Usability and performance characteristics of the pediatric air-Q® intubating laryngeal airway

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 (V_T 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 V_T 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).     

The second-generation air-Q intubating laryngeal mask for airway maintenance during anaesthesia in adults: a report of the first 70 uses

The second-generation air-Q intubating laryngeal airway is a newer commercially available supraglottic airway device. In this retrospective review, we describe our initial clinical experience of 70 insertions. The ease and number of insertion attempts, airway leak pressure, device positioning, duration of use, success of fibreoptic-aided intubation and oropharyngeal morbidity were recorded. The intubating laryngeal airway was successfully inserted in all 770 patients and functioned adequately as a primary airway in all 57 patients in which it was used. The median airway leak pressure was 25 and 30 cmH2O for the single-use and reusable devices (P = 0.001), respectively. Fibreoptic-aided intubation using the intubating laryngeal airway as a conduit was successful in 12/13 (92%) cases. One in four (26%) patients complained of mild sore throat postoperatively before discharge. In our series, the intubating laryngeal airway performed adequately as a primary airway during anaesthesia with respect to ease of insertion, adequacy of airway maintenance, and as a conduit for intubation in both anticipated and unanticipated difficult airways. Further investigation is warranted regarding the role of the intubating laryngeal airway as a conduit for both blind and fibreoptic-aided intubation. In addition, the incidence of postoperative throat complaints deserves further scrutiny.     

Retrospective audit of the air-Q intubating laryngeal airway as a conduit for tracheal intubation in pediatric patients with a difficult airway

Objectives: To assess the efficacy of the ILA as a conduit for tracheal intubation in pediatric patients with a difficult airway. Aim: The primary goals of this retrospective audit were to assess the clinical performance of the ILA in pediatric patients with a difficult airway, expand on our initial favorable experience with this device, and collect pilot data for future prospective and comparison studies. Methods: The charts of patients with a difficult airway in whom the ILA was used during a period of 1 year in a freestanding pediatric institution were reviewed following a practice change in the authors’ institution favoring the ILA over the laryngeal mask airway as a conduit for tracheal intubation. Results: Thirty‐four pediatric patients had an ILA placed during the course of their airway management. Eight of the 34 patients in this cohort required emergent airway management. The median age was 47.1 (0.3–202.2) months and the median weight was 16.3 (3.9–86.0) kilograms. Three of the cases were unanticipated difficult airways and the remaining were anticipated difficult airways as a result of craniofacial syndromes (n = 21), cervical spine instability or immobility (n = 7), or airway hemorrhage (n = 3). Thirty‐three of the 34 patients (97%) were intubated on the first attempt through the ILA, with the aid of a fiberoptic bronchoscope (n = 25), a Shikani Optical Stylet (n = 7), or blindly (n = 2). In one patient, blind tracheal intubation required a second attempt for successful intubation, making the overall success rate 100%. Oxygen desaturation was noted in 6 of the 34 cases. Conclusions: In a series of pediatric patients with difficult airways, the ILA was successfully used as a conduit for tracheal intubation in all patients. Visualization techniques may offer a greater degree of success in intubations through the ILA due to the potential for epiglottic down‐folding in children.     

Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study

Background: Air‐Q^TM intubating laryngeal airway (ILA) has been used successfully as a conduit for tracheal intubation in pediatric difficult airway. However, its use as an airway device and conduit for intubation in infants is not yet evaluated. Aims: The primary objective was to evaluate ILA as a conduit for tracheal intubation in infants, and secondary objectives were to evaluate ILA in terms of ease of insertion and ventilation, oropharyngeal leak pressure (OLP), glottic view, and complications. Methods: Twenty infants with normal airway were included. After induction of general anesthesia and neuromuscular blockade, ILA (size 1.0/1.5) was inserted. Fiberoptic bronchoscope (FOB)–guided intubation and removal of ILA with the stabilizing stylet was attempted. Results: The mean age and weight of the infants were 7.5 ± 2.3 months and 7.3 ± 1.8 kg. The ILA sizes 1.0 and 1.5 were inserted in 10 infants each according to the weight of the infants. The mean OLP was 18.5 ± 1.8 cm H₂O, and mean time for insertion of ILA was 13.3 ± 3.9 s. Glottic view was grade I in 6, grade II in 1, grade III in 4, and grade IV in nine infants. Tracheal intubation was successful in 19/20 infants. The mean endotracheal tube (ETT) insertion time and mean total time (ILA insertion to the confirmation of ETT placement) were 95.6 ± 32.3 s and 306.42 ± 120.2 s respectively. Conclusion: The ILA is a safe and easy‐to‐use supraglottic airway device for intubation with FOB in infants with normal airway. Insertion and removal of ILA are easy with satisfactory oropharyngeal seal and ventilation.     

