Atemwegsmanagement in der Kinderanästhesie

Airway management in newborns, infants, and children is a challenge to anesthesia practitioners due to the particular anatomic and physiological characteristics. The larynx is positioned more cephalad, the occiput is protuberant, and the neck is short, which makes a special position for anesthesia induction necessary. The high respiratory frequency due to high oxygen demand and carbon dioxide production has to be taken into consideration during manual as well as mechanical ventilation. Different devices are available for airway management. Simple mask ventilation can be improved by a Wendl tube. The classic laryngeal mask can be recommended as a safe airway device in many indications, specifically in children with an upper respiratory airway infection. If intubation is indicated, an optimal size and position of the endotracheal tube has to be provided. Fiberoptic endotracheal intubation is recommended if a difficult airway is known or anticipated due to a craniofacial syndrome.     

严重气道狭窄患者气管内治疗的麻醉管理

目的：探讨严重气道狭窄患者气管内治疗的麻醉管理方法。方法：10例不同原因气道狭窄患者分别进行狭窄气道内支架置入术、支架或异物取出术或气管造口处“T”管置入术,分别于全身麻醉下采用气管插管、喉罩及高频喷射等不同的保障气道及通气的方法。结果：经气管导管或喉罩支气管镜下定位气道内支架成功放置7例;感染气管支架或异物取出失败各1例,但均清除部分坏死组织,解除部分气道梗阻;经气管导管手控呼吸及高频喷射通气下“T”型硅胶管成功放置1例。结论：严重气道狭窄患者气管内治疗的麻醉管理关键在于保障气道内操作时的气道通畅。气管插管、喉罩及高频喷射等可灵活应用于不同的病例,其选择主要取决于气道梗阻的部位、严重程度及治疗方法,医护人员的通力协作也是成功的保障之一,经喉罩通气下行气管内操作为可行的方法之一。     

The laryngeal mask airway.

The laryngeal mask airway (LMA) is a new concept in airway management. A miniature inflatable mask is positioned in the hypopharynx, forming a low-pressure seal around the laryngeal inlet. The mask is attached via a tube to the breathing circuit. It is inserted after induction of anesthesia without the need for muscle relaxants or laryngoscopy. The LMA can be used to facilitate both spontaneous and controlled ventilation in adults and children. The LMA has been used for a wide variety of surgical procedures but is probably best suited to short procedures, especially if a light general anesthetic is used in combination with a regional technique. It may be particularly useful in outpatient anesthesia, as it avoids the need for intubation or muscle relaxants. It can be used as an alternative to mask anesthesia or when an endotracheal tube would have been inserted to allow surgical access. It has been used successfully in cases of difficult or failed intubation, although its role here needs further appraisal. It does not protect against aspiration of stomach contents and should not be used when aspiration is a risk. Controversy exists regarding its use to facilitate positive-pressure ventilation (PPV) due to concern that gases under pressure may be forced into the stomach and predispose the patient to regurgitation. It may be more difficult to use in children. It is now widely used in the United Kingdom; however, it is not yet available for sale in the U.S. It has already had a major effect on practice in Britain and has the potential to do the same in the United States.     

Pediatric airway management : cuffed endotracheal tube and other devices for tracheal intubation

Uncuffed endotracheal tubes have been commonly used in pediatric patients, but cuffed pediatric endotracheal tubes are recently introduced and stirred up a controversy. Uncuffed tubes may require multiple laryngoscopies, pollute the environment, and cause pulmonary aspiration as well as unstable ventilation. A recent study revealed that the contours of the airway and the tracheal tube are different, so that the pressure exerted on some parts of the cricoid mucosa may not be appropriate. Cuffed endotracheal tubes overcome these shortcomings if anesthesiologists pay close attention to the insertion length of the tube and cuff pressure. Laryngeal mask airway has worked well, with few complications, as a ventilatory device in pediatric patients whose tracheas cannot be intubated and/or whose lungs cannot be ventilated with conventional techniques. It is also used for a conduit for fiberoptic intubation and emergent airway with patients in the prone position. The lightwand (Trachlight) is another device for pediatric intubation and is recommended as the first-line option in patients who can be ventilated but in whom laryngoscopic intubation has failed. AirWayScope (Pentax-AWS) is a novel intubation device which combines an airway, camera and monitor It can be an epoch-making intubation device for infants and children if a smaller size is available in the future.     

Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate? <?6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S_pO₂? <?90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)? <?9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)? <?90?mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate ?>?29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.     

Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate ?29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.     

Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.     

Differential lung ventilation by use of a combination of a laryngeal mask airway and an endotracheal tube in a pediatric patient with atelectasis of the right lung

A 5-month-old boy was diagnosed as having complete atelectasis of the right lung due to RS virus infection at the age of 1 month. Conventional respiratory physical therapy, inhalation therapy and mechanical ventilation through an endotracheal tube failed to re-expand the right lung, while the left lung gradually became overinflated. We therefore tried differential lung ventilation by using a combination of a laryngeal mask airway and an extra long endotracheal tube (ID, 3.5 mm; length, 280 mm; Portex Pediatric Tracheal Tube, Extra length; SIMS Portex Co., Ltd. UK). Following induction of anesthesia, a laryngeal mask airway #2 was inserted. Then, an extra long endotracheal tube was inserted through the laryngeal mask airway and was guided to the right main bronchus with the aid of a fiberscope. The right lung was selectively lavaged and inflated with high pressure while ventilation was maintained through the laryngeal mask airway. The SpO2 value was maintained at more than 95% throughout the procedure despite some leakage from the ventilation system. The case demonstrates that differential lung ventilation by use of a combination of a laryngeal mask airway and extra long endotracheal tube is useful for the treatment of a pediatric patient with severe atelectasis.     

Laryngeal tube II : alternative airway for children?

Difficult airway situations both expected and unexpected, present major challenges to every anesthesiologist, especially in pediatric anesthesia. However, the integration of extraglottic airway devices, such as the laryngeal mask, into the algorithm of difficult airways has improved the handling of difficult airway situations. A device for establishing a supraglottic airway, the laryngeal tube (LT), was introduced in 1999. The LT is an extraglottic airway designed to secure a patent airway during either spontaneous breathing or controlled ventilation. The design of the device has been revised several times and a further development is the LTS?II/LTS-D, which provides an additional channel for the insertion of a gastric drain tube. This article reports on the successful use of the LTS?II in 12 children aged from 2 days to 6 years when endotracheal intubation, alternative mask or laryngeal mask ventilation failed. Use of the LTS?II was associated with a high level of success, securing the airway when other techniques had failed. The potential advantage of the LTS?II over the standard LT is an additional suction port, which allows gastric tube placement and can be used as an indirect indicator of correct placement. With a modified insertion technique using an Esmarch manoeuvre, placement was simple and fast to perform. In emergency situations when direct laryngoscopy fails or is too time-consuming the LTS?II tube is recommended as an alternative device to secure the airway. As with all extraglottic airway devices, familiarity and clinical experience with the respective device and the corresponding insertion technique are essential for safe and successful use, especially in emergency situations.     

Combined use of high-frequency jet ventilation and abdominal lift for laparoscopic cholecystectomy in a patient with glottic impairment

Effective airway management during laparoscopic anesthesia is important to minimize the adverse consequences of the carbon dioxide (CO2) pneumoperitoneum (PP). During PP, reduced respiratory excursion and tidal volumes with increased CO2 absorption may lead to hypoxia, hypercapnia, and respiratory acidosis. Although these problems can usually be avoided by use of positive pressure ventilation and an endotracheal tube, patients with a restricted airway who cannot be intubated pose a unique challenge. High-frequency jet ventilation (HFJV) has been described as an alternative to endotracheal intubation in other settings. The use of the small-diameter jet tube allows relatively unobstructed access to the larynx during laryngeal surgery. In patients with glottic impairment related to vocal fold immobility, jet ventilation allows positive pressure ventilation without the use of an endotracheal tube or tracheostomy in cases where lung and diaphragmatic compliance permit adequate excursion for ventilation and glottal diameter permits an adequate outflow of air. In this report, we describe the successful use of HFJV combined with an abdominal lifting technique and low-pressure PP for laparoscopic surgery in a patient with glottic compromise related to vocal fold immobility. Using these techniques, a laparoscopic cholecystectomy was performed successfully without endotracheal intubation or the need for a tracheostomy.     

Poor Man’s LMA: achieving adequate ventilation with a poor mask seal

PURPOSE: This report describes a technique of ventilation prior to laryngoscopy and intubation that proved to be simple, inexpensive and effective for a patient whose airway evaluation suggested difficult mask ventilation. The technique is called Poor Man's LMA. CLINICAL FEATURES: A 60-yr-old male, measuring 170 cm, weighing 117 kg, edentulous and with a full beard, was to undergo uvulopalatopharyngoplasty. After induction of general anesthesia with a hypnotic, analgesic and non-depolarizing muscle relaxant, it was soon determined that mask bag ventilation was difficult due to an inadequate seal between the mask and the patient's full beard. To improve ventilation, an endotracheal tube was placed into the oropharynx, the lips and nose compressed by a colleague in order to prevent gas egress, and effective manual ventilation established by connecting the circle system to the endotracheal tube. Subsequent direct laryngoscopy and intubation were accomplished without incident. CONCLUSION: The patient's clinical features made conventional mask bag ventilation difficult and inadequate. The Poor Man's LMA technique improved oxygenation and ventilation in preparation for intubation. Further investigations on the usefulness of this technique are warranted.     

