Die Kehlkopfmaske bei schwieriger Intubation

Objective. The laryngeal mask airway (LMA) was prospectively used in patients who were difficult to intubate to evaluate whether it improves ventilation compared to a face mask, facilitates fibreoptic intubation, and how often blind intubation would be possible. Methods. In a university hospital, 30 patients who were difficult to intubate (35 operative procedures) and 50 normal subjects were investigated; 23 patients had had radical resection of a facial tumor with irradiation at a previous time and 7 could not be intubated conventionally (grade 3 and 4 visibility of the larynx according to Cormack [14]). Blind intubation was attempted with a bent bougie, a 6.0-mm uncuffed tube, or a straight bougie. Results. Insertion of the LMA was possible in all except 1 patient with a mouth opening of 1?cm. Ventilation via the LMA was always excellent and, for tumor patients, superior to a face mask. In tumor patients, leak pressure was higher than in patients with normal cervical anatomy either with or without difficult intubation conditions (25.2±7.9, P<0,05, vs. 20.8±4.4 vs. 20.6±4.9?cmH₂O; n.s.; Fig.?2). Fibreoptic intubation through the LMA was successful in all cases and easier than via a nasal or oral route. Blind intubation was successful in 22% of difficult to intubate patients and 19% of normals, mainly using a 6.0?mm uncuffed endotracheal tube. Substitution of an uncuffed oral tube inserted via the LMA by a nasal endotrachel tube using a reinforced stomach tube is described (Fig.?4). Conclusion. The LMA improves ventilation, facilitates fibreoptic intubation, and offers the possibility for blind endotracheal intubation in difficult to intubate patients. Blind intubation though the LMA has to be practised extensively to have a high sucess rate. The LMA represents an additional aid for the anaesthetic management of patients who are difficult to intubate.     

Comparison of the Performance of ‘Intubating LMA’ and ‘Cobra PLA’ as an aid to blind endotracheal tube insertion in patients scheduled for elective surgery under general anesthesia

ObjectiveSupraglottic airways (SGA) through which blind endotracheal intubation is made possible is an area of considerable interest. Our study aimed at comparing the Cobra Perilaryngeal Airway (CPLA) with the Intubating Laryngeal Mask Airway (ILMA) with regard to the performance of the former as a conduit for facilitating blind endotracheal intubation.MethodsAmerican Society of Anesthesiologists (ASA) I–II patients consenting to the study, with no predictors of difficult airway, scheduled for elective surgery were randomized into two groups of 30 each. Anesthesia was induced with fentanyl, propofol and vecuronium. CPLA was inserted in Group I and ILMA in Group II. Fibreoptic scoring of the laryngeal view was done through the SGA. Blind intubation through either CPLA or ILMA was then carried out with cuffed polyvinyl chloride (PVC) tube in Group I and ILMA-tracheal tube in Group II.ResultsDemographic and surgical data were comparable between the two groups. The success rate of intubation (87% through CPLA and 90% through ILMA) (p value 1), number of attempts made and the fibreoptic scores (p value 0.12) were comparable between the two groups. Insertion time was significantly longer in Group I as compared with Group II (9 s vs. 4 s; p value 0.004). Trauma and sore throat were more common in Group I (p value ?0.1, 0.19 respectively). Hemodynamic monitoring showed more tachycardia during CPLA insertion as compared with ILMA (p value 0.006).ConclusionWe conclude that CPLA can be used as an effective conduit for blind endotracheal intubation with cuffed PVC tube and has comparable efficacy in tracheal intubation as that with ILMA.     

A multicenter study for evaluating a new intubating laryngeal mask airway]

A multicenter study was performed to evaluate the success of endotracheal intubation using an intubating laryngeal mask (ILM, Fastrach) in patients in ASA status I or II, aged 20 years or more, who underwent general anesthesia. A total of 191 patients were studied, and 24 of them were estimated difficult to intubate by the ordinary method with laryngoscope. Endotracheal intubation was successfully performed through ILM in 162 of the 191 (success rate of 84.8%). The mean time required for intubation in these successful cases was 19.1 seconds. The success rate did not depend on the clinical experience of anesthesiologists, and the individual success rate was improved as they became more experienced. Of the 24 patients who had been estimated difficult to intubate with laryngoscope, 23 were successfully intubated with success rate of 95.8%. In summary, endotracheal intubation through ILM was easy regardless of the anesthesiologist's experience, and seemed to be valuable for patients who were difficult to intubate.     

