Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus laryngeal mask airway in anaesthetized paralysed patients

The ProSeal laryngeal mask airway (PLMA) is a new laryngealmask device with a larger, wedge-shaped cuff and a drainagetube. We tested the hypothesis that directly measured mucosalpressure and oropharyngeal leak pressure (OLP) are higher forthe PLMA compared with the laryngeal mask airway (LMA     

食管引流型与标准型喉罩通气道在全身麻醉患者的应用

目的比较食管引流型喉罩通气道(PLMA)和标准型喉罩通气道(SLMA)在全身麻醉患者的应用。方法ASAⅠ~Ⅱ级择期整形外科手术患者60例,随机均分为PLMA组和SLMA组,常规麻醉诱导后,分别插入PLMA或SLMA,并将通气罩充气至60cmH2O。评价两种喉罩通气道的插入特征、气道密封压和漏气部位,记录麻醉诱导前后、喉罩插入时和喉罩插入后5min内SBP、DBP和HR的变化情况。记录麻醉期间发生的呼吸并发症和呼吸道损伤情况。结果PLMA组首次插入即获得满意肺通气的例数高于SLMA组,但PLMA组操作时间明显长于SLMA组(P<0·05)。PLMA组通气罩充气量和气道密封压明显高于SLMA组(P<0·05)。两组插入操作所致的血液动力学反应相似,而且均非常轻微。结论与SLMA相比,PLMA可达到更好的气道密封性,并可提供良好的胃管插入通路,是全身麻醉患者安全有效的呼吸道管理工具之一。     

Airway rescue in acute upper airway obstruction using a ProSeal Laryngeal mask airway and an Aintree catheter: a review of the ProSeal Laryngeal mask airway in the management of the difficult airway

We report the successful use of a ProSeal Laryngeal mask airway (PLMA) to rescue the airway when emergency tracheal intubation and ventilation of the lungs were impossible after haemorrhage into the neck following carotid endarterectomy, despite evacuation of the clot. The airway was re-established after placement of a PLMA. Fibreoptic examination of the airway revealed severe supraglottic swelling compromising airway patency. An Aintree catheter was placed in the trachea under fibreoptic guidance and a tracheal tube railroaded over this. The use of the PLMA in seven cases of difficult airway management and 11 cases of airway rescue is reviewed. Use of the PLMA was associated with high levels of success, often rescuing the airway when other techniques had failed. No complications of use of the PLMA were reported in these cases. The PLMA appears to be a useful device to assist in management of the difficult airway and for airway rescue. Potential advantages over the classic laryngeal mask airway include improved airway seal and reduced risk of aspiration. The gum elastic bougie-guided insertion technique is recommended when the PLMA is used for airway rescue.     

不同头颈位置时i-gel喉罩对全麻手术患者气道密封压和通气效果的影响

目的 探讨不同头颈位置时i-gel喉罩对全麻手术患者气道密封压(OLP)和通气效果的影响.方法 择期全麻手术患者30例,性别不限,年龄32 ～ 64岁,BMI 18 ～ 30 kg/m2,ASA分级Ⅰ或Ⅱ级.麻醉诱导后,采用单手旋转盲插法置人i-gel喉罩,置入成功后行机械通气.分别在头颈正中位、俯屈位、仰伸位及侧旋位(右侧)时记录OLP、呼出潮气量(VTE)、气道峰压(PPeak)和通气效果,并采用纤维支气管镜观察咽部解剖结构显露情况.结果 与头颈正中位比较,头颈俯屈位时OLP和PPeak升高,VTE降低,头颈仰伸位时OLP和PPeak降低,VTE升高,头颈俯屈位时通气效果较差(P＜0.05),不同头颈位置时咽部解剖结构显露程度差异无统计学意义(P＞0.05).结论 i-gel喉罩用于全麻手术患者时应避免头颈俯屈位.     

