Newer Airway Gadgets: Rescuers in Difficult Airway Scenarios

Background: As anaesthetists, we may constantly be in the learning curve of the management of difficult airway scenario. It can have a disastrous outcome if one is not adequately prepared with the right equipment. