective placement of a laryngeal mask (120 males and 120 females). The patients were randomly divided into four groups according to sex: a control group (randomization for female patients, RF0; randomization for male patients, RM0) and three remimazolam groups (RF1, RM1 / RM2, RF2 / RM3, RF3), with 30 patients in each group. Induction was established by vital capacity rapid inhalation induction (VCRII), using 8% sevoflurane and 100% oxygen (6 L/min) in all patients. The (RF1, RM1), (RM2, RF2), and (RM3, RF3) groups were continuously injected with remimazolam at doses of 1, 1.5, and 2.0 mg/kg/h, respectively, while the (RM0, RF0) group was injected with an equal volume of normal saline. The end-expiratory concentration of sevoflurane was adjusted to a preset value after the patient's eyelash reflex disappeared. After the end-expiratory concentration of sevoflurane was kept stable for at least 15 min, the laryngeal mask was placed, and the patient's physical response to the mask placement was observed immediately and within 30 s of placement. The MAC of sevoflurane was measured using the up-and-down sequential method of Dixon. RESULTS: The calculated MAC of end-expiratory sevoflurane during laryngeal mask insertion in adult females was (2.94 ± 0.18)%, (2.69 ± 0.16)%, (2.32 ± 0.16)% and (1.83 ± 0.15)% in groups RF0, RF1, RF2 and RF3; (2.98 ± 0.18)%, (2.80 ± 0.19)%, (2.54 ± 0.15)% and (2.15 ± 0.15)% in male groups RM0, RM1, RM2 and RM3, respectively. The MAC values were significantly lower in the (RF1-RF3, RM1-RM3) group when compared to the (RF0, RM0) group. There was no significant difference between (RF0, RF1) and (RM0, RM1), but the MAC value of the RF2-RF3 group was significantly lower than that of the RM2-RM3 group. CONCLUSIONS: Remimazolam can effectively reduce end-expiratory sevoflurane MAC values during laryngeal mask placement in adults. When remimazolam was measured above 1.5 mg/kg/h, the effect of inhibiting laryngeal mask implantation in female patients was stronger than that in male patients. Remimazolam at a dose of 1-2 mg/kg/h combined with sevoflurane induction can be safely and effectively used in these patients.

Comparison between the standard method and the 30° curved tongue depressor-aided technique for insertion of a laryngeal mask airway: a randomized controlled trial.

BACKGROUND: Laryngeal mask airway (LMA) has been increasingly used for airway management; however, LMA insertion can be difficult and cause adverse effects. Therefore, the rapid, safe, and effective insertion of LMA is necessary. This study aimed to compare the efficacy of the standard method with that of the 30° curved tongue depressor-aided technique for LMA insertion to determine the superior technique. METHODS: This study included 154 patients aged 18-70 years (American Society of Anesthesiologists class I or II) scheduled for general anesthesia. The patients were randomly assigned to the standard LMA insertion group (Group C, n = 77) or the 30° curved tongue depressor-aided LMA insertion group (Group T, n = 77). The primary outcome evaluated was the first-attempt success rate. The secondary outcomes were the second-attempt success rate, insertion time, fiberoptic position grade, oropharyngeal leak pressure (OPLP), and adverse events. RESULTS: The first-attempt success rate was significantly higher in Group T than in Group C (97.40% vs. 88.31%, P = 0.029). The second-attempt success rate (P = 0.209), insertion time (P = 0.340), fiberoptic position grade (P = 0.872), and OPLP (P = 0.203) were slightly improved in Group T; however, there was no statistical significance. Bleeding events were reduced in Group T than in Group C (6.49% vs. 14.29%); however, there was no statistical significance. The incidence of sore throat symptoms was significantly reduced in Group T than in Group C (5.19% vs. 15.58%, P = 0.035). CONCLUSIONS: The curved tongue depressor-aided technique significantly improved the first-attempt success rate of LMA insertion and reduced the incidence of sore throat symptoms. TRIAL REGISTRATION: KCT0004964; Registered at https://cris.nih.go.kr on April 27, 2020.

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

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

Comparison of leak fraction between the laryngeal mask airway and endotracheal tube during anesthesia: a single-center retrospective study.

