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Fukutome T, Amaha K, Nakazawa K, Nakazawa K, Kawamura H: Tracheal intubation through the intubating laryngeal mask airway (LMA-Fastrach) in patients with difficult airways. Anaesth Intensive Care 26: 387-91
Abstract
The intubating laryngeal mask airway was used in 31 adult patients in whom tracheal intubation was known or suspected to be difficult. The intubating laryngeal mask airway was successfully inserted in 30 patients and provided a clinically patent airway. In the remaining one patient it was impossible to insert the device correctly. Tracheal intubation through the device was successful in 28 of 30 patients (93%). These results suggest that the intubating laryngeal mask airway has a potential role for tracheal intubation in adult patients with difficult airways.
... The introduction of laryngeal mask airway (LMA) in 1985 by Brain,[2] was a major breakthrough in difficult airway management; however, its role in facilitating tracheal intubation is limited. Intubating laryngeal mask airway (ILMA) was designed to overcome this limitation and since than there have been a number of reports of successful intubation through the ILMA in cases of unanticipated and anticipated difficult airway.[3456] ...
Background:
A specially designed wire-reinforced endotracheal tube — the Fastrach silicone tube (FTST) designed to facilitate endotracheal intubation through intubating laryngeal mask airway (ILMA) are expensive and not readily available. Hence, it is worth considering alternative such as polyvinyl chloride tracheal tube (PVCT), which is disposable, cheap and easily available. The aim of the present study was to compare the clinical performance of FTST with conventional PVCT for tracheal intubation through ILMA.
Methods:
After informed consent, 60 ASA I-II adults with normal airway undergoing elective surgery were randomly allocated to undergo blind tracheal intubation through ILMA with a FTST or conventional PVCT. Overall success rate, ease of insertion, number of attempts for successful intubation, critical incidence during intubation and post-operative sore throat were compared.
Results:
The overall success rate with FTST was 96.63% and 93.33% with PVCT; in addition, the first-attempt success rate was 86.25% with FTST compared to 82.14% with PVCT. The time taken for intubation was 18.6 ± 6.8 s. in FTST group and 22.42 ± 8.5 s. in PVCT group. Incidence of sore throat was 21.42% in PVCT group compared with 6.89% in FTST group.
Conclusion:
Blind tracheal intubation through an ILMA with the conventional PVCT instead of FTST is a feasible alternative in patients with normal airways.
Im Jahr 1997 stellte Dr. Brain, der Erfinder der Larynxmaske (LMA), die Intubationslarynxmaske vor (ILM, internationaler Freiname: Intubating Laryngeal Mask Airway, ILMA, Handelsname LMA-Fastrach; Brain et al. 1997a,b). Schwerpunkt der ILM sind die erfolgreiche blinde Intubation bei schwieriger oder konventionell unmöglicher Intubation, wobei die ILM die gleichen herausragenden Beatmungseigenschaften wie eine LMA aufweist.
Airway management in the critical care setting encompasses a wide, diverse range of topics, well beyond simply tracheal intubation. The delivery of oxygen and effective ventilation is affected by a multitude of clinical situations in the intensive care arena that can be lifesaving but equally could threaten the patient’s outcome if not properly executed in a timely manner. From noninvasive ventilation devices extending to an accidently decannulated “fresh” bleeding tracheostomy site, it is imperative that the ICU offers the ability to deploy an experienced airway team equipped with basic and advanced airway adjuncts coupled with primary and secondary rescue strategies in the pursuit of improved patient safety.
