Awake tracheal intubation through the laryngeal mask in neonates with upper airway obstruction

Neonates with Pierre Robin or Treacher-Collins syndrome are at risk of upper airway obstruction and may require surgical fixation of the tongue to the mandible. Such neonates are at high risk of hypoxia during induction of anesthesia and thus awake fiberoptic intubation would be required. We experienced neonates in whom awake fiberoptic intubation could not be carried out, because of severe hypoxia. Awake insertion of the laryngeal mask solved this problem. A 1-month-old neonate with Pierre Robin syndrome and another with Treacher-Collins syndrome were scheduled for surgical fixation of the tongue to the mandible, for constant upper airway obstruction. In both patients, awake fiberoptic intubation was attempted but abandoned, because SpO(2) rapidly decreased during the attempts. Awake insertion of the laryngeal mask relieved upper airway obstruction and facilitated oxygenation. Fiberoptic intubation through the laryngeal mask was easily achieved. Anesthesia was then induced. No hypoxia occurred after insertion of the laryngeal mask. In a further two neonates with Treacher-Collins syndrome and in one neonate with Pierre Robin syndrome, awake fiberoptic intubation through the laryngeal mask was also successful. We believe that in neonates with predicted difficult intubation, who are at risk of upper airway obstruction and awake fiberoptic intubation could aggregate hypoxia, awake insertion of the laryngeal mask can be useful in facilitating oxygenation (by relieving upper airway obstruction) and in facilitating fiberoptic intubation.     

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.     

Fiberoptic intubation via laryngeal mask airway under general anesthesia in the patients with halo vest

Since 1991, we gave anesthesia to 155 patients with halo vest. All of 128 whose airways could be kept patent by laryngeal mask airway (LMA) were successfully intubated fiberoptically via LMA using the tube exchange catheter under general anesthesia. Four patients developed airway obstruction during the induction of anesthesia, two of whom were awakened and subsequently intubated by awake fiberoptic intubation. In one patient LMA could keep the airway patent. In the other patient, cervical immobilization by halo device was released and the intubation was performed with a laryngoscope. For 8 patients, awake fiberoptic intubation was chosen from the preoperative evaluation of the positioning of head and neck. Fifteen patients were intubated with a laryngoscope without trying LMA fiberoptic intubation. No patient developed neurological injury attributed to the intubation. LMA fiberoptic intubation has several advantages. Patients do not feel discomfort under general anesthesia. Ventilation is kept continued until LMA is removed. Even less experienced residents can intubate easily and safely without assistance. However, we must carefully diagnose and select the patient whose airway can be kept patent under general anesthesia. The motionless pictures of the intubation procedures can be seen on the web site: www.hosp.go.jp/~kobe/.     

Management of airway in patients with laryngeal tumors

STUDY OBJECTIVE: To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period. DESIGN: Retrospective analysis. SETTING: University-affiliated veterans administration medical center. PATIENTS: Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia). INTERVENTIONS: Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia. MEASUREMENTS AND MAIN RESULTS: When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next. CONCLUSIONS: With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.     

Bronchoscopic removal of bronchial foreign bodies through the laryngeal mask airway in pediatric patients

The laryngeal mask airway was used to perform fiberoptic removal of bronchial foreign bodies (peanuts) in two pediatric patients. Laryngeal mask airway offers easy access to the airway, safe respiratory management and direct visualization of the airway during bronchoscopic procedures. Laryngeal mask airway allows the use of larger bronchoscopes than can usually be used for children when bronchoscopy is performed through an endotracheal tube. In each case, the peanuts were removed safely and easily using a Fogarty catheter through the fiberoptic bronchoscope. These cases suggest that laryngeal mask airway is useful in maintaining a secure airway during the removal of bronchial foreign bodies in children.     

Bronchoscopic removal of bronchial foreign bodies through the laryngeal mask airway in pediatric patients.

The laryngeal mask airway was used to perform fiberoptic removal of bronchial foreign bodies (peanuts) in two pediatric patients. Laryngeal mask airway offers easy access to the airway, safe respiratory management and direct visualization of the airway during bronchoscopic procedures. Laryngeal mask airway allows the use of larger bronchoscopes than can usually be used for children when bronchoscopy is performed through an endotracheal tube. In each case, the peanuts were removed safely and easily using a Fogarty catheter through the fiberoptic bronchoscope. These cases suggest that laryngeal mask airway is useful in maintaining a secure airway during the removal of bronchial foreign bodies in children.     