The intubating laryngeal mask. II: a preliminary clinical report of a new means of intubating the trachea

We have assessed the efficacy of a new laryngeal mask prototype, the intubating laryngeal mask airway (ILMA), as a ventilatory device and blind intubation guide. The ILMA consists of an anatomically curved, short, wide bore, stainless steel tube sheathed in silicone which is bonded to a laryngeal mask and a guiding handle. It has a single moveable aperture bar, a guiding ramp and can accommodate an 8 mm tracheal tube (TT). After induction of anaesthesia with propofol 2.5 mg kg-1 and fentanyl 2.5 micrograms kg-1, the device was inserted successfully at the first attempt in all 150 (100%) patients and adequate ventilation achieved in all, with minor adjustments required in four patients. Placement did not require movement of the head and neck or insertion of the fingers in the patient's mouth. Blind tracheal intubation using a straight silicone cuffed TT was attempted after administration of atracurium 0.5 mg kg-1. If resistance was felt during intubation, a sequence of adjusting manoeuvres was used based on the depth at which resistance occurred. Tracheal intubation was possible in 149 of 150 (99.3%) patients. In 75 (50%) patients no resistance was encountered and the trachea was intubated at the first attempt, 28 (19%) patients required one adjusting manoeuvre and 46 (31%) patients required 2-4 adjusting manoeuvres before intubation was successful. There were 13 patients with potential or known airway problems. The lungs of all of these patients were ventilated easily and the trachea intubated using the ILMA. In 10 of 13 (77%) of these patients, no resistance was encountered and the trachea was intubated at the first attempt; three of 13 (23%) patients required one adjusting manoeuvre. Tracheal intubation required significantly fewer adjusting manoeuvres in patients with a predicted or known difficult airway (P < 0.05). We conclude that the ILMA appeared on initial assessment to be an effective ventilatory device and intubation guide for routine and difficult airway patients not at risk of gastric aspiration.      

The intubating laryngeal mask airway: rocuronium improves endotracheal intubating conditions and success rate

STUDY OBJECTIVE: To assess intubating conditions without neuromuscular blocking drugs, to determine the relation between the dose of rocuronium and the probability of achieving excellent or at least good (good or excellent) intubating conditions with the intubating laryngeal mask airway (ILMA), and finally, to determine the relationship between rocuronium use and the success rate of endotracheal intubation. DESIGN: Prospective, randomized, double-blinded, placebo-controlled study. SETTING: University-affiliated medical center. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients undergoing elective surgery. INTERVENTIONS: Anesthesia was induced with propofol 2.5 mg/kg and fentanyl 1 microg/kg. One minute after loss of consciousness, patients received rocuronium 0.2 mg/kg or saline. In the rocuronium group, if intubating conditions were scored as poor, rocuronium dose in the next patient was increased by 0.05 mg/kg. If intubating conditions were scored as good, no change was made, but if conditions were scored as excellent, the dose was decreased by 0.05 mg/kg. One minute after rocuronium or saline administration, an ILMA was used to intubate the trachea. If intubation was unsuccessful, a second attempt was made using the ILMA. MEASUREMENTS: We recorded intubating conditions and the success rate of tracheal intubation. MAIN RESULTS: Without rocuronium, the probability of achieving at least good intubating conditions with the ILMA was 30%. A rocuronium dose of 0.2 mg/kg resulted in a probability of 80% to achieve at least good intubating conditions. Rocuronium significantly increased the success rate of the second intubation attempt. CONCLUSION: To achieve good or excellent intubating conditions with the ILMA, a rocuronium dose lower than the standard intubating dose of 0.6 mg/kg can be used. Neuromuscular blockade increases the success rate of intubation if a second attempt is necessary.     

Comparison of times to achieve tracheal intubation with three techniques using the laryngeal or intubating laryngeal mask airway

We compared the times to intubate the trachea using three techniques in 60 healthy patients with normal airways: (i) fibreoptic intubation with a 6.0-mm reinforced tracheal tube through a standard laryngeal mask airway (laryngeal mask-fibreoptic group); (ii) fibreoptic intubation with a dedicated 7.0-mm silicone tracheal tube through the intubating laryngeal mask airway (intubating laryngeal mask-fibreoptic group); (iii) blind intubation with the dedicated 7.0-mm silicone tracheal tube through the intubating laryngeal mask airway (intubating laryngeal mask-blind group). Mean (SD) total intubation times were significantly shorter in the intubating laryngeal mask-blind group (49 (20) s) than in either of the other two groups (intubating laryngeal mask-fibreoptic 74 (21) s; laryngeal mask-fibreoptic group 75 (36) s; p < 0.001). However, intubation at the first attempt was less successful with the intubating laryngeal mask-blind technique (15/20 (75%)) than in the other two groups (intubating laryngeal mask-fibreoptic 19/20 (95%) and laryngeal mask-fibreoptic 16/20 (80%)) although these differences were not statistically significant. We conclude that in this patient group, all three techniques yield acceptable results. If there is a choice of techniques available, the intubating laryngeal mask-blind technique would result in the shortest intubation time.     

The intubating laryngeal mask airway in failed fibreoptic intubation

PURPOSE: Prediction of difficult tracheal intubation is not always reliable and management with fibreoptic intubation is not always successful. We describe two cases in which blind intubation through the intubating laryngeal mask airway (ILMA FasTrach) succeeded after fibreoptic intubation failed. CLINICAL FEATURES: The first patient, a 50 yr old man, was scheduled for elective craniotomy for intracerebral tumour. Difficulty with intubation was not anticipated. Manual ventilation was easily performed following induction of general anesthesia, but direct laryngoscopy revealed only the tip of the epiglottis. Intubation attempts with a styletted 8.0 mm endotracheal tube and with the fibreoptic bronchoscope were unsuccessful. A #5 FasTrach was inserted through which a flexible armored cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. The second patient, a 43 yr old man, presented with limited mouth opening, swelling of the right submandibular gland that extended into the retropharynx and tracheal deviation to the left. He was scheduled for urgent tracheostomy. Attempted awake fibreoptic orotracheal intubation under topical anesthesia showed gross swelling of the pharyngeal tissues and only fleeting views of the vocal cords. A #4 FasTrach was easily inserted, a clear airway obtained and a cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. CONCLUSION: The FasTrach may facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.     

The intubating laryngeal mask airway with and without fiberoptic guidance

We conducted this feasibility study using the intubating laryngeal mask airway (ILMA) and a polyvinyl chloride tracheal tube to compare success rates, hemodynamic effects, and postoperative morbidity with two methods of tracheal intubation. After ethics approval and informed consent, 90 healthy ASA physical status I or II women with normal airways were enrolled in the randomized, controlled study. After a standardized inhaled anesthesia induction protocol, tracheal intubations using ILMA with fiberoptic guidance (ILMA-FOB) and ILMA inserted blindly without fiberoptic guidance (ILMA-Blind) were compared with the control group of direct laryngoscopy (laryngoscopy group). All 90 patients were successfully ventilated. For tracheal intubation, success rates were equal in all three groups (97%). Total intubation times were longer for the ILMA-FOB group (77 s versus 48.5 s for laryngoscopy and 53.5 s for ILMA-Blind). The laryngoscopy group had a larger increase in mean arterial blood pressure to tracheal intubation. There were no differences in postoperative sore throat or hoarseness among the groups. In conclusion, success rates are equally high for tracheal intubation using ILMA-Blind and ILMA-FOB techniques in women with normal airways. IMPLICATIONS: The intubating laryngeal mask airway (ILMA) can be used as a primary airway for oxygenation and ventilation. Both methods of tracheal intubation using the ILMA were equally successful. Postoperative morbidity in the ILMA groups was similar to that in the laryngoscopy group. For women with normal airways, both the ILMA inserted blindly and the ILMA with fiberoptic guidance are suitable alternatives to laryngoscopy for tracheal intubation.     

Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management

BACKGROUND: The intubating laryngeal mask airway (ILMA; Fastrach; Laryngeal Mask Company, Henley-on-Thames, UK) may provide an alternative technique to fiberoptic intubation (FIB) to facilitate the management of the anticipated difficult airway. The authors therefore compared the effectiveness of the ILMA with FIB in patients with anticipated difficult intubation. METHODS: One hundred patients, with at least one difficult intubation criteria (Mallampati class III or IV, thyromental distance < 65 mm, interincisor distance < 35 mm) were enrolled (FIB group, n = 49; ILMA group, n = 51) in this prospective randomized study. Anesthesia was induced with propofol and maintained with alfentanil and propofol after an efficient mask ventilation has been demonstrated. The success of the technique (within three attempts), the number of attempts, duration of the successful attempt, and adverse events (oxygen saturation < 90%, bleeding) were recorded. RESULTS: The rate of successful tracheal intubation with ILMA was 94% and comparable with FIB (92%). The number of attempts and the time to succeed were not significantly different between groups. In case of failure of the first technique, the alternative technique always succeeded. Failures in FIB group were related to oxygen desaturation (oxygen saturation < 90%) and bleeding, and to previous cervical radiotherapy in the ILMA group. Adverse events occurred significantly more frequently in FIB group than in ILMA group (18 vs. 0%, P < 0.05). CONCLUSION: The authors obtained a high success rate and comparable duration of tracheal intubation with ILMA and FIB techniques. In patients with previous cervical radiotherapy, the use of ILMA cannot be recommended. Nevertheless, the use of the ILMA was associated with fewer adverse events.     

The intubating LMA: a comparison of insertion techniques with conventional tracheal tubes

PURPOSE: To compare the performance of the intubating laryngeal mask airway (ILMA) in assisting blind tracheal intubation with conventional tracheal tubes of different curvatures and the frequency of possible associated complications. METHODS: After informed consent, 240 ASA I-II adults undergoing elective surgery participated in a randomized, single blind clinical trial to receive blind trachea intubation via ILMA with a conventional tracheal tube curved with normal (Normal group) or reversed (Reverse group) direction. More than three attempts at intubation was regarded as failure. The lowest oxygen saturation during intubation was recorded and postintubation sore throat and hoarseness were evaluated with verbal analog scales. RESULTS: The overall success rates of intubation with Normal and Reverse groups were not different (96.7% and 94.2% respectively). Successful intubation at the first attempt was higher in the Reverse group than in the Normal group (86.7% vs 75.0%, P=0.033). The incidence of sore throat was higher in the Normal group than in the Reverse group (19.2% vs 9.2% respectively, P =0.042). CONCLUSIONS: Blind trachea intubation via an ILMA with the conventional curved tracheal tube is feasible and highly successful. Reverse curve direction is preferable at the first attempt of intubation for its higher success rate and lower incidence of complications.     

The intubating laryngeal mask airway does not facilitate tracheal intubation in the presence of a neck collar in simulated trauma

Tracheal intubation must be performed with great care in the multiply injured patient when it must be assumed that the cervical spine may be damaged. Use of conventional direct laryngoscopy usually requires removal of the neck collar and manual in-line stabilization of the head and neck. The intubating laryngeal mask (ILMA) has been designed to facilitate tracheal intubation in the neutral position. We used the ILMA to intubate the trachea in 10 patients wearing a neck collar and with cricoid pressure applied in a simulated trauma scenario. The ILMA was difficult to insert and ventilation proved difficult. In only two patients was intubation successful. These problems were probably caused by the neck collar strap under the chin lifting up and tipping the larynx anteriorly. On the basis of these findings, ILMA use in a subject wearing a neck collar cannot be recommended.      

Comparison of the Intubating Laryngeal Mask Airway with the Fiberoptic Intubation in Anticipated Difficult Airway Management

Background: The intubating laryngeal mask airway (ILMA; Fastrach (TM); Laryngeal Mask Company, Henley-on-Thames, UK) may provide an alternative technique to fiberoptic intubation (FIB) to facilitate the management of the anticipated difficult airway. The authors therefore compared the effectiveness of the ILMA with FIB in patients with anticipated difficult intubation.