Lighted stylet-guided intubation via the intubating laryngeal airway in a patient with Hallermann-Streiff syndrome

Purpose

Hallermann-Streiff syndrome is a congenital syndrome associated with oculomandibulofacial abnormalities and potentially difficult airways. This case report describes the novel use of a lighted stylet-guided tracheal tube insertion through a new supraglottic airway, the intubating laryngeal airway (ILA?), in a patient with Hallermann-Streiff syndrome who had anticipated difficult airway.

Clinical features

A 26-year-old male with Hallermann-Streiff syndrome was scheduled for a vitrectomy. The patient had mandibulofacial dystocia with a bird-like appearance, a mouth opening of 4 cm, a receding chin, and a Mallampati class 3 examination. The surgeon requested muscle paralysis and no movement during surgery. After receiving midazolam, fentanyl and propofol, a size 3.5 ILA? was inserted and lung ventilation was easy to perform. A 7.5-mm internal diameter tracheal tube was mounted on a lighted stylet with its inner rigid stylet removed. After succinylcholine administration, the lighted stylet-tracheal tube assembly was inserted via the ILA? until the transillumination just vanished below the sternal notch. The lighted stylet was removed, the circuit was connected, and capnography confirmed tracheal placement of tube. The ILA? was deflated and left in situ. Upon emergence from anesthesia, the tracheal tube, and subsequently the ILA?, were removed without complications.

Conclusions

This case presents a novel use of a lighted stylet-guided tracheal tube insertion through the ILA? in a patient with Hallermann-Streiff syndrome. This intubation technique can be considered in patients with difficult airways as a primary route of intubation, or as a secondary rescue strategy.     

The air-Q as a conduit for fiberoptic aided tracheal intubation in adult patients undergoing cervical spine fixation: A prospective randomized study

The air-Q? intubating laryngeal airway is a supraglottic airway device which was designed to allow adequate patient ventilation and reliable blind endotracheal tube intubation.ObjectivesTo investigate the efficacy of air-Q as a conduit for fiberoptic endotracheal intubation in adult patients with limited cervical spine mobility compared with fiberoptic-guided intubation alone.DesignProspective randomized study.PatientsSixty adult (12 female) patients, ASA physical status I and II scheduled for cervical spine fixation under general anesthesia. Patients were randomized into two parallel groups. Exclusion criteria includes, history of difficult airway, mouth opening <3 cm, Mallampati class ?III and, increased risk of aspiration of gastric contents.InterventionIn the first group, endotracheal intubation was aided with the fiberoptic scope while patients in the second group were intubated with the fiberoptic scope guided with the air-Q as a conduit. The number of attempts and time to successful insertion of air-Q and endotracheal tube were recorded. The fiberoptic quality of the vocal cords view as seen through the air-Q and ease of endotracheal tube insertion were also assessed.ResultsThe air-Q was easily inserted in all patients of the second group with mean insertion time (22.6 ± 4.3 s). The air-Q provided a good fiberoptic view of the vocal cords and successful tracheal intubation in 29 (96.7%) patients of the second group on the first attempt. Time to tracheal intubation in the second group was significantly shorter than the first group (21.6 ± 5.7 and 29.8 ± 6.2 s respectively). The air-Q was easily removed without any complications.ConclusionsThe air-Q as a conduit for fiberoptic scope provided a better view of the vocal cords and, less insertion time of the endotracheal compared to fiberoptic-aided endotracheal intubation in adult patients with limited cervical spine mobility scheduled for cervical spine fixation.     

Problems and complications in airway management by endotracheal intubation and laryngeal mask airway

The endotracheal intubation and laryngeal mask airway confer many advantages for surgical patients. However, a number of problems and complications with airway management by endotracheal intubation and laryngeal mask airway have been documented. In this report, several problems by using endotracheal intubation (e.g. hoarseness, arytenoids dislocation) and laryngeal mask airway (e.g. aspiration, oropharyngeal leak, gastric distension) are summarized.     

Airway management options in a prone achondroplastic dwarf with a difficult airway after unintentional tracheal extubation during a wake-up test for spinal fusion: To flip or not to flip?

Purpose

To present a case of unintentional tracheal extubation in a prone positioned patient with a known difficult airway.