The use of the laryngeal mask airway (LMA), which offers the benefits of ease in insertion and prevention of tracheal damage, is associated with a risk of flow leakage. This study analyzed our extensive database to compare leakage associated with the use of LMA and endotracheal tube (ETT). Adult patients who underwent chest wall, abdominal wall, inguinal region, limb, transurethral, or transvaginal surgery and received either LMA or ETT between January 2007 and March 2020 were included. The leak fraction was calculated as (inspiratory tidal volume-expiratory tidal volume)/(inspiratory tidal volume) × 100% every minute during intraoperative stable positive pressure ventilation. The median leak fraction was calculated for each case. The leak fraction in the LMA group demonstrated a left-skewed distribution with a larger proportion of excessive leak fraction. The leak fraction in the LMA group (median, 7.9%; interquartile range, 4.8-11.4%) was significantly lower than that in the ETT group (median, 9.1%; interquartile range: 5.5-12.4%; P < 0.001). This tendency was consistent across subgroups divided by sex, age, type of surgery, and ventilation mode. We propose that LMA provides leakage comparable to or less than ETT in most cases if stable positive pressure ventilation is achieved.

Comparison of the Laryngeal Mask Airway ProSeal and the Streamlined Liner of the Pharynx Airway During General Anesthesia: A Systematic Review and Meta-analysis.

PURPOSE: The purpose of this article is to compare the safety of the laryngeal mask airway ProSeal (PLMA) and the streamlined liner of the pharynx airway (SLIPA) during general anesthesia. DESIGN: This study is a systematic review and meta-analysis. METHODS: Two authors performed searches of Embase, Web of Science, and PubMed to identify clinical trials that compared PLMA and SLIPA in patients receiving general anesthesia. Relative risk (RR) with corresponding 95% confidence intervals (CI) were used to pool the dichotomous data. The mean difference (MD) and the associated 95% CI were applied to pool continuous data. RevMan 5.0 software was used for data analysis. FINDINGS: A total of 15 studies with 1263 patients were included. There was no significant difference between PLMA and SLIPA in the rate of insertion success on the first attempt (RR = 1.02, 95% CI [0.95, 1.09], P = .59), airway sealing pressure (MD = 0.75, 95% CI [-0.09, 1.58], P = .08) and the incidence of a sore throat (RR = 0.85, 95% CI [0.7, 1.04], P = .12). The insertion time of PLMA was shorter than SLIPA (MD = 5.24, 95% CI [0.51, 9.98], P = .03), and the incidence of bloodstaining on the device was lower (RR = 0.72, 95% CI [0.55, 0.94], P = .02). CONCLUSIONS: Both devices have a high rate of insertion success on the first attempt and airway sealing pressure. But PLMA has a shorter insertion time and less incidence of blood staining, which is more advantageous than SLIPA.

Comparison of weight-based and pinna size method for ProSeal laryngeal mask airway size selection in children receiving general anesthesia: A randomized clinical study.

Background and Aims: Several methods are in use for LMA ProSeal™ size selection in pediatric patients. Weight-based method is most commonly used. Pinna size-based method is a promising new technique for accurate size selection. Material and Methods: A total of 146 children aged between 6 months and 12 years undergoing surgery under general surgery were included. They were randomized into either pinna-based group (group X) or weight-based group (group Y). Both groups were compared for accurate placement of ProSeal™ laryngeal mask airway (PLMA), ease of insertion, number of attempts needed, and peak airway pressures. Results: A Comparable number of patients had a Brimacombe score of 3 and above, indicating correct placement in both groups (P = 0.407). PLMA was easily inserted in 79.5% and 87.7% of patients of groups X and Y, respectively (P = 0.180). Insertion was found to be difficult in 20.5% of patients in group X, whereas it was difficult in only 12.3% of patients of group Y (P = 0.180). The two groups were comparable as per the number of attempts needed for insertion (P = 0.161). Mean peak airway pressures too were comparable between both groups. Ease of insertion too, was statistically insignificant between both groups. Conclusions: Pinna size-based estimation of LMA size is an effective alternative method to weight-based selection.

Comparative evaluation of insertion characteristics of PLMA using different techniques in the pediatric age group.