Methods: One hundred patients, with at least one difficult intubation criteria (Mallampati class III or IV, thyromental distance < 65 mm, interincisor distance < 35 mm) were enrolled (FIB group, n = 49; ILMA group, n = 51) in this prospective randomized study. Anesthesia was induced with propofol and maintained with alfentanil and propofol after an efficient mask ventilation has been demonstrated. The success of the technique (within three attempts), the number of attempts, duration of the successful attempt, and adverse events (oxygen saturation < 90%, bleeding) were recorded.

Results: The rate of successful tracheal intubation with ILMA was 94% and comparable with FIB (92%). The number of attempts and the time to succeed were not significantly different between groups. In case of failure of the first technique, the alternative technique always succeeded. Failures in FIB group were related to oxygen desaturation (oxygen saturation < 90%) and bleeding, and to previous cervical radiotherapy in the ILMA group. Adverse events occurred significantly more frequently in FIB group than in ILMA group (18 vs. 0%, P < 0.05).     

The intubating laryngeal mask airway after induction of general anesthesia versus awake fiberoptic intubation in patients with difficult airways

We performed the current study to compare tracheal intubation (TI) using awake fiberoptic intubation (AFOI) and TI using the intubating laryngeal mask airway (ILMA) in patients with difficult airway. Our hypothesis was that patients with difficult airways could be safely intubated after induction of anesthesia using the ILMA. After ethics approval and informed consent, 38 patients who were identified to have difficult airways were randomly assigned to AFOI or TI using the ILMA. Patients in the AFOI group had the usual sedation and airway topicalization. Patients in the ILMA group were induced with propofol for ILMA insertion and succinylcholine for TI. The first TI attempt was done blindly via the ILMA and all subsequent attempts were performed with fiberoptic guidance. All patients in the ILMA group were successfully ventilated. Successful TI was achieved in all patients in both groups. However, in 10% of the patients in the ILMA group, TI was achieved by a second anesthesiologist who was more experienced with the use of the ILMA. In a postoperative questionnaire, patients in the ILMA group were more satisfied with their method of TI (P < 0.01). The ILMA is a useful device in the management of patients with difficult airways and may be a valuable alternative to AFOI when AFOI is contraindicated or in the patient with the unanticipated difficult airway. IMPLICATIONS: The intubating laryngeal mask airway is a useful device in the management of patients with difficult airways and may be a valuable alternative to awake fiberoptic intubation (AFOI) when AFOI is contraindicated or in the patient with the unanticipated difficult airway.     

Comparison of the single use and reusable intubating laryngeal mask airway

We compared the times to intubate the trachea using the single use (Group S) and reusable (Group C) intubating laryngeal mask (ILMA(TM)), in 84 healthy patients with normal airways undergoing elective gynaecological surgery. There was no significant difference in the ease of insertion of the ILMA or the tracheal tube, or time to successful insertion (Group S, 101.4 s (SD 63.2) vs Group C, 90.4 s (SD 46.1), p = 0.366). The ILMA was successfully inserted on first attempt in 63% of Group S patients and in 68% of Group C patients. After one or two attempts the overall success rate for both groups was 93%. There was a failure to insert the ILMA in two patients in each group. There was no difference in side-effects (desaturation S(p)o(2) < 95%, bleeding, oesophageal intubation, lip, dental or mucosal injury, or sore throat postoperatively). We conclude that the disposable ILMA is an acceptable alternative to the reusable ILMA.     

Tips and tricks to increase the success rate of blind tracheal intubation through the Air-Q™ versus the intubating laryngeal mask airway Fastrach™