Clinical features

This case report describes the unintended tracheal extubation of an achondroplastic dwarf with kyphosis undergoing spinal fusion and instrumentation. The patient had a history of obstructive sleep apnea and a difficult airway requiring fibreoptic-guided tracheal intubation through an air-Q? supraglottic airway device. Abrupt head movement during a wake-up test to evaluate lost motor-evoked potential signals resulted in dislodgement of the tracheal tube. Airway obstruction was evidenced by rapid oxygen desaturation and the absence of end-tidal capnography waveforms despite apparent chest excursions. An air-Q was used for successfully rescuing the airway and quickly re-establishing oxygenation and ventilation, which eliminated the need for emergent supine positioning for airway management. The air-Q was then used as a conduit for fibreoptic-guided tracheal intubation while the patient remained in the prone position.

Conclusion

This case highlights some of the safety advantages of supraglottic airway devices for airway rescue and subsequent tracheal intubation even with the patient in the prone position. The use of an air-Q may have the advantages of not requiring an intubation introducer technique and allowing for direct tracheal intubation with an appropriately sized cuffed tracheal tube.     

Case of airway management by laryngeal mask airway for a child with laryngeal web undergoing adenotonsillectomy

We report a case of airway management by laryngeal mask airway (LMA) for a 4-year-old boy with laryngeal web undergoing adenotonsillectomy. Although the patient had no symptoms of airway stenosis, we detected a subglottic laryngeal web during the preoperative examination. The opening orifice of the laryngeal web was estimated to be too small for intubation, and we chose to manage the airway with LMA and spontaneous respiration. Using the LMA and Davis-Crowe mouth gag, we were able to provide the surgeon with the same exposure as with intubation while effectively managing the airway.     

The laryngeal mask airway

Two cases of emergency prehospital airway control using the laryngeal mask are described. The patients were trapped following road traffic accidents and limited access prevented tracheal intubation. The laryngeal mask airway may be a useful alternative to tracheal intubation in some cases of prehospital trauma care.     

Repeated attempts improve tracheal tube insertion time using the intubating laryngeal airway in a mannequin

Study ObjectiveTo determine if repeated performance of endotracheal tube insertion via the intubating laryngeal airway (ILA) would shorten insertion time in mannequins.DesignProspective study.SettingClinical Skills Laboratory, Department of Anesthesia, Toronto Western Hospital.Participants65 department anesthesiologists.MeasurementsAfter a video training session, anesthesiologists with no previous experience with the ILA performed 5 consecutive ILA-guided tracheal tube intubations on a mannequin. Each participant completed Task 1: insertion of an ILA; Task 2: blind insertion of a tracheal tube through the ILA, and Task 3: removal of the ILA. The time required for each task and the total intubation time for the three tasks over the 5 attempts were recorded. These times were compared using repeated-measures analysis of variance. The success rate among the 5 attempts was compared using Chi-Square analyses.Main ResultsA total of 65 anesthesiologists performed 5 ILA-guided tracheal intubations each. Total intubation time decreased from the first to the fifth attempt (92.6 ± 22.7 sec, 74.5 ± 19.2 sec, 66.5 ± 16.5 sec, 65.9 ± 19.9 sec, and 60.8 ± 16.3 sec; P < 0.001). Significant differences in intubation times were noted between the first and second, and the second and third attempts (P < 0.001 and P = 0.02, respectively). The success rate did not change over the 5 attempts (84.6%, 89.2%, 84.6%, 89.2%, and 90.8%; P = 0.737).ConclusionsTotal intubation time decreased by 34% (92.6 to 60.8 sec) over the 5 attempts in mannequins. The success rate ranged from 84.6% to 90.8% and did not differ significantly over the 5 attempts.     

The cardiovascular response to insertion of the intubating laryngeal mask airway

Sixty-one patients received a standardised anaesthetic and were randomly assigned to three groups: tracheal intubation via direct laryngoscopy, tracheal intubation via an intubating laryngeal mask airway with immediate removal of the device, and tracheal intubation via an intubating laryngeal mask airway with delayed removal. The cardiovascular response to intubation was of a similar magnitude in all groups, although delayed removal of the intubating laryngeal mask airway was associated with a second pressor response. Norepinephrine changed significantly over time following direct laryngoscopy and following immediate removal of the intubating laryngeal mask airway, but not after delayed removal. The findings of this study do not support using the intubating laryngeal mask instead of direct laryngoscopy purely to decrease the response to intubation.     

