supraglottic airways
TRANSCRIPT
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Advancement in Supraglottic Airways
Speaker- Dr Mohammed zahid yergatti, DA(DNB)
Moderator- Dr Madhavi singh, MD
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Definition
• These are airway devices that facilitate oxygenation and ventilation without endotracheal intubation. Some also refer them as extraglottic
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Classification Based on sealing mechanism• Perilaryngeal sealers- • All LMAs• I-Gel• Air- Q Intubating laryngeal airway
• Pharyngeal sealers-• Combitube• Streamlined liner of pharynx airway(SLIPA)• Laryngeal tube
• Both• Cobra perilaryngeal airway(cobra PLA)
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Based on evolution• First generation devices- simple airway tubes
• Classic LMA• Flexible LMA• CobraPLA
• Second generation- with addition of drainage tubes• Proseal LMA• I-Gel • LMA supreme• SLIPA
• Third generation- cuffless, two drain tubes, small bowl• Baska mask.
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Timeline- few out of 17 variants• Classic laryngeal mask airway(cLMA)- 1988• Esophagael tracheal combitube- 1988• LMA fastrach- 1995• LMA Proseal- 2000• Laryngeal tube- 2003• I-Gel-2003• Air-Q- 2004• LMA supreme- 2007• Baska mask ~2012
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LMA- laryngeal mask airway
• Dr archie brain is first credited with invention and development of LMA
• He first used a goldmans mask and attached it a obliquely cut endotracheal tube.
• It was introduced in 1988.
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Classic LMA
Main shortcomings- • Bending of tip, if we keep pushing during insertion it can push
the epiglottis over larynx and cause obstruction of airway• Rotation and dislodgment of the bowl, • lesser sealing pressure, more risk of aspiration, inaccurate
placement
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Esophageal- tracheal combitube
• PVC double lumen with two inflatable cuffs
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• Ventilation either through tracheal or oesophageal port
• Distal ballon either seals trachea or oesophageous.
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advantages
• Requires minimal training and minimal mouth opening• Useful in non fasted pts during emergency
disadvantages• Only adult and small adult sizes available • Oesophagel trauma• Problems in maintaing seal with movement.
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Porseal LMA
Developed basically for more better sealing pressure and acsess to oesophaeous.
Modifications over classic LMA-Larger and deeper bowl with no grilleDarinage tube running parallel to airwayLarger deeper bowl and dorsal exension of cuff
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Advantages over classic LMA
• Gastric tube port- for gastric access, checking correct positioning, bougie guided insertion.
• Dorsal cuff- better seal and airway pressure- not present in 2 ½ & below.– with drain tube occluded it prtected airway to
soiling pressures of 68cm of H20*• Bite block• Strap/Hinge for hooking the bougie/introducer.
*Evans NR, Gardner SV, James MF. ProSeal laryngeal mask protects against aspiration of fluid in the pharynx. Br J Anaesth 2002; 88: 584–7
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Disadvantages over cLMA
• More incidence of trauma, equivocal incidence of sore throat*
• Slightly longer insertion time compared to cLMA.
• 20% more airway resistance than cllasic airway.
*Brimacombe J, Keller C, Fullekrug B, et al. A multicenter study comparing the ProSeal™ and Classic™laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology 2002; 96: 289–95.
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Comparison of PLMA with cLMA
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Performance of proseal
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Laryngeal tube
• Multi use , single lumen• Two low pressure cuffs- distal and proximal• Two anterior oval ventilating ports between the cuffs.
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advantages
Easy insertionMinimal mouth opening required. High ventilation pressure can be usedCan be used to intubate trachea
disadvantagesAirway obstruction- narrowingTrauma to pharynxCuff rupture
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I-Geltm
• Single-use non-inflatable mask made of a gel-like thermoplastic elastomer.