The cuffed oropharyngeal airway vs. the laryngeal mask airway: a randomised cross-over study of oropharyngeal leak pressure and fibreoptic view in paralysed patients

We conducted a randomised cross-over study of 20 patients to test the hypothesis that oropharyngeal leak pressure and the fibreoptic view differ between the cuffed oropharyngeal airway and laryngeal mask airway in paralysed patients. We also tested the design premise that inflation of the cuffed oropharyngeal airway cuff elevates the epiglottis from the posterior pharyngeal wall. Both airways were inserted into each patient in random order. Oropharyngeal leak pressure and fibreoptic view were documented at zero volume and after each additional 10 ml up to the maximum recommended volume for each device. The laryngeal mask had a higher maximum (23 vs. 16 cmH2O, p = 0.03), minimum (9 vs. 2 cmH2O, p < 0.02) and overall (17 vs. 9 cmH2O, p < 0.001) oropharyngeal leak pressure compared with the cuffed oropharyngeal airway. The glottic inlet was visible more frequently with the laryngeal mask (96 vs. 39%, p < 0.0001). There was no elevation of the epiglottis from the posterior pharyngeal wall with the cuffed oropharyngeal airway. We conclude that the laryngeal mask forms a more effective seal and provides a better fibreoptic view of the glottic inlet than the cuffed oropharyngeal airway in paralysed patients. Inflation of the cuffed oropharyngeal airway cuff does not cause elevation of the epiglottis.     

喉罩通气全麻联合硬膜外阻滞在腹腔镜胆囊切除术中应用

目的 观察喉罩通气全麻联合硬膜外阻滞在腹腔镜胆囊切除术中的可行性.方法 选择140例择期行腹腔镜胆囊切除的患者,行T8～T9间隙穿刺置管,用1.5%利多卡因行硬膜外阻滞,阻滞平面在T4以下.常规麻醉诱导后,置入4#或5#喉罩,气囊注气20～30 mL,手控通气,观察呼吸道阻力和胸廓起伏状况.结果 本组患者硬膜外穿刺置管均顺利,阻滞效果满意,麻醉平面均在T4以下,插入喉罩时血压、心率无明显变化.气腹后血压均回升(20.6±5.0)mm Hg,心率变化不明显,气道压力均升高(5.7±1.6)cm H2O,手术过程顺利,术后苏醒迅速,在取胆囊时所有患者均恢复自主呼吸.结论 喉罩通气全麻联合硬膜外阻滞,不会造成声带和气道机械损伤,应激反应轻,意识恢复快,是一种安全可行的麻醉方法.     

The ProSeal Laryngeal Mask Airway is more effective than the LMA-Classic in pediatric anesthesia: a meta-analysis

Study ObjectiveTo determine, in pediatric patients, whether the ProSeal Laryngeal Mask Airway (PLMA) has advantages over the LMA-Classic (cLMA) in leak pressure, placement difficulty, incidence of adverse events, postoperative blood staining, laryngospasm, bronchospasm, and hoarseness.DesignMeta-analysis.SettingMetropolitan university medical center.MeasurementsMEDLINE (1966–2011), EMBASE (1980–2011), and the CENTRAL (1977–2011) databases was searched for randomized controlled trials (RCTs). The relative risk (RR), mean difference (MD), and corresponding 95% confidence intervals (CIs) were calculated using RevMan 5 statistical software for dichotomous and continuous outcomes, respectively.Main ResultsOf the 13 RCTs that met study inclusion criteria, 8 trials comprising 557 patients were analyzed. Leak pressure was higher in the PLMA (RR = 5.02, 95% CI = 3.64, 6.4). The difference in rate of successful placement on the first attempt did not differ between the two devices (RR = 1.00, 95% CI = 0.94, 1.06). The incidence of gastric insufflation was lower with the PLMA (RR = 0.20, 95% CI = 0.07, 0.61). The incidence of postoperative blood staining on the mask did not differ (RR = 1.08, 95% CI = 0.52, 2.21), nor was there any difference between the two devices in incidence of laryngospasm or bronchospasm (RR = 0.75, 95% CI = 0.18, 3.21), or hoarseness (RR = 3.00, 95% CI = 0.13, 70.83). There was no difference in laryngeal view between the PLMA and cLMA (RR = 1.06, 95% CI = 0.90, 1.26). The maximum tidal volume per kg was greater with the PLMA (MD = 4.16, 95% CI = 3.56, 4.76).ConclusionsThe PLMA (in sizes 1,1.5, 2, and 2.5) offers some advantages over the cLMA in pediatric anesthesia.     