A French survey of paediatric airway management use in tonsillectomy and appendicectomy

BACKGROUND: There are no epidemiological data describing tracheal intubation and laryngeal mask airway (LMATM) use in paediatric anaesthesia. This analysis focused on the factors leading to the indication for an airway management procedure, i.e. tracheal intubation and laryngeal mask airway vs face mask during general anaesthesia for tonsillectomy and appendicectomy. METHODS: The data were recorded in the French survey of Practical Anaesthesia performed in 1996. Two main types of surgical procedures were selected: tonsillectomy and appendicectomy because of the number of patients and the need to use an invasive airway management technique. RESULTS: During a 1-year period, 627 anaesthetics for appendicectomy and 653 anaesthetics for tonsillectomy were recorded in the sample under consideration. Tracheal intubation or laryngeal mask airway was undertaken in 66% of tonsillectomies and 84% of appendicectomies. Univariate analysis showed that tracheal intubation/laryngeal mask were used significantly more often in older children, with long duration of anaesthesia, in nonambulatory procedures and in procedures performed at an academic centre. When these variables were included in a multivariate analysis, the duration of anaesthesia over 30 min was a factor linked to the use of tracheal intubation/laryngeal mask airway for the two types of surgery (P < 0.0001). For tonsillectomy, inpatients were 2.9 times more likely to be intubated (or have an laryngeal mask airway) than were outpatients. For appendicectomy, older children were 3.4 times more likely to be intubated (or have an laryngeal mask airway) than younger children. CONCLUSIONS: This large French survey shows that the use of tracheal intubation/laryngeal mask airway in this country is primarily related to a predicted long duration of anaesthesia.     

The difficult paediatric airway: a new method of intubation using the laryngeal mask airway™, Cook® airway exchange catheter and tracheal intubation fibrescope

We describe a new technique of intubation for use in difficult paediatric airway cases utilizing the laryngeal mask airway, a Cook Airway Exchange Catheter and a paediatric intubation fibrescope. This method has a number of potential advantages over previously described methods.     

Use of a larynyngeal mask airway during aortic valve replacement

We report the elective use of a laryngeal mask airway during cardiac surgery for congenital tracheal stenosis. A 53-year-old woman with severe aortic valve stenosis was scheduled for aortic valve replacement. During anesthesia induction, the anesthesiologists attempted conventional intubation but failed. Fiberoptic tracheal examination and computed tomography showed a tracheal stenosis with 5 mm minimal diameter. A laryngeal mask airway was used at the patient's rescheduled surgery. The laryngeal mask airway use did not lead any surgical complication. We concluded that the laryngeal mask airway may be considered as an alternative to conventional intubation in patients with tracheal stenosis.     

Laryngeal mask airway for Caesarean section

The use of a laryngeal mask airway is described in a patient for emergency Caesarean section, when tracheal intubation was not possible. Provision of the laryngeal mask airway for use in the Maternity Unit is discussed.     

Difficult airway management in the neonate: a simple method of intubating through a laryngeal mask airway

Tracheal intubation through a laryngeal mask airway is one option for securing an airway in the patient with a difficult airway. A variety of techniques and equipment have been used to stabilize the position of the tracheal tube while removing the laryngeal mask airway. We have shown that if a fibreoptic bronchoscope is used to place an tracheal tube through a laryngeal mask in neonates, additional equipment is not needed to remove the laryngeal mask airway without endangering tracheal tube placement. This is possible even in small neonates.     

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.     

New equipment and techniques for airway management in trauma

A patent, unobstructed airway is fundamental in the care of the trauma patient, and is most often obtained by placing a cuffed tube in the trachea. The presence of shock, respiratory distress, a full stomach, maxillofacial trauma, neck hematoma, laryngeal disruption, cervical spine instability, and head injury all combine to increase tracheal intubation difficulty in the trauma patient. Complications resulting from intubation difficulties include brain injury, aspiration, trauma to the airway, and death. The use of devices such as the gum-elastic bougie, McCoy laryngoscope, flexible and rigid fiberscopes, intubating laryngeal mask, light wand, and techniques such as rapid-sequence intubation, manual in-line axial stabilization, retrograde intubation, and cricothyroidotomy, enhance the ability to obtain a definitive airway safely. The management of the failed airway includes calling for assistance, optimal two-person bag-mask ventilation, and the use of the laryngeal mask airway, Combitube, or surgical airway. The simulation of airway management using realistic simulator tools (e.g. full-scale simulators, virtual reality airway simulators) is a promising modality for teaching physicians and advanced life support personnel emergency airway management skills.     

Use of a larynyngeal mask airway during aortic valve replacement

We report the elective use of a laryngeal mask airway during cardiac surgery for congenital tracheal stenosis. A 53-year-old woman with severe aortic valve stenosis was scheduled for aortic valve replacement. During anesthesia induction, the anesthesiologists attempted conventional intubation but failed. Fiberoptic tracheal examination and computed tomography showed a tracheal stenosis with 5 mm minimal diameter. A laryngeal mask airway was used at the patient's rescheduled surgery. The laryngeal mask airway use did not lead any surgical complication. We concluded that the laryngeal mask airway may be considered as an alternative to conventional intubation in patients with tracheal stenosis.