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.     

Using the intubating laryngeal mask airway for ventilation and endotracheal intubation in anesthetized and unparalyzed acromegalic patients

Airway management may be difficult in acromegalic patients. The purpose of the study was to evaluate the intubating laryngeal mask airway (ILMA) as a primary tool for ventilation and intubation in acromegalic patients. Twenty-three consenting consecutive adult acromegalic patients presenting for transsphenoidal resection of pituitary adenoma were enrolled in the study. Anesthesia was induced using propofol (1.5 mg/kg followed by 0.5-mg/kg increments); the ILMA was inserted when the bispectral index fell below 50. The ILMA was successful as a primary airway for oxygenation and ventilation at the first attempt for 21 (91%) patients, while 2 (9%) patients required a second attempt. Patient movement was noticed in five (21.7%) of the patients during ILMA insertion. An attempt at tracheal intubation through the ILMA was performed following administration of a mean 395 +/- 168-mg dose of propofol. Overall success rates for tracheal intubation were 82% (19 patients). The first-attempt success rate for tracheal intubation was 52.6% (10 patients), second- and third-attempt success rates were 42.1% (8 patients) and 5.3% (1 patient), respectively. Coughing or movement during intubation was observed in 12 (63.2%) of the patients. Direct laryngoscopy permitted intubation in three cases and blind intubation using a bougie in the fourth case. ILMA can be used as a primary airway for oxygenation in acromegalic patients (manual bag ventilation), but the rate of failed blind intubation through the ILMA precludes its use as a first choice for elective airway management.     

Intubating laryngeal mask airway in morbidly obese and lean patients: a comparative study

BACKGROUND: The intubating laryngeal mask airway (ILMA) was designed using the characteristics of healthy-weight subjects but was shown to be an effective airway device in morbidly obese patients. The authors compared airway management quality in morbidly obese and lean patients with use of the ILMA. METHODS: Fifty morbidly obese and 50 lean patients (mean body mass indexes, 42 and 27 kg/m, respectively) were enrolled in this prospective study. After induction of general anesthesia, characteristics of airway management were judged on safety and efficiency parameters, including success rate at ventilation and intubation and airway management quality criteria, such as the number of patients who required adjustment maneuvers, the number of failed tracheal intubation attempts, the total duration of airway management, and an overall difficulty visual analog scale score. RESULTS: The ILMA was successfully inserted and adequate ventilation through the ILMA was achieved in all 100 patients. The success rates of tracheal intubation through the ILMA were similar in obese and lean patients (96% and 94%, respectively). The numbers of failed blind tracheal access attempts and patients who required airway-adjustment maneuvers were significantly reduced in obese patients as compared with lean patients. Four obese patients experienced transient episodes of oxygen desaturation (oxygen saturation < 90%) before adequate bag ventilation was established with the ILMA. CONCLUSION: The authors confirmed that the ILMA was an efficient airway device for airway management of both lean and obese patients. In the conditions of this study, the authors observed that airway management with the ILMA was simpler in obese patients as compared with lean patients.     

Airway management using the intubating laryngeal mask airway for the morbidly obese patient

We studied the effectiveness of the intubating laryngeal mask airway (ILMA) in morbidly obese patients scheduled for bariatric surgery. We included 118 consecutive morbidly obese patients (body mass index, 45 +/- 5 kg/m(2)). After the induction of general anesthesia, the laryngeal view was classified by the first observer according to the method of Cormack and Lehane. The ILMA was then inserted, and the trachea was intubated through the ILMA by a second observer. The rate of successful tracheal intubation with ILMA was 96.3%. The success rate, the number of attempts, and the total duration of the procedure were not different among patients with low-grade (Cormack 1-2) and patients with high-grade (Cormack 3-4) laryngeal views. The time required for insertion of the ILMA was slightly longer in patients with high-grade laryngeal views. Failures of the technique were not explained by the experience of the practitioner or airway characteristics. No adverse effect related to the technique was reported. Results of this study suggest that using the ILMA provides an additional technique for airway management of morbidly obese patients. IMPLICATIONS: The intubating laryngeal mask airway (ILMA) provides an additional technique for airway management of morbidly obese patients. The best choice of the primary technique (laryngoscopy or ILMA) for tracheal intubation of an adult obese patient remains to be determined.     

The intubating laryngeal mask airway facilitates tracheal intubation in the lateral position

Although the difficulty of tracheal intubation in the lateral position has not been systematically evaluated, airway loss during surgery in a laterally positioned patient may have hazardous consequences. We explored whether the intubating laryngeal mask airway (ILMA) facilitates tracheal intubation in patients with normal airway anatomy, i.e., Mallampati grade or=5 cm, positioned in the lateral position. We evaluated whether this technique can be used as a rescue when the airway is lost during the middle of surgery in laterally positioned patients with respect to success rate and intubation time. Anesthesia was induced with propofol, fentanyl, and vecuronium in 50 patients undergoing spine surgery for lumbar disk herniation (Lateral) and 50 undergoing other surgical procedures (Supine). Patients having disk surgery (Lateral) were positioned on their right or left sides before induction of general anesthesia, and intubation was performed in that position. Patients in the control group (Supine) were anesthetized in supine position, and intubation was performed in that position. Intubation was performed blindly via an ILMA in both groups. The time required for intubation and number and types of adjusting maneuvers used were recorded. Data were compared by the Mann-Whitney U test, Fisher's exact test, chi(2) test, or unpaired Student's t-test, as appropriate. Data presented as mean (SD). Demographic and airway measures were similar in the two groups, except for mouth opening, which was slightly wider in patients in the lateral position: 5.1 (0.9) versus 4.6 (0.7) cm. The time required for intubation was similar in each group ( approximately 25 s), as was intubation success (96%). We conclude that blind intubation via an ILMA offers a frequent success rate and a clinically acceptable intubation time (<1 min) even in the lateral position. IMPLICATIONS: Blind intubation via the intubating laryngeal mask airway (ILMA) offers frequent success and a clinically acceptable intubation time even in patients in the lateral position.     

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.     

The intubating laryngeal mask airway (ILMA): initial experience in Singapore

We have evaluated the intubating laryngeal mask airway (ILMA) for ventilation and for blind tracheal intubation. After induction of anaesthesia with fentanyl 1 microgram kg-1 and propofol 3 ml kg-1, the ILMA was placed successfully on the first attempt in all 100 patients. After administration of atracurium 0.5 mg kg-1, blind tracheal intubation was successful in 97% of patients--50% on the first attempt, 42% on the second and 5% on the third. Success was improved by pulling the metal handle of the ILMA towards the intubator in an "extension" manoeuvre, if intubation was not possible on the first attempt. These findings confirm the effectiveness of the ILMA in an Asian population.      

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.     

Intubating Laryngeal Mask Airway in Morbidly Obese and Lean Patients: A Comparative Study

Background: The intubating laryngeal mask airway (ILMA) was designed using the characteristics of healthy-weight subjects but was shown to be an effective airway device in morbidly obese patients. The authors compared airway management quality in morbidly obese and lean patients with use of the ILMA.

Methods: Fifty morbidly obese and 50 lean patients (mean body mass indexes, 42 and 27 kg/m2, respectively) were enrolled in this prospective study. After induction of general anesthesia, characteristics of airway management were judged on safety and efficiency parameters, including success rate at ventilation and intubation and airway management quality criteria, such as the number of patients who required adjustment maneuvers, the number of failed tracheal intubation attempts, the total duration of airway management, and an overall difficulty visual analog scale score.

Results: The ILMA was successfully inserted and adequate ventilation through the ILMA was achieved in all 100 patients. The success rates of tracheal intubation through the ILMA were similar in obese and lean patients (96% and 94%, respectively). The numbers of failed blind tracheal access attempts and patients who required airway-adjustment maneuvers were significantly reduced in obese patients as compared with lean patients. Four obese patients experienced transient episodes of oxygen desaturation (oxygen saturation < 90%) before adequate bag ventilation was established with the ILMA.     

Conventional tracheal tubes for intubation through the intubating laryngeal mask airway

The laryngeal mask airway (LMA)-Fastrach silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n=50), prewarmed PVCT (n=50), and LAT (n=50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P <0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P <0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P <0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.     

