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Concept: Laryngeal mask airway

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To test the hypothesis that muscle relaxant is not necessary in patients who are undergoing laparoscopic gynecological surgery with a ProSeal Laryngeal Mask Airway (ProSeal LMA™).

Concepts: Laparoscopic surgery, Laryngeal mask airway, Surgery

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INTRODUCTION: Various supraglottic airway devices are routinely used to maintain airway patency in children and adults. However, oropharyngeal airways or laryngeal masks (LM) are not routinely used during neonatal resuscitation. METHOD: The aim of this article was to review the available literature about the use of supraglottic airway devices during neonatal resuscitation. We reviewed books, resuscitation manuals and articles from 1830 to the present using the search terms “Infant”, “Newborn”, “Delivery Room”, “Resuscitation”, “Airway management”, “Positive Pressure Respiration”, “Oropharyngeal Airway” and “Laryngeal Mask”. RESULTS: No study was identified using oropharyngeal airways during neonatal resuscitation. Four trials including 509 infants compared positive pressure ventilation with a LM, bag and mask or an endotracheal tube. Infants in the LM group were intubated less frequently compared to infants in the bag and mask ventilation group 4/275 vs. 28/234 (OR 0.13, 95% CI 0.05-0.34). Infants resuscitated with the LM had significantly less unsuccessful resuscitations 4/275 vs. 31/234 (OR 0.10, 95% CI 0.03-0.28). Two trials including 34 preterm infants compared surfactant administration via LM vs. endotracheal tube. LM surfactant administration was safe and no adverse events were reported. CONCLUSION: The efficacy and safety of oropharyngeal airways during neonatal resuscitation remain unclear and randomized trials are required. The current evidence suggests that resuscitation with a LM is a feasible and safe alternative to mask ventilation in infants >34 weeks gestation and birth weight >2000g. However, further randomized control trials are needed to evaluate short- and long-term outcomes following use of laryngeal masks. In addition, surfactant administration via LM should be used only within clinical trials.

Concepts: Systematic review, Airway management, Endotracheal tube, Laryngeal mask airway, Randomized controlled trial, Infant, Childbirth, Oropharyngeal airway

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PURPOSE: The air-Q® intubating laryngeal airway (ILA) is a supraglottic device (SGD) designed specifically to function as both a primary airway and a bridging device and conduit for fibreoptic intubation in difficult airway scenarios. This observational study evaluated the usability and performance characteristics of pediatric air-Q ILA sizes 1.0, 1.5, 2.0, and 2.5 when used as a primary airway. METHODS: One hundred ten children, American Society of Anesthesiologists physical status I-III and undergoing elective surgery, received a weight-appropriate air-Q ILA following induction of anesthesia. The evaluation criteria included ease of insertion, quality of ventilation, presence of gastric insufflation, oropharyngeal leak pressures (OLPs) and maximum tidal volumes (VT max) in five different head positions, and fibreoptic view of the glottis. RESULTS: For sizes 1.0, 1.5, 2.0, and 2.5, the median [P25,P75] neutral OLPs (cm H2O) were 23.0 [20.0,30.0], 16.5 [15.0,20.8], 14.0 [10.0,17.8], and 14.0 [11.3,16.8], respectively. The median [P25,P75] neutral VT max values (mL·kg(-1)) were 17.4 [14.3,19.7], 20.3 [16.8,25.5], 17.8 [14.5,22.1], and 14.0 [11.6,16.0], respectively. Median [P25,P75] ease of insertion scores (0-10; 0 = easiest ever, 10 = most difficult ever) were 1 [1,2], 2 [2,3], 2 [1,2.8], and 2 [2,3] respectively. Ventilation was adequate in 108/110 cases, and a fibreoptic view of the vocal cords was obtained in 102/110 cases. CONCLUSIONS: The air-Q ILA functions acceptably as a primary SGD in infants and children. The OLPs are lower than published values for the ProSeal laryngeal mask airway (LMA ProSeal™), the current pediatric SGD of choice, but adequate tidal volumes are readily achievable. The fibreoptic views of the glottis portend well for fibreoptic intubation through the device. (This trial was registered at clinicaltrials.gov number, NCT00885911).

Concepts: Observational study, Human voice, Oropharyngeal airway, Intubation, Endotracheal tube, Anesthesia, Surgery, Laryngeal mask airway

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BACKGROUND: In Dutch ambulance practice, failure or inability to intubate patients with altered oxygenation and/or ventilation leaves bag-valve mask ventilation as the only alternative, which is undesirable for patient outcome. A novel Laryngeal Mask Airway Supreme (LMA-S) device may be a suitable alternative. AIM: To evaluate the effectiveness and suitability of the LMA-S for emergency medical services in daily out-of-hospital emergency practice. METHODS: After a period of theoretical and practical training of ambulance paramedics in the use of the LMA-S, prospective data were collected on the utilisation of LMA-S in an observational study. Procedures for use were standardised and the evaluation included the number of direct intubation attempts before using LMA-S, attempts required, failure rate and the adequacy of ventilation. Data were analysed taking patient characteristics such as age and indication for ventilatory support into account. RESULTS: The LMA-S was used 50 times over a period of 9 months (33 involving cardiorespiratory arrest, 14 primary and three rescue). The LMA-S could be applied successfully in all 50 cases (100%) and was successful in the first attempt in 49 patients (98%). Respiratory parameters showed adequate oxygenation. All paramedics were unanimously positive about the utilisation of LMA-S because of the easiness of the effort of insertion and general use, and emphasised its value as a useful resource for patients in need. CONCLUSIONS: Ensuring ventilation support by using LMA-S by paramedics in prehospital emergency practice is safe and effective.

