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232 Airway Management

Use Flexible Reinforced Laringeal Mask (SUFRLM) and Wired Endotracheal

Tube (WETT) in oral surgery of adult patients with regard to: surgical condi-

tions, time of induction and emergence of anesthesia and time of discharge

from the recovery room. In adition we also compared the postoperative inci-

dence of dysphagia, dysphonia and sore throat between both devices.

Materials and Methods: Prospective randomized study conducted on 28

adult patients, 14 in each group, of ASA I - III, who were submitted to oral

surgery under general anesthesia between January and December of 2011.

 Anesthesia was induced with fentanyl and propofol and no muscular relaxant

was used. SUFRLM or WETT was inserted and cuff inflated. Anesthesia was

maintained with O2 and Sevoflurane. The data were collected by the anesthe-

siologist and the recovery nurse that was blind for the type of airway device

used. The output data were processed by the SPSS statistical soft ware, com-

paring dichotomous variables with Chi2 test, at a significance level of 0.05.

Results and Discussion: No statistical diffrences were found in what con-

cerns to induction (SUFRLM 6.71 min Vs WETT 5.14 min, p= 0.27, CI 95%

(0.48 - 3.6)) and emergence (SUFRLM 4.57 min Vs WETT 5.79 min, p= 0.277,

CI 95% (0.46- 1.03)) times.The recovery time in the WETT group was shorter

than the SUFRLM group (SUFRLM 163.15 min Vs WETT 103.21 min, p= 0.01,

CI 95% (28.3 - 91.57)). There were no statistical differences in the surgical

conditions, the incidence of dysphonia or dysphagia and suplemental O2 

needs in the recovery room. The incidence of sore throat was higher in the

SUFRLM group (SURFLM n=5 (35%) vs WETT n=0 (0%), p= 0.014).

Conclusion(s): The use of SUFRLM appears to be responsible for higher re-

covery times, and superior incidence of sore trhoat when compared with the

WETT, in oral surgery in adults. Nevertheless we will continue studying this

subject in order to achieve a more representative sample.References:1. J Anesth 21:99, 2007;

2. European Journal of Anaesthesiology 27:11 pp941-946, 2010.

19AP3-1

The effect of cricoid pressure on glottic view improvement at

laryngoscopy

Maleki A., Zahedi H.

Tehran University/Tebi Center Hospital, Department of Anaesthesiology,

Tehran, Iran, Islamic Republic of 

Background and Goal of Study: The effect of cricoid pressure on the view at

laryngoscopy is unknown. However, cricoid pressure may make the best view

at lar yngoscopy.1 Cricoid pressure is a superficially simple in practice but it is

a complex manoeuvre which is difficult to perform optimally.2,3 The aim of the

present study was to evaluate the efficacy of cricoid pressure on laryngeal

view improvement at laryngoscopy.Materials and Methods: The investigation was carried out as a prospective

randomized double blind study. A total of 84 patients undergoing standard-

ized general anesthesia presenting for elective ophthalmic surgery in Fara-

bi Hospital in 2010-2011 years. Then patients were randomly assigned to :

Group I (with cricoid pressure) (n = 42), group II (without cricoid pressure)

(n = 42) at laryngoscopy. Cricoid pressure was applied in an upward and

backward direction with t wo fingers by the thumb and forefinger on each side

of cricoid cartilage. All patients were assessed by one blind anesthesiologist

for laryngoscopic views and their changes in each groups. Results were ana-

lyzed by X2 test. A P value of < 0.05 was taken as significant.

Results and Discussion: Demographic data were similar in two groups

(p>0.05). The grades of the in first view at Laryngoscopy was not significantly

dif ference in groups (p=0.803). The changes in glottic view show significant

dif ference between two groups (p=0.000). The improved view was 69% in

pressure group and 23.8% in without pressure group (p=0.000). The changes

in glottic views was better with cricoid pressure in an upward and backward

direction.

Conclusion(s):Use of cricoid pressure in an upward and backward directionwith the thumb and forefinger on each side of cricoid cartilage, can provide

the best view at laryngoscopy. It is safe and effective by trained anesthesi-

ologist. These data suggest cricoid pressure particularly in an upward and

backward direction, should be considered when the initial glottic view is not

adequate for intubation.

References:1. Randell T, Määttänen M, Kyttä J. The best view at laryngoscopy using the McCoy

laryngoscope with and without cricoid pressure. Anaesthesia. 1998 Jun;53(6):536-9.

2. Jabalameli M, Hashemi J, Mazoochi M. The ef fect of differ ent Sellick’s maneuver on

laryngoscopic view and intubation time. Journal of Research in Medical Sciences 2005;

10 (5):285-287.

3. Brimacombe J, Berry A. Review article: Cricoid pressure. CAN I ANAESTH 1997; 44:

4: 414-425.

19AP3-2

Consideration of the devices which can decrease the air

leakage while in using LMA

Tennichi T., Toyama K., Taki Y., Nagase N.