改良Proseal喉罩与改良普通喉罩在无痛纤维支气管镜检查中的气道管理

目的比较改良Proseal喉罩和改良普通喉罩在无痛纤维支气管镜检查中气道管理的效果。方法选择行纤维支气管镜检查患者40例,随机均分为两组:改良Proseal喉罩组(P组)和改良普通喉罩组(L组)。全麻诱导后徒手插入喉罩,接麻醉机,控制或辅助通气。记录两组麻醉前(T0)、插入喉罩即刻(T1)、插入喉罩3min(T2)的SBP、DBP、HR和SpO2,同时记录喉罩插入时间和并发症,并进行喉罩通气评估、纤维支气管镜评估和气道密封压测定。结果两组患者喉罩插入时间及各时点的SBP、DBP、HR和SpO2差异均无统计学意义;P组气道密封压明显高于L组(P<0.01);P组喉罩通气、纤维支气管镜评分优良率均为100%,明显高于L组的85%、80%(P<0.01);术毕P组1例喉罩粘血,明显少于L组的7例(P<0.05)。结论改良Proseal喉罩在气密性、通气评估、纤维支气管镜评估等方面好于改良普通喉罩,但对血流动力学的影响两者无明显差异。     

Intubating laryngeal mask airway for fiberoptic bronchoscopy in a woman with right bronchial tumor

A 37-year-old woman with bronchial tumor was scheduled for the removal of the mass with fiberoptic bronchoscope. Intubating laryngeal mask airway (ILMA) was used for fiberoptic surgery. Through a size 3 ILMA, a 5.9 mm outer diameter fiberoptic bronchoscope reached the trachea easily. The operation was successfully performed with assisted ventilation. Intraoperative laryngospasm was treated with intravenous suxamethonium. The ILMA allowed removal of the bronchial tumor with fiberoptic bronchoscope.     

Proseal喉罩与支纤镜联合Aintree导管用于颈椎不稳患者气管插管的临床研究

目的 通过与清醒经鼻支纤镜插管对比,研究Proseal喉罩与支纤镜联合Aintree导管用于颈椎不稳患者气管插管的有效性和安全性。方法 因颈椎骨折或严重颈椎间盘突出拟行颈椎减压内固定手术的患者40例,随机分配至以下两组：A组20例,清醒表麻后行经鼻支纤镜引导插管,然后麻醉诱导;B组20例,常规麻醉诱导后置入Proseal喉罩,沿喉罩在支纤镜引导下将Aintree导管插入气管内,退出喉罩后经Aintree导管置入气管插管。监测插管前（T0）、开始插管（T1）、插管成功时（T2）、插管成功后1min（T3）、插管成功后3min（T4）的平均动脉压（MAP）和心率（HR）;记录支纤镜插管时间、插管总时间（表麻时间或置喉罩时间加支纤镜插管时间）和插管相关并发症。结果 A组有1例因不能配合改为诱导后支纤镜插管,B组所有病例插管成功。T2和T3两时点,A组HR（92±17次/分,95±18次/分）显著高于B组（78±13次/分,83±17次/分）;T3时点A组MAP（93±28mmHg）显著高于B组（80±24mmHg）（P<0.05）;A组在T2、T3两时点的HR、MAP均显著高于各自的T0时点基础值（P<0.05）。插管的总时间两组相当（A组184±55s,B组179±27s,P>0.1）,而B组支纤镜插管时间较短（A组62±32s,B组39±18s,P<0.05）。两组患者术后无任何插管相关并发症。结论 Proseal喉罩与支纤镜联合Aintree导管用于颈椎不稳患者气管插管与传统支纤镜清醒插管效果相当,但血流动力学更平稳,是安全有效的困难气道处理新技术。     

Difficult tracheal intubation in a patient suspected of malignant hyperthermia

We report anesthetic management of a patient suspected of malignant hyperthermia with difficult tracheal intubation. A 64-year-old man was scheduled for a fixation of humerus bone fractures in prone position. He had a history of difficult tracheal intubation due to masseter spasm, and his niece was suspected to be malignant hyperthermia. Anesthesia was induced with propofol using a target controlled infusion. No muscle relaxant was given and spontaneous breathing was maintained. Trials for tracheal intubation failed whenever using a standard laryngoscope, a bronchofiberscope, a laryngeal mask airway or an intubating laryngeal mask airway. Resecting the epiglottic elevating bar of an intubating laryngeal mask airway enabled fiberoptic tracheal intubation. No symptom suggesting malignant hyperthermia developed.     