BackgroundThe Air-Q intubating laryngeal airway is a new supraglottic airway device which overcomes some of the limitations inherent to the intubating laryngeal mask airway (ILMA Fastrach^™) for tracheal intubation. Previous studies showed lower success rate of the Air-Q^™ versus ILMA Fastrach^™. This study was conducted to illustrate new maneuvers for increasing the success rate of Air-Q^™ versus ILMA Fastrach^™ and compare between both devices.MethodsOne-hundred and seventy adult patients, ASA I or II, aged >16 years old undergoing elective surgery under general anesthesia were divided randomly into 2 equal groups (85 each). Group A: using Air-Q ILA size 3.5 or size 4.5 Group B: using ILMA size 4 or size 5 according to the manufacturer’s recommendations for body weight in both groups. The time and the total success rate of blind intubation through them in 2 attempts only were recorded. In Group A, extension of the head with cricoid pressure was applied. The hemodynamic response to devices insertion and the complications related to both devices were compared.ResultsIn Group A, the total success rate in 2 attempts was 94.12%, while in Group B, it was 96.47%. However, this difference was not statistically significant. The first attempt success rate was 81.18% in Group A, while it was 82.35% in Group B. The total time to intubate the hemodynamic response to device insertion and the incidence of complications (sore throat, trauma and hoarseness of voice) showed no statistically significant difference between both groups.ConclusionThis study showed that extension of the head with cricoid pressure greatly increases the success rate of blind intubation through the Air-Q to 94.12% versus the ILMA Fastrach 96.47% with no statistically significant difference between both devices.     

A modified method for intubation of a patient with ankylosing spondylitis using intubating laryngeal mask airway (LMA-Fastrach)--a case report

We present an instance of successful use of an intubating laryngeal mask airway (LMA-Fastrach) and a Cook airway exchanger (CAE) for ventilation and intubation in a patient with severe ankylosing spondilitis (AS) receiving total hip arthroplasty. This measure may serve as an effective alternative for airway management in patients with difficult airway. A 61-year-old male was scheduled for right total hip arthroplasty because of degenerative osteoarthritis. He had been suffering from extensive ankylosing spondylitis, with the cervical spine markedly fixed in anterior flexion. Besides he could not open his mouth widely (35 mm when fully open) also because of ankylosis of jaw. Although we advised an awake fiberoptic tracheal intubation for anesthesia but he refused owing to a previous painful experience. After induction of anesthesia with glycopyrrolate, fentanyl, thiamylal sodium and succinylcholine, we inserted a # 5 Fastrach ILMA for primary airway maintenance. Then through the lumen of the ILMA we introduced the CAE as a guide for endotracheal tube (ETT) intubation. After applying the RAPI-FIT adapter to the CAE, we connected it to the capnography monitor for the confirmation of airway. We finally inserted an endotracheal tube into the trachea using the CAE as a guide. The whole procedure was uneventful and smooth. In sum, the modified Fastrach intubation method may facilitate tracheal intubation in patients with severe ankylosing spondilitis. It may be an alternative way for successful airway management in patients with difficult airway.     

The intubating laryngeal mask. I: development of a new device for intubation of the trachea

The standard laryngeal mask airway (LMA) functions both as a ventilatory device and as an aid to blind/fibrescopic-guided tracheal intubation. We describe the radiological and laboratory work used to bioengineer a new laryngeal mask prototype, the intubating laryngeal mask airway (ILMA). The aim was to create a new airway system with better intubation characteristics than the LMA. Other design goals were to eliminate the need for head-neck manipulation and insertion of fingers in the mouth during placement. Development was aided by analysis of magnetic resonance images of the human pharynx and laboratory testing with a variety of tracheal tubes. The principal features of this new system are an anatomically curved, rigid airway tube with an integral guiding handle, an epiglottic elevating bar replacing the mask bars, a guiding ramp built into the floor of the mask aperture and a modified silicone tracheal tube developed for use with the device.      

Blind tracheal intubation through two supraglottic devices: i-gel versus Fastrach intubating laryngeal mask airway (ILMA)

