Author Archives: AirAdmin

Nasotracheal intubation over a bougie vs. non‐bougie intubation: a prospective randomised, controlled trial in older children and adults using videolaryngoscopy

Posted on by

Nasotracheal intubation over a bougie vs. non‐bougie intubation: a prospective randomised, controlled trial in older children and adults using videolaryngoscopy*

First published: 15 September 2017
https://doi.org/10.1111/anae.14029
Cited by: 4

*Presented in part at the Society for Airway Management Annual Meeting, Atlanta, Georgia, USA, September 2016

*You can respond to this article at http://www.anaesthesiacorrespondence.com

Summary

video: click here.

Conventionally, nasotracheal intubation has consisted of blind nasal passage and external manipulation of the tube through the glottis (‘conventional technique’), a technique associated with a high incidence of nasal trauma. We evaluated a novel technique for routine asleep (i.e. post‐induction) nasotracheal intubation using a bougie (‘bougie technique’), which uses a nasopharyngeal airway to guide a paediatric bougie nasotracheally for use as a Seldinger tracheal intubation guide. Two hundred and fifty‐seven older children (> 8 years) and adults were randomly assigned to videolaryngoscopy‐assisted nasotracheal intubation using either the conventional or the bougie technique. The hypothesis was that the bougie technique would result in less nasopharyngeal trauma. The bougie technique was associated with significantly less nasopharyngeal bleeding than the conventional technique at both 60–90 s (55% vs. 68%; p = 0.033) and 5 min (51% vs. 70%; p = 0.002). The severity of bleeding was also significantly less with the bougie technique, with an OR for active bleeding of 0.42 (95%CI 0.20–0.87; p = 0.020) at 60–90 s and 0.15 (95%CI 0.06–0.37; p < 0.0001) at 5 min. Magill forceps were needed significantly less often with the bougie technique (9% vs. 28%, p = 0.0001) and there was no difference in first attempt and overall success rates between the two techniques (p = 0.133 and p = 0.750, respectively). Not only is nasal intubation over a bougie as successful as the conventional technique, it also significantly decreases both the incidence and severity of nasopharyngeal trauma, as well as the need for the use of Magill forceps.

source: https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14029

 

Should Emergency Physicians Abandon Face-Mask Ventilation?

Posted on by

by Richard M. Levitan, MD, FACEP

Face-mask ventilation is considered a fundamental procedural skill in emergency medicine. We have historically deployed it when patients are apneic, are hypoventilating, or need assistance with oxygenation. We keep bag-mask units at the head of every bed in the emergency department.

The world of airway management has evolved since the self-inflating bag-valve mask (BVM) was first created more than 50 years ago. In elective anesthesia, the laryngeal mask airway (LMA) has entirely replaced face-mask ventilation as a strategy for airway and anesthetic management in cases with a low risk of aspiration. In fact, the laryngeal mask is now used in the majority of elective anesthesia cases worldwide. It also has a rapidly growing presence in the world of prehospital care, especially in the United Kingdom and Europe.

The tip of the laryngeal mask wedges into the upper esophagus, behind the cricoid cartilage. It provides a wedge-shaped “stopper” to the upper esophagus; it’s not quite as effective as a tracheal tube in isolating the trachea from the esophagus but is far better than pushing gas by face mask into the shared upper aero-digestive tract of the pharynx.

LMA-type devices have replaced intubation and mask ventilation in elective anesthesia because they are better for both patients and operators. The laryngeal mask “sits” itself around the curve of the tongue and stays in position. The face mask requires continued downward pressure on the mask to maintain a seal. It can also be augmented by compressive head straps. The laryngeal mask can be easily used to bag a patient with one hand stabilizing the top of the device and the other squeezing the bag. This is not the case with a face mask. Holding the mask against the face works poorly, even with an “E-C grip” (using first and seconds digits [“C”] to hold the nasal bridge of the mask and the third, fourth, and fifth digits [“E”] to hold the lower mask).

Face-mask ventilation is as ergonomically smooth as walking in ski boots. The mask seals by being pushed onto the face, but this motion also pushes the mandible, base of the tongue, and epiglottis downward. And particularly in supine patients with no muscular tone, the base of the tongue, epiglottis, and mandible fall backward, causing “collapse” of the airway. Without continuous active lifting of the angle of the mandible, the airway obstructs. Conversely, the laryngeal mask seal is achieved by the same soft tissues falling backward onto the bowl of the device. It is not the inflation of a cuff that creates a mucosal seal; the newest and best laryngeal masks have, in fact, no cuffs at all. They mirror the laryngeal anatomy.

ILLUSTRATION: Chris Whissen & shutterstock.com

Figure 1 (Left): Pressurization of the nasopharynx in an upright patient causes passive opening of the airway as the soft palate is pushed away from the posterior pharynx.
(Right): Face-mask ventilation in a supine patient causes the oropharynx to be pressurized. As pressure increases, air will enter the esophagus and subsequently the stomach.

The laryngeal mask is, in fact, the only gravity-enhanced ventilation device. Gravity and loss of tone defeat the face mask. Conversely, administration of propofol, which induces a deep loss of upper-airway tone, is far and away the most commonly used medication for laryngeal mask anesthesia. The loss of tone in a supine position is ideal for creating the laryngeal mask seal around the bowl of the device. The soft tissues of the upper airway (base of tongue, epiglottis, and perilaryngeal structures) collapse backward onto the bowl of the LMA as muscular tone about the mandible is abolished.

In addition to the ergonomic challenges of doing effective mask ventilation—trying to create a face seal while pressing against the face but pulling up on the mandible simultaneously—there are many physiologic reasons why mask ventilation in a flat position is bad for oxygenation and also why it has a high risk for regurgitation. As a face mask is squeezed over the mouth, the oropharynx gets pressurized (see Figure 1). The goal is to have air only go into the lungs as opposed to the collapsed esophagus. Unfortunately, as pressure increases, especially at about 20 cmHg, air will enter the esophagus and subsequently the stomach. This insufflation of the stomach then leads to regurgitation of stomach contents back up the esophagus to the perilaryngeal area of the hypopharynx (at the top of the esophagus). Regurgitation risk is dramatically increased by having the patient’s stomach and head on the same level or, in an obese patient, the stomach higher than the mouth when the patient is supine. As the stomach gets insufflated, gravity promotes regurgitation of stomach contents into the upper airway.

The LMA, in contradistinction to a face mask, provides some isolation of the esophagus and larynx. The tip of an LMA-type device wedges into the upper esophagus. It’s not a complete isolation like a cuffed tube in the trachea, but by “corking” the top of the esophagus, there is some protection from gas entering the esophagus. Additionally, the bowl of the LMA is sitting directly under the laryngeal inlet, so the amount of pressure needed to get oxygen into the lungs is less than what is used typically with a face mask, having to start from outside the mouth and flow around the tongue.

In addition to the ergonomic difficulties of face-mask ventilation, problems creating an effective seal, and issues delivering oxygen into the lungs at low pressure, mask ventilation in a supine position has many disadvantages in terms of oxygenation.

In a flat position, the abdominal contents push the diaphragm upward, reducing the functional residual capacity of the lungs. Additionally, the posterior lung segments collapse.

Unlike pressurization of the oropharynx, pressurization of the nasopharynx causes passive opening of the airway as the soft palate is pushed away from the posterior pharynx (see Figure 1). Combining nasal oxygen with pulling on the mandible is an incredibly easy and fast way to open the upper airway. Oxygen shoots from the nasopharynx, down into the upper airway, and into the trachea. In the patient who is upright, the diaphragm drops and the lungs expand. Through the miracle of hemoglobin, oxygen is drawn down the trachea as it gets absorbed across the alveolar capillary membrane even without positive pressure ventilation (apneic oxygenation).

I used to bag patients as my initial response to hypoxemia in the emergency setting. Now, I put Oxygen On, Pull on the mandible, and Sit the patient up (OOPS). I have done this in the setting of oversedation and narcotic overdose, which resulted in complete apnea, and oxygenation improves quickly. I sometimes augment nasal oxygen at the top of the flow meter 15+ liters with a non-rebreather to boost oxygen flow >30 lpm.

In cardiac arrest, I used to bag patients while preparing to intubate. Now, I use passive apneic oxygenation and, if necessary, place an LMA-type device to run the initial portion of the code.

My current use of mask ventilation is only when I want to deliver some positive end-expiratory pressure (PEEP; PEEP valves should be on every BVM). This is generally only used when inducing patients for intubation. I gently ventilate for a couple of breaths when I use muscle relaxants to confirm that I can bag the patient and to expand the alveoli during the onset phase of muscle relaxants. I always do so in a head-elevated position (at least ear-to-sternal notch). I am careful to use low pressure, low volumes, and low rates, except in situations of compensatory respiratory alkalosis. My use of face-mask ventilation in these settings is generally with a nasal cannula, which helps stent the airway open and augment flow. I choose to perform face-mask ventilation in this situation, as opposed to an LMA, because I am worried about the LMA device being inserted too early, which could trigger active vomiting before rapid-sequence intubation medications kick in.

The role of face-mask ventilation in emergency situations is rapidly diminishing. I believe the first response to hypoxia should always be Os up the nose, either a standard nasal cannula combined with a non-rebreather to get flows >30 lpm or special high-flow, warm, humidified nasal cannula systems. Sit the patient upright as much as possible and pull on the mandible. In cardiac arrest, passive oxygenation and an LMA-type device should be used preferentially over bagging a patient in a flat position. If you have to use a face mask to provide PEEP (ie, BVM with a PEEP valve or continuous positive airway pressure mask), always do so in an upright position.

ACEP Now – http://www.acepnow.com/article/emergency-physicians-abandon-face-mask-ventilation/

Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis.

Posted on by

Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis.

Schmidt AR1, Ulrich L2, Seifert B3, Albrecht R4, Spahn DR2, Stein P5,6.

Author information

Source: http://www.ncbi.nlm.nih.gov/pubmed/26944389

Abstract

BACKGROUND:

Pre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child.

METHODS:

Data from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions.

RESULTS:

In primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae.

CONCLUSION:

Difficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.

APS Releases Exhaustive Guidelines for Post-Op Pain – Anesthesiology News

Posted on by

PS Releases Exhaustive Guidelines for Post-Op PainThe American Pain Society (APS) has released comprehensive new guidelines for pain management following surgery. Studies have shown that a majority of patients who undergo surgery report inadequate postoperative pain relief, which could affect their quality of life and increase their risk for postsurgical complications and persistent pain, according to the APS. “The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery,” said Roger Chou, MD, lead author and head of the Oregon Evidence-based Practice Center, in a press release.

The evidence-based guidelines contain 32 recommendations for clinicians and supports the use of a multimodal approach to pain management, which includes a variety of analgesic medications and techniques and non-pharmacologic interventions.
The guidelines were developed by a multidisciplinary expert panel on management of postoperative pain. The guidelines are published in The Journal of Pain (2016;17(2):131-157).

Source: APS Releases Exhaustive Guidelines for Post-Op Pain – Anesthesiology News

Airway Management During Persistent Flooding Of the Oropharyngeal Airway

Posted on by
Airway Management During Persistent Flooding Of the Oropharyngeal Airway
(from: http://www.anesthesiologynews.com/Review-Articles/Article/01-16/Airway-Management-During-Persistent-Flooding-Of-the-Oropharyngeal-Airway/34624?ses=ogst)
image
Jay S. Han, BSc, MSc, MD

Resident, Department of Anesthesiology
University Health Network
University of Toronto
Toronto, Canada
Joseph A. Fisher, MD, FRCP(C)

Staff, Department of Anesthesiology and Pain Management
University Health Network
University of Toronto
Toronto, Canada


The authors reported no relevant financial disclosures.

Endotracheal intubation remains the standard of care when definitive control of the airway is required.1 Unlike intubation in elective anesthesia, patients in an emergency department requiring airway access are assumed to have a full stomach and are therefore at risk for aspiration during intubation.2

In these patients, laryngoscopy itself may cause fluids from the esophagus to flood the pharyngeal cavity.1 Indeed, pulmonary aspiration occurs in 4% to 20% of all emergency intubations.3,4 This is especially a risk in patients with acute epistaxis, gastrointestinal bleeding, or a history of airway trauma.5-7

Aspiration of as little as one fourth of a mouthful (0.4 mL/kg) of stomach contents may cause severe pulmonary injury or even death.8 Moreover, the presence of oropharyngeal fluids in the airway obstructs the view of the vocal cords, resulting in repeated and often unsuccessful attempts at direct visualization of the larynx, interrupted by urgent suctioning of the oropharynx. Attempts at mask ventilation to maintain oxygenation may force fluids and particles into the lung. Standard airway management algorithms deal with this scenario in a cursory manner or not at all.9,10

Defaulting to the emergency establishment of surgical airway through a cricothyroidotomy—a procedure not practiced commonly by many emergency physicians—may also not be a suitable alternative. Even with successful cricothyroidotomy, air leaks from the larynx may prevent adequate lung ventilation. A cricothyroidotomy airway does not protect the lungs from aspiration of blood, airway secretions and stomach contents. There may not be any alternative but to deal with the massive fluid accumulation.

In this manuscript, we present 4 maneuvers to resolve the problem of rapid fluid accumulations in the pharynx obscuring laryngeal visualization. We expect that at least some of these methods are known to many critical care workers, but we suspect that few know them all. Indeed, we did not find them in our review of the published literature and standard textbooks. Our aim is to present the methods together to enlarge the repertoire of front-line health care workers in managing heavy secretion loads during attempts at airway access.

Murphy Eye Suction

The Murphy “eye” is a port at the distal end of an endotracheal tube (ETT) that was historically intended to provide right upper lobe lung ventilation in the case of inadvertent right main bronchus intubation. Although this port is unlikely to provide any benefit for its intended use, it can be used to hold a tracheal suction catheter while an assistant occludes the catheter’s bypass port to provide suction at the tip (Figures 1 and 2). The ETT is then used as a wand to direct the suction ports of the suction catheter. When the larynx is in clear view, the suction tip can be passed through the larynx and act as a guide for the ETT. The tracheal suction catheter can then be withdrawn before the ETT cuff is inflated. Alternatively, when there is good visualization, an assistant can withdraw the suction catheter immediately prior to passing the ETT through the laryngeal opening.

image

Figure 1. Tracheal catheter held by Murphy eye.
image

Figure 2. Use of the ETT as a suction wand.

There are 2 holes in the suction tubing, one proximal to the ETT through which the stylet is passed. The stylet is used for shaping the distal end of the ETT. The second hole can be any distance distal to the ETT and acts like a suction valve. An assistant can occlude this hole when suction is required. The appendix illustrates the construction of this configuration.
ETT, endotracheal tube

ETT as a Suction Wand

Should fluid accumulation exceed the suctioning capacity of the tracheal catheter or contain suspended solid food particles and/or clots, the ETT itself can be turned into a suction wand by attaching its proximal end directly to the suction tubing (Figure 2 and Appendix). Note that there is no suction applied to the lung when the ETT is in the trachea if the proximal hole is not occluded. If tracheal suction is required, it should be performed with a tracheal suction catheter passed down the ETT to avoid atelectasis and lung damage.

image

Appendix. Construction of the ETT as a suction wand.

A) The distal expanded portion of the suction tubing connector is cut off.
B) The tip of the suction tubing is wedged into the ETT connector.
C) Scissors are used to cut a proximal hole in the suction tubing.
D) Scissors are used to cut a distal hole in the suction tubing.
E) The stylet is passed through the distal hole in the suction tubing into the ETT.
F) When suction is required, an assistant occludes the proximal hole in the suction tubing. Once the tip of the ETT is in the larynx, the suction tubing and stylet are removed together and positive pressure ventilation can be provided.
ETT, endotracheal tube

Head-Down Tilt

It may be difficult to decide on optimal patient positioning during laryngoscopy. Head-up tilt may reduce fluid being regurgitated from the stomach. The disadvantage of this position is that fluid coming from the nasopharynx or mouth will pool in the pharynx. Very little accumulation of fluid is required to obstruct the view of the larynx. Furthermore, if the operator is standing at the head of the bed, it is much more difficult to view the larynx during laryngoscopy if the head of the patient’s bed is tilted up.

Consider instead tilting the patient’s head down. Until the nasopharynx is filled with fluid, the air-fluid level will be in the nasopharynx, leaving the larynx exposed, and reducing the risk for aspiration. If there are no contraindications (such as craniofacial trauma11), one can additionally pass a nasopharyngeal airway and attach suction tubing with a hole cut in the distal portion of the tubing to provide continuous drainage (Figure 3). The tip of the nasopharyngeal airway can remain in the nasopharynx during attempts at laryngeal intubation, as it does not obscure the view of the larynx or obstruct the advancement of the ETT. Continuous suction at the level of the pharynx may allow continued visualization of the larynx with less head-down tilt.

image

Figure 3. Head-down tilt.

This results in oropharyngeal fluid flowing into the nasopharynx, which acts like a fluid reservoir keeping the oropharynx unobscured by fluid.

The “Blind” Advance

The fourth strategy is most suitable if the source of the fluid is the gastrointestinal tract, especially in the presence of a large amount of particulate material in the pharynx. In this case, the ETT is advanced blindly and the cuff is inflated (Figure 4). A suction catheter is then passed down the ETT and aspirated. If air is aspirated (confirming that the ETT is in the trachea), then after suitable airway toilet, the patient may be ventilated by applying positive pressure to the self-inflating bag. If gastric fluid is aspirated, or if the catheter tip becomes occluded (indicating that the esophagus has collapsed around the suction catheter openings), then:

  • a piece of tape is placed over the ETT connector, occluding the lumen of the tube;
  • the ETT is advanced so that the ETT connector is flush with the mouth;
  • the cuff is inflated with at least 10 cc of air;
  • the pharynx is suctioned thoroughly;
  • the patient is ventilated by applying positive airway pressure to the face mask with a self-inflating bag; and
  • position is confirmed by listening for air entry in the lungs and over the stomach.
image

Figure 4. Blindly passing the ETT.

If the ETT goes into the stomach, it is advanced until the end is flush with the mouth and the connector of the tube is covered with tape. The oropharynx is well suctioned and the patient can then be ventilated manually.

Once the patient is adequately ventilated, then:

  • a gastric tube is passed through the ETT to decompress the stomach; and
  • the ETT is left in place to prevent regurgitation of stomach contents.

This optimizes the conditions for a second attempt at endotracheal intubation using a direct or indirect method.

Comments

The 4 methods that we describe are designed to supplement the standard repertoire of methods of managing difficult airways and potentially circumvent the need for a surgical airway. Passing the tracheal suction catheter through the Murphy eye is certainly the fastest to implement. Its major limitation, however, is the diameter of the suction tubing, which limits the rate of fluid aspiration.

Using the ETT itself as a suction wand provides a larger bore for aspiration in the presence of massive pharyngeal flooding from the stomach, large particles such as food, or viscous mucous secretions12 that tend to clog even the standard Yankauer suction wand. Moreover, by modifying the ETT such that it also acts as a suction device, the clinician is able to maintain constant visualization of the vocal cords while advancing an ETT.

Placing the patient in a steep head-down tilt reduces pooling at the larynx and may also decrease the likelihood of aspiration of fluid. Its major limitations are that it may not be useful for viscous secretions, and head-down tilt makes the operator position for laryngoscopy more awkward.

Finally, the improvised combined airway can actually be a first-line approach with massive flooding of the airway, especially with vomit. The ventilation approach is similar in concept to several commercially available double-lumen endoesophageal tubes (Combitube).

A major concern during all emergency endotracheal intubations is the risk for aspiration of fluids or particulate matter into the lungs. In a study examining the incidence of cardiac arrest during emergency intubations, it was found that 83% of cases were associated with profound hypoxemia (oxygen saturation <70%) during the airway procedure,13 which is likely to occur with fluid aspiration after multiple failed intubation attempts. The airway maneuvers presented here may be considered in all emergency patients who are at risk for fluid aspiration, as the time taken to switch between an ETT and a suction wand may be the determining factor for the success of laryngeal intubation or the extent of aspiration.

While clearly these are improvised methods that require some time to assemble, they can be prospectively assembled and placed on designated airway carts throughout the emergency department to allow their use when needed, with minimal disruption.

Conclusion

In summary, we present 4 airway maneuvers intended to help manage fluid accumulations in the pharynx during attempts at endotracheal intubation. Our intention is to increase the repertoire of techniques for managing difficult airways of front-line health care workers in the emergency department.

References

  1. Kabrhel C, Thomsen TW, Setnik GS, et al. Videos in clinical medicine. Orotracheal intubation. N Engl J Med. 2007;356(17):e15.
  2. Taryle DA, Chandler JE, Good JT Jr, et al. Emergency room intubations—complications and survival. Chest. 1979;75(5):541-543.
  3. Oswalt JL, Hedges JR, Soifer BE, et al. Analysis of trauma intubations. Am J Emerg Med. 1992;10(6):511-514.
  4. Thibodeau LG, Verdile VP, Bartfield JM. Incidence of aspiration after urgent intubation. Am J Emerg Med. 1997;15(6):562-565.
  5. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. 1995;25(5):592-596.
  6. Perry M, Dancey A, Mireskandari K, et al. Emergency care in facial trauma—a maxillofacial and ophthalmic perspective. Injury. 2005;36(8):875-896.
  7. Carducci B, Lowe RA, Dalsey W. Penetrating neck trauma: consensus and controversies. Ann Emerg Med. 1986;15(2):208-215.
  8. DePaso WJ. Aspiration pneumonia. Clin Chest Med. 1991;12(2):269-284.
  9. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98(5):1269-1277.
  10. Walls RM. The emergency airway algorithms. In: Walls RM, Murphy MF, Luten R, eds. Manual of Emergency Airway Management. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004.
  11. Ellis DY, Lambert C, Shirley P. Intracranial placement of nasopharyngeal airways: is it all that rare? Emerg Med J. 2006;23(8):661.
  12. Vandenberg JT, Lutz RH, Vinson DR. Large-diameter suction system reduces oropharyngeal evacuation time. J Emerg Med. 1999;17(6):941-944.
  13. Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA Guidelines in the remote location. J Clin Anesth. 2004;16(7):508-516.
Copyright © 2016 McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form.

EyePro – eyelid occlusion dressing

Posted on by

EyeProTM

Available in Europe here.

eyePropic

https://youtu.be/PhvpIRO1HNI

Literature and Discussion:

Introduction

Many injuries sustained during anaesthesia are due to human error and may be avoided through high standards of clinical practice. Ocular injury occurs during 0.1- 0.5 % of general anaesthetics when eyes are taped and is usually corneal in nature1,2. This incidence has been reported at 44% in one study of untaped eyes during general anaesthesia3.Eye injuries account for 2% of medico-legal claims against anaesthetists in Australia and United Kingdom1,3 and 3% in the USA4.

Affect of General Anaesthesia on Eyes

General anaesthesia reduces the tonic contraction of the orbicularis oculi muscle, causing lagophthalmos ie. the eyelids do not close fully in 60% of patients1.

In addition, general anaesthesia reduces tear production and tear-film stability, resulting in corneal epithelial drying and reduced lysosomal protection. The protection afforded by Bell’s phenomenon (in which the eyeball turns upwards during sleep, protecting the cornea) is also lost during general anaesthesia5.

Mechanism of Injury

Corneal abrasions are the most common injury; they are caused by direct trauma, exposure keratopathy3,6,7or chemical injury6,8.

An open eye increases the vulnerability of the cornea to direct trauma from objects such as face masks, laryngoscopes, identification badges, stethoscopes, surgical instruments, anaesthetic circuits, or drapes.

Exposure keratopathy refers to the drying of the cornea with subsequent epithelial breakdown9. When the cornea dries out it may stick to the eyelid and cause an abrasion when the eye reopens10.

Chemical injury can occur if cleaning solutions such as Betadine, chlorhexidine or alcohol are inadvertently spilt into the eye, such as when the face or mouth is being prepped for surgery2,3.

Therefore, the anaesthetist must ensure that the eyes are fully closed and remain closed throughout the procedure, in order to avoid exposure keratopathy. Seemingly trivial contact can result in corneal abrasion and the risk of this occurring is markedly increased if exposure keratopathy is already present3.

Corneal abrasions can be excruciatingly painful in the postoperative period, may hamper postoperative rehabilitation and may require ongoing ophthalmological review and after care. In extreme cases there may be partial or complete visual loss.

Methods to Prevent Eye Injuries

Methods to prevent perioperative corneal injuries include simple manual closure of the eyelids, taping the eyelids shut, use of eye ointment (although this is controversial, see below), bio-occlusive dressings and suture tarsorrhaphy. However, none of the protective strategies are completely effective; vigilance is always required ie. the eyes need to be inspected regularly throughout surgery to check they are closed1.

Problems with current methods

For many years, in most western countries, the eyes of patients undergoing general anaesthesia have been routinely taped or stuck down with adhesive dressings in an attempt to combat these problems.

Unfortunately many of the adhesives used on medical products today are temperature and time sensitive ie. their adhesive strength may increase or decrease when applied to a 37 degree Celsius body11 and the longer they are applied, the greater the variability in their adhesiveness. What may seem the perfect adhesive strength before application can change as the operation progresses; leading to failure of stick or “over stickiness”. In the former case, the eyelids may move apart and in the latter, may cause bruising, eyelid tears and eyelash removal.

Rolls of tapes are often “laying around” the operating theatre and may not be hygienically clean12. Most of these tapes are translucent and so it is not possible to see if the patient’s eyes are opened or closed throughout the case. It is not uncommon for the eyelids to move open as the case progresses, even with adhesive tapes stuck onto them.

In a practical sense, these medical tapes/dressings may be difficult to remove from a patient because their ends can become stuck flush with the skin.

As noted above, there have been several studies looking at the efficacy and safety of eye ointments/lubricants as adjuncts with tape or as a stand-alone management for intra-operative eye closure. Unfortunately many in common use have problems. Petroleum gel is flammable and is best avoided when electrocautery and open oxygen are to be used around the face. Preservative-free eye ointment is preferred, as preservative can cause corneal epithelial sloughing and conjunctival hyperemia8; they have been implicated in blurred vision in up to 75% of patients.

They do not protect from direct trauma5,13.

Adverse Outcomes Associated With Intra-operative Injuries

Increased length of stay. Due to ophthalmology consults required, associated infections and treatment13
Increased costs. Due to increased length of stay, cost of treating the complications14
Pain and discomfort for patient. Corneal abrasions are extremely painful for the patient and the treatment consists of drops and ointments applied in the eye which may cause discomfort for the patient13,14

Current Concepts In the Management of The Difficult Airway

Posted on by
Current Concepts In the Management of The Difficult Airway
(source: http://www.anesthesiologynews.com/ViewArticle.aspx?d=Educational+Reviews&d_id=161&i=May+2015&i_id=1183&a_id=32361&ses=ogst)
Download pdf: CurentConcepts.pdf
Volume 12, Number 1
image
Carin A. Hagberg, MD

Joseph C. Gabel Professor and Chair Department of Anesthesiology
The University of Texas Medical School at Houston
Director of Advanced Airway Management
Memorial Hermann Hospital–Texas Medical Center
Houston, Texas
Executive Director 2009-Present, Society for Airway Management

Dr. Hagberg has received grant support from Ambu, Karl Storz Endoscopy, Mallinckrodt, and MedcomFlow, and is also an unpaid consultant for Ambu, Covidien, and SonarMed.

Editor’s note: All acronyms are listed on page 28.

Management of the difficult airway remains one of the most relevant and challenging tasks for anesthesia care providers. This review focuses on several of the alternative airway management devices/techniques and their clinical applications, with particular emphasis on the difficult or failed airway. It includes descriptions of many new airway devices, several of which have been included in the ASA Difficult Airway Algorithm.1

Alternative Airway Devices

A common factor preventing successful tracheal intubation is the inability to visualize the vocal cords during the performance of DL. Many devices and techniques are now available to circumvent the problems typically encountered with a difficult airway using conventional DL.

Endotracheal Tube Guides

Several ET guides have been used to aid in intubation or extubation, including both reusable/disposable and solid/hollow introducers, stylets, and tube exchangers (Table 1).

Table 1. Endotracheal Tube Guides
Name (Manufacturer) Description Length, cm Clinical Applications Special Features
Aintree Intubation Catheter
(Cook Medical)		 Polyethylene 19 Fr AEC allows passage of an FOB through its lumen. Has 2 distal side holes and is packaged with Rapi-Fit adapters. Color: light blue. 56 Exchange of SGAs for ETs ≥7.0 mm using an FOB. Its hollow lumen allows insertion of an FOB directly through the catheter so that the airway can be indirectly visualized. Large lumen (4.7 mm) allows passage of FOB. Rapi-Fit adapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use.
Arndt Airway Exchange Catheter Set
(Cook Medical)		 Polyethylene 8.0 and 14 Fr AEC with a tapered end, multiple side ports, packaged with a stiff wire guide, bronchoscope port, and Rapi-Fit adapters. Color: yellow. 50, 65, 78 Exchange of LMAs and ETs using a FOB. Tapered end and multiple side ports. Rapi-Fit adapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use.
Cook Airway Exchange Catheters
(Cook Medical)		 8.0, 11, 14, and 19 Fr polyethylene designs facilitate exchange of SLT or DLT of ≥4.0 mm ID. The DLT versions are EF with soft tips. Colors: yellow, green; soft-tip is purple. 43, 83, 100 The Cook AEC is intended for uncomplicated, atraumatic, ET exchange for both SLTs and DLTs. EF with 2 distal side holes. The soft-tip version offers a more flexible tip to help minimize tracheal trauma. Rapi-Fit adapters as above, but should be used primarily for jet ventilation because of length. Single use.
Cook Staged Extubation Set
(Cook Medical)
(Available outside of US only)		 Soft-tipped marked extubation wire to maintain continuous airway access, wire holder and Tegaderm for securement, soft-tipped Reintubation Catheter, Rapi-Fit adapters to assist in oxygen delivery, if necessary. Accommodates ETs >5.0 mm ID. Provides a tool for a more complete extubation strategy, which should be in place for every patient. Uses an atraumatic wire to maintain continuous airway access and a soft-tipped reintubation catheter to facilitate a successful reintubation if required and delivery of oxygen when desired.
CoPilot VL Single-Use Bougie
(Magaw Medical)		 14 Fr polyethylene single-use ET introducer with coudé tip. Color: orange 60. Accommodates ETs ≥6.0 mm ID. Facilitate endotracheal intubation. May also be used for tube exchange. Single use.
CoPilot VL Rigid Stylet
(Magaw Medical)		 Reusable CoPilot VL intubation stylet. Accommodates ETs ≥6.0 mm ID. Reusable CoPilot VL intubation stylet for use with VL to facilitate ET placement. Reusable, easy to high level disinfect or sterilize.
Frova Intubating Introducer
(Cook Medical)		 Polyethylene 8.0 and 14 Fr AEC with angled distal tip with 2 side ports. Has hollow lumen and is packaged with a stiffening cannula and removable Rapi-Fit adapters. 14 Fr also packaged in box of 10. Colors: 8 Fr, yellow; 14 Fr, blue. 35, 65 Facilitates endotracheal intubation and allows simple ET exchange. Can also be used by placing it first in the ET, with its tip protruding, or placing it directly into the glottis and then placing the ET over it. Can be used in pediatric population for ETs as small as 3.0 mm. Hollow lumen allows oxygenation/ventilation in all sizes. Single use.
GlideRite Rigid Stylet
(Verathon)		 Reusable, sterilizable, semirigid stylet that conforms to GlideScope unique blade angulation; provides improved maneuverability in ET placement. 26.6. Accommodates ETs ≥6.0 mm ID. Designed to work with GlideScope AVL, GVL, Cobalt, and Ranger VLs to facilitate intubations in OR, ED, and emergency settings. Reusable, durable stainless steel; easy to clean and sterilize in an autoclave.
Introes Pocket Bougie
(BOMImed)		 Single-use 14 Fr (4.7 mm) malleable ET introducer made from special blend of Teflon. Packaged in box of 10. 60. Accommodates ETs ≥5.0 mm ID. Designed to facilitate endotracheal intubation for both DL and VL. Unique curvature designed to follow natural path of airway. Flexibility allows for manipulation of distal tip for anterior airways. Customizable coudé tip angles. Self-lubricated bougie, Tactiglide technology for tactile sensation, optimal curve with shape memory, balanced rigidity with soft-tissue protection, nonremovable depth markings, packaged sterile.
Muallem ET Tube Stylet
(VBM Medizintechnik)		 Single-use 8.0, 12, 14 Fr stylet; malleable, but with soft and atraumatic coudé tip. Color: green. 40, 65 Difficult intubation. Malleable stylet with soft coudé tip and graduation marks for insertion depth.
OptiShape Stylet
(Truphatek International)		 Reusable, sterilizable, semirigid stylet with optimal shape memory for indirect intubation procedures. 4 sizes. Accommodates ETs 2.5-3.5, 4.0-5.5, 5.0-6.5, and 7.0-9.0 mm ID. Facilitates smooth passage of ET in both routine and difficult intubations. Especially useful in combination with the variety of VLs that employ >42-degree angles. Designed with the ideal curve to closely follow the blade shape and ensure successful passage of ET through vocal cords. Easily adjustable to a variety of ET sizes. Suitable for use in combination with a variety of VLs that employ >42-degree angle of vision.
Pocket Introducer
(VBM Medizintechnik)		 Single-use 15 Fr Introducer with coudé tip. Color: blue. 65 Facilitates endotracheal intubation. Folded to only 20 cm, unfolds to 65 cm within seconds, ideal space solution for emergency bags.
Portex Venn Tracheal Tube Introducer
(Smiths Medical)		 15 Fr ET introducer made from a woven polyester base, with a coudé tip (angled 35 degrees at its distal end). Also known as the gum elastic bougie. Color: golden brown. 60 Proven useful in patients with an anterior larynx (grades 2b, 3, and 4) and those with limited mouth opening. Can be used by slightly protruding through the ET, or placing directly into the glottis and then placing an ET over it. Nondisposable and reusable. Size 5.0 Fr is single use. Has memory properties. Coudé tip effectively detects “tracheal clicks” to confirm correct placement. Part of a range of introducers, stylets, and guides for adults and pediatrics. Can be reused after cold-water disinfection.
Rapid Positioning intubation Stylet (RPiS)
(Airway Management Enterprises)		 Single-use flexible stylet with tip that allows 180-degree flexion and retroflexion. Tip protrudes 5 cm from the end of ET. Color: blue 38, ETs ≥6.0 mm ID. Provides greater visibility and control of tip similar to a FOB (with 1 provider) in difficult and routine intubations with VL. Single-use stylet with atraumatic soft tip.
Single-Use Bougie
(Smiths Medical)		 15 Fr, PVC ET introducer with coudé tip. Has a hollow lumen that discourages reuse and is provided sterile. Color: ivory. 70 Single-use product reduces risk for cross-contamination. Otherwise, same as Portex Venn Tracheal Tube Introducer. Similar to Portex Venn Tracheal Tube Introducer, but hollow lumen allows oxygenation/ventilation. Single use.
S-Guide
(VBM Medizintechnik)		 Single-use 15 Fr stylet, malleable, with atraumatic coudé tip and hollow for oxygenation. 65 Difficult intubation. Ideal for nonchanneled VL. Malleable stylet with soft tip and oxygenation possibility (3 in 1). Unique oxygen connector included.
Truflex Flexible Stylet
(Truphatek International)		 Reusable, stainless steel stylet. Has flexible tip with upward lift action of 30-60 degrees, depending on size of ET. Suitable for use with ETs 6.5-8.5 mm ID. Using a dynamic intubation stylet eases clinical coordination difficulties associated with use of VLs by providing greater control of the ET tip direction. Also offers easy and improved laryngeal entry of ET in difficult or routine intubations. Adjustable stopper allows use of ET tubes of differing lengths. Can be used in both direct and indirect intubations.
VBM Introducer
(VBM Medizintechnik)		 Single-use 15 Fr introducer with coudé tip and hollow for oxygenation. Color: orange. 65 Difficult intubation with oxygenation possibility. Supplied with unique removable connector to allow oxygenation with 15-mm connector or jet. Graduation marks for insertion depth.
VBM Tube Exchanger
(VBM Medizintechnik)		 Single-use 11, 14, and 19 Fr tube exchanger that is hollow to allow oxygenation. Color: blue. 80 Exchange of ETs. Similar to Muallem ET Introducer.

Lighted Stylets

In the past decade, many lighted stylets have been developed, including light wands, which rely on transillumination of the tissues of the anterior neck to demonstrate the location of the tip of the ET—a blind technique, unless combined with DL, and visual scopes, which use fiber-optic imagery and allow indirect visualization of the airway. They also can be used alone or in conjunction with DL (Table 2).

Table 2. Stylets
Name (Manufacturer) Description Size Clinical Applications Special Features
Lighted Stylets
Aaron Surch-Lite
(Bovie Medical Industries)		 10-in sterile, single-use, flexible stylet. Adult Usable for routine blind intubations or additional illumination during laryngoscopy, but especially useful when FOB unavailable
(eg, outside locations or ambulances), or when bronchoscopy is difficult to perform (eg, obscured airway or limited head motion allowed).		 Can be used alone or with other techniques. Completely disposable. Intended for single use. Individually packaged in boxes of 3.
AincA Lighted Stylet
(Anesthesia Associates)		 Easily malleable, lighted stylet with adjustable ET holder. Shapes and guides ET while forwardly illuminating passage. Completely reusable device consisting of removable handle with xenon bulb. Adult and children (ETs ≥5.0 mm). Infant (ETs ≥3.0 mm). Same as Aaron Surch-Lite. Can be used alone or with other techniques. Handle-mounted xenon light source is always on and keeps stylet tip cold. Uses 2 AA batteries. System is completely reusable and sterilizable.
Tube-Stat Lighted Intubation Stylet
(Medtronic)		 Similar to AincA lighted stylet. Nasotracheal: 33 cm shaft. Orotracheal: 25 cm shaft. Ideal for difficult intubations, teaching. Minimizes neck flexion and head hyperextension in trauma cases.
Vital Signs Light Wand Illuminating Stylet
(GE Healthcare)		 Similar to AincA lighted stylet. Adult Flexible lighted stylet for use with or without a laryngoscope. Especially useful in soiled or bloody airways. Bright light provides excellent verification of ET positioning, even during difficult intubations. ET temperature will not rise above 42∞C (108∞F).
Viewing Stylets
AincA VideoStylet
(Anesthesia Associates)		 Easily malleable, video imaging stylet with built-in ET holder. Shapes and guides ET while forwardly illuminating the passage and providing full-color image. Completely reusable device consisting of removable VideoStylet and attached rechargeable LCD monitor. Adult and children
(ETs ≥6.0 mm)		 Usable for routine intubations or video imaging during laryngoscopy, but especially useful when FOB unavailable (eg, outside locations or ambulances), or when bronchoscopy is difficult to perform (eg, obscured airway or limited head motion allowed). Provides rapid learning curve due to similarity to standard ET advancement techniques, but with added benefit of an attached, clear video image of all landmarks forward of ET tip. Allows for single-handed use with imaging or used in conjunction with a laryngoscope, as desired for physical alignment. Reusable system. Sterilized by Glutaraldehyde or Sterrad.
air-Vu Plus Fiber-optic Stylet
(Cookgas; distributed by Mercury Medical)		 High-resolution, stainless steel, rigid stylet. Incorporates an adjustable tube stop and optional oxygen port for oxygen insufflation. Adult (ETs ≥5.5 mm) Allows for visualization during intubation through an air-Q laryngeal mask. Portable, durable rigid stylet that allows for a fiber-optic view during intubation through the airQ light source. Options include GreenLine laryngoscope handle or fiber-optic light source (4 AA batteries).
Ambu aScope 3
(Ambu)		 Single-use flexible videoscope. OD: 5.0 mm; working channel ID: 2.2 mm. 60 cm long Alternative to standard reusable flexible bronchoscopes. Useful for visualization during intubation through SGAs. Fully disposable flexible scope avoids cleaning/disinfecting issues. Attaches to high-quality aView Monitor with on-board recording of video images.
Ambu aScope 3 Slim
(Ambu)		 Single-use flexible videoscope. OD: 5.0 mm; working channel ID: 2.2 mm. 60 cm long Equivalent to standard reusable pediatric flexible bronchoscopes. Especially useful for positioning double-lumen endobronchial tubes or bronchial blockers. Fully disposable flexible scope avoids cleaning/disinfecting issues. Attaches to high-quality aView Monitor with on-board recording of video images.
Bonfils Retromolar Intubation Endoscope
(KARL STORZ Endoscopy)		 High-resolution rigid fiber-optic stylet with a fixed 40-degree curved shape at the distal end. Available with standard eyepiece or DCI to endoscopic camera system. Can be used within C-MAC system while using the portable monitor of the C-MAC VL with C-CAM camera head. 3.5 and 5.0 mm OD. ET must be ≥0.5 mm larger to fit. Able to elevate a large, floppy epiglottis and navigate through the oropharynx of patients with excessive pharyngeal soft tissue, midline obstruction, limited mouth opening, or fragile veneers on incisors. Fixed-shape shaft with adjustable eyepiece that allows ergonomic movement during intubation, in addition to adapter for fixation of ETs and oxygen insufflation. Portable, rugged, and better maneuverability than flexible FOB. Used with battery-powered or portable light source.
Brambrink Intubation Endoscope
(KARL STORZ Endoscopy)		 High-resolution semi-rigid fiber-optic stylet with a 40-degree curved shape at distal end, 40× magnification, fixed eyepiece, movable ET holder, and an insufflation port. 2.0 mm OD. ET must be ≥0.5 mm larger to fit. Similar to Bonfils Retromolar Intubation Fiberscope. Available for DCI video cameras.
Clarus Video System 30000V (Clarus Medical) Malleable (shapeable) rigid stylet scope with attached LCD screen and adjustable curve shape provides view from end of stylet; USB for recharging lithium ion battery and option to connect to notebook or monitor; red LED for transillumination. Assist with DL/VL or used as independent device. Also malleable for use through intubating supraglottic ventilatory devices. 5 mm OD. ETs ≥5.5 mm. ET intubation, confirmation, extubation (with video); LMA placement, positioning, and intubation with certain LMAs. Provides access with limited mouth opening; malleable stylet provides shaping to reduce cervical movement. Red LED provides better illumination than the white LED, and better transillumination when used like a light wand when use of the scope is contraindicated because of blood or vomit.
Levitan GLS
(Clarus Medical)		 Portable high-resolution optics from end of stylet, malleable (shapeable) rigid stainless steel stylet that protects the illumination optic fibers. Comes in preformed hockey-stick shape that can be changed, if necessary. Built-in tube stop to hold ET in place with integral oxygen port for oxygen insufflation during intubation. Assist with DL/VL like regular stylet or used as independent device. Also malleable to be used through intubating supraglottic ventilatory devices. Optional adapter uses smartphones to transform optics to video. Adult (ETs ≥5.5 mm ID). Originally designed as adjunct to DL. Many use it as a stand-alone device similar to the Shikani for intubation, cric/trach tubes, LMAs, and intubation through LMAs or just positioning or checking placement of the same. GreenLine laryngoscope handle or a Turbo LED can be used for light sources. Very similar to the SOS, but requires user to cut the ET because it does not have a movable tube stop.
PocketScope
(Clarus Medical)		 Conveniently sized, easy-to-clean, and cost-effective (reusable) flexible stylet that has a patented, deflected, nondirectable tip. Optional adapter uses smartphones to transform optics to video. Often used to confirm placement and patency of airways. Adult (ETs ≥4.0 mm ID). Allows for visualization during intubation through ILMA or quick confirmation of SGA, DLTs, or ET placement/positioning patency. May also be used for extubation. Has been modified with a patented deflected tip that allows it to be used for viewing while performing nasal intubation.
SensaScope
(Acutronic Medical Systems)		 Hybrid S-shaped, semi-rigid fiber-optic intubation video stylet. Has a 3-cm steerable tip with video chip that can be flexed in sagittal plane 75 degrees in both directions with lever at proximal end of device. Has no working channel. Adult (ETs ≥6.5 mm ID). Similar to Brambrink Intubation Endoscope. Offers an improved view of glottis, simultaneous direct and endoscopic views, full visual control over passage of ET, and confirmation of final position. No need for extreme head extension or forced traction of laryngoscope. Can be rapidly assembled for immediate use.
Shikani Optical Stylet
(SOS; Clarus Medical)		 Viewing stylet: high-resolution, stainless steel, malleable (shapeable) fiber-optic stylet that comes in preformed hockey-stick shape. Has adjustable tube stop and integral oxygen port for oxygen insufflation. Use to assist with DL/VL like regular stylet or used as independent device. Also malleable for use through intubating supraglottic ventilatory devices. Optional adapter uses smartphones to transform optics to video. Adult (ETs ≥5.5 mm ID). Pediatric (ETs 2.5-5.0 mm ID). Similar to flexible FOB. Can be used alone or as adjunct to laryngoscopy and is especially useful for those unable to maintain skills with a bronchoscope. Has the simple form of a standard stylet, plus the advantage of a fiber-optic view and maneuverability of its tip. Portable, rugged, and able to lift tissue. Light source options are light cable, Turbo LED, or GreenLine laryngoscope handle with adapter.

Viewing Stylets

Viewing stylets provide a view from the tip of the ET. Whereas the view from a VL is at the end of the laryngoscope, viewing stylets provide a view from the tip of the ET for steering the ET through the cords. The stylet size for this device allows it to be placed within an ET as an independent instrument, or as an adjunct to VL or DL. Additionally, some can be used to place an ET through intubating supraglottic ventilatory devices for visualization of ET placement through the SGA (Table 2).

Video Laryngoscopes

Video-assisted techniques have become pervasive in various surgical disciplines, as well as in anesthesiology. As more VLs are introduced into clinical practice, and as airway managers become more skillful with the technique of video-assisted laryngoscopy, it could well become standard procedure for patients with known or suspected difficult airways. It also may become the standard for routine intubations as the equipment and users’ skills improve and the cost of the devices decreases, with the potential for important savings in time and decreased morbidity in patients. It is beyond the scope of this review to discuss all of the laryngoscopes that have been manufactured; thus, only some of the most recently developed blades will be described (Table 3).

Table 3. Video Laryngoscopes
Name (Manufacturer) Description Size Clinical Applications Special Features
Airtraq Avant
(Prodol Meditec; distributed by Teleflex)		 Disposable VL that provides a magnified angular view of the glottis without alignment of oral, pharyngeal, and tracheal axes. Includes a guiding channel to both hold and direct ET toward the vocal cords. Reusable optic piece (up to 50 intubations) and anti-fog heater resists lens clouding. Disposable blade and eye-cup. MRI conditional use. Also optional: A-360 camera and smartphone adapter. Regular adult for ET 7.0-8.5 mm ID. Small adult for ET 6.0-7.5 mm ID. Intended to facilitate intubation in both routine and difficult airway situations. Useful in all cases where ET intubation is desired. Also appropriate for emergency settings, cervical spine immobilization, fiberscope guidance, tube exchange, and foreign body removal. Optics fully isolated from patient, preventing cross-contamination. Advanced airway device with built-in anti-fog system, and low-temperature light source. Can be used with standard ETs. Integral tracking channel allows ET to be directed without a stylet or bougie. May be used in MRI suite as MRI compatible.
Airtraq SP
(Prodol Meditec; distributed by Teleflex)		 The SP model is single use with all the features of the Avant but fully disposable. Both Airtraq models have an optional snap-on camera, with integrated 2.8-in touch screen that flips and rotates on 2 axes and can be attached to all Airtraq models. It records and can Wi-Fi connect to smartphone/iPad/iPhone/PC. 6 color-coded sizes available: regular adult for ET 7.0-8.5 mm ID; small adult for ET 6.0-7.5 mm ID; pediatric for ET 4.0-5.5 mm ID; infant for ET 2.5-3.5 mm ID; nonchanneled blade; and double-lumen ETs. Same as Airtraq Avant. Same as Airtraq Avant but totally disposable and self-contained. 3-y shelf-life.
Berci-Kaplan DCI Video Laryngoscope System
(KARL STORZ Endoscopy)		 VL system with interchangeable laryngoscope blades. Platform system enables DCI camera head to snap onto any standard eyepiece fiberscopes (flexible or semi-rigid). Required components include camera control unit, xenon light source, and monitor. Telepack portable combination video/light source/monitor unit is also available for use with this system. MAC 2-4, Miller 0, 1, 4, Dörges universal blade and D-Blade for difficult, very anterior airways. Useful for anterior airways, obese patients, and patients with limited mouth opening or neck extension. Variety of blade sizes and designs accommodates patients ranging from morbidly obese to neonate (500 g). Additionally useful for teaching purposes, verification of ET position, aiding application of external laryngeal manipulation, or passage of an intubating introducer. May also be used for nasal intubation and ET exchange. The wide-angle camera allows improved visualization and video documentation of laryngoscopy and intubation. Extreme positioning of the head is unnecessary. Blades provide 80-degree field of view.
C-MAC Video Laryngoscope (KARL STORZ Endoscopy) Instant on, battery-powered VL with standard shaped interchangeable Macintosh and Miller blades for obese adults through neonates as well as a difficult airway blade (D-Blade) for very anterior airways. Blades house high-resolution CMOS distal chip and LED technology. Real-time viewing on 7-in LCD monitor. Dörges D-Blade has angle of view with approximately 80-degree acute curvature design. MAC 2-4, Miller 0 and 1, MAC 3 and 4 with channel for suction, D-Blade, and S-Blade (single-use). Single-use blade. Same as DCI. Highly portable system for use in all hospital settings. Unique platform design is compatible with multiple intubation devices, including video laryngoscopes, the F.I.V.E. distal chip flexible video scopes, and standard eyepiece scopes (fiber-optic and semi-rigid) via C-CAM camera head. Built-in still and video image capture on memory card, with real-time playback on monitor. Angled distal lens provides 80-degree field of view. Inherent anti-fog design. Unit can be pole mounted or inserted into waterproof field bag. No special ETs or stylets needed. Can be used while battery is charging.
C-MAC Pocket Monitor
(KARL STORZ Endoscopy)		 Highly portable rescue device, 2.4-in monitor fits directly on all C-MAC blades. LCD 4.3 ratio high-resolution screen works in direct sunlight; rechargeable battery lasts 1 h; ergonomic screen can be moved in several directions and folded away for transportation; fully immersible. Same as C-MAC. Ideal for ICU, crash carts, ED and all prehospital environments including EMS, ambulatory services, air transport, and military. Has familiar blade design and 80-degree field of view. Lightweight, handheld, and battery-operated device well suited for areas outside the OR. Waterproof.
CoPilot VL
(Magaw Medical)		 Portable VL with an acutely angled blade and C-shaped channel for a bougie. Rechargeable lithium polymer internal battery provides >2 h of continuous use. Built-in anti-fog mechanism. Adult sizes 3 and 4. Same as DCI. Patented bougie port is designed to facilitate ET placement. Single use.
GlideScope Titanium Video Laryngoscope
(Verathon)		 GlideScope Titanium systems are available in reusable options and feature streamlined, low-profile blade designs and durable, lightweight titanium construction. Built-in anti-fog mechanism. With new snapshot and on-screen playback features. 4 reusable blade designs. LoPro 3 and 4 angled blades, and Mac-style 3 and 4 blades. Compatible with full line of GlideScope AVL pediatric blades. More VL options for routine and difficult airways—including new MAC-style blades—provide clinicians with a choice of airway tools for a wide range of patients, clinical settings, and teaching purposes. Reusable blades and video cable, as well as the single-use Smart Cable, can be completely immersed in the recommended cleaning solution (IPX8 compliant). Includes anti-fog capability, plus real-time recording, display, and playback features on 6.4-in digital, color GlideScope Video Monitor.
GlideScope AVL
(Advanced Video Laryngoscope; Verathon)		 Portable advanced VL features a digital color monitor and digital camera for DVD clarity. Also includes integrated real-time recording and onboard video tutorial. Anti-fog feature to resist lens fogging. Reusable and single-use options available. With new snapshot and on-screen playback features. 6 disposable blades, sizes 0-4. Reusable blades in 4 sizes: GVL 2-5. DVD-quality airway view enables intubation in a wide range of adult and pediatric patients, including preterm/small child and morbidly obese, bloody or anterior airways, and patients with limited neck mobility. Optimized for demanding applications in the OR, ED, ICU, and NICU. Can be used for teaching. Real-time recording, onboard video tutorial, anti-fog feature to resist lens fogging, advanced resolution output to an external monitor, intuitive user controls and status icons, lightweight and easily transportable, impact-resistant, durable polycarbonate-coated video screen. Disposable blades allow quick turnaround and help limit the possibility of cross-contamination.
GlideScope Ranger and Ranger Single Use Video Laryngoscopes
(Verathon)		 Portable VL designed for EMS and military paramedics. Compact and rugged. Operational in seconds. Reusable Ranger offers 2 blade sizes: 3 and 4. Ranger Single Use is offered with 6 disposable sizes: 0-4. Ideal for EMS (ground and air), military, ED, ICU, and crash cart settings. Offers same benefits as AVL, GVL. Ranger models are compact, rugged, portable, and built to military and EMS specifications. Powered by rechargeable lithium polymer battery; 1.5 lb. Awarded US Army Airworthiness and US Air Force Safe-to-Fly certifications. Reusable and disposable.
King Vision Video Laryngoscope
(Ambu)		 Durable, fully portable digital VL with a high-quality reusable display and disposable blades. Display aligned with blade, ergonomic handle integrated into blade, the disposable blades incorporate the camera and light source, anti-fog coating on distal lens. Channel is soft, allowing for easy ET detachment. One size, 2 versions, correlating to size 3 laryngoscope. Channeled blade allows use of 6.0-8.0 mm ET and minimum mouth opening of 18 mm. Standard blade requires minimum mouth opening of 13 mm. Facilitates both routine and difficult intubations. Can be used alone or with other techniques. Powered by 3 AAA batteries. Organic LED screen allows wide-angle viewing in various lighting conditions. Video out available for connection to external display or video-capture device.
King Vision Video Laryngoscope aBlade System
(Ambu)		 Reusable video adapter attaches to the existing King Vision display to allow use of lower-cost aBlades. Same as original offering: size 3 with channeled and standard (nonchanneled) aBlade versions. Facilitates both routine and difficult intubations. Can be used alone or with other techniques. Powered by 3 AAA batteries; high fidelity 2.4-in screen allows wide-angle viewing. Video out available for connection to external display or video-capture device.
McGrath MAC
(Aircraft Medical; distributed by Covidien)		 Portable VL designed for everyday use in the OR, ICU, and ED. Uses disposable MAC-shaped blades as well as acutely curved X3 Blade. Durable (drop tested up to 2 m). Screen displays minute-by-minute battery life countdown. Blade sizes 2, 3, and 4 and X3. Dual capability combines the benefits of a video-supported anterior view as well as a direct visualization to support a wide range of airways from routine to more extreme cases. No additional training required. Supports direct and indirect visualization due to video support. Slimline blade for improved agility. Blade shape requires less tube curvature than other VLs for easier insertion and a stylet is not always required. Highly portable and lightweight. No electrical outlet required, thus ideal for settings outside the OR. Uses disposable blades for quick turnaround between uses and for limiting cross-contamination. Monitor located on the handle to remain in a more natural line. Waterproof.
McGrath Series 5 Video Laryngoscope
(Aircraft Medical; distributed by Teleflex)		 Portable VL with adjustable-length, single-use disposable blade that can be disarticulated from the handle to further assist with difficult airways. Flat-screen monitor located on the handle to remain in a more natural line of sight with patient. McGrath Series 5 HLDi is the new “High Level Disinfection Immersible” system that is entirely waterproof. Adjusts to fit many adult and pediatric sizes. Useful in patients with limited mouth opening or head and neck movement, anterior airways; obese patients; patients in whom an increased hemodynamic response is a concern; and for teaching. Highly portable and lightweight. Uses disposable blades for quick turnaround between uses and for limiting cross-contamination. Adjustable blade allows use of different blade lengths on the spot. Low-profile blade and disarticulating handle can accommodate patients with very limited mouth opening and severely limited movement of the head and neck. Monitor is located on the handle to remain in a more natural line of sight with the patient.
Venner AP Advance Video Laryngoscope
(Venner Capital)		 Fully portable VL with 3.5-in monitor that attaches to a reusable handle. Self-contained LED light source. Built-in anti-fogging mechanism. MAC 3 and 4, and Difficult Airway Blade. Similar to C-MAC VL. Can be used as traditional laryngoscope and converted to VL by attachment of monitor.
VividTrac

(MercuryMedical/​FujiFilm/​SonoSite)

 Video intubation device that works on many computer systems equipped with USB II port as a standard USB camera, using available video camera applications on Windows, Mac, and Linux systems. Alternatively, automated video display software (VividVision) can be downloaded. ET 6.0-8.5 mm. Intended to facilitate intubation in both routine and difficult airway situations. VividTrac is inserted more like an oral airway device (or LMA) than a laryngoscope blade. The ET can be preloaded or inserted once visualization is achieved in the VividTrac tube channel.

Indirect Rigid Fiber-Optic Laryngoscopes

These laryngoscopes were designed to facilitate tracheal intubation in the same population that would be considered for flexible fiber-optic bronchoscopy, such as patients with limited mouth opening or neck movement. Relative to the flexible FOBs, they are more rugged in design, control soft tissue better, allow for better management of secretions, are more portable (with the exception of the new portable FOBs), and are not as costly. Intubation can be performed via the nasal or oral route and can be accomplished in awake or anesthetized patients (Table 4).

Table 4. Indirect Rigid Fiber-Optic Laryngoscopes
Name (Manufacturer) Description Size Clinical Applications Special Features
Dörges Emergency Laryngoscope Blade
(KARL STORZ Endoscopy)		 Developed in Europe as a universal blade that combines features of both the MAC and Miller laryngoscope blades. One size only for patients >10 kg to adult. Blade is inserted into oropharynx to appropriate depth, which correlates with patient’s size. 10- and 20-kg markings on the blade.
Modified MAC Blades
AincA Flex-Tip Fiber-Optic Laryngoscope Blade
(Anesthesia Associates)		 Flexible tip or levering fiber-optic MAC laryngoscope blades designed with a hinged tip controlled by a lever at the proximal end. Designed to fit standard handles. Adult sizes 3 and 4. Pediatric size 2. Controlled manipulation of large or floppy epiglottis. Also useful in patients with a recessed mandible and decreased mouth opening. Useful in patients with a recessed mandible and decreased mouth opening. A lever controls the tip angle through 70 degrees during intubation to lift the epiglottis, if necessary, to improve laryngeal visualization.
AincA Macintosh Viewing Prisms
(Anesthesia Associates)		 An optically polished viewing prism for attachment to most MAC laryngoscope blades (conventional OR fiber-optic). Effectively repositions the practitioner’s viewpoint to the forward portion of the MAC curve via a 30-degree refraction without inverting the image. Clips to the vertical flange of the MAC to “look around the curve of the blade.” Sizes 2, 3, and 4 for use on MAC laryngoscope blades of sizes 2, 3, and 4. Allows viewing of the vocal cords even in a patient with an anterior airway position. Also useful during nasal intubation (with impaired view) and for postoperative examination of the larynx. Built-in clip on each prism allows attachment to any MAC-type laryngoscope blade that has a standard thickness vertical flange. Usable on both conventional and fiber-optic–type MAC blades. Reusable and sterilizable.

Supraglottic Ventilatory Devices

The Laryngeal Mask Airway (Teleflex) is the single most important development in airway devices in the past 25 years. Since its introduction into clinical practice, it has been used in more than 300 million patients worldwide. Other supraglottic ventilatory devices are available for routine or rescue situations. The most recently developed supraglottic ventilatory devices have a gastric channel or are intended to be used as a conduit for fiber-optic–guided intubation (Table 5).

Table 5.Supraglottic Ventilatory Devices
Name (Manufacturer) Description Size Clinical Applications Special Features
AES The Guardian CPV
(AES)		 All-silicone laryngeal mask with a vented gastric tube and CPV that constantly monitors cuff pressure. Adult sizes 3, 4, 5. SGA with built-in CPV to minimize postoperative sore throat. Color indicator bands provide instant feedback regarding pressure changes. The CPV detects changes caused by temperature, nitrous oxide levels, and movement within the airway, enabling clinician to maintain a recommended cuff pressure of 60 cm H2O. Single use.
AES Ultra
(AES)		 All-silicone laryngeal mask with standard cuff valve. Adult sizes 3, 4, 5, 6. Standard all-silicone SGA. All silicone. Single use.
AES Ultra Clear
(AES)		 Silicone cuff and PVC tube, laryngeal mask with standard cuff valve. Adult sizes 3, 4, 5, 6. Combines all-silicone cuff with PVC tube for cost savings. All silicone cuff with PVC tube. Single use.
AES Ultra Clear CPV
(AES)		 Silicone cuff and PVC tube, laryngeal mask with CPV that constantly monitors cuff pressures. Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6. Similar to AES Ultra CPV. Similar to AES Ultra CPV.
AES Ultra CPV
(AES)		 All-silicone laryngeal mask with CPV that constantly monitors cuff pressures. Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6. SGA with built-in CPV to minimize postoperative sore throat. Color indicator bands provide instant feedback regarding pressure changes. The CPV detects changes caused by temperature, nitrous oxide levels, and movement within the airway, enabling clinician to maintain a recommended cuff pressure of 60 cm H2O. Single use.
AES Ultra EX
(AES; distributed by Anesthesia Associates)		 All-silicone, multiple-use laryngeal mask. Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6. Reusable, standard SGA. 40 uses.
AES Ultra Flex CPV
(AES)		 Wire-reinforced, silicone cuff and tube with CPV that constantly monitors pressure changes in the cuff. Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6. Wire-reinforced SGA that accommodates repositioning of the head and neck. Color indicator bands provide instant feedback regarding pressure changes. Single use. The cuff pressure indicator detects changes caused by temperature, nitrous oxide levels, and movement within the airway. The CPV enables the clinician to maintain a recommended cuff pressure of 60 cm H2O.
AES Ultra Flex EX
(AES; distributed by Anesthesia Associates)		 All-silicone, wire-reinforced, multiple-use laryngeal mask. Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6. Reusable, wire-reinforced SGA, designed to accommodate repositioning of the head and neck during surgery. 40 uses.
air-Q Blocker Disposable Laryngeal Mask
(Cookgas; distributed by Mercury Medical)		 Combines the features of air-Q Disposable Laryngeal Mask, with an additional soft, flexible guide tube located to the right of the breathing tube. This channel provides access to the esophagus with a NGT or Blocker tube that allows clinicians to vent, suction and further block the esophagus. Sizes (2.5, 3.5, and 4.5) that can accommodate standard ETs ≤8.5 mm. Also available in kits with syringe and lubricant packet. Enhanced version of the standard air-Q. Indicated as primary airway device when oral ET is not necessary or as aid to intubation in difficult situations. The soft guide tube allows access to the posterior pharynx and esophagus by supporting and directing medical instruments beneath the air-Q mask and into the pharynx and esophagus. Medical instruments especially suited are suction catheters, NGTs up to size 18.0 Fr, and the newly designed air-Q Blocker tubes. The Blocker tubes are designed to suction the pharynx, or suction, vent, and block the upper esophagus during use of the air-Q Blocker airway. Removable color-coded connector allows intubation with standard ETs ≤8.5 mm.
air-Q Disposable Laryngeal Mask
(Cookgas; distributed by Mercury Medical)		 Hypercurved intubating laryngeal airway with removable color-coded connectors. Anterior portion of mask is recessed; larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using air-Q reusable removal stylet. Sizes (1.0, 1.5, 2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs ≤8.5 mm. Same as air-Q Reusable Laryngeal Mask. Removable color-coded connector allows intubation with standard ETs ≤8.5 mm.
air-Q Reusable Laryngeal Mask
(Cookgas; distributed by Mercury Medical)		 Hypercurved intubating laryngeal airway that resists kinking, and removable airway connector. Anterior portion of mask is recessed; larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using air-Q reusable removal stylet. Sizes (0.5, 1.0, 1.5, 2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs 4.0-8.5 mm. Similar to both LMA Classic and LMA Fastrach. Allows easy access for flexible fiber-optic devices. Use as routine masked laryngeal airway. Removable connector allows intubation with standard ETs ≤8.5 mm. Designed to minimize folding of the cuff tip on insertion. Integrated bite block reinforces the tube while diminishing need for a separate bite block. Color-coded removable connectors tethered to the airway tube, avoiding episodes of misplaced connectors.
air-Q SP
(Cookgas; distributed by Mercury Medical)		 Combines features of the air-Q disposable laryngeal masks with added advantage of a self-pressurizing mask. No inflation line or pilot balloon is needed. PPV or spontaneously breathing patients inflate the mask during the uptake of ventilation. Sizes (1.0, 1.5, 2.0, 2.5, 3.5, 4.5) that can accommodate standard ET tubes ≤8.5 mm. Same as regular air-Q but eliminates need for mask inflation. PPV self-pressurizes mask cuff. On exhalation, mask cuff decompresses to level of PEEP. Removable connector allows intubation with standard ETs.
air-Q SP Reusable
(Cookgas; distributed by Mercury Medical)		 Combines features of the air-Q reusable laryngeal masks with added advantage of a self-pressurizing mask. No inflation line or pilot balloon is needed. PPV or spontaneously breathing patients inflate the mask during the uptake of ventilation. Sizes (0.5, 1.0, 1.5, 2.0, 2.5, 3.5, 4.5) that can accommodate standard ETs 4.0-8.5 mm. More secure than a face mask and less invasive than intubation with an ET when tracheal intubation not necessary or during unexpected difficult airway situation. Incorporates the air-Q design with Self-Inflating Mask.
Ambu AuraFlex
(Ambu)		 Disposable wire-reinforced flexible LMA. Adult and pediatric sizes 2-6. Designed for use in ENT, ophthalmic, dental, and torso surgeries. Integrated pilot tube, and high flexibility enables positioning away from the surgical field, without loss of seal. Single use. EasyGlide texture and extra-soft cuff ease insertion and removal. Convenient depth marks for monitoring correct position of the mask.
Ambu AuraGain
(Ambu)		 Second-generation laryngeal mask, featuring anatomic curve for rapid placement, gastric access for suction and decompression of the stomach via a gastric tube, and integrated direct intubation capability for management of expected or unexpected difficult airway. Adult sizes 3-5. Useful for ventilation and intubation. Appropriate for management of expected or unexpected difficult airway. Allowable ET size is designated on each device; gastric access channel ≤14 Fr tube.
Ambu Aura-i
(Ambu)		 Laryngeal mask with built-in curve and bite blocker designed as a conduit for optical endotracheal intubation. Adult and pediatric sizes 1-6. Combines everyday routine use of SGA with direct intubation capability in case of difficult airway situations. Anatomically correct curve designed as Ambu AuraOnce and Ambu Aura40 but specially designed as a conduit for intubation. Compatible with standard ETs.
Ambu AuraOnce
(Ambu)		 A laryngeal mask with a special built-in curve that replicates natural human anatomy. It is molded in 1 piece with an integrated inflation line and no epiglottic bars on the anterior surface of the cuff. Adult and pediatric sizes 1-6. Allows easy access for flexible fiber-optic devices. For use in both anesthesia and emergency medicine. Anatomically correct curve facilitates placement. One-piece mold. EasyGlide texture for ease of insertion. Convenient depth marks for monitoring correct position of the mask. MRI safe. Extra-soft cuff. If intubation necessary or desired, recommend intubation over Aintree AEC. Single use.
Ambu AuraStraight
(Ambu)		 Similar to the LMA Unique but without epiglottic bars on the anterior surface of the cuff. Adult and pediatric sizes 1-6. For use in both anesthesia and emergency medicine. Single-use, one-piece mold. EasyGlide texture for ease of insertion. Convenient depth marks for monitoring correct position of the mask. MRI safe. Extra-soft cuff.
Ambu Aura40 (Ambu Inc.) Same design as the Ambu AuraOnce, but reusable. Adult and pediatric sizes 1-6. Routine use SGA. Reusable.
Ambu Aura40 Straight
(Ambu)		 Similar to LMA Classic. No epiglottic bars on anterior surface of the cuff. Adult and pediatric sizes 1-6. Routine use SGA. Reusable. Available only in US.
CobraPLA
(Pulmodyne)		 Large ID LT tube, which is soft and flexible with a tapered, striated tip. Now has improved distal curve, softer tube, and softer head. It has a high-volume, low-pressure oropharyngeal cuff. Adult and pediatric sizes 0.5-6. Routine use SGA. Disposable. If intubation becomes necessary or desired, will accommodate ET ≤8.0 mm. Single use.
CobraPLUS
(Pulmodyne)		 Similar to the CobraPLA. Includes temperature monitor and distal gas sampling in all sizes. Adult and pediatric sizes 0.5-6. Routine use SGA. Added benefit: able to measure core temperature. Distal CO2 can be monitored in pediatric patients. Similar to CobraPLA, but allows monitoring of patient’s core temperature. In neonatal and infant patients, has ability to increase the accuracy of end-tidal CO2 and volatile gas analysis. If intubation necessary or desired, will accommodate ET ≤8.0 mm. Single use.
Esophageal Tracheal Combitube
(Covidien)		 A disposable DLT that combines the features of a conventional ET with those of an esophageal obturator airway. Has a large proximal latex oropharyngeal balloon and a distal esophageal low-pressure cuff with 8 ventilatory holes in between. Two adult sizes. 41 Fr: height >5 ft. 37 Fr: height 4-6 ft. Routine use SGA but not contraindicated in nonfasting patients. Appropriate for prehospital, intraoperative, and emergency use. Especially useful for patients in whom direct visualization of vocal cords is not possible, patients with massive airway bleeding or regurgitation, limited access to airway, and patients in whom neck movement is contraindicated. Ventilation possible with either tracheal or esophageal intubation. Distal cuff seals off the esophagus to prevent aspiration of gastric contents. Allows passage of an oro-gastric tube when placed in the esophagus. Single use.
i-gel
(Intersurgical)		 SGA with a noninflating cuff, designed to mirror the anatomy over the laryngeal inlet, with an integral bite block, buccal cavity stabilizer, and gastric channel. Also incorporates wide-bore airway channel for use as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5). Adult sizes 3-5 and pediatric sizes 1-2.5. Adult sizes accommodate ET sizes 6.0-8.0 mm. Indicated for use in routine and emergency anesthesia and resuscitation in adult patients. i-gel is not indicated for use in resuscitation in children. Can be used as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5). Gastric channel provides early warning of regurgitation, allows for the passing of a NGT to empty the stomach contents and can facilitate venting of gas from the stomach (except size 1). Noninflating cuff allows easy and rapid insertion, provides high seal pressures, and minimizes risk for tissue compression. Gastric channel provides early warning of regurgitation. Buccal cavity stabilizer reduces risk for rotation or displacement and integral bite block prevents occlusion of airway channel. Wide-bore airway channel also allows for use as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5).
i-gel O2 Resus Pack
(Intersurgical)		 SGA with a supplementary oxygen port, an integral color-coded hook ring to secure airway support strap and identify size; designed to facilitate ventilation. Includes noninflating cuff to mirror anatomy, with an integral bite block, buccal cavity stabilizer, and gastric channel. The pack contains an i-gel O2 second-generation SGA, a sachet of lubricant, and an airway support strap. Adult sizes 3-5.Adult sizes accommodate ET sizes 6.0–8.0 mm. Indicated for use in routine and emergency anesthesia and resuscitation in adult patients. Can be used as a conduit for intubation with fiber-optic guidance. i-gel O2 also can be used to provide supplementary oxygen during postoperative care or patient transfer. Gastric channel provides early warning of regurgitation, allows for the passing of NO tube to empty stomach contents and can facilitate venting of gas from the stomach. Noninflating cuff allows easy and rapid insertion, provides high seal pressure, and minimizes risk for tissue compression. Supplementary oxygen port allows for administration of passive oxygenation as a component of cardio-cerebral resuscitation. Gastric channel provides early warning of regurgitation. Buccal cavity stabilizer reduces risk for rotation or displacement and integral bite block prevents occlusion of airway channel. The wide-bore airway channel also allows for use as a conduit for intubation with fiber-optic guidance.
KING LT
(Ambu)		 Multi-use, latex-free, single-lumen silicone tube with oropharyngeal and esophageal low-pressure cuffs, 2 ventilation outlets, insertion marks, and a blind distal tip (almost like a single-lumen, shortened Combitube). Color-coded connectors for each size. Sizes 0-5. Reusable SGA but with ventilator seal characteristics. Easily inserted, possible aspiration protection, and allows both PPV and spontaneous breathing. Reusable (≤50 times).
KING LT-D
(Ambu)		 Same design as the KING LT, except disposable. Adult sizes 3-5 and pediatric sizes 2, 2.5. Same as KING LT. Also available in a kit. Single use.
KING LTS
(Ambu)		 Double-lumen LT that incorporates a second (esophageal) lumen posterior to the ventilation lumen. Adult sizes 3-5 and pediatric sizes 0, 1, 2, 2.5. Same as KING LT, except that it has a second lumen for gastric access, similar to LMA ProSeal. Allows easy passage of a gastric tube to evacuate stomach contents. Distal tip reduced in size to facilitate insertion. Reusable.
KING LTS-D
(Ambu)		 Same as KING LTS, except disposable. Adult sizes 3-5. Same as KING LTS. Allows passage of 18 Fr gastric tube. Also available in a kit.
LMA Classic
(Teleflex)		 Safe, general-purpose airway for routine elective inpatient and outpatient surgical procedures. Adult sizes 3,4,5,6 and pediatric sizes 1, 1.5, 2, 2.5. Although originally developed for airway management of routine cases with spontaneous ventilation, it is now listed in the ASA Difficult Airway Algorithm as an airway ventilatory device or a conduit for endotracheal intubation. Can be used in both pediatric and adult patients in whom ventilation with a face mask or intubation is difficult or impossible. Can also be used as bridge to extubation and with pressure support or PPV. May be used ≤40 times before discarding.
LMA Classic Excel
(Teleflex)		 Has the benefits of LMA Classic and its improved design facilitates intubation. Adult sizes 3-5. Improves on features of the original LMA Classic Airway, facilitating intubation, and is reusable ≤60 times. Removable connector and epiglottic elevating bar to facilitate intubation. Works with ET ≤7.5 mm. Reusable ≤60 times.
LMA Fastrach
(Teleflex)		 Designed to facilitate blind intubation without moving head or neck, allowing for single-handed insertion. Allows continuous ventilation between intubation attempts. Adult sizes 3-5 that can accommodate special ETs 6.0-8.0 mm. Designed for anatomically difficult airway and included in AHA’s and ASA’s difficult airway algorithms. Supplied in a sterile version for single-use only, as well as in a nonsterile reusable version, which may be used ≤40 times before discarding.
LMA Flexible
(Teleflex)		 Has a reinforced airway tube that allows it to be positioned away from the surgical field while maintaining a good seal. Adult sizes 3, 4, 5, 6 and pediatric sizes 2, 2.5. Ideal for ENT, ophthalmic, and dental surgery, or other procedures where the surgeon and anesthesiologist compete for airway access. Supplied in a sterile version for single use only, as well as in a nonsterile reusable version that may be used ≤40 times before discarding.
LMA ProSeal
(Teleflex)		 Double-cuff design enables seal pressures ≥30 cm H2O to be achieved and the drain tube separates the alimentary and respiratory tracts. Adult sizes 3,4,5 and pediatric sizes 1, 1.5, 2, 2.5. The drain tube higher seal pressures together with the flexible airway tube enable longer periods of ventilation with minimal posterior pharyngeal wall damage, therefore expanding the types of procedures where a LMA can be used. Second cuff allows tighter seal for PPV. Reusable.
LMA Supreme
(Teleflex)		 Combines features of all previous LMAs to provide increased safety and ease of use. The higher seal pressure and gastric access provide a higher degree of safety. Designed to channel fluids away from the airway in the unlikely event of active or passive regurgitation and allows for diagnostic positioning. Adult sizes 3, 4, 5 and pediatric sizes 1, 1.5, 2, 2.5. For routine procedures or to manage higher-risk patients. Allows for easy insertion, higher seal pressures, and provides gastric access to suction or to decompress the stomach. First Seal Technology is designed to provide adequacy of gas exchange. Second Seal Technology is designed to reduce risk for insufflation during ventilation. Designed to provide a passive conduit for unexpected regurgitation. The angle of the LMA Supreme Airway facilitates ease of insertion in various head positions.
LMA Unique
(Teleflex)		 Original, disposable LMA design. Sterile, latex-free, available with or without syringe and lubricant. Soft cuff and airway tube allow for conformity to patients’ natural anatomy. Adult and pediatric sizes 1-5. Same as LMA Classic. Included in AHA 2000 Guidelines for CPR and Emergency Medicine Cardiovascular Care. Single use.
Rüsch Easy Tube
(Teleflex)		 Disposable LT that combines the features of a conventional ET with those of an esophageal obturator airway similar in design to the Combitube. Small, 28 Fr; large, 41 Fr. Same as Esophageal Tracheal Combitube. Similar to Combitube with following differences: single lumen at distal tip, soft latex-free cuff, open proximal second lumen allows use of fiber-optic device or passage of a suction catheter or tube exchanger. Single use.
Soft-Seal Laryngeal Mask
(Smiths Medical)		 Similar in shape to the LMA Unique, but differs in its 1-piece design, in which the cuff is softer and there is no “step” between the tube and the cuff, an integrated inflation line, no epiglottic bars on the anterior surface of the cuff, and a wider ventilation orifice. Adult and pediatric sizes 1-5. Same as LMA Classic. Allows easy access for flexible fiber-optic devices. If intubation necessary or desired, will accommodate ET up to 7.5 mm. Single use.
Solus Satin Laryngeal Mask Airway
(Intersurgical)		 A range of single-use, latex-free LMAs with a softer airway tube to provide more flexibility. Adult sizes 3-5. Indicated for use in anesthesia and emergency medicine. Single-use LMA, comes sterile and ready for use. Classic cuff shape for optimum anatomic conformance with a firm, smooth-surfaced back plate to aid ease of insertion. Has a softer airway tube to provide more flexibility. Clear, pliable airway tube allows for early detection of rising fluids. Cuff size indicators are accurately aligned and prominently displayed at top of tube and on pilot balloon. Essential user information on exposed section of airway tube for quick visual reference.
Solus Standard Laryngeal Mask Airway
(Intersurgical)		 A range of single-use, latex-free LMAs. Adult sizes 3-5 and pediatric sizes 1-2.5. Indicated for use in anesthesia and emergency medicine. Single-use LMA, comes sterile and ready for use. Classic cuff shape for optimum anatomic conformance with a firm, smooth-surfaced back plate to aid ease of insertion. Clear, pliable airway tube allows for early detection of rising fluids. Cuff size indicators are accurately aligned and prominently displayed at top of tube and on pilot balloon. Essential user information on exposed section of airway tube for quick visual reference.

Special Airway Techniques

Awake Intubation

For managing patients in whom a difficult airway is suspected or anticipated, securing the airway before induction of general anesthesia adds to the safety of anesthesia and helps minimize the possibility of major complications, including hypoxic brain damage and death. To perform awake intubation, the patient must be adequately prepared for the procedure. Good topical anesthesia is essential to obtund airway reflexes and can be provided by various topical agents and administrative devices (Table 6). Other relatively new devices can be used to best position patients and maintain an open airway during awake intubation (Table 7).

Atomizing devices currently available for delivering topical anesthesia to nasal, oral, pharyngeal, laryngeal, and tracheal tissues include the DeVilbiss Model 15 Medical Atomizer (DeVilbiss Healthcare), the Enk Fiberoptic Atomizer Set (Cook Medical), the LMA MADgic Laryngo-Tracheal Atomizer (Teleflex), and the LMA MADgic Airway (Teleflex). Although any technique of tracheal intubation can be performed under topical anesthesia, flexible fiber-optic intubation is most commonly used.

Table 6. Devices for Special Airway Techniques
Name (Manufacturer) Description Size Clinical Applications Special Features
Awake Intubation
DeVilbiss Model 15 Medical Atomizer
(DeVilbiss Healthcare)		 Metal atomizer; includes glass receptacle (for liquid), pair of metal outlet tubes extending from metal atomizing nozzle, and adjustable tip for directing spray to inaccessible areas of the throat. Can be used with or without RhinoGuard tip cover. Length: 10.5 in. Intended for the application of topical anesthetics to the nose, oropharynx, and upper airway of patients, at the direction/discretion of a clinician. Includes glass receptacle for dispensing the liquid; adjustable swivel top and vented nasal guard attached to a hand bulb. Can be used with all types of oil or water solutions that are compatible with rhodium metal plating. The all-metal top can be autoclaved. Reusable.
Enk Fiberoptic Atomizer Set
(Cook Medical)		 Device for atomizing small doses of local anesthetics. Atomizer set consists of a pressure-resistant oxygen tube and a connecting tube attached by a 3-way side-arm fitting with a small flow control opening. The set also contains an introducer catheter and 2 syringes (1 mL). To apply topical anesthetics to laryngotracheal area through the working channel of a bronchoscope using oxygen flow. Designed and intended for use by those trained and experienced in techniques of flexible fiber-optic intubation. An accessory to a bronchoscope. Delivery form: fine spray mist using oxygen flow through the working channel bronchoscope. Sterile. Single use.
EZ-Spray
(Alcove Medical)		 Disposable atomizer device that comprises a plastic receptacle, atomizer nozzle, and gas inlet tube. Tubing is connected from an air or oxygen flowmeter nipple to the gas inlet tube on the device. Application of topical anesthetic to the nose, oropharynx, and upper airway of patients, at the direction/discretion of a clinician. Trigger-valve system provides controlled release of compressed gas to atomizing nozzle, creating liquid spray. Gas flow adjusted to desired setting. Use with either oil- or water-based solutions. Nonsterile. Single use.
LMA MADdy Pediatric Mucosal Atomization Device
(Teleflex)		 Delivers intranasal/intraoral medications in a fine mist that enhances absorption and improves bioavailability for fast and effective drug delivery. Typical particle size: 30 microns. System dead space: 0.12 mL (with syringe), 0.07 mL (device only). Tip diameter: 0.19 in (4.8 mm). Applicator length: 4.5 in (11.4 cm). Application of topical anesthetics to oropharynx and upper airway region. Fits through vocal cords, down LMA, or into nasal cavity. Child-friendly and no sharps (bright colors in a toylike presentation make procedure less scary for young patients). Flexible (internal stylet provides support, malleability, and memory). Disposable (single-patient use eliminates risk for cross-contamination). Practitioner-controlled (patient needs targeted specially by medication, concentration, position, and location).
LMA MADgic Airway Intubating Airway with Mucosal Atomization and Oxygen Delivery (Teleflex) For difficult and awake airways requiring a fiber-optic scope, the device combines atomized topical anesthetic and oxygen delivery in an innovative and elegantly designed fiber-optic–compatible oral airway. Typical particle size 30-100 microns. System dead space 0.15 mL. Oxygen flow rate 2-3 L/min at 50 psi. Size 9 cm airway (6.5-8.0 ET). For use with FOB. Intubating airway with mucosal atomization and oxygen delivery.
LMA MADgicWand Mucosal Atomization Device
(Teleflex)		 Combines atomized topical anesthesia and oxygen delivery in a fiber-optic oral airway. Packaged in box of 20. Typical particle size: 30-100 microns. System dead space: 0.25 mL. Allows retraction of soft tissue while applying topical anesthesia in a fine, gentle mist. Used to apply topical anesthetic to the airway before awake intubation. Device blade positioned along floor of the mouth can be directed immediately in front of laryngeal inlet to generate a fine mist by a piston syringe. Nonsterile. Single use.
LMA MADgic Laryngo-Tracheal Atomizer
(Teleflex)		 Mucosal atomization device that incorporates a small flexible, malleable tube with an internal stiffening stylet that connects to 3-mL syringe. Typical particle size: 30-100 microns. System dead space: 0.25 and 0.13 mL. Tip diameter: 0.18 in (4.6 mm). Applicator length: 8.5 in (21.6 cm) and 4.5 in (11.4 cm). Application of topical anesthetics to oropharynx and upper airway region. Fits through vocal cords, down LMA, or into nasal cavity. Malleable applicator retains memory to adapt to individual patient’s anatomy. Delivery of a fine spray mist generated by a piston syringe. Luer connection adapts to any luer lock syringe. Nonsterile. Single use.
LMA MAD Nasal-Intranasal Mucosal Atomization Device (Teleflex) Disposable, compact atomizer for delivery of medications to the nose and throat in a fine, gentle mist. Typical particle size: 30-100 microns. System dead space: 0.13 and 0.07 mL. Tip diameter: 0.17 in (4.3 mm). Applicator length: 1.65 in (4.2 cm). Intranasal medication delivery offers rapid, effective method to deliver selected medications to patient without need for a painful shot and without delays in onset seen with oral medications. Rapidly effective (atomized nasal medications absorb directly into bloodstream, avoiding first-pass metabolism; atomized nasal medications absorb directly into the brain and cerebrospinal fluid via olfactory mucosa to nose–brain pathway, achieves medication levels comparable to injections). Controlled administration (exact dosing, exact volume, titratable to effect [repeat if needed]; atomizes in any position; atomized particles are optimal size for deposition across broad area of mucosa).
Retrograde
Cook Retrograde Intubation Set
(Cook Medical)		 Available as a complete set in 6.0, 11, or 14 F. 14 F version includes Airway Exchange Catheter with Rapi-Fit adapters allow for delivery of oxygen. 6.0 F=50 cm; 14 F=60 cm, extra-stiff floppy tipped guidewire = 110 cm. Technique used for securing a difficult airway, either alone or with other alternative airway techniques. Especially useful in patients with limited neck mobility or patients who have suffered airway trauma. 6.0 Fr places tubes ≥2.5 mm ID; 14 Fr places tubes ≥5 mm ID. Packaged as a complete kit with everything needed to perform a retrograde intubation. Recently added Arndt AEC allows for patient oxygenation and facilitates placement of an ET. Disposable.
Face Mask Ventilation
Endoscopy Mask
(VBM Medizintechnik)		 Face mask with diaphragm to allow simultaneous ventilation and endoscopy. Newborn, infant, child, and adult.
  • Fiber-optic intubation
  • Airway endoscopy
  • Gastroenterology
  • Transesophageal echocardiography
 Available in different sizes and with different sizes of diaphragms for a perfect seal during endoscopy. Special bronchoscope airway available to protect equipment and aid endoscopy.
Flow-Safe II CPAP System
(Mercury Medical)		 Disposable CPAP with deluxe mask and comfortable head harness, color-coded manometer for verifying CPAP pressure and pressure-relief system. Flow-Safe II works with standard flowmeters that can deliver >10 cm H2O at 15 LPM. Accepts standard nebulizers and standard CO2 sampling lines. Child, small adult, and large adult. Built-in manometer for verified pressure readings. No assembly of separate apparatus and the pressure-relief valve automatically adjusts to avoid excess pressure. Lighter, easier to handle, and designed to form a better anatomical seal. The elastic head harness is easy to place with Velcro straps that easily adjust for patient comfort.
Flow-Safe II EZ CPAP System
(Mercury Medical)		 Disposable CPAP similar to Flow-Safe II that also includes an integrated nebulizer. The system requires only 1 oxygen source to run both the CPAP and nebulizer devices. CPAP system includes color-coded manometer for verifying CPAP pressure and pressure-relief system. Flow-Safe II EZ works with standard flowmeters that can deliver >10 cm H2O at 15 LPM. Higher flow pressures may be necessary when running both CPAP and the nebulizer. Child, small adult, and large adult. The Flow-Safe II EZ CPAP device is a respiratory aid intended for use with a face mask, nebulizer, and gas-supplying device to elevate pressure in the patient’s lungs while delivering aerosolized medication. Mask features elastic head harness; quick-disconnect clips, and straight rotating port. Built-in manometer and pressure-relief valve. CPAP and nebulization through a single oxygen source.
Transtracheal Jet Ventilation
AincA Manual Jet Ventilator
(Anesthesia Associates)		 Portable jet ventilation device with thumb depression mechanism that initiates controlled burst of oxygen flow. Customizable assembly includes DISS inlet connection, 5 ft of inlet tubing, flow control knob, on/off thumb control, internal filter, back pressure gauge, and 2 ft of outlet hose ending in a luer-lock male fitting. Connects to any tool or port that has a luer-lock female connection (ie, malleable stylets, various adapters, etc.). Jet ventilation catheters of malleable copper with luer lock fittings accommodate adults, children, and infants. Adapters allow direct connection to bronchoscope or ET. Manual jet ventilation for oxygen saturation maintenance and usable for emergency direct TTJV and for laser throat surgery (elimination of plastic ET in laser path). Easy factory customization available for hose lengths and oxygen source connection type (DISS vs various quick-disconnect types) as well as optional pressure regulator (with gauge) and standard or custom regulator-to-source connection hoses. Adapters, fittings, and connectors available. Completely reusable and sterilizable.
AincA MRI Conditional 3.0 Tesla Manual Jet Ventilator
(Anesthesia Associates)		 Similar to AincA Manual Jet Ventilator but certified MRI conditional–compatible for use in units ≤3.0 Tesla strength. Jet ventilation catheters of malleable copper with luer lock fittings accommodate adults, children, and infants. MRI conditional 3.0 Tesla. Similar to the AincA Manual Jet Ventilator, but fully certified for use in MRI suites with coil strength to 3.0 Tesla. Allows emergency oxygen saturation maintenance while determining how to solve airway issues. Easy factory customization available for hose lengths and oxygen source connection type (DISS vs various quick-disconnect types). Adapters, fittings, and connectors available. Completely reusable and sterilizable.
Enk Oxygen Flow Modulator Set
(Cook Medical)		 Complete set including 15-G needle with reinforced fluorinated ethylene propylene catheter, syringe (5 cc), connecting tubing, and Enk oxygen flow modulator with tracheal catheter connector. 7.5 cm (2.0 mm ID). Similar to the AincA Manual Jet Ventilator. Recommended for use when jet ventilation is appropriate but not available. Packaged as complete set with everything needed to perform TTJV. Disposable.
Manual Jet Ventilator
(Instrumentation Industries)		 Complete set includes an on/off valve, 6 ft of high-pressure tubing, and 4 ft of small-bore tubing. Jet ventilation catheter size 13 G can accommodate adults, and 14 G children. Same as Manujet III. Can also be used in unobstructed difficult airway management. Offered with and without an adjustable pressure regulator. Partially reusable outlet tube is disposable. NOTE: Outlet tube is single use.
Manujet III
(VBM Medizintechnik)		 Complete set including 13-ft high-pressure hose assembly with oxygen DISS fittings, 40-degree small bore tube assembly (with luer lock fitting) and 3 jet ventilation catheters (13, 14, and 16 G). Jet ventilation catheters can accommodate adults, children, and infants. Well-accepted method for securing ventilation in rigid and interventional bronchoscopy. Because airflow is generally unidirectional, it is important that air has a route to escape (unobstructed airway). Packaged as complete kit with jet ventilation catheters to perform TTJV. Includes gauge and regulator.
O2-Trio
(Pulmodyne)		 Emergency disposable CPAP device. 3 – FiO2 levels 3 – PEEP settings BiTrac ED Mask Offers PEEP levels 2.5–20 cm H2O. Allows dial in FiO2 levels of ~30%, 60%, and 90%. Constant flow obtained regardless of the amount of oxygen in the tank. Disposable CPAP generator with ≤21 specific combinations of FiO2 and PEEP.
Trans-tracheal Catheter
(Acutronic Medical System)		 Small jet needle for puncturing the trachea in an emergency for use with jet ventilation. 13 G, 14 G Applications in ICU for patients with severe lung injuries, ARDS, or bronchopleural fistulas. Provides ventilation to patient who is unable to be intubated.
Table 7. Positioning Devices
Name (Manufacturer) Description Clinical Applications Special Features
Chin-UP
(Dupaco; distributed by Mercury Medical)		 Hands-free airway support device used to lift up patient’s chin and hold it in position to keep the airway open. Aids during monitored anesthesia care and total IV anesthesia sedation procedures. Disposable polyurethane foam cushions.
Face-Cradle
(Mercury Medical)		 Fully adjustable cushion set accommodates most adult head sizes. For use in prone-position surgeries. Fully adjustable offering the clinician greater visibility of patient’s face.
RAMP Rapid Airway Management Positioner
(Airpal Patient Transfer Systems)		 Air-assisted medical device that can be inflated to transfer and position patients for various procedures. Allows for the positioning of a patient for DL, extubation, and central venous access. Enhances the safe apnea period, bag valve mask ventilation, and chest wall excursion. Base of RAMP is integrated with an Airpal platform (air-assisted lateral patient transfer and positioning device). Inflates and deflates, thus can remain in place during surgery and reinflate for extubation. Reusable.
Troop Elevation Pillow
(Mercury Medical)		 Foam positioning device that quickly achieves the head elevated laryngoscopy position. Includes many accessories (head cradle, arm board pads, additional pillow). Aids airway management for obese patients by aligning upper airway axes, and facilitating mask ventilation, laryngoscopy, DL, and central venous access. Allows patients to breathe more comfortably during preoxygenation and regional anesthesia. Available in disposable and reusable formats. Troop Elevation Pillow may be added for super morbidly obese patients.