Concepts: Laryngeal mask airway, Mechanical ventilation, Intubation, Ambulance, Endotracheal tube, Paramedic, Emergency medical technician, Emergency medical services

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Upper airway ultrasound is a valuable, non-invasive, simple, and portable point of care ultrasound (POCUS) for evaluation of airway management even in anatomy distorted by pathology or trauma. Ultrasound enables us to identify important sonoanatomy of the upper airway such as thyroid cartilage, epiglottis, cricoid cartilage, cricothyroid membrane, tracheal cartilages, and esophagus. Understanding this applied sonoanatomy facilitates clinician to use ultrasound in assessment of airway anatomy for difficult intubation, ETT and LMA placement and depth, assessment of airway size, ultrasound-guided invasive procedures such as percutaneous needle cricothyroidotomy and tracheostomy, prediction of postextubation stridor and left double-lumen bronchial tube size, and detecting upper airway pathologies. Widespread POCUS awareness, better technological advancements, portability, and availability of ultrasound in most critical areas facilitate upper airway ultrasound to become the potential first-line non-invasive airway assessment tool in the future.

Concepts: Larynx, Laryngeal mask airway, Intubation, Future, Biopsy, Tracheotomy, Cricoid cartilage, Endotracheal tube

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Mortality rates from birth asphyxia in low-income countries remain high. Face mask ventilation (FMV) performed by midwives is the usual method of resuscitating neonates in such settings but may not always be effective. The i-gel is a cuffless laryngeal mask airway (LMA) that could enhance neonatal resuscitation performance. We aimed to compare LMA and face mask (FM) during neonatal resuscitation in a low-resource setting.

Concepts: Performance, Infant mortality, Childbirth, Laryngeal mask airway

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INTRODUCTION: Airway management is an important component of cardiopulmonary resuscitation (CPR). Recent guidelines recommend keeping any interruptions of chest compressions as short as possible and not lasting more than 10 seconds. Endotracheal intubation seems to be the ideal method for establishing a secure airway by experienced providers, but emergency medical technicians (EMT) often lack training and practice. For the EMTs supraglottic devices might serve as alternatives. METHODS: 40 EMTs were trained in a 1-hour standardised audio-visual lesson to handle six different airway devices including endotracheal intubation, Combitube, EasyTube, I-Gel, Laryngeal Mask Airway and Laryngeal tube. EMTs performances were evaluated immediately after a brief practical demonstration, as well as after 1 and 3 months without any practice in between, in a randomised order. Hands-off time was pair-wise compared between airway devices using a repeated-measures mixed-effects model. RESULTS: Overall mean hands-off time was significantly (p<0.01) lower for Laryngeal tube (6.1s; confidence interval 5.2-6.9s), Combitube (7.9s; 95% CI 6.9-9.0s), EasyTube (8.8s; CI 7.3-10.3s), LMA (10.2s; CI 8.6-11.7s), and I-Gel (11.9s; CI 10.2-13.7s) compared to endotracheal intubation (39.4s; CI 34.0-44.9s). Hands-off time was within the recommended limit of 10s for Combitube, EasyTube and Laryngeal tube after 1 month and for all supraglottic devices after 3 months without any training, but far beyond recommended limits in all three evaluations for endotracheal intubation. CONCLUSION: Using supraglottic airway devices, EMTs achieved a hands-off time within the recommended time limit of 10s, even after three months without any training or practice. Supraglottic airway devices are recommended tools for EMTs with lack of experience in advanced airway management.

Concepts: Endotracheal tube, Laryngeal mask airway, Emergency medical technician, First aid, Cardiopulmonary resuscitation, Defibrillation, Advanced life support, Emergency medical services

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This video demonstrates the placement of a laryngeal mask airway, an alternative airway device that is both efficacious and easy to place. The laryngeal mask airway is routinely used for patients receiving general anesthesia and, increasingly, in patient resuscitation.

Concepts: Emergency medical services, First aid, Laryngeal mask airway, Patient, Doctor-patient relationship, Medicine, Physician, Illness

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INTRODUCTION: Effective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA. METHODS AND ANALYSIS: The primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study. ETHICS AND DISSEMINATION: Approval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field. TRIAL REGISTRATION: ISRCTN: 18528625.

Concepts: Asystole, Defibrillation, Endotracheal tube, Paramedic, Laryngeal mask airway, Cardiopulmonary resuscitation, Cardiac arrest, Emergency medical services

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The Supreme™ laryngeal mask airway (SLMA) is a single-use LMA with double lumen design that allows separation of the respiratory and the alimentary tract, hence potentially reducing the gastric volume and risk of aspiration. The purpose of this prospective cohort study is to evaluate the the role of the SLMA as an airway technique for women undergoing category 2 and 3 Cesarean delivery under general anesthesia.

Concepts: Digestive system, Abdomen, Digestion, Caesarean section, Childbirth, Anesthesia, Laryngeal mask airway