Anesthetic Management by Laryngeal Mask Airway in a Patient With a History of Difficult Intubation Resulting in Dental Injuries

Disabled patients may face respiratory problems during general anesthesia because of head and neck anomalies. We describe a case of dental treatment under general anesthesia using a laryngeal mask airway in a disabled patient who faced difficulty in endotracheal intubation on several occasions, 5 of which resulted in dental injuries.Key Words: Laryngeal mask airway, General anesthesia, Difficult intubation, Dental injuryPatients with disabilities may need to receive multiple dental treatments under general anesthesia. Furthermore, some of them need special care regarding respiratory management during the induction of anesthesia because of malformations of their head and neck.¹ Therefore, dental anesthesiologists should adopt a method of general anesthesia that is as minimally invasive and as safe as possible for these patients. Respiratory management using a laryngeal mask airway (LMA) has been reported to be easier than and as reliable as an endotracheal tube.² We report a case of dental treatment under general anesthesia using an LMA in a disabled patient who had previously experienced complications due to difficulty in endotracheal intubation on several occasions, approximately 5 of which resulted in dental injuries.     

Anesthesic management of a patient with Stickler's syndrome

Stickler's syndrome is a connective-tissue disease of autosome dominant inheritance. This report concerns a 3-year-old girl with Stickler's syndrome who underwent arthroplasty under general anesthesia. After slow induction of anesthesia with an inhalation anesthetic, neither a oropharyngeal airway nor a laryngeal mask airway fitted her, and mask ventilation and endotracheal intubation became difficult. Endotracheal intubation was performed not with a muscle relaxant but under deep anesthesia. Care should be taken when planning anesthesia for a case of this syndrome because airway management is often difficult and emergency surgery for detached retinas might be required.     

Use of a tracheoscopic ventilation tube for endotracheal intubation in the difficult airway

Difficult endotracheal intubation is a clinical challenge for anesthesiologists and other practitioners of airway management. The use of a tracheoscopic ventilation tube, a novel airway device, for endotracheal intubation during general anesthesia in two patients with difficult airways after unsuccessful direct laryngoscopy is presented.     

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.     

Management des schwierigen Atemwegs

Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. In the case of anticipated airway difficulties the airway should be secured when the patient is awake with maintenance of spontaneous ventilation. Unaltered a flexible bronchoscopic intubation technique is advised as a standard of care in such patients. The importance of maintenance of oxygenation is emphasized. Face mask ventilation and the use of supraglottic devices are recommended if unexpected airway difficulties occur. Face mask ventilation may be facilitated and optimised by early administration of neuromuscular blocking agents. If required, in not fastened patients threatened by acute hypoxia, carefully applied and pressure-controlled ventilation may ensure sufficient oxygenation until the airway is secured. Apnoeic oxygen techniques are recommended in high-risk patients and to relieve the time pressure of falling oxygen saturation during decision-making processes. The early use of video laryngoscopy is advised for endotracheal intubation in the case of failed direct laryngoscopy or if intubation is expected to be difficult. For the coverage of cannot intubate-cannot oxygenate scenarios, second generation supraglottic devices and invasive airway access are advocated. The discussion regarding the optimal technique for emergency invasive airway access is still in progress. In the case of uncontrollable respiratory deterioration and progressive hypoxia, the algorithm must be consistently executed and without delay due to ineffective activities (straightforward strategy). Although there is no evidence to support the selection of a particular approach, the importance and the need for a defined airway concept/algorithm in any anesthesia department is fostered. Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.     

The laryngeal tube for difficult airway management: a prospective investigation in patients with pharyngeal and laryngeal tumours