Flexible Fiber-Optic Intubation

Flexible fiber-optic intubation is a very reliable approach to difficult airway management and assessment. It has a more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited, as well as in patients of any age and in any position. Technological advances—including improved optics, battery-powered light sources, better aspiration capabilities, increased angulation capabilities, and improved reprocessing procedures—have been developed. The Airway Mobilescope (MAF; Olympus) is a portable, flexible endoscope with expanded viewing and recording capability, incorporating a monitor, LED light source, battery, and recording device in a single unit. A completely disposable system, the aScope (Ambu) also is available. Rescue techniques, such as DL and placing a retrograde guidewire through the suction channel, may be performed if the glottic opening cannot be located with the scope, or if blood or secretions are present. Insufflation of oxygen or jet ventilation through the suction channel may provide oxygen throughout the procedure, and allow additional time when difficulty arises in passing the ET into the trachea.

Retrograde Intubation

Retrograde intubation (Table 6) is an excellent technique for securing a difficult airway either alone or in conjunction with other airway techniques. Every anesthesia care provider should be skilled in employing this simple, straightforward technique. It is especially useful in patients with limited neck mobility that is associated with cervical spine pathology or in those who have suffered airway trauma. Cook Medical has 2 retrograde intubation sets: a 6.0 Fr for placing tubes of ≥2.5 mm ID, and a 14.0 Fr for placing tubes of ≥5.0 mm ID.

Transtracheal Jet Ventilation

TTJV is a well-accepted method for securing ventilation in rigid and interventional bronchoscopy, and there are several commercial manual jet ventilation devices available (Table 6). The Enk Oxygen Flow Modulator (Cook Medical) is recommended for use when jet ventilation is appropriate but not available. An MRI Conditional 3.0 Tesla manual jet ventilator (Anesthesia Associates, AincA) is also now available to enable TTJV in the MRI suite for both planned and emergency procedures (Table 6).

Cricothyrotomy

Cricothyrotomy (Table 8), a lifesaving procedure, is the final option for “cannot-intubate, cannot-ventilate” patients according to all airway algorithms, whether they concern prehospital, ED, ICU, or surgical patients. In adults, needle cricothyrotomy should be performed with catheters at ≥4 cm and ≤14 cm in length. A 6.0 Fr reinforced fluorinated ethylene propylene Emergency Transtracheal Airway Catheter (Cook Medical) has been designed as a kink-resistant catheter for this purpose. Percutaneous cricothyrotomy involves using the Seldinger technique to gain access to the cricothyroid membrane. Subsequent dilation of the tract permits passage of the emergency airway catheter. Surgical cricothyrotomy is performed by making incisions through the cricothyroid membrane using a scalpel, followed by the insertion of an ET. This is the most rapid technique and should be used when equipment for the less-invasive techniques is unavailable and speed is particularly important.

Table 8. Cricothyrotomy Devices
Name (Manufacturer) Description Size Clinical Applications Special Features
Needle Cricothyrotomy
Emergency Transtracheal Airway Catheter
(Cook Medical)		 6 Fr reinforced fluorinated ethylene propylene catheter. 5.0 and 7.5 cm. A lifesaving procedure that is the final option for “cannot-ventilate, cannot-intubate” patients in all airway algorithms. Designed to be kink-resistant, specifically for the purpose of needle cricothyrotomy.
Percutaneous Cricothyrotomy
Melker Emergency Cricothyrotomy Catheter Set
(Cook Medical)		 Complete set including syringe (10 cc), 2- to 18-G introducer needles with TFE catheter (short and long), 0.038-in diameter Amplatz extra-stiff guidewire with flexible tip, scalpel, curved dilator with radiopaque stripe, and PVC airway catheter. Also available in a Special Operations kit, which includes all of the above in a slip peel pouch and 2 airway catheters. Standard kit: 3.8 cm (3.5 mm ID), 4.2 cm (4 mm ID), and 7.5 cm (6 mm ID). Special kit: 4.2 and 7.5 cm. Same as Emergency Transtracheal Airway Catheter. Intended for use with the Seldinger technique via cricothyroid membrane; however, has capability to be used as a surgical cricothyrotomy. Packaged as complete kit with everything needed to perform a percutaneous cricothyrotomy. The Special Operations kit comes in a slip peel pouch for easy transport to offsite locations. Also can be used in OR. Comes with 2 differently sized airway catheters to reduce number of kits needed in the field. Disposable.
Pertrach Emergency Cricothyrotomy Kit
(Pulmodyne)		 Contents include 2 splitting needles, cuffed or uncuffed trach tube, dilator with flexible leader, twill tape, syringe, extension tube, and scalpel (optional). Adult: 6.8 cm (5.6 mm ID). Child: 3.9 cm (3 mm ID), 4 cm (3.5 mm ID), 4.1 cm (4 mm ID), and 4.4 cm (5.0 mm ID). Use in failed orotracheal or nasotracheal intubation, and/or fiber-optic bronchoscopy. Immediate airway control in patients with maxillofacial, cervical spine, head, neck, and multiple trauma. Also used when endotracheal intubation is impossible and/or contraindicated. Immediate relief of upper airway block. Serves as an emergency cricothyrotomy or tracheostomy device that uses a patented splitting needle and dilator to perform rapid and simple procedures.
Quicktrach Emergency Cricothyrotomy Device
(VBM Medizintechnik)		 Complete kit includes airway catheter, stopper, needle, and syringes that come preassembled. Adult (4 mm ID) and child (2 mm ID). Same as Melker Emergency Cricothyrotomy Catheter Set. Packaged as complete kit with everything needed to perform a percutaneous cricothyrotomy—even the neck tape and connecting tube. Removable stopper is used to prevent a “too-deep” insertion and avoid the possibility of perforating the rear tracheal wall. Conical needle tip allows for the smallest necessary stoma and reduces the risk for bleeding. Easily transported to offsite locations. Disposable.
Surgical Cricothyrotomy
Melker Surgical Cricothyrotomy Set
(Cook Medical)		 Cuffed cricothyrotomy tube, scalpel, tracheal hook Trousseau dilator, and blunt, curved dilator in compact package for convenient storage. 9 cm (5 mm ID). This set provides the tools that clinicians can use if they prefer a surgical approach to performing emergency cricothyrotomy. Complete and convenient packaging.
Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Medical) Same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for percutaneous technique. Also includes for surgical technique: tracheal hook, safety scalpel, Trousseau dilator, and blunt curved dilator. 9 cm (5 mm ID). Same as Melker Emergency Cricothyrotomy Catheter Set. 50% of tray same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for the percutaneous technique. The other 50% includes all items needed to perform a surgical emergency cricothyrotomy.
Surgicric
(VBM Medizintechnik)		 Surgical cricothyrotomy set. Surgicric I: rapid 4-step technique Surgicric II: classical surgical technique Surgicric III: Seldinger technique 6 mm ID. Three different sets that provide clinicians several choices for the performance of emergency cricothyrotomy. Small pack size ideal for emergency bags. Soft tip is atraumatic. Locking mechanism prevents accidental dislocation.

Tracheostomy

Tracheostomy (Table 9) establishes transcutaneous access to the trachea below the level of the cricoid cartilage. Emergency tracheostomy may be necessary when acute airway loss occurs in children under the age of 10 or those whose cricothyroid space is considered too small for cannulation, as well as in individuals whose laryngeal anatomy has been distorted by the presence of pathologic lesions or infection.

Table 9. Tracheostomy Devices
Name (Manufacturer) Description Size Clinical Applications Special Features
Percutaneous Dilatational Tracheostomy
Ciaglia Blue Dolphin Balloon Percutaneous Tracheostomy Introducer
(Cook Medical)		 Complete kit with size-specific Blue Dolphin balloon dilator. Available with or without Shiley 6 or 8 percutaneous tracheostomy tubes. Tray version is available that includes lidocaine/epinephrine, 15-mm swivel connector, chlorhexidine skin prep, drape, and suture. 21, 24, 26, 27, 28, 30 Fr introducers. One-step dilation and tracheal tube insertion. Establishes transcutaneous access to the trachea below the level of the cricoid cartilage by Seldinger technique. Unique balloon-tipped design dilatation and tracheal tube insertion in 1 step. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy.
Ciaglia Blue Rhino Percutaneous Introducer Set
(Cook Medical)		 Complete kit includes 24, 26, and 28 Fr loading dilators and Shiley 6 or 8 percutaneous disposable dual-cannula tracheostomy tube. Tray version available that includes lidocaine/epinephrine, connector, chlorhexidine skin prep, drape, needle driver, and suture. 74 mm (6.4 mm ID); 79 mm (7.6 mm ID). Same as Portex Ultraperc Percutaneous Dilatation Tracheostomy Kit. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The single dilator with a hydrophilic coating and flexible tip results in a simpler, less traumatic insertion. The wire guide has a Safe-T-J tip to reduce trauma. Disposable.
Laserjet Catheter
(Acutronic Medical Systems)		 Double-lumen jet catheter. Diameter: 12 Fr; Length: 40 cm, 70 cm For use in laser airway procedures and difficult airway procedures. Laser-safe tube, dual lumen provides extra ability for monitoring of pressures and end-tidal CO2.
Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit
(Smiths Medical)		 Complete set with or without a tracheostomy tube. 70 mm (7 mm ID); 5.5 mm (8 mm ID); 81 mm (9 mm ID). Establishes transcutaneous access to the trachea below level of cricoid cartilage. Allows for smooth insertion of the tracheostomy tube over a Seldinger wire. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The dilator is single-staged and prelubricated with an ergonomic handle to facilitate insertion. Disposable.
Weinmann Tracheostomy Exchange Set
(Cook Medical)		 Includes Cook Airway Exchange Catheter, Tracheostomy loading dilators, and a Blue Rhino dilator for redilation if necessary. For use with tracheostomy tubes as follows: 74 mm (6.4 mm ID); 79 mm (7.6 mm ID). Used to facilitate exchange of adult tracheostomy tubes allowing for stomal redilation, if required. The only device available that provides an AEC to maintain stomal access and that also allows redilation of stoma if resistance is met.
Shiley TracheoSoft XLT Extended-Length Tracheostomy Tubes
(Covidien)		 Available in 4 ISO sizes (5, 6, 7 and 8 mm ID). Each size offers the choice of cuffed or uncuffed stylets, and proximal or distal extensions. Disposable inner cannula; replacements sold in packages of 10. 90 mm (5 mm ID); 95 mm (6 mm ID); 100 mm (7 mm ID); 105 mm (8 mm ID). Flexible dual cannula tube for patients with unusual anatomy. Proximal length extension for thick necks; distal length extension for long necks, tracheal stenosis, or tracheomalacia. The only fixed-flange extended-length tube with disposable inner cannula. Flexible inner cannula conforms to shape of the outer cannula. 16 configurations to fit a wide variety of patients. Disposable.
Surgical Tracheostomy
Surgical tracheostomies are performed by making a curvilinear skin incision along relaxed skin tension lines between sternal notch and cricoid cartilage. A midline vertical incision is then made dividing strap muscles, and division of thyroid isthmus between ligatures is performed. Next, a cricoid hook is used to elevate the cricoid. An inferior-based flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall. Finally, the tracheostomy tube is inserted, the cuff is inflated, and it is secured with tape around the neck or stay sutures.