Aim : Introduction: The intubating laryngeal mask airway (ILMA; Fastrach™; Laryngeal Mask Company, Henley-on-Thames, UK) guided tracheal intubation is a better alternative to fiberoptic endoscope (FOE) guided tracheal intubation in patients with anticipated difficult airway. Therefore we compared the effectiveness of ILMA with FOE in patients with anticipated difficult intubation. Methods: Sixty patients, with at least one difficult intubation marker (Mallampati grade III or IV, thyromental distance < 6.0 cm , mentohyoid distance < 4.5 cm) were randomly divided into ILMA group and FOE group of 30 patients each in this prospective randomized study. Induction was done by propofol and maintained with fentanyl and propofol after efficient mask ventilation was possible. The success of the device (within three attempts), the number of attempts, duration of attempts, haemodynamic parameters(HR,SBP,DBP and MAP) were recorded at different time intervals and adverse events (oxygen saturation < 90%, soft tissue trauma, bronchospasm) were recorded. Results: The rate of successful tracheal intubation with ILMA was 100% and was comparable with FOB (93.33%). The number of attempts and duration of attempts were significantly lesser in ILMA group. In case of failure of FOE device, ILMA was always successful in those patients. Both the devices were equally potent in terms of haemodynamic stability. Adverse events (oxygen saturation < 90%, soft tissue trauma, bronchospasm) were significantly more with patients where FOE was used. Conclusion: we conclude from our study that ILMA guided tracheal intubation is a better alternative to FOE guided tracheal intubation in patients with anticipated difficult airway with respect to ease of insertion (number and duration of attempts), however the success rate of intubation with both the devices were similar. The adverse events were less in ILMA guided tracheal intubation as compared to FOE guided intubation and both the groups were comparable in terms of haemodynamic stability. © 2015, Datta Meghe Institute of Medical Sciences Deemed University. All rights reserved.
Supraglottic airway devices (SADs) are used to keep the upper airway open to provide unobstructed ventilation. Early (first-generation) SADs rapidly replaced endotracheal intubation and face masks in > 40% of general anesthesia cases due to their versatility and ease of use. Second-generation devices have further improved efficacy and utility by incorporating design changes. Individual second-generation SADs have allowed more dependable positive-pressure ventilation, are made of disposable materials, have integrated bite blocks, are better able to act as conduits for tracheal tube placement, and have reduced risk of pulmonary aspiration of gastric contents. SADs now provide successful rescue ventilation in > 90% of patients in whom mask ventilation or tracheal intubation is found to be impossible. However, some concerns with these devices remain, including failing to adequately ventilate, causing airway damage, and increasing the likelihood of pulmonary aspiration of gastric contents. Careful patient selection and excellent technical skills are necessary for successful use of these devices.
In the 2010 American Heart Association guidelines, supraglottic devices (SGDs) such as the laryngeal mask are proposed as alternatives to tracheal intubation for cardiopulmonary resuscitation. Some SGDs can also serve as a means for tracheal intubation after successful ventilation. The purpose of this study was to evaluate the effect of chest compression on airway management with four intubating SGDs, aura-i(®) (aura-i), air-Q(®) (air-Q), i-gel(®) (i-gel), and Fastrack(®) (Fastrack), during cardiopulmonary resuscitation using a manikin.
Twenty novice physicians inserted the four intubating SGDs into a manikin with or without chest compression. Insertion time and successful ventilation rate were measured. For cases of successful ventilation, blind tracheal intubation via the intubating SGD was performed with chest compression and success or failure within 30 s was recorded.
Chest compression did not decrease the ventilation success rate of the four intubating SGDs (without chest compression (success/total): air-Q, 19/20; aura-i, 19/20; i-gel, 18/20; Fastrack, 19/20; with chest compression: air-Q, 19/20; aura-i, 19/20; i-gel, 16/20; Fastrack, 18/20). Insertion time was significantly lengthened by chest compression in the i-gel trial (P < 0.05), but not with the other three devices. The blind intubation success rate with chest compression was the highest in the air-Q trial (air-Q, 15/19; aura-i, 14/19; i-gel, 12/16; Fastrack, 10/18).
This simulation study revealed the utility of intubating SGDs for airway management during chest compression.
Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group's mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.
Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.
The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative "Plan B" technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, "cannot intubate, cannot oxygenate" situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.
Abstract This review discusses the history, developments, benefits, and complications of supraglottic devices in prehospital care for adults and pediatrics. Evidence supporting their use as well as current controversies and developments in out-of-hospital cardiac arrest and rapid sequence airway management is discussed. Devices reviewed include the Laryngeal Mask Airway, Esophageal Tracheal Combitube, Laryngeal Tube, I-Gel, Air-Q, Laryngeal Mask Airway Fastrach, and the Supraglottic Airway Laryngopharyngeal Tube (SALT).
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