BACKGROUND AND OBJECTIVE: Since the introduction of the laryngeal mask into clinical practice, various additional supraglottic ventilatory devices have been developed. Although it has been demonstrated that the laryngeal tube is an effective airway device during positive pressure ventilation no clinical study has been performed thus far regarding its use in patients with predicted ventilation and intubation difficulties. METHODS: The aim of this study was to prospectively evaluate the use of the laryngeal tube for temporary oxygenation and ventilation in adult patients with supraglottic airway tumours scheduled to undergo a pharyngeal-laryngeal oesophagoscopy and bronchoscopy under general anaesthesia. In addition to our standard airway management with face mask ventilation and rigid bronchoscopy, all patients were temporarily ventilated with an laryngeal tube. Also, in patients requiring laryngeal biopsies, endotracheal intubation was performed with a 6.0 mm microlaryngeal tracheal tube. Minute ventilation volumes, tidal volumes, ventilation pressures, end-expiratory CO2 concentration, oxygen saturation and arterial blood gas samples were measured. RESULTS: From 54 enrolled patients only patients with relevant tumour masses were evaluated (n = 23). Mask ventilation was performed without difficulty in 15 of 23 patients. Mechanical ventilation with the laryngeal tube was possible in 22 of 23 patients with an audible leak present in three. Conventional endotracheal intubation was successfully performed in 19 of 23 patients. During face mask ventilation, minute volume, tidal volume, ventilation pressure, end-tidal CO2, oxygen saturation and arterial PO2 were significantly lower and PCO2 significantly higher (P < 0.05, paired t-test). No statistically significant differences were noted between the laryngeal tube and the microlaryngeal tracheal tube. CONCLUSIONS: The possibility of difficult ventilation and intubation must always be considered, in patients with supraglottic airway tumours. In these cases, the laryngeal tube can be considered for routine airway management and may be useful in the 'cannot-intubate' situation although difficulties should be anticipated in patients with previous irradiation, specifically of the throat area.     

Airway management in obese patients

The well-known difficulties in airway management in obese patients are caused by obesity-related airways and respiratory changes. Anesthesiologists confront a number of troubles, including rapid oxygen desaturation, difficulty with laryngoscopy/intubation and mask ventilation, and increased susceptibility to the respiratory depressant effects of anesthetic drugs. Preoperative assessment of the airways in the obese should include examination of specific predictors of difficult mask ventilation other than those for difficult intubation. Difficulties in airway management are decreased after providing optimal preoxygenation and positioning (“ramped”). Other strategies may include availability of alternative airway management devices, including new video laryngoscopes that significantly improve the visualization of the larynx and thereby facilitate intubation. If awake intubation is mandatory, it may be performed with fibrobronchoscope after providing an adequate topical anesthesia and sedation with short-acting drugs, such as remifentanil. Succinylcholine for rapid sequence induction might be replaced by rocuronium where sugammadex is available for reversal. A complete reversal of neuromuscular block, measured by train-of-four monitoring, should be obtained before extubation, which requires a fully awake patient in the same position with airway equipment used for intubation.     

Maskenbeatmung als Rückzugsstrategie zur endotrachealen Intubation

The goal of ventilation in an unprotected airway is to optimize oxygenation and carbon dioxide elimination of the patient. This can be achieved with techniques such as mouth-to-mouth ventilation, but preferably with bag-valve-mask ventilation. Securing the airway with an endotracheal tube is the gold standard, but excellent success in emergency airway management depends on initial training, retraining, and actual frequency of a given procedure in the routine. "Patients do not die from failure to intubate; they die from failure to stop trying to intubate or from undiagnosed oesophageal intubation" (Scott 1986). Therefore, adequate face mask ventilation has absolute priority in airway management by an unexperienced rescuer. During ventilation of an unprotected airway, stomach inflation and subsequent severe complications may result. Careful ventilation can be performed with low inspiratory pressure and flow, and subsequently with a low tidal volume at a high inspiratory fraction of oxygen. This could be a strategy to achieve more patient safety.     

Airway management in the lateral position: a randomized controlled trial

It may be required to ensure patency of the airway in the lateral position in certain circumstances. We performed a prospective randomized clinical trial investigating the effects of left lateral patient positioning on airway anatomy and subsequent airway management. Laryngoscopic airway examination was performed in anesthetized patients, in the supine and left lateral positions, and in the presence and absence of cricoid pressure. Patients were randomized to airway management via an endotracheal tube or laryngeal mask airway (LMA). The left lateral position resulted in a deterioration of laryngoscopic view in 35% of patients and improvement in none. In the lateral position, failure of airway management occurred in more patients with the endotracheal tube versus LMA (8 of 39 versus 1 of 30; P = 0.03), and the mean time to successful completion of airway management was longer with tracheal intubation compared with the LMA (39 +/- 19 s versus 26 +/- 12 s; P = 0.002). LMA use results in more reliable airway control compared to tracheal intubation in the lateral position. The LMA should be considered as the primary airway device when instituting airway management in this position. IMPLICATIONS: Inadequate airway management may be fatal. There are recommendations for airway difficulties, but the evidence favoring any specific strategy is limited. This study suggests that, in the lateral position, a laryngeal mask airway more rapidly and reliably establishes airway control than attempts at endotracheal intubation. It further suggests that placing a patient with an inadequate airway into the lateral position will hinder, not help, airway management.