Background and Aims: The laryngeal mask airway ProSeal (PLMA) insertion should be easy, fast, and atraumatic. Most studies have been done on adults who cannot be considered as the reflection of pediatric patients. In this study, we compared the first attempt success rate of three techniques of PLMA insertion: introducer, 90° rotation, and pharyngoscopy technique in the pediatric population. Material and Methods: In this prospective comparative randomized study, a total of 135 patients of American Society of Anesthesiology grade I and II, aged three to eleven years, with normal airways scheduled for elective surgery, were randomly allocated into three groups: introducer, 90° rotation, and pharyngoscopy group. Parameters evaluated were: first attempt insertion success rate, insertion time, ease of insertion score, hemodynamic parameters, oropharyngeal seal pressure, manipulations, PLMA blood staining, postoperative sore throat, and hoarseness. Results: First attempt insertion success rate was higher in the 90° rotation (97.78%) and pharyngoscopy (97.78%) group as compared to the introducer group (93.33%). But the result was not statistically significant. PLMA insertion time was the least in the rotation group, followed by the pharyngoscopy and introducer group (P < 0.0001). Mean arterial pressure and heart rate were significantly raised in the pharyngoscopy versus rotation group and the introducer versus 90° rotation group after PLMA insertion. Oropharyngeal seal pressure was significantly higher in the introducer as compared to the rotation group (P = 0.007). Conclusion: All three techniques had a high first-attempt insertion success rate. As the rotation technique had the best result in insertion time and hemodynamic response, it may be considered a good alternative to pharyngoscopy and introducer technique in pediatric patients of age three to eleven years with a normal airway.

Randomized Trial of Surfactant Therapy via Laryngeal Mask Airway Versus Brief Tracheal Intubation in Neonates Born Preterm.

OBJECTIVE: To evaluate the possible noninferiority of surfactant administration via laryngeal mask airway (LMA) vs endotracheal tube (ETT) in avoiding the requirement for mechanical ventilation in preterm neonates with respiratory distress syndrome (RDS). STUDY DESIGN: This was a randomized controlled trial including infants born at 27 to 36 weeks of gestation, >800 g, diagnosed with RDS and receiving fraction of inspired oxygen 0.30-0.60 via noninvasive respiratory support. Infants were randomized to surfactant via LMA (with atropine premedication) or ETT (InSuRE approach with atropine and remifentanil premedication). Primary outcome was failure of surfactant treatment to prevent the need for mechanical ventilation. RESULTS: Patients were randomized, 51 to LMA and 42 to the ETT group. Both groups had similar baseline characteristics, with birth weights ranging from 810 to 3560 g. Failure rate was 29% in the ETT group and 20% in the LMA group (P = .311). This difference was due to early failures (within 1 hour), with 12.5% in the ETT group and 2% in the LMA group (P = .044). Surfactant therapy via LMA was non-inferior to administration via ETT; failure risk difference -9.0% (CI -∞ to 5.7%). Efficacy in decreasing fraction of inspired oxygen, number of surfactant doses administered, time to wean off all respiratory support, rates of adverse events, and outcomes including pneumothorax and BPD diagnosis did not differ between groups. CONCLUSIONS: Surfactant therapy via LMA was noninferior to administration via ETT and it decreased early failures, possibly by avoiding adverse effects of premedication, laryngoscopy, and intubation. These characteristics make LMA a desirable conduit for surfactant administration. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02164734.

The airway and the British Journal of Anaesthesia: 100 years.

Airway-related articles have featured heavily in the British Journal of Anaesthesia since it was founded in 1923. In the 100 years thereafter, 1102 airway-related articles have been published in the journal, written by 2955 unique authors from 55 different countries. In this editorial, we highlight some of the major publications in airway management and their impact on the specialty. Summaries of the most cited articles are contained within online supplementary material as well as links to all airway-related articles for readers who wish to delve deeper into this body of work.

Laryngeal mask airway in neonatal stabilization and transport: a retrospective study.