• Epiglottic rest to prevent epiglottic downfolding
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• Gastric access channel (not present in size 1)• Built-in bite block• Buccal cavity stabiliser
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Lisa Sohn • Razan Nour • Narasimhan Jagannathan-Update on Airway DevicesCurr Anesthesiol Rep (2015) 5:147–155 DOI 10.1007/s40140-015-0100-2
• Advantages- – It has better anatomical fit and improves its airway
seal as it approaches body temperature.– Less risk for injuries related to cuff hyperinflation
and decreases the time for successful insertion.– i-gel in meta analysis has been found to be having
greater airway leak pressures and superior fibreoptic views compared to other SGAs.
– Wide lumen allows for airway rescue and assisted intubation.
– Effective in prone position rescue.
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video
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• Large inflatable plastic cuff no post cuff.• Finns in the mask of bowl to prevent epiglottic
obstruction.• Pharyngeal seal intermediate between cLMA and
Proseal LMA.
LMA supreme
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Advantages• Reinforced tip- less chance of folding.• Anatomic curve facilitates insertion• Oval cross section for improved stability.
disadvantages• Drain tube runs through the middle of airway
dividing it into narrow two lumens- limiting its use for intubation, airway inspection.
• PVC is more harder and more traumatic than silicone.
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SLIPA-Streamlined Liner of the Pharynx Airway
• Plastic uncuffed disposable• Hollow boot shaped distal part• Anatomically fits pharynx
– Toe rests in oseophageal entrance– Bridge fits in pyriform fossa– Heel – anchors to softpalate– Large size prevents aspiration of regurgitated fluid
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advantges
• Greater airway sealing pressue for PPV• cuffless
disadvantages• More trauma• Prone to airway variability as occupies pace
upto softpalate.
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Baska mask
• 3rd generation supraglottic irway• Smaller bowel compared to other LMAs- less
risk of including oesophageal opening• Adjustable tab in shaft to increase angulation to
allow easy negotiation of oropharyngeal curve• Double gastric channel- one channel is open to
air so less chance of oesophageal wall impinging the gastric opening during suction
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• Bigger distal gastric channel opening so more larger particulate can be sucked out
• During extubation – if pt bites the bowl the gastric channels can be opened for airway.
• Cuffless- membranous bowl which inflates during each positive pressure.
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video
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• The mean insertion time was lesser than PLMA*
• It had higher sealing pressures than PLMA- 29.98+- 8.51 vs 24.5+-6.19 cm of H2O*
*Sharifa Ali Sabeeh Al-Rawahi et al- ORIGINAL ARTICLE – A comparative analysis of the Baska® Mask vs. Proseal® laryngeal mask for general anesthesia with IPPV- Anaesthesia, Pain & Intensive Care-ISSN 1607-8322, ISSN (Online) 2220-5799
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Role in difficult airway algorithm
• Clear recommendation by Difficult airway society 2015 guidelines in both anticipated and unanticipaed difficult airway.
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• Specially important in can’t intubate, can’t ventilate situations
• Laryngeal mask exchange recommended in at risk extubations*
*DAS 2015 guidelines
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Airway rescue with proseal LMA case reports
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Airway rescue with i-gel
• i-gel is established in emergency airway control. Case reports are present where it has been used for airway rescue when cLMA and PLMA have failed*
• I-gel has been used for airway rescue in prone position**
*Anaesthesia, 2008, 63, pages 1010–1026- Use of an i-gelTM for airway rescue**The use of a laryngeal mask airway for emergent airway management in a prone child.Dingeman RS, Goumnerova LC, Goobie SM Anesth Analg. 2005 Mar; 100(3):670-1
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Supraglottic airway guided ET intubation and fibre optic laryngoscopy
• LMA fastrach• LMA proseal• LMA supreme• I-gel• Air q• Ambu aura• Slipa
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Comparing fibreoptic views through supraglottic airways*
(1) full view of glottis (2) vocal cords, arytenoids, and inferior surface of epiglottis visible (3) only superior surface of epiglottis visible (4) no part of epiglottis or larynx visible
*BioMed Research International Volume 2015 (2015), Article ID 201898, 8 pageshttp://dx.doi.org/10.1155/2015/201898Comparison of Five 2nd-Generation Supraglottic Airway Devices for Airway Management Performed by Novice Military Operators
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DAS guidelines for fibreoptic intubation with Supraglottic airway
video
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Thank you