A randomized comparison of the i-gel and the ProSeal laryngeal mask airway in pediatric patients: performance and fiberoptic findings

Purpose

We compared the insertion performance of the pediatric size 1.5–3 i-gel airway device with that of the ProSeal laryngeal mask airway (PLMA) in anesthetized children in a prospective, randomized, controlled manner.

Methods

We included 134 children, aged 3 months to 15 years, scheduled for elective surgery under general anesthesia. They were randomly divided into the i-gel and the PLMA groups according to the airway device used. The primary outcome variable was oropharyngeal leak pressure. Other outcome variables were ease of insertion, required time for insertion, fiberoptic view, and first-attempt and overall success rates.

Results

There were no differences in the ease of insertion, insertion time, or leak pressure between the devices. Fiberoptic view was significantly better with the i-gel than with the PLMA (P = 0.002). The view was significantly better with the sizes 2, 2.5, and 3 i-gel than with the size 1.5 i-gel (P = 0.02, 0.004 and 0.002, respectively), and the view was significantly better with the sizes 2.5 and 3 PLMA than with the size 1.5 PLMA (P = 0.02 and 0.005, respectively). The first-attempt success rates were 94 and 97 % in the i-gel and the PLMA groups, respectively; the success rates including the second attempt were 100 % in both groups. No children developed side effects requiring treatment with either device.

Conclusion

Both the pediatric i-gel and the PLMA were successfully inserted in children. The fiberoptic view was better with the i-gel than with the PLMA.     

Laryngeal mask airway size selection in males and females: ease of insertion, oropharyngeal leak pressure, pharyngeal mucosal pressures and anatomical position

We have compared ease of insertion, oropharyngeal leak pressure, directly measured pharyngeal mucosal pressure and anatomical position (assessed fibreoptically) for the size 4 and size 5 laryngeal mask airway (LMA) in 20 male and 20 female patients. Microchip pressure sensors were attached to the LMA at locations corresponding to the piriform fossa, hypopharynx, base of the tongue, lateral and posterior pharynx, and the oropharynx. Oropharyngeal leak pressure, mucosal pressure and fibreoptic position were recorded during inflation of the cuff from 0 to 30 ml in 10-ml increments. In males, oropharyngeal leak pressure over the inflation range was higher for size 5 (21 vs 17 cm H2O; P = 0.01); mucosal pressure over the inflation range was higher in the posterior pharynx for size 4 (7 vs 2 cm H2O; P = 0.007), and higher in the piriform fossa (8 vs 5 cm H2O; P = 0.003) and hypopharynx (9 vs 5 cm H2O; P = 0.003) for size 5. In females, oropharyngeal leak pressure over the inflation range was the same (21 vs 21 cm H2O), but mucosal pressure over the inflation range was higher in the piriform fossa (21 vs 8 cm H2O; P = 0.003) and posterior pharynx (4 vs 2 cm H2O; P = 0.004) for size 4, and higher in the lateral pharynx (5 vs 1 cm H2O; P = 0.01) and oropharynx (11 vs 5 cm H2O; P = 0.009) for size 5. The distribution of mucosal pressure was different for size 4 between males and females, but not for size 5. For both males and females, fibreoptic position was similar. We conclude that the size 5 LMA is optimal in males, but either size is suitable for females. The shape of the pharynx may be different between males and females.      

喉罩通气全麻应用于老年人腹部手术的临床观察

目的 探讨气管捕管和喉罩通气道用于老年全身麻醉对血液动力学的影响.方法 将40例老年全麻腹部手术患者随机分为2组.喉罩组(L组):全麻诱导后置入喉罩;插管组(M组):全麻后喉镜下气管插管维持通气.分别记录诱导前(T0)、簧喉罩或气管导管前(T1).喉罩置人或气插管即刻(T2),之后2min(T3),4min(T4),6...     