Intra-ocular pressure changes associated with intubation with the intubating laryngeal mask airway compared with conventional laryngoscopy

This open, prospective, randomised study was designed to evaluate the changes in intra-ocular pressure and haemodynamics after tracheal intubation using either the intubating laryngeal mask airway (ILMA) or direct laryngoscopy. Sixty adult patients, ASA physical status 1 or 2 with normal intra-ocular pressure were randomly allocated to one of the two techniques. Anaesthesia was induced with propofol followed by rocuronium. Tracheal intubation was performed using either the ILMA or Macintosh laryngoscope. Intra-ocular pressure, heart rate and blood pressure were measured immediately before and after tracheal intubation and then minutely for five minutes. In the laryngoscopy group there was a significant increase in intra-ocular pressure (from 7.2+/-1.4 to 16.8+/-5.3 mmHg, P<0.01), which did not return to pre-intubation levels within five minutes, and also in mean arterial pressure after tracheal intubation, which returned to baseline levels after five minutes. In the ILMA group there were no significant changes in intra-ocular pressure (from 7.6+/-1.8 to 10.4+/-2.8 mmHg, P >0.05) or mean arterial pressure after tracheal intubation. Time to successful intubation was longer with the ILMA, 56.8+/-7.8 seconds, compared with the laryngoscopy group, 33+/-3.6 seconds (P<0.01). Mucosal trauma was more frequent with the ILMA (eight of 30) compared with the laryngoscopy group (three of 30) (P<0.01). The postoperative complications were comparable. In terms of minimising increases in intra-ocular pressure and blood pressure, we conclude that the ILMA has an advantage over direct laryngoscopy for tracheal intubation.     

Fibreoptic nasal intubation in children with anticipated and unanticipated difficult intubation

The establishment of a tracheal airway with direct laryngoscopy can be either a very difficult or an impossible task in children with congenital or acquired facial malformations. Out of 46 patients categorized as difficult tracheal intubation, fibreoptic laryngoscopy was used successfully in 44 children anaesthetized by mask with sevoflurane and oxygen or by an intravenous infusion of propofol and mask oxygenation. There were two failures (4.3%). One was due to excessive bleeding and secretions produced by the multiple attempts to intubate with direct laryngoscopy and the other failure in a patient with Pierre Robin syndrome and very small nasal passages that precluded the introduction of the endoscope. Fibreoptic laryngoscopy was successful in 37 cases (80.4%) on the first attempt to intubate and in seven (15.2%) on a second or third attempt. We conclude that fibreoptic laryngoscopy in anaesthetized children with difficult anticipated or unanticipated tracheal intubation in trained hands is a safe technique that can be lifesaving. Therefore, we urge all anaesthesia trainees to become proficient in fibreoptic tracheal intubation.     

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 microg/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. CONCLUSIONS: Use of rocuronium did not significantly improve the success rate in performing tracheal intubation through the ILMA. However, it produced dose-related decreases in coughing and movement after tracheal intubation and reduced difficulties associated with removal of the ILMA device.     

Removal of the connector on the laryngeal mask airway provides a useful alternative to the intubating laryngeal mask

PURPOSE: We describe two cases in which fiberoptic intubation through the standard laryngeal mask airway (LMA) was successful with large-bore tracheal tubes (TTs) when an intubating LMA (ILMA) could not be used. CLINICAL FEATURES: Patient # 1, with obstructive sleep apnea, underwent elective surgical repair. His mouth opening was just under 25 mm, but difficult intubation was not anticipated. We induced general anesthesia, easily ventilated the patient by mask, and established neuromuscular blockade. Direct laryngoscopy and attempts to insert either a #5 or a #4 ILMA into the mouth failed. A standard #4 LMA, with the connector removed, was inserted, through which a 7.0 mm nasal RAE TT, fiberoptically guided, passed into the trachea at the first attempt. Patient #2, with a loosened implant after left hip arthroplasty, underwent revision prosthesis. Her neck movement was limited. We thus planned awake securing of the airway, but the patient refused. We induced anesthesia and established bag-mask-valve ventilation. The limited neck movement prevented direct laryngoscopy. Visualizing the laryngeal inlet with the fiberoptic bronchoscope (FOB) proved impossible as bloody secretions obscured the FOB's tip. Ventilation by mask was easy. As an ILMA was not available, we removed a #5 LMAs connector and passed an 8.0 mm nasal RAE TT through the LMA. Fiberoptic-guided intubation was easy. In both cases, the remainder of the intraoperative course was uneventful. CONCLUSION: A standard LMA whose connector has been removed to allow passage of TTs of >6.0 mm internal diameter may be substituted for the ILMA when necessary.     