Takaoka City Hospital, Department of Anaesthesiology and Intensive Care,

Takaoka, Japan

Background and Goal Study: Laryngeal mask airway (LMA) is the advanced

airway management tools. But, when we use LMA under mechanical ven-tilation, we often encounter the air leakage. Therefore, we saw if we can’t

decrease the air leakage.

Then, we discovered that the air leakage while in using LMA could be de-

creased by pressing the body surface of the neck.

 As the result of trial and error, we made new devices for decreasing the air

leakage and evaluated the effect of them.

Material and method: We found that the air leakage could be decreased

by compressing external side between infrahyoid region on both sides and

upper border of thyroid cartilage percutaneously with two cylindrical gauze

(2cm thick around, 5~8cm long).

Then, we made devises which can be fixed by wrapping them around their

neck with Velcro.

We made varied sizes of them and put it which can decrease the air leakage

most effectively on.

Eighty-one patients were undergone general anesthesia while in using LMA.

When the air leakage occurred, we put it on. Then, we divided them into four

groups based on amount of leaking air.

Result:  Air leakage was occurred in thirt y-nine patients. Among them, we

used the devices in thirt y-six patients belonging to three groups (group2,3,4).

(amount of leaking air; group1: none, group2: 79±43ml, group3: 223±87ml,

group 4: avaluative)

 After using the devices, the air leakage decreased significantly for every

group.

(amount of leaking air; group2: 31±30ml, group3: 26±18ml, group4:

60±50ml) (P< 0.0005)

Furthermore, there were no problems of the breathing, blood circulatory and

nerve system.

Discussion: According to a report, some people increased the amount of cuff

when the air leakage occurred. But it was pointed out the possibility of tissue

perfusion abnormality.

No one has reported whether the air leakage could be decreased by com-

pressing the regions percutaneously.

The regions fall under near the outside superior border of the thyroid car tilage

anatomically.

There were no complications. Therefore, it can be concluded that the devicesare safe to use.

Conclusion: While in using LMA under mechanical ventilation, the devices

can decrease the air leakage safely.

19AP3-3

Comparison of the Laryngeal Mask Airway SupremeTM 

insertion techniques: reverse insertion technique vs. 

standard insertion technique

Tampo A., Suzuki A., Sako S., Iwasaki H.

 Asahikawa Medical University, Depar tment of Anaesthesiology and Intensive

Care, Asahikawa, Japan

Background and Goal of Study: Laryngeal Mask Airway (LMA) is widely

used for routine and dif ficult airway management, and also in emergency situ-

ations. “Thumb insertion” is a well known technique used when the anaesthe-

siologist is restricted to access patient’s head end. The latest LMA, Supreme™

(SLMA), has an anatomical shaped design with holding tab so that the anes-thesiologist does not need to insert an index finger along with the LMA shaft.

In addition, the insertion of the SLMA from patient side is not studied yet.

Thus, we conducted the manikin study to evaluate that SLMA is also use-

ful when the performer is restricted to standard insertion approach. In this

study, we compared the utility of SLMA with standard and reverse insertion

techniques.

Materials and Methods:  After institutional approval and written informed

consent from participants, twenty seven anesthesiologists in our department

attempted insertion of SLMA with standard and reverse (approach from the

side) insertion techniques on an air way management trainer manikin (Laerdal

Medical, Stavanger, Norway). After brief introduction of the device and prac-

tice for inserting the SLMA into the manikin, participant performed two inser-

tion with different techniques. For each technique, insertion time (the time that

the participant hold the device to complete the first successful ventilation),

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233 Airway Management

ease of insertion (scored with verbal rating scale; VRS), were evaluated. Af ter

insertion, ventilation status was evaluated. SLMA position was evaluated with

the percentage of glottic opening (POGO) score by using a fiberoptic bron-

choscope to observe the vocal cord via the outlet of the SLMA air conduit.

For statistical analysis, paired t-test was used and P < 0.05 is considered as

significant. Data are reported as mean ± sd.

Results and Discussion: The time for insertion showed no difference be-

tween both techniques (13.4 ± 2.1 sec with the standard technique, and 13.9

± 2.4 sec with the reverse technique).

However, the ease of insertion score was grater with the standard technique

(94.4 ± 5.4) compared to the reverse technique (87.5 ± 11.2). The ventilation

status and POGO scores were not significant between the two techniques.

Conclusions: Reverse insertion technique of LMA SupremeTM  is equally ef-

fective compared with standard insertion technique. This technique can be

used under emergency situations that the access to the patient head end is

restricted.

19AP3-4

Evaluation of the LMA position using ultrasound in pediatric

patients

Kim J.M., Kil H.-K.