Laryngeal mask airway placement in paediatric patients: a comparison of two general anaesthetic techniques

Guidelines for paediatric practice suggest that the laryngeal mask airway (LMA) is best inserted after a period of inhalational anaesthesia. This study compared the success rate and incidence of complications for LMA placement using two different techniques of general anaesthesia. Sixty ASA I or II patients between the ages of 19 months and 14 years of age were studied. In Group 1, anaesthesia was induced with propofol, 4 mg·kg⁻¹, and placement of the LMA was then attempted. In Group 2, anaesthesia was similarly induced with propofol, but the lungs were then ventilated with halothane in oxygen for placement of the LMA. Although limb movement occurred more often in Group 1 ( P < 0.001), there were no differences between the groups for other complications, nor for success in placing the LMA. We conclude that in paediatric patients, the LMA may be successfully placed using propofol, 4 mg·kg⁻¹ alone.     

低套囊压力下ProSeal或Supreme喉罩用于腹腔镜手术患者气道管理的效果

目的 评价低套囊压力下ProSeal和Supreme喉罩用于腹腔镜手术患者气道管理的效果.方法 择期仰卧位腹腔镜手术患者60例,ASA分级Ⅰ或Ⅱ级,年龄20～70岁,体重50～80 kg,随机分为ProSeal喉罩组(P组)和Supreme喉罩组(S组),每组30例.喉罩置入成功后,用手持测压计监测套囊充气压力并维持其为35 cm H2O,记录气道密闭压及气腹前后机械通气时气道压峰值和平均气道压,记录术后并发症的发生情况.结果 两组气腹后机械通气时气道压峰值高于气腹前(P＜0.05),两组间比较差异无统计学意义(P＞0.05);术中气腹前后均无漏气现象发生;两组气道密闭压比较差异无统计学意义(P＞0.05);两组拔除喉罩后表面带有血丝及术后咽痛发生率比较差异无统计学意义(P＞0.05).结论低套囊压力(35 cm H2O)下ProSeal和Supreme喉罩通气效果均较好,可安全地用于腹腔镜手术患者的气道管理.     

喉罩与气管插管在患儿全身麻醉气道管理中的安全性Meta分析

目的采用Meta分析比较喉罩与气管插管在患儿全身麻醉气道管理中的安全性及有效性。方法计算机检索Cochrane、Pubmed、Web of Science、Embase、万方和中国知网等数据库,检索时间从建库到2019年7月,纳入比较喉罩与气管插管在患儿全身麻醉气道管理中应用的临床随机对照试验(RCT)。由两位研究员按照纳入与排除标准选择试验、提取资料,并根据Cochrane系统手册提供的质量评价标准评价纳入研究质量,采用RevMan 5.2软件进行Meta分析。主要结局指标包括术后喉痉挛及咽喉疼痛的发生率,次要结局指标包括术后咳嗽、声嘶的发生率、MAP和HR的波动等。结果最终纳入35项RCT,共3 010例患儿,其中喉罩组1 502例,气管插管组1 508例。Meta分析结果显示:与气管插管组比较,喉罩组术后喉痉挛(RR=0.36,95%CI 0.24～0.54,P0.001)、咽喉疼痛(RR=0.32,95%CI 0.25～0.42,P0.001)的发生率明显降低;喉罩组支气管痉挛、术后咳嗽、低氧血症及术后声嘶的发生率明显降低(P0.005);喉罩组麻醉诱导期间MAP和HR的波动明显较小(P0.001)。两组术后黏膜损伤、恶心呕吐、反流误吸、胃肠胀气及一次置入成功率差异无统计学意义。结论患儿全身麻醉时选择喉罩可以有效降低喉痉挛和咽喉疼痛,且对患儿的血压、心率影响较小。     

Thyroplasty under general anesthesia using a laryngeal mask airway and fibreoptic bronchoscope

Purpose

To report the management of a patient, with unilateral vocal cord paralysis, undergoing thyroplasty, under general anesthesia.