The intubating laryngeal mask airway: an initial assessment of performance

A new prototype of the laryngeal mask airway (LMA), the intubating laryngeal mask airway (ILMA), was used to facilitate tracheal intubation in 100 fasted patients presenting for elective surgery. Alignment of the ILMA with the larynx was assessed fibreoptically before intubation without the investigator performing the intubation being aware of the view score. Ease of intubation correlated with the view obtained and with the degree of manipulation of the ILMA needed to achieve tracheal intubation. Intubation was successful in 93 patients. Of the seven intubation failures, five occurred in the first 20 patients. Conventional connection to the breathing system and ventilation of the lungs of the patients were possible throughout the intubation procedure.      

Intubation in a patient with lingual tonsil hypertrophy using an intubating laryngeal mask airway in combination with fiberoptic intubation

A 66-yr-old man was scheduled for colon resection under general anesthesia. There were no findings suggesting difficulty of airway management. After induction of anesthesia, manual ventilation via a facemask was suboptimal, but increased fresh gas flow improved it. At direct laryngoscopy after achieving muscular relaxation, the arytenoids and epiglottis could not be seen even by an expert anesthesiologist. Intubating laryngeal mask airway (ILMA) was inserted to patient's larynx and ventilation could be continued. Tracheal intubation through ILMA was impossible because of hard resistance for inserting the endotracheal tube. Fiberoptic bronchoscopy revealed that the hypertrophied lingual tonsil obstructed the aperture of ILMA. Several attempts were made for intubation using fiberoptic tracheal intubation technique through ILMA and finally the patient's trachea was intubated without any bleeding or swelling of laryngeal tissues. The effectiveness of ILMA for the patient with lingual tonsil hypertrophy is still unknown, but the insertion of ILMA might be considered for safe airway management in combination with a fiberscope.     

Tracheal intubation through the intubating laryngeal mask airway training on manikin: comparison of single use and reusable devices from the same manufacturer

Introduction

Recently, the French Society for Anaesthesia and Intensive Care (SFAR) has updated algorithms for difficult airway management, in which, the place of the intubating laryngeal mask (ILMA) is well defined. Moreover, in the guidelines, the SFAR recommended that the training for the different techniques for difficult intubation should initially be achieved on manikins. However, few data are available for disposable ILMA learning process on manikins.

Study design

To compare, on manikin, the learning curves of the disposable and reusable ILMA.

Materials and method

Forty operators (anaesthesiologist, nurse, resident), experienced with conventional tracheal intubation but novice to commercially available ILMAs (Sebac, Pantin, France), underwent videotape learning and manikin training. After randomisation, each participant had to perform 10 timed consecutive tracheal intubations with either reusable or disposable ILMA. The learning curve was built according to the duration of successful procedure. Failure was considered if tracheal intubation could not be achieved or if the procedure lasted more than five minutes.

Results

No difference was noted between the two groups in terms of learning curves, number and repartition of the failed attempts during the learning process.

Conclusion

This study shows that both disposable and reusable ILMA share similar learning process on manikins. Further studies are needed to evaluate the efficiency of the disposable ILMA in the clinical field of difficult intubation.     

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.     

Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation

Background: Out-of-hospital airway management is a critical skill, demandingexpert knowledge and experience. The intubating laryngeal maskairway (ILMA) is a ventilatory and intubating device which maybe of value in this arena. We evaluated the ILMA for out-of-hospitalmanagement of the difficult airway. Methods: Twenty-one anaesthesia-trained emergency physicians (EPs) completeda training programme and used the ILMA in patients with difficult-to-manageairways. Indications for use of the ILMA included patients withdifficult laryngoscopy, multiple intubation attempts, limitedaccess to the patient’s head, presence of pharyngo-laryngealtrauma, and gastric fluids or bleeding obscuring the view ofthe vocal cords. Results: During the study period, 146 of 2513 patients underwent trachealintubation or alternate rescue airway insertion. In 135 patients,laryngoscopy was performed and Cormack–Lehane view wasrecorded as grade I in 72 (53.3%), II in 45 (33.3%), III in10 (7.4%), and IV in 8 (5.9%). EPs encountered 11 patients (7.5%)with difficult-to-manage airways. ILMA insertion and ventilationwas possible in 10 patients in the first and one patient inthe second attempt. ILMA-guided tracheal intubation was successfulin all patients, in 10 after the first and in 1 after two attempts. Conclusions: In this study, ventilation and intubation with ILMA was successfulin all patients with difficult-to-manage airways. Our data supportthe use of the ILMA as rescue device for out-of-hospital airwaymanagement by staff who have appropriate airway skills and havereceived appropriate training.