Yonsei University College of Medicine, Department of Anaesthesiology and

Pain Medicine, Seoul, Korea, Republic of 

Background and Goal of Study:  Although the LMA insertion is not dif ficult

and the majority of cases with LMA fare well in ventilation, the fiberscopicassessment demonstrates a high incidence of LMA malpositioning. The fiber-

scopic grading of Rowbottom et al. is commonly used for positioning LMA,

but the rotated degree of LMA is not considered in that grading. We hypoth-

esized that the LMA can af fect the position of the arytenoids/thyroid cartilages

and it may be detected on ultrasound.

This study was designed to assess the predictability of detecting the rotated

LMA according to the position change of arytenoids/thyroid cartilages using

the ultrasound.

Materials and Methods: Children, aged 1 ms - 6 years, undergoing infraum-

bilical surgery were enrolled. Ultrasound was performed on the supraglottic

and vocal cords area before and after the LMA insertion. Transverse images

were obtained on the end-expiratory phases. LMA-position was evaluated

with Bonfils fiberscope. Position grading was made as usual. If grade >3 was

showed, LMA was repositioned while observing with fiberscopy. If the face of

LMA was rotated to one-side, the LMA was rotated to the opposite side a little.

The ultrasound findings of pre- and post-LMA were compared. On fiberscopic

images, conventional LMA grade and the degree of rotation were measured.

Results and Discussion: A total of 26 cases were completed in the study. In9/26 cases, LMA was rotated to left or right side in a range of 10-40◦. In 8/9

cases, ultrasound showed asymmetrical elevation of the arytenoids/thyroid

cartilage after the LMA insertion.

LMA- grade Number Rotated LMA US-detectable

I 13 6 5

II 6 2 2

III 3 0 0

IV 0 0 0

V 4 1 1

[Table1. Patients characteristics]

[Sonographic findings and fiberscopic finding]

Conclusion(s): Real-time ultrasound can be useful in positioning of the ro-

tated LMA

19AP3-5

Real-time changes of pressure-volume curve provide objective

information on efficiency of face mask ventilation during

induction of anaesthesia: an observational study

Hascilowicz T., Kiyama S., Hobo S., Ohashi Y., Yoshioka S., Uezono S.

 Jikei University School of Medicine, Department of Anaesthesiology and

Intensive Care, Tokyo, Japan

Background and Goal of Study: Face mask ventilation (FMV) is one of es-sential skills of anaesthetists. Opioids, sedatives and neuromuscular blocking

agents (NMBA), as well as patient- and anaesthetist-related factors, influence

ef ficiency of FMV. However, no objective methods to assess efficiency of FMV

have been established. The purpose of the present study was to examine

whether real-time visualization of pressure-volume curve (P-V curve) changes

enables objective assessment of FMV during induction of anaesthesia.

Materials and Methods: Ten anaesthetists (trainees and staf f-grade) ven-

tilated lungs of 26 patients following induction of general anaesthesia. P-V

curves continuously drawn on the spirometry display of Aisys Carestation (GE

Healthcare, Helsinki, Finland) were video-recorded. Shape and tilt of diagonal

line of P-V curves were graphically processed and analysed.

Results: 1) Changes of P-V curve were easily recognised in a real-time fash-

ion. 2) P-V curve changed significantly during FMV in 11 patients (42%). 3)

P-V curve changes corresponded well with the subjective “feel” of easier FMV

after administration of NMBA. 4) In patients with subjectively more difficult but

possible FMV, shape of P-V curves showed characteristic sequential increase

of tilt angle, which reflected effects of drugs used for induction as well as

gradually improving fitting of a face mask.

Conclusion(s):Real-time observation of the P-V cur ve during induction of an-

aesthesia provides objective information on the ef ficiency of FMV. Compared

to other parameters used to assess FMV efficiency (e.g. VTi /V

Te ratio, P

max), P-V

curve can be a visual objective proof of ease or difficulty of FMV.

[PV curve changes during mask ventilation]

19AP3-6

Jet speed: subjective and objective review of speed at which

anaesthetists can perform needle cricothyroidotomy and jet

ventilation

Shonfeld A., Boynton C., Vaughan D.

Northwick Park Hospital, Department of Anaesthesiology, London, United

KingdomBackground and Goal of Study: Needle cricothyroidotomy (NCTO) is an im-

portant rescue technique in can’t intubate, can’t ventilate scenarios [1]. NAP4

highlighted the difficulty in performing NCTO and lack of successful oxygen-

ation [2]. This projects aim was to look at performance of anaesthetists of all

grades in performing the procedure.

Materials and Methods: We constructed a model larynx from a sheep’s lar-

ynx and trachea and medical adhesive tape and gained consent from par-

ticipants. We instructed the participants to perform a NCTO and attempt to

oxygenate. We then gave an example demonstration of how to perform a

NCTO and use the Sanders jet ventilator. The par ticipants were then asked to

perform a NCTO and oxygenate again and the first and second times were

compared. The candidates completed a questionnaire before and after the

practical assessment.

Results and Discussion: The candidates ranged from 1st  year trainees to

senior consultants. 20% of anaesthetists had previously performed a NCTO