Clinical Features

A 25-yr-old man developed hoarseness and occasional episodes of pulmonary aspiration, caused by unilateral vocal cord paralysis. He was scheduled for thyroplasty, in an attempt to ease phonation and to decrease or prevent further episodes of pulmonary aspiration. He refused local anesthesia with sedation and it was therefore decided to attempt the procedure under general anesthesia. The paralysed vocal cord was displaced inwards by a wedge inserted through a window in the thyroid cartilage. We assessed the ideal position of the wedge by using a fibreoptic bronchoscope and laryngeal mask airway during general anesthesia, instead of phonation.

Conclusion

We describe the successful use of a general anesthetic for a thyroplasty, a procedure normally done under local anesthesia with or without sedation, in a patient who was keen to have surgery, but who refused local anesthesia with sedation.     

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/.     

A comparison of four methods for assessing oropharyngeal leak pressure with the laryngeal mask airway (LMA) in paediatric patients

BACKGROUND: This study compares four tests for assessing oropharyngeal leak pressure with the laryngeal mask airway (LMA). We tested the hypothesis that the oropharyngeal leak pressure and interobserver reliability differs between tests. METHODS: Eighty paralysed anaesthetized paediatric patients (weight 10-30 kg) were studied with the intracuff pressure set at 60 cmH2O. Four different oropharyngeal leak pressure tests were performed in random order on each patient by two observers blinded to each other's measurements. Test 1 involved detection of an audible noise. Test 2 involved detection of endtidal CO2 in the oral cavity. Test 3 involved observation of the aneroid manometer dial as the pressure increased and noting the airway pressure at which the dial reaches stability. Test 4 involved detection of an audible noise by neck stethoscopy. RESULTS: The mean oropharyngeal leak pressure was 12.5 cmH2O and was similar between tests. The intraclass correlation coefficient was 0.99 for all tests and was classed as excellent. CONCLUSIONS: We conclude that all four tests provide accurate and reliable information about oropharyngeal leak pressure in children.     

Size 2 ProSeal laryngeal mask airway: a randomized, crossover investigation with the standard laryngeal mask airway in paediatric patients

Background. One of the main concerns with the use of the standardlaryngeal mask airway (SLMA) in small infants is that its low-pressureseal might be inadequate for positive pressure ventilation sothat there is a risk of gas leakage into the stomach with thesubsequent risk of regurgitation. The new ProSeal^TM LMA (PLMA)has been shown to form a more effective seal than the SLMA andto facilitate gastric tube placement in adults. The first paediatricsize PLMA became available recently. Methods. Thirty anaesthetized, non-paralysed children aged 46(19) months, weighing 16 (10–21) kg, were studied. TheSLMA and PLMA were inserted in random order into each patient.Airway leak pressure and maximum tidal volume were measured.Ease of insertion, quality of initial airway and fibreopticposition were also determined. Gastric tube placement was assessedfor the PLMA. Results. The airway leak pressure and maximum tidal volume weresignificantly higher for the PLMA (P=0.001). Ease of insertionand quality of initial airway were similar for both devices.Air entry into the stomach occurred more frequently with theSLMA (P=0.005). Gastric tube placement was possible in all patients. Conclusions. The size 2 PLMA offered some advantages over thesame size of SLMA in this crossover investigation. The highreliability of gastric tube placement and the significantlyincreased airway leak pressure might have important implicationsfor use of this device for positive pressure ventilation ininfants.      

Prevention of aspiration under general anesthesia by use of the size 2 1/2 ProSeal laryngeal mask airway in a 6-year-old boy: a case report

We report a case where use of the size 2 1/2 ProSeal laryngeal mask airway helped to prevent pulmonary aspiration of regurgitated gastric fluid. We describe the management of this case and discuss the potential advantages of this modified laryngeal mask airway for supraglottic airway management in pediatric patients.