Percutaneous dilatational tracheostomy is the most commonly performed tracheostomy technique, yet it is still considered invasive and can cause trauma to the tracheal wall. Translaryngeal tracheostomy, a newer tracheostomy technique, is considered safe and cost-effective, and can be performed at the bedside. It may be beneficial in patients who are coagulopathic. Surgical tracheostomy is more invasive, and should be performed on an elective basis and in a sterile environment.

Conclusion

Most airway problems can be solved with relatively simple devices and techniques, but clinical judgment born of experience is crucial to their application. As with any intubation technique, practice and routine use will improve performance and may reduce the likelihood of complications. Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require combinations of devices and techniques.

References

  1. ASA Difficult Airway Algorithm. Anesthesiology. 2013;118[2]:251-270

Recommended Reading

  1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98(5):1269-1277.
  2. Miller CG. Management of the difficult intubation in closed malpractice claims. ASA Newsletter. 2000;64(6):13-19.
  3. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg. 2000;90(3):745-756.
  4. Frass M, Kofler J, Thalhammer F, et al. Clinical evaluation of a new visualized endotracheal tube (VETT). Anesthesiology. 1997;87(5):1262-1263.
  5. Tuckey JP, Cook TM, Render CA. Forum. An evaluation of the levering laryngoscope. Anaesthesia. 1996;51(1):71-73.
  6. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anesth. 2003;50(6):611-613.
  7. Agro F, Barzoi G, Montecchia F. Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization (letter). Br J Anaesth. 2003;90(5):705-706.
  8. Gorback MS. Management of the challenging airway with the Bullard laryngoscope. J Clin Anesth. 1991;3(6):473-477.
  9. Bjoraker DG. The Bullard intubating laryngoscopes. Anesthesiol Rev. 1990;17(5):64-70.
  10. Wu TL, Chou HC. A new laryngoscope: the combination intubating device. Anesthesiology. 1994;81(4):1085-1087.
  11. Verghese C. Airway management. Curr Opin Anaesthesiol. 1999;12(6):667-674.
  12. Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology. 1996;84(3):686-699.
  13. Patel P, Verghese C. Delayed extubation facilitated with the use of a laryngeal mask airway in the intensive care unit. Anaesthesia. 2000;55(4):396.
  14. Brimacombe J, Keller C, Hörmann C. Pressure support ventilation versus continuous positive airway pressure with the laryngeal mask airway: a randomised, crossover study of anesthetized adult patients. Anesthesiology. 2000;92(6):1621-1623.
  15. Dörges V, Ocker H, Wenzel V, et al. The laryngeal tube: a new simple airway device. Anesth Analg. 2000;90(5):1220-1222.
  16. Gaitini LA, Vaida SJ, Somri M, et al.. A comparison of the Cobra, Perilaryngeal Airway, and Laryngeal Mask Airway Unique in spontaneously breathing adult patients. Anesthesiology. 2004;101:A518.
  17. Gupta B, McDonald JS, Brooks JH, et al. Oral fiberoptic intubation over a retrograde guidewire. Anesth Analg. 1989;68(4):517-519.
  18. Sivarajan M, Stoler E, Kil HK, et al. Jet ventilation using fiberoptic bronchoscopes. Anesth Analg. 1995;80(2):384-387.
  19. Audenaert SM, Montgomery CL, Stone B, et al. Retrograde-assisted fiberoptic tracheal intubation in children with difficult airways. Anesth Analg. 1991;73(5):660-664.
  20. Klain M, Smith RB. High-frequency percutaneous transtracheal jet ventilation. Crit Care Med. 1977;5(6):280-287.
  21. Enk D, Busse H, Meissner A, et al. A new device for oxygenation and drug administration by transtracheal jet ventilation. Anesth Analg. 1998;86(25):S203.
  22. Safar P, Penninckx J. Cricothyroid membrane puncture with special cannula. Anesthesiology. 1967;28(5):943-948.
  23. Safar P, Bircher NG. Cardiopulmonary Cerebral Resuscitation (3rd ed.). London, England: WB Saunders; 1988.
  24. Wong EK, Bradrick JP. Surgical approaches to airway management for anesthesia practitioners. In: Hagberg CA, ed. Handbook of Difficult Airway Management. Philadelphia, PA: Churchill Livingstone; 2000:209-210.
  25. Gibbs M, Walls R. Surgical airway. In: Hagberg CA, ed. Benumof’s Airway Management 2nd ed. Philadelphia, PA: Mosby Elsevier; 2007:678-696.
  26. Sarpellon M, Marson F, Nani R, et al. Translaryngeal tracheostomy (TLT): a variant technique for use in hypoxemic conditions and in the difficult airway [in Italian]. Minerva Anesth. 1998;64(9):393-397.
Abbreviation Key
AEC airway exchange catheter
AHA American Heart Association
ARDS acute respiratory distress syndrome
ASA American Society of Anesthesiologists
CCD charge-coupled device
CMOS complementary metal oxide semiconductor
CPAP continuous positive airway pressure
CPR cardiopulmonary resuscitation
CPV Cuff Pilot valve
DCI direct-coupled interface
DISS diameter index safety system
DL direct laryngoscopy
DLT double-lumen tube
ED emergency department
EF extra firm
EMS emergency medical services
ENT ear, nose, and throat
ET endotracheal tube
FOB fiber-optic bronchoscope
Fr French
ICU intensive care unit
ID internal diameter
ILMA intubating laryngeal mask airway
ISO International Organization for Standardization
LCD liquid crystal display
LED light-emitting diode
LMA laryngeal mask airway
LT laryngeal tube
LTA laryngeal tracheal anesthesia
MAC Macintosh
MRI magnetic resonance imaging
NGT nasogastric tube
NICU neonatal intensive care unit
NTSC National Television System Committee
OD outer diameter
OR operating room
PEEP positive end-expiratory pressure
PPV positive pressure ventilation
PVC polyvinyl chloride
PVP polyvinylpyrrolidone
SGA supraglottic airway
Stat sterile single-use blade
TFE tetrafluoroethylene
TTJV transtracheal jet ventilation
USB universal serial bus
VL video laryngoscope/laryngoscopy

– See more at: http://www.anesthesiologynews.com/ViewArticle.aspx?d=Educational+Reviews&d_id=161&i=May+2015&i_id=1183&a_id=32361&ses=ogst#sthash.v5MmdQ9q.dpuf

3-D video simulates severe bleeding for combat medics’ training

Posted on by

3-D video simulates severe bleeding for combat medics’ training

Fluid dynamics principles used to calculate and model highly realistic anatomy and bleeding from a shrapnel wound

Yesterday at 6:00 PM (source: http://www.ems1.com/ems-products/Bleeding-Control/articles/33158048-3-D-video-simulates-severe-bleeding-for-combat-medics-training/?nlid=&utm_source=iContact&utm_medium=email&utm_content=TopNewsRelated1Title&utm_campaign=EMS1Member)

By EMS1 Staff

BOSTON — A 3-D simulation of hemorrhage, caused by shrapnel in a human lower leg, was created as a training aide for combat medics.

The video, presented at the fluid dynamics meeting of the American Physical Society by UCLA investigators, adapts smoothed particle hydrodynamics and a 3-D reconstruction of the skin, bone and internal tissue of a lower leg.

The team simulated a lower leg shrapnel wound because of the frequency of those injuries on the battlefield and because the geometry of the leg is relatively easy to model, reported the New Scientist.

“We’re genuinely hopeful that our simulations will enhance the educational experience for medical trainees,” said Jeff Eldredge, who led the work. “We are solving the governing equations of fluid dynamics and tissue mechanics, so these are truly physics-based simulations.”

In the future the research team hopes to add treatments, like tourniquets and drugs, to allow medics to see the real-time impacts on hemorrhage control.

 

FDA: Heater–Cooler Devices Linked to Infection

Posted on by
FDA: Heater–Cooler Devices Linked to Infection
The FDA issued a warning about possible infections associated with heater–cooler devices and issued steps that health care providers and facilities could take to mitigate risks to patients.

Heater–cooler devices are used during cardiothoracic surgeries, as well as other medical and surgical procedures to warm or cool a patient to optimize medical care and improve patient outcomes. These devices include water tanks that provide temperature-controlled water to external heat exchangers or warming/cooling blankets through closed circuits. Although the water in the circuits does not come into direct contact with the patient, there is the potential for contaminated water to enter other parts of the device or be aerosolized through the device’s exhaust vent into the environment and to the patient, according to the FDA.

The FDA reviewed adverse event reports, medical literature, and information from national and international public health agencies, and found that the use of heater–cooler devices has been associated with nontuberculous mycobacterial (NTM) infections, primarily in patients undergoing cardiothoracic surgical procedures.
Nontuberculous mycobacteria are common in the environment and can be found in soil and water, including tap water sources. They are typically not harmful, but in rare cases may cause infections among immunocompromised individuals.
Between January 2010 and August 2015, the FDA received 32 medical device reports (MDRs) of patient infections associated with heater–cooler devices or bacterial heater–cooler device contamination. Twenty-five of these MDRs were reported to the FDA in 2015.
Some reports described NTM infections related to cardiothoracic surgeries, but other reports do not specify the procedures the patients underwent. Eight reports were related to three events describing patient infections occurring in U.S. health care facilities. The remaining 24 reports involved health care facilities outside the United States, most of these in Western Europe. In some cases, patients presented with infections several months to years after their surgical procedures. Of note, half of the 32 reports submitted to the FDA described bacterial contamination of the heater–cooler device without known patient involvement or infection. The FDA is not aware of NTM infections acquired by hospital staff.
The FDA said there was a possibility that there were more infections, but they went unreported. Not everyone recognizes that infections, particularly NTM infections, may be associated with the use of or exposure to a particular medical device, the agency said. The FDA continues to evaluate reports through follow-up with health care facilities and manufacturers to determine which factors may have contributed to the reported events.
In addition to following standard precautions, the FDA recommends that facilities and staff using heater–cooler devices consider implementing the following measures to reduce risk to patients:
  • Strictly adhere to the cleaning and disinfecting instructions provided in the manufacturer’s device labeling. Ensure you have the most current version of the manufacturer’s instructions for use readily available to promote adherence.
  • Do not use tap water to rinse, fill, refill or top off water tanks, as this may introduce NTM organisms. Use only sterile water or water that has been passed through a filter of less than or equal to 0.22 μm.
  • When making ice needed for patient cooling during surgical procedures, use only sterile water or water that has been passed through a filter of less than or equal to 0.22 μm. Deionized water and sterile water created through reverse osmosis are not recommended because it may corrode metal components of the system.
  • Direct the heater–cooler’s vent exhaust away from the surgical field to mitigate the risk of aerosolizing heater–cooler tank water into the sterile field and exposing the patient.
  • Establish regular cleaning, disinfection and maintenance schedules for heater–cooler devices.
  • Develop and follow a comprehensive quality control program for maintenance, cleaning and disinfection of heater–cooler devices.
  • Immediately remove from service heater–cooler devices that show discoloration or cloudiness in the fluid lines/circuits, which may indicate bacterial growth. Consult the hospital infection control officials to perform the appropriate follow-up measures, and report events of device contamination to the manufacturer.
  • Consider performing environmental, air, and water sampling and monitoring if heater–cooler contamination is suspected.
Health care facilities should follow their internal procedures for notifying and culturing patients if they suspect infection associated with heater–cooler devices.
The FDA also asked that any suspected infections be reported to FDA MedWatch.

– See more at: http://www.anesthesiologynews.com/ViewArticle.aspx?ses=ogst&d=Web+Exclusive&d_id=175&i=October+2015&i_id=1232&a_id=34058#sthash.AN6k0f73.dpuf

(source: http://www.anesthesiologynews.com/ViewArticle.aspx?ses=ogst&d=Web+Exclusive&d_id=175&i=October+2015&i_id=1232&a_id=34058)

TRUMLA – All-in-one superabsorbent stretcher pad cover and patient transfer device

Posted on by

TRUMLA

All-in-one superabsorbent stretcher pad cover and patient transfer device

 

Trumla

The superabsorbent, tear-proof stretcher pad cover and patient transfer device has numerous advantages in any situation requiring patient
transport.
First: up to 2.5 Liters (2.64 US quarts) of potentially infectious fl uid, is reliably absorbed and stored in the collection core. Stretcher, beds, and
treatment tables stay clean and dry. Cleaning the stretcher after using Trumla is typically much quicker and easier.
Secondly, because of the reinforced edges on the pad cover, patients weighing up to 210 kg (462 lbs) can be easily and securely transferred.
The Trumla® pad cover can also remain with the patient during transfer from the emergency vehicle to the hospital, where it can then be safely
disposed of. A clean and secure solution that benefi ts both patients and medical professionals.

 

Quick Facts
● Superabsorbent
● Demonstrated to absorb up to 2,5 liters (2.64 US quarts)
● Proven to trap germs
● Rip-proof up to 210 kg body weight (approx. 463 pounds)
● Reliable patient transfer device, size 220 x 100 cm
● Easy disposal
● Enormous potential to save time and costs when cleaning the vehicle and stretcher
● Shorter downtime for EMVs, quicker turnaround to be operational again

 

The process of cleaning and preparing an ambulance, including the stretchers, for use again after an emergency call requires a great deal of time and effort. Depending on the amount and consistency of the fl uid that has been exuded during patient transport, cleaning the vehicle and stretchers can take up to and sometimes longer than half an hour. The total costs for cleaning and disinfecting materials, personnel, and missed revenue due to being grounded can quickly add up. Using the superabsorbent stretcher pad Trumla® can significantly decrease these expenses.