Background and objectivesThe use of supraglottic devices as a means of rescue in patients difficult to intubate or ventilate has increased in the field of anaesthetics and in emergency medicine. This study is designed to evaluate the success rate of blind intubations using two supraglottic devices, the Fastrach ILMA and the i-gel mask.Patients and methodsA total of 80 patients (40 per group) were included. After positioning them a leak test was performed, the glottis view was checked with a fibrobronchoscope, and an attempt was made to introduce an endotracheal tube through the device, and the procedure was repeated. Adequate ventilation was evaluated, as well as the grade of fibrobronchoscope view, the success of the intubation, and the complications observed after their use.ResultsThere were no differences in the incidence of adequate ventilation with either device. The glottis view (Brimacombe scale) was better with i-gel (77.78% versus 68.42%) at the second attempt, but not on the first. A higher percentage of intubations were achieved with the Fastrach ILMA (70% versus 40%; P=.013). The incidence of throat pain was similar with both devices, but post-operative dysphonia was more frequent with i-gel (20% versus 0; P=.0053).ConclusionsBoth devices were equally effective in achieving adequate ventilation; however, the Fastrach ILMA enabled a higher number of intubations to be made than i-gel and with a lower incidence of post-operative dysphonia.     

Use of the Intubating Laryngeal Mask Airway: Are Muscle Relaxants Necessary?

Background: The intubating laryngeal mask airway (ILMA) is designed to facilitate blind tracheal intubation. The effect of a muscle relaxant on the ability to perform tracheal intubation through the ILMA device has not been previously evaluated. This randomized, double-blind, placebo-controlled study was designed to evaluate rocuronium, 0.2 or 0.4 mg/kg administered intravenously, on the success rate and incidence of complications associated with ILMA-assisted tracheal intubation.

Methods: A total of 75 healthy patients were induced with propofol 2 mg/kg and fentanyl 1 [mu]g/kg intravenously. After insertion of the ILMA device, patients were administered either saline, rocuronium 0.2 mg/kg, or rocuronium 0.4 mg/kg in a total volume of 5 ml. At 90 s after administration of the study drug, tracheal intubation was attempted using a disposable polyvinyl tube. If unsuccessful, a reusable silicone tube was tried. In addition to recording the time and number of attempts required to secure the airway, the incidence of complications during placement of the tracheal tube and removal of the ILMA were noted.

Results: Tracheal intubation was successful in 76-96% of the patients. The overall success rates and times required to secure the airway were similar in all three treatment groups. The high-dose rocuronium group experienced less patient movement (8 vs. 28 and 48%) and coughing (12 vs. 20 and 52%) than the low-dose rocuronium and saline groups, respectively. Use of rocuronium was also associated with a dose-related decrease in the requirement for supplemental bolus doses of propofol during intubation and removal of the ILMA device.     

Die schwierige Intubation beim Erwachsenen

Goal of this review. We review the recent literature and our experience in order to determine how one can recognize and handle patients with difficult endotracheal intubation. Definition and incidence.?An intubation is called difficult if a normally trained anesthesiologist needs more than 3 attempts or more than 10 min for a successful endotracheal intubation.“ The incidence of difficult intubation depends on the degree of difficulty encountered showing a range of 1–18% of all intubations to about 2/10000 – 1/million for ?cannot ventilate – cannot intubate“ situations. Three ?cannot ventilate – cannot intubate“ situations are presented that occurred at our institution in the last 10 years out of about 85000 anaesthesias. Preoperative recognition. Intubation will be overtly difficult in patients with a small mouth opening, protruding upper teeth, a stiff neck, engorgement of the tongue, cervical swelling after an operation for a face tumour, or in patients with an unstable cervical spine. In about 50–70%, a difficult intubation can be detected preoperatively in patients with grossly normal cervical anatomy by three indirect signs: if the soft palate cannot be visualized (Mallampati classification), if the inframandibular space is smaller than normal, and if the mobility of the atlanto-occipital joint is reduced to below 15°. It is essential that these indirect parameters be tested preoperatively, especially in patients in whom general anaesthesial is planned for a caesarean section or if an ileus intubation is planned. Handling. General handling of difficult intubation, use of special material including a portable unit, and confirmation of the endotracheal position of an endotrachaeal tube are outlined (CO₂ et, SaO₂, fibreoptic bronchoscopy, direct visualization of the translaryngeal position of the tube). The laryngeal mask airway, transtracheal jet ventilation, and the mini-coniotomy are selectively presented as alternative airways. The American Society of Anesthesiologists' (ASA) difficult airway algorithm is presented. Conclusion. With better preoperative evaluation and clear guidelines and training for difficult intubation anaesthetic morbidity and mortality can be reduced.