Use of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders.

Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation.     

The Glottic Aperture Seal Airway: A New Ventilatory Device

Background: None of the presently used airway devices are ideal regarding ease of insertion, alignment with the laryngeal inlet, and provision of a high-pressure seal from the environment. The purpose of this study was to determine, in awake volunteers, the performance of a new ventilatory device, the glottic aperture seal airway, regarding ease of insertion, alignment with the laryngeal inlet, and forced exhalation seal pressure (PFES).

Methods: The glottic aperture seal airway consists of a curved tubular component that ends in the middle of an elliptical foam cushion glottic component. The posterior surface of the foam has a curved flexible plastic backing, which imparts a 60 [degree sign] angle between the proximal half and the distal half of the foam cushion. When the glottic aperture seal airway is properly in situ in a supine patient, the proximal half of the foam cushion is opposite the laryngeal inlet. The posterior surface of the plastic backing has a balloon attached to it. Inflation of the balloon presses the ventilation hole and foam cushion up against the laryngeal inlet, thereby creating a seal from the environment. Using the laryngeal mask airway as a control device, the glottic aperture seal airway was tested for time and ease of insertion, fiberoptic alignment with the laryngeal inlet, and PFES in 18 lightly sedated and locally anesthetized volunteers.

Results: The glottic aperture seal and laryngeal mask airways were inserted with equal ease and speed. The fiberoptic alignment with the larynx was excellent for both the glottic aperture seal and laryngeal mask airways. In all volunteers, the mean +/- SD PFES values at 0-, 10-, 20-, 30-, and 40-ml balloon inflation volumes of the glottic aperture seal airway were 23.4 +/- 11.8, 29.6 +/- 12.4, 42.7 +/- 12.5, 56.9 +/- 5.6, and 60 +/- 0 cm H2 O, respectively; the PFES at >or= to 20 ml balloon inflation volume of the glottic aperture seal airway was significantly greater than with the laryngeal mask airway (19.4 +/- 6.7 cm H2 O, P < 0.01). A PFES of >or= to 60 cm H2 O was achieved with the glottic aperture seal airway in all volunteers (n = 2 at 10 ml, n = 3 at 20 ml, n = 9 at 30 ml, and n = 4 at 40 ml). The glottic aperture seal airway did not cause any trauma.     

Airway management of a patient with Forestier's disease

Forestier's disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestier's disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available.     

Laryngeal nerve monitoring during thyroid surgery in pregnancy

A 32-week parturient required partial thyroidectomy for suspicious carcinoma. The surgeon requested laryngeal nerve monitoring to decrease the chances of laryngeal nerve injury during surgery. After rapid-sequence induction of general anesthesia and intubation, a size 3 laryngeal mask airway was inserted posterior to the endotracheal tube and the cuff inflated with 15 mL of air. A fiberoptic bronchoscope inserted through the laryngeal mask airway provided an unhindered view of vocal cords for laryngeal nerve identification and testing during surgery. This combined technique also offered the advantages of a secured airway, as well as positive pressure ventilation in the parturient during thyroid surgery.     

The laryngeal mask airway Unique versus the Soft Seal laryngeal mask: a randomized, crossover study in paralyzed, anesthetized patients