Laryngeal mask airway (LMA) may be considered by health caregivers of level I-II hospitals for neonatal resuscitation and stabilization before and during interhospital care, but literature provides little information on this aspect. This study reviewed the use of LMA during stabilization and transport in a large series of neonates. This is a retrospective study evaluating the use of LMA in infants who underwent emergency transport by the Eastern Veneto Neonatal Emergency Transport Service between January 2003 and December 2021. All data were obtained from transport registry, transport forms, and hospital charts. In total, 64/3252 transferred neonates (2%) received positive pressure ventilation with an LMA, with increasing trend over time (p = 0.001). Most of these neonates were transferred after birth (97%), due to a respiratory or neurologic disease (95%). LMA was used before the transport (n = 60), during the transport (n = 1), or both (n = 3). No device-related adverse effects were recorded. Sixty-one neonates (95%) survived and were discharged/transferred from the receiving center. CONCLUSION: In a large series of transferred neonates, LMA use during stabilization and transport was rare but increasing over time, and showed some heterogeneity among referring centers. In our series, LMA was safe and lifesaving in "cannot intubate, cannot oxygenate" situations. Future prospective, multicenter research may provide detailed insights on LMA use in neonates needing postnatal transport. WHAT IS KNOWN: • A supraglottic airway device may be used as an alternative to face mask and endotracheal tube during neonatal resuscitation. • The laryngeal mask may be considered by health caregivers of low-level hospitals with limited exposure on airway management, but literature provides little information on this aspect. WHAT IS NEW: • In a large series of transferred neonates, laryngeal mask use was rare but increasing over time, and showed some heterogeneity among referring centers. • The laryngeal mask was safe and lifesaving in "cannot intubate, cannot oxygenate" situations.

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study.

INTRODUCTION: Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS: The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS: Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS: EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

Laryngeal mask airway facilitates a safe and smooth emergence from anesthesia in patients undergoing craniotomy: a prospective randomized controlled study.

BACKGROUND: Endotracheal extubation under deep anesthesia (deep extubation) has been proved to present stable hemodynamics and steady intracranial pressure during emergence from anesthesia in patients undergoing craniotomy. This study aims to examine, in comparison with deep extubation, if a laryngeal mask airway (LMA) could provide a safer and smoother emergence from anesthesia in patients undergoing craniotomy. METHODS: This prospective randomized controlled study was conducted on patients undergoing elective craniotomy for brain tumors. After the complement of the surgical procedure, the patients had anesthesia maintained with end-tidal sevoflurane concentration 2.5% and also fully regained muscle power (Time Zero), they were randomly assigned to ETT Group (n = 29) for deep extubation or to LMA Group (n = 29), where the endotracheal tube was replaced by a laryngeal mask airway. The primary outcomes were respiratory complications, airway interventions and hemodynamic changes through emergence from anesthesia till 30 min following Time Zero. The secondary outcomes were re-operation incidence in 24 h, stay time in the intensive care unit and postoperative hospital days. RESULTS: At 5 min before Time Zero either oxygen partial pressures (PaO2) or carbon dioxide partial pressures (PaCO2) between the two groups were comparable. No significant PaCO2 change was noted in both groups in 5 min after Time Zero, yet there was a remarkably lower PaO2 in ETT Group at that time point, 188.9 (± 71.1) in ETT Group vs 264.4 (± 85.4) in LMA Group. In ETT Group, coughs and snores were considerably more frequent, and thus more interventions were needed to maintain adequate respiration. From Time Zero on, blood pressures (systolic, diastolic and mean) and heart rates in ETT Group were generally higher than those in LMA Group, but the differences were insignificant at all time points except heart rate at 10 min after Time Zero. The secondary outcomes between the two groups were similar. CONCLUSIONS: Compared with deep extubation, a LMA, as a temporary airway replacement, facilitates a safer and smoother emergence from anesthesia for patients undergoing craniotomy, in terms of better oxygen saturation, fewer respiratory complications and fewer airway interventions. TRIAL REGISTRATION: The study was conducted after receiving approval from Institutional Review Board of Chang Gung Memorial Hospital, Linkou Branch, Taiwan (registration number 202102115A3; January 27, 2022), and the clinicaltrials.gov (NCT05253404) on 23 February 2022.

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

BACKGROUND: To compare the effects of laryngeal mask mechanical ventilation and preserved spontaneous breathing on postoperative atelectasis in children undergoing day surgery. METHODS: Children aged 3-7 who underwent elective day surgery were randomly divided into a spontaneous breathing group (n = 23) and a mechanical ventilation group (n = 23). All children enrolled in this trial used the same anesthesia induction protocol, the incidence and severity of atelectasis before induction and after operation were collected. In addition, the baseline data, intraoperative vital signs, ventilator parameters and whether there were complications such as reflux and aspiration were also collected. SPSS was used to calculate whether there was a statistical difference between these indicators. RESULTS: The incidence of atelectasis in the spontaneous breathing group was 91.30%, and 39.13% in the mechanical ventilation group, and the difference was statistically significant (P = 0.001). There was a statistically significant difference in carbon dioxide (P < 0.05), and the severity of postoperative atelectasis in the mechanical ventilation group was lower than that in the spontaneous breathing group (P < 0.05). In addition, there were no significant differences in the vital signs and baseline data of the patients (P > 0.05). CONCLUSION: Laryngeal mask mechanical ventilation can reduce the incidence and severity of postoperative atelectasis in children undergoing day surgery, and we didn't encounter any complications such as reflux and aspiration in children during the perioperative period, so mechanical ventilation was recommended to be used for airway management. TRIAL REGISTRATION: The clinical trial was registered retrospectively at the Chinese Clinical Trial Registry. ( https://www.chictr.org.cn . Registration number ChiCTR2300071396, Weiwei Cai, 15 May 2023).

Airway management for a patient with tracheobronchomegaly undergoing lobectomy: a case report.

BACKGROUND: Tracheobronchomegaly (TBM) is a rare disorder mainly characterized by dilatation and malacia of the trachea and major bronchi with diverticularization. This will be a great challenge for airway management, especially in thoracic surgery requiring one-lung ventilation. Using a laryngeal mask airway and a modified double-lumen Foley catheter (DFC) as a "blocker" may achieve one-lung ventilation. This is the first report introducing this method in a patient with TBM. CASE PRESENTATION: We present a 64-year-old man with TBM receiving left lower lobectomy. Preoperative chest computed tomography demonstrated a prominent tracheobronchial dilation and deformation with multiple diverticularization. The most commonly used double-lumen tube or bronchial blocker could not match the distorted airways. After general anesthesia induction, a 4# laryngeal mask was inserted, through which the modified DFC was positioned in the left main bronchus with the guidance of a fiberoptic bronchoscope. The DFC balloon was inflated with 10 ml air and lung isolation was achieved without any significant air leak during one-lung or two-lung ventilation. However, the collapse of the non-dependent lung was delayed and finally achieved by low-pressure artificial pneumothorax. The surgery was successful and the patient was extubated soon after the surgery. CONCLUSIONS: Using a laryngeal mask airway with a modified double-lumen Foley catheter acted as a bronchial blocker could be an alternative method to achieve lung isolation.

The effect of class 3 obesity on the functionality of supraglottic airway devices: a historical cohort analysis with propensity score matching.

PURPOSE: Supraglottic airway devices (SGAs) have been increasingly used as a primary airway in patients undergoing anesthesia as an alternative to endotracheal tubes. Second-generation devices have expanded their applicability to include uses in patients with obesity. Nevertheless, there is limited evidence of SGA suitability for patients with class 3 obesity (body mass index [BMI] ≥ 40 kg·m-2). As such, we compared rates of SGA functionality between patients with class 3 obesity and patients without class 3 obesity undergoing general anesthesia. METHODS: We performed a propensity score matching analysis using inverse probability of treatment weighting to compare the functionality of SGAs in adult patients with class 3 obesity vs without class 3 obesity. These patients underwent surgery at a hospital in Queensland, Australia from November 2017 to September 2020 and had a SGA inserted as part of their anesthetic care. All data were collected from patients' electronic medical records. We included 321 patients in the cohort with class 3 obesity and 471 in the cohort without class 3 obesity (control/comparison). The estimated effect of class 3 obesity on SGAs was calculated using adjusted odds ratios (AORs) with their 95% confidence intervals (CIs). RESULTS: The overall weighted prevalence of nonfunctional SGAs was 3.2%, with a significantly higher rate in the class 3 obesity cohort compared with the control cohort (4.7% vs 2.1%) (P = 0.04). This adjusted analysis illustrates that class 3 obesity was associated with an almost four times higher odds of a nonfunctional SGA (odds ratio [OR], 2.3; 95% CI, 1.0 to 5.1; AOR, 3.9; 95% CI, 1.4 to 10.6) than patients without class 3 obesity. CONCLUSION: Patients with class 3 obesity (BMI ≥ 40 kg·m-2) had greater than three-fold odds of nonfunctional intraoperative SGAs than patients without class 3 obesity.

RéSUMé: OBJECTIF: Les dispositifs supraglottiques (DSG) sont de plus en plus utilisés comme accès primaire aux voies aériennes en tant qu'alternative aux sondes endotrachéales chez les patient·es bénéficiant d'une anesthésie. Les dispositifs de deuxième génération ont élargi leur applicabilité pour inclure des utilisations chez les personnes souffrant d'obésité. Néanmoins, il existe des données probantes limitées concernant l'adéquation des DSG pour la patientèle souffrant d'obésité de classe 3 (indice de masse corporelle [IMC] ≥ 40 kg·m­2). Pour cette raison, nous avons comparé les taux de fonctionnalité des DSG entre une patientèle souffrant d'obésité de classe 3 et une patientèle sans obésité de classe 3 bénéficiant d'une anesthésie générale. MéTHODE: Nous avons réalisé une analyse d'appariement des scores de propension en utilisant la probabilité inverse de pondération du traitement pour comparer la fonctionnalité des DSG chez la patientèle adulte atteinte d'obésité de classe 3 vs sans obésité de classe 3. Ces patient·es ont bénéficié d'une intervention chirurgicale dans un hôpital du Queensland, en Australie, entre novembre 2017 et septembre 2020, et un DSG a été inséré dans le cadre de leurs soins anesthésiques. Toutes les données ont été recueillies à partir des dossiers médicaux informatisés des patient·es. Nous avons inclus 321 personnes dans la cohorte souffrant d'obésité de classe 3 et 471 dans la cohorte sans obésité de classe 3 (témoin/comparaison). L'effet estimé de l'obésité de classe 3 sur les DSG a été calculé à l'aide de rapports de cotes ajustés (RCA) avec leurs intervalles de confiance (IC) de 95%. RéSULTATS: La prévalence pondérée globale des DSG non fonctionnels était de 3,2 %, avec un taux significativement plus élevé dans la cohorte avec obésité de classe 3 que dans la cohorte témoin (4,7 % vs 2,1 %) (P = 0,04). Cette analyse ajustée illustre que l'obésité de classe 3 était associée à un risque presque quadruplé de non-fonctionnalité du DSG (rapport de cotes [RC], 2,3; IC 95 %, 1,0 à 5,1; RCA, 3,9; IC 95 %, 1,4 à 10,6) que chez des patient·es sans obésité de classe 3. CONCLUSION: Les personnes atteintes d'obésité de classe 3 (IMC ≥ 40 kg·m­2) présentaient plus de trois fois plus de risque de non-fonctionnalité péropératoire de DSG que les personnes sans obésité de classe 3.

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

BACKGROUND: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has received extensive attention for its utility in tubeless anesthesia. Still, the effects of its carbon dioxide accumulation on emergence from anesthesia have not been reported. This randomized controlled trial aimed at exploring the impact of THRIVE combined with laryngeal mask (LM) on the quality of emergence in patients undergoing microlaryngeal surgery. METHODS: After research ethics board approval, 40 eligible patients receiving elective microlaryngeal vocal cord polypectomy were randomly allocated 1:1 to two groups, THRIVE + LM group: intraoperative apneic oxygenation using THRIVE followed by mechanical ventilation through a laryngeal mask in the post-anesthesia care unit (PACU), or MV + ETT group: mechanically ventilated through an endotracheal tube for both intraoperative and post-anesthesia periods. The primary outcome was duration of PACU stay. Other parameters reflecting quality of emergence and carbon dioxide accumulation were also recorded. RESULTS: Duration of PACU stay (22.4 ± 6.4 vs. 28.9 ± 8.8 min, p = 0.011) was shorter in the THRIVE + LM group. The incidence of cough (2/20, 10% vs. 19/20, 95%, P < 0.001) was significantly lower in the THRIVE + LM group. Peripheral arterial oxygen saturation and mean arterial pressure during intraoperative and PACU stay, Quality of Recovery Item 40 total score at one day after surgery and Voice Handicap Index-10 score at seven days after surgery were of no difference between two groups. CONCLUSIONS: The THRIVE + LM strategy could accelerate emergence from anesthesia and reduce the incidence of cough without compromising oxygenation. However, these benefits did not convert to the QoR-40 and VHI-10 scores improvement. TRIAL REGISTRATION: ChiCTR2000038652.

Preliminary evaluation of SaCoVLM video laryngeal mask-guided intubation in airway management for anesthetized children.

BACKGROUNDS: To preliminary evaluate the application of novel SaCoVLM video laryngeal mask -guided intubation for anesthetized children. METHODS: One hundred twenty-four children with microtia (ages 5-15 years,) who required general intubation anaesthesia, were enrolled in the study. After induction of general anesthesia,guided tracheal intubation under direct vision of the SaCoVLM was performed. Our primary outcome was first-pass success rate of guided tracheal tube placement. Secondary outcome included glottic visualization grades, the first-attempt success rate of LMA placement, the time for LMA placement and time to endotracheal intubation as well as the time for LMA removal after successful intubation, the fiberoptic grade of laryngeal view, the baseline and postinduction hemodynamic parameters were also recorded,and the incidence 24 h complications after operation. RESULTS: The first-pass success rate of guided tracheal tube placement was 91.1% (95%CI = 1.04-1.14), the status of glottic visualization was classified: grade 1 in 27cases, grade 2 in 36 cases, grade 3 in 41 cases and grade 4 in 20 cases. The first success rate of LMA placement was 92.7% (95%CI = 1.03-1.13), the time for LMA insertion was 15.7 (±9.1) s, intubation time was 30.9 (±17.6) s and withdrawl time was 24.9 (±9.3) s. The incidence of postoperative sore throat at 2 h was 29%, and 16.1% at 24 h, without dysphagia and hypoxia. CONCLUSION: The SaCoVLM video laryngeal mask-guided intubation is feasible in children, with a high success rate, could be a new promising device to guide intubation in airway management. TRIAL REGISTRATION: This study was approved by the University's Institutional Review Board and written informed consent was obtained from all subjects participating in the trial. The trial was registered prior to patient enrollment at clinicaltrials.gov (ChiCTR2200061481, http://www.chictr.org.cn . Principal investigator: Juan Zhi; Date of registration: 26/06/2022.

A randomized controlled trial comparing three supraglottic airway devices used as a conduit to facilitate tracheal intubation with flexible bronchoscopy.

PURPOSE: Once difficult ventilation and intubation are declared, guidelines suggest the use of a supraglottic airway (SGA) as a rescue device to ventilate and, if oxygenation is restored, subsequently as an intubation conduit. Nevertheless, few trials have formally studied recent SGA devices in patients. Our objective was to compare the efficacy of three second-generation SGA devices as conduits for bronchoscopy-guided endotracheal intubation. METHODS: In this prospective, single-blinded three-arm randomized controlled trial, patients with an American Society of Anesthesiologists Physical Status of I-III undergoing general anesthesia were randomized to bronchoscopy-guided endotracheal intubation using AuraGain™, Air-Q® Blocker, or i-gel® devices. We excluded patients with contraindications to an SGA or drugs and who were pregnant or had a neck, spine, or respiratory anomaly. The primary outcome was intubation time, measured from SGA circuit disconnection to CO2 measurement. Secondary outcomes included ease, time, and success of SGA insertion; success of intubation on first attempt; overall intubation success; number of attempts to intubate; ease of intubation; and ease of SGA removals. RESULTS: One hundred and fifty patients were enrolled from March 2017 to January 2018. Median intubation times were similar across the three groups (Air-Q Blocker, 44 sec; AuraGain, 45 sec; i-gel, 36 sec; P = 0.08). The i-gel was faster to insert (i-gel: 10 sec; Air-Q Blocker, 16 sec; AuraGain, 16 sec; P < 0.001) and easier to insert (Air-Q Blocker vs i-gel, P = 0.001; AuraGain vs i-gel, P = 0.002). Success of SGA insertion, success of intubation, and number of attempts were similar. The Air-Q Blocker was easier to remove than the i-gel (P < 0.001). CONCLUSION: All three second-generation SGA devices performed similarly regarding intubation. Despite minor benefits of the i-gel, clinicians should select their SGA based on clinical experience. STUDY REGISTRATION: ClinicalTrials.gov (NCT02975466); registered on 29 November 2016.

RéSUMé: OBJECTIF: Une fois qu'une ventilation et une intubation difficiles sont déclarées, les lignes directrices préconisent le recours à un dispositif supraglottique comme modalité de sauvetage pour ventiler le patient et, si l'oxygénation est rétablie, être ensuite utilisé comme conduit d'intubation. Toutefois, peu d'études ont formellement analysé l'utilisation des dispositifs supraglottiques récents chez de véritbales patients. Notre objectif était de comparer l'efficacité de trois dispositifs supraglottiques de deuxième génération utilisés comme conduits pour l'intubation endotrachéale guidée par bronchoscopie. MéTHODE: Dans cette étude prospective randomisée contrôlée à trois bras et à simple insu, les patients de statut physique I-III selon l'American Society of Anesthesiologists bénéficiant d'une anesthésie générale ont été randomisés à recevoir une intubation endotrachéale guidée par bronchoscopie via les dispositifs AuraGain™, Air-Q® Blocker ou i-gel®. Nous avons exclu les patients présentant des contre-indications à l'utilisation d'un dispositif supraglottique ou aux médicaments, ainsi que les patientes enceintes et les patients présentant une anomalie au niveau du cou, de la colonne vertébrale ou des voies aériennes. Le critère d'évaluation principal était le temps d'intubation mesuré entre le moment de déconnexion du dispositif supraglottique du circuit et le moment de mesure du CO2. Les critères d'évaluation secondaires comprenaient la facilité, le délai et la réussite de l'insertion du dispositif supraglottique; la réussite de l'intubation à la première tentative; la réussite globale de l'intubation; le nombre de tentatives d'intubation; la facilité d'intubation; et la facilité de retrait du dispositif supraglottique. RéSULTATS: Cent cinquante patients ont été recrutés de mars 2017 à janvier 2018. Les délais d'intubation médians étaient similaires dans les trois groupes (Air-Q Blocker : 44 sec; AuraGain : 45 sec; i-gel : 36 sec; P = 0,08). L'i-gel était plus rapide à insérer (i-gel : 10 sec; Air-Q Blocker : 16 sec; AuraGain : 16 sec; P < 0,001) et plus facile à insérer (Air-Q Blocker vs i-gel : P = 0,001; AuraGain vs i-gel : P = 0,002). La réussite de l'insertion du dispositif supraglottique, la réussite de l'intubation et le nombre de tentatives étaient similaires. L'Air-Q Blocker était plus facile à retirer que l'i-gel (P < 0,001). CONCLUSION: Les trois dispositifs supraglottiques de deuxième génération ont tous affiché une performance similaire en matière d'intubation. Malgré des avantages mineurs de l'i-gel, les cliniciens devraient choisir leur dispositif supraglottique en fonction de leur expérience clinique. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02975466); enregistrée le 29 novembre 2016.

Anesthesia for Nonintubated Video-Assisted Thoracoscopic Surgery.

With the growing adoption of Enhanced Recovery After Surgery protocols across all surgical groups, including thoracic surgery, coupled with improved video-assisted thoracoscopic surgery (VATS) equipment and techniques, nonintubated thoracoscopic surgery has gained significant popularity in recent years. Avoiding tracheal intubation with an endotracheal or double-lumen tube and general anesthesia may reduce or eliminate the risks associated with traditional mechanical ventilation, one-lung ventilation, and general anesthesia. Studies have shown a trend toward better preservation of postoperative respiratory function and improved postoperative lengths of hospital stay, morbidity, and mortality; however, these have not been conclusively proven. This review article discusses the advantages of nonintubated VATS, the types of thoracic surgery in which this technique has been described, patient selection, appropriate anesthetic techniques, surgical concerns, potential complications relevant to the anesthesiologist during the conduct of nonintubated VATS surgery, and suggested management of these complications.