The LMA Classic™ as a conduit for tracheal intubation in adult patients: a review and practical guide

Unexpected difficulty in maintaining an open airway following induction of anaesthesia remains an ever-present hazard. Repetitive attempts at direct laryngoscopy and intubation are generally acknowledged to be inappropriate. The LMA Classic™ is recognised as a rescue ventilation device in failed intubation scenarios and its specific role is well defined in international airway management protocols. Should clinical conditions dictate the need for tracheal intubation following placement of an LMA Classic™, it may be retained to serve as a conduit for intubation. Utilising the LMA Classic™ as a conduit for intubation is considered a rescue manoeuvre, only resorted to when conventional methods such as direct laryngoscopy have failed. Therefore, it is important that this approach to intubation has a high success rate and that airway management specialists are familiar with the different available options, the relevant limitations and the pitfalls. A short description of the components of the LMA Classic™, specifically relating to its function as an intubating conduit, is provided in this review. Its limitations as a conduit are then listed, followed by a description of the most popular techniques of intubation via the LMA Classic™. By adhering to a number of basic principles outlined in this review, limitations may be overcome, pitfalls avoided, and an escape conduit added for the anaesthetist who is faced with a difficult-to-intubate airway.Keywords: laryngeal mask airway; intubation; intubating conduit; bougie; catheter; guidewire; failed intubation; difficult airwa

The LMA Classic™ as a conduit for tracheal intubation in adult patients : a review and practical guide

Unexpected difficulty in maintaining an open airway following induction of anaesthesia remains an ever-present hazard. Repetitive attempts at direct laryngoscopy and intubation are generally acknowledged to be inappropriate. The LMA Classic™ is recognised as a rescue ventilation device in failed intubation scenarios and its specific role is well defined in international airway management protocols. Should clinical conditions dictate the need for tracheal intubation following placement of an LMA Classic™, it may be retained to serve as a conduit for intubation. Utilising the LMA Classic™ as a conduit for intubation is considered a rescue manoeuvre, only resorted to when conventional methods such as direct laryngoscopy have failed. Therefore, it is important that this approach to intubation has a high success rate and that airway management specialists are familiar with the different available options, the relevant limitations and the pitfalls. A short description of the components of the LMA Classic™, specifically relating to its function as an intubating conduit, is provided in this review. Its limitations as a conduit are then listed, followed by a description of the most popular techniques of intubation via the LMA Classic™. By adhering to a number of basic principles outlined in this review, limitations may be overcome, pitfalls avoided, and an escape conduit added for the anaesthetist who is faced with a difficult-to-intubate airway.http://www.sajaa.co.za/index.php/sajaaam201

General questions of anaesthesiology

This book covers information about basic principles and methods of the modern anesthesiology. For English-speaking students of higher educational institutions III-IV levels of accreditation, postgraduates

Management of New Special Devices for Intubation in Difficult Airway Situations

Difficult airway management in critically ill patients has serious implications, as failing to secure a stable airway can lead to a brain injury or even death. Early recognition of a difficult airway can allow the clinician to minimize the potential morbid-mortality. In this chapter, we describe all about the common scenarios that we may tackle when we need to secure a patent airway. It is important to know common definitions about the airway, pre-visualize potential problems and knowing how to be aware of the different pathways on managing and solving the different problems that clinicians may face. It is highlighted to know all the different medical equipment and medication used when an airway is suspected not to be easy to manage or when problems arrive without warning and the practitioner needs to rapidly change the plan on the go. We discuss the current most relevant guidelines and literature about this subject trying to give a practical approach

First clinical experience of tracheal intubation with the SensaScope®, a novel steerable semirigid video stylet

Background. Problems with tracheal intubation are a major cause of anaesthesia-related morbidity and mortality. Difficulty with tracheal intubation is primarily a consequence of failure to see the vocal cords with conventional direct laryngoscopy. We report our experience with use of the SensaScope® for tracheal intubation in routine clinical practice. Methods. The SensaScope® is a hybrid steerable semirigid S-shaped video stylet. Its handling and performance were assessed by anaesthetists with a minimum of 1 yr of experience. They performed four intubations each with the device in anaesthetized elective surgical patients. The view of the glottis with the Macintosh laryngoscope was compared with the view shown on the monitor by the SensaScope®. The time taken to complete intubation, the final tracheal tube (TT) position and the degree of difficulty of the procedure were recorded. Results. Thirty-two patients were studied. All Macintosh Cormack and Lehane grade 3 patients were converted to grade 1 or 2 with the SensaScope®. Mean intubation time was 25 (12) s and correct mid-tracheal TT cuff position was achieved in all cases. The degree of difficulty was 3.0 (1.8) on a numerical scale ranging from 0 to 10. All operators rapidly became familiar with the device and mastered its technique of use. Conclusion. The SensaScope® is a reliable and effective device for tracheal intubation under vision of the normal airway. It has great potential to facilitate management of difficult airway situations in anaesthetized and paralysed patient

Learning curve of fiberoptic bronchoscope-guided tracheal intubation through supraglottic airway device for pediatric airway management: a manikin study

Background Although fiberoptic-guided endotracheal intubation using a supraglottic airway device (SAD) is a good alternative for the management of difficult airways, its learning curve for residents has not been evaluated in pediatric patients. We aimed to train residents using a pediatric manikin and obtain learning curves to evaluate the efficiency of the training. Methods We conducted a single-armed prospective study with anesthesiology residents. Plain endotracheal tube (ETT) intubation guided by a fiberoptic bronchoscope through Ambu® AuraGainTM was demonstrated in a pediatric manikin to the participants before training. The procedure was divided into four steps: SAD insertion, vocal cord identification, carina identification, and ETT insertion into the trachea. The results and elapsed procedure times of each trial were recorded. The learning curves for the participants were constructed and analyzed using the cumulative sum method. Results All the 30 participants acquired proficiency at the end of practice between eight and 25 trials. The overall success rate for the procedure was 92.8%, and above 80% for all participants. Mean ± standard deviation procedure time was 71.3 ± 50.7 s. The 4th step accounted for 86.2% and 48.0% of the total failures and procedure time, respectively. The procedure time rapidly decreased in the 2nd trial; a modest decline was observed thereafter. Conclusions Trainees can obtain proficiency for fiberoptic-guided intubation through SAD within 25 times when using pediatric manikin. Effect of the training on performance in actual clinical situation should be studied

Comparison between Fentanyl and Dexmedetomidine for Awake Fiberoptic Intubation

BACKGROUND: Endotracheal Intubation using a Fiberoptic bronchoscope in the Awake State, if performed without proper sedation, can be an extremely unpleasant and discomforting experience for the patient. At present, various classes of drugs are used. This study aims to test the efficacy and efficiency of Dexmedetomidine and Fentanyl on various parameters for sedation during Awake Fiberoptic Intubation. METHODOLOGY: A total of 60 patients posted for elective surgery undergoing Awake Fiberoptic Intubation were included. A detailed history, physical examination and routine investigations were done for all the patients. IV line was secured with a 18G Cannula. All vital parameters (HR, NIBP, Respiratory Rate, O2 Saturation, and ECG) were being continuously monitored. Baseline heart rate and Mean Arterial pressure readings were taken. Patients were randomly allocated into two groups, i. Group A – Receiving Inj. Dexmedetomidine at a dose of 1ug/kg over 10 min. ii. Group B – Receiving Inj. Fentanyl at a dose of 2ug/kg over 10 min. RESULTS: In analysis, we have observed that both Group A and Group B has comparable demographic characteristics (Age, sex, weight). Further, Ramsay sedation score (P value 0.004 < 0.05), cough score (P value 0.001 < 0.005), post intubation score (P value 0.002 < 0.05) were significantly favourable in Group A than in Group B. Significantly less desaturation were observed in Group A than Group B. Hemodynamic parameters like Heart Rate and Mean Arterial pressure did not show significant variability between baseline and post intubation values in Group A when compared with that of Group B. CONCLUSION: In our study, we have shown that Inj. Dexmedetomidine (1ug/kg over 10 min) is more effective than Inj. Fentanyl (2ug/kg over 10 min) for Awake Fiberoptic Intubation in terms of better sedation, intubating conditions and tolerance to intubation

A prospective randomised study to compare and evaluate macintosh laryngoscope and king vision video laryngoscope for routine intubation in adults scheduled for elective surgery.

The present study compared the King Vision Video Laryngoscope (KVVL) channelled blade with Macintosh laryngoscope (ML) with regard to the laryngoscopic view, laryngoscopic time and time required to complete the tracheal intubation with head in neutral position. We aimed to investigate any disadvantages that the King Vision Video Laryngoscope may have with regard to hemodynamics when used in routine clinical practice. Methods: Eighty patients undergoing elective surgery requiring general anaesthesia and tracheal intubation were randomly allocated to receive tracheal intubation using the King Vision Video Laryngoscope or the Macintosh laryngoscope. Following a standardised general anaesthetic, data were collected during and after laryngoscopy and endotracheal intubation. Results: The mean tracheal intubation time (TTI) for the King Vision Video Laryngoscope and Macintosh laryngoscope respectively were 24.9 and 26.5seconds, (p =0.596). The mean duration of laryngoscopy (DOL) for the King Vision Video Laryngoscope and Macintosh laryngoscope respectively were 46.5 and 46.4 seconds (p = 0.925). Only 37.5% in ML group had Cormack Lehane grade 1 glottic view while all in KVVL had grade 1 glottic view. The xi percentage of patients who did not required optimisation manoeuvres were respectively 72.5% and 27.5% for KVVL and ML. The change in hemodynamic profile was comparable between both groups. Conclusion: King Vision Video Laryngoscope has comparable efficacy related to intubation time, duration of laryngoscopy, success rate and ease of intubation. Although King Vision provided greater percentage of best laryngoscopic view with less requirement of optimising manoeuvres, it provides no added benefit with regard to fluctuation of the hemodynamic response to intubation. Therefore, we conclude that the King Vision Video Laryngoscope may be used in routine clinical practice for tracheal intubation