We tested the hypothesis that ease of insertion, oropharyngeal leak pressure, fiberoptic position, ease of ventilation, and mucosal trauma are different for the Soft Seal laryngeal mask airway (SSLM) and the laryngeal mask airway Unique (LMA-U). Ninety paralyzed, anesthetized adult patients (ASA I-II; 18-80 yr old) were studied. Both devices were inserted into each patient in random order. Oropharyngeal leak pressure and fiberoptic position were determined during cuff inflation from 0-40 mL in 10-mL increments and at an intracuff pressure of 60 cm H(2)O. Ease of ventilation was determined by controlling ventilation for 10 min at 8 and 12-mL/kg tidal volume and recording hemoglobin oxygen saturation, end-tidal CO(2), leak fraction, peak airway pressure, and the presence or absence of gastric insufflation. Mucosal trauma was determined by examining the first randomized device for the presence of visible and occult blood. Insertion time was shorter (P = 0.0001) and fewer attempts were required (P = 0.005) for the LMA-U. There were no failed uses of either device. Oropharyngeal leak pressures were similar, but fiberoptic position was superior with the LMA-U (P < or = 0.0003). There were no differences in hemoglobin oxygen saturation, end-tidal CO(2), leak fraction, or peak airway pressure at either tidal volume. Gastric insufflation was not detected in either group at either tidal volume. The frequency of visible (P = 0.009) and occult blood (P = 0.0001) was less with the LMA-U. We conclude that the LMA-U is superior to the SSLM in terms of ease of insertion, fiberoptic position, and mucosal trauma, but similar in terms of oropharyngeal leak pressure and ease of ventilation.     

The new air-QTM intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series

The air-Q intubating laryngeal airway (ILA) is a new supraglottic airway device which may overcome some limitations inherent to the classic laryngeal mask airway for tracheal intubation. We present a case series of patients with anticipated difficult airway in whom the air-Q ILA was successfully used as a conduit for fiberoptic intubation.     

Anaesthetic management of a patient with relapsing polychondritis undergoing laparoscopic surgery

We describe the anaesthetic management of a patient with relapsing polychondritis who underwent laparoscopic cholecystectomy. We failed to secure a patent airway with a ProSeal laryngeal mask airway, probably because of the deformity of the larynx. The glottis was small and it was only possible to pass a 5.5 mm cuffed endotracheal tube into the trachea. Positive pressure ventilation with 5 cm H2O positive end-expiratory pressure and surgery were safely performed. In relapsing polychondritis, recurrent inflammation and destruction of laryngeal and tracheobronchial cartilage causes airway obstruction, and various sizes of tracheal tubes and other airway manipulation devices should be prepared.     

喉罩全麻白内障患儿手术苏醒期拔管时机的探讨

目的 降低惠儿全麻苏醒期喉罩拔出后呼吸道并发症的发生率,为患儿喉罩拔管时机的选择提供临床依据.方法 采用计算机随机将择期喉罩全麻下行白内障手术的患儿60例分为镇静状态喉罩拔管组(镇静组,33例)和清醒状态喉罩拔管组(清醒组,27例).在麻醉后恢复室观察并记录两组患儿拔出喉罩后呼吸道并发症发生率.结果 手术苏醒期,镇静组无一例发生呛咳,清醒组13例出现呛咳,两组比较,差异有统计学意义(P＜0.01).结论 患儿镇静状态下拔出喉罩能降低拔管后呛咳发生率,以保证患儿安全渡过全麻苏醒期.     

Cervical stabilization with halo fixation: anesthetic implications--case reports

Halo fixation is often used to provide stability in patients with unstable cervical spine. These fixation devices pose unique challenges to the anesthesiologists encountered while securing an airway. Management of airway in patients with halo fixation is complicated by the fixed position, limited access to the face, and immobilization of neck. We managed two different patients, one in which halo fixation was done for atlanto-axial dislocation (AAD); and the other, who came with halo fixation and underwent wound debridement under general anesthesia. In the former case, procedure was carried out with laryngeal mask anesthesia and patient breathing spontaneously whereas, in the later case, procedure was performed after securing the airway using awake fiberoptic intubation technique.     

Le glottiscope AWS-Pentax™, alternative à la fibroscopie dans deux cas d’intubation difficile prévue du brûlé grave

Intubating patients with facial burn is difficult to most anesthesiologists. Awake flexible fiberoptic intubation is the gold standard for management of anticipated difficult tracheal intubation. However, serious facial burn and dysmorphic syndrome can make fiberoptic intubation more difficult or impossible. We report the use of awake oral intubation using the Pentax-Airway Scope (AWS) in two major burn patients with facial injury, in whom awake fiberoptic intubation was impossible. As shown in morbidly obese patient and in patients with unstable necks, AWS could be useful to facilitate tracheal intubation in awake, facial burn patients presenting with a potentially difficult airway. Awake AWS intubation seems as a potential alternative to awake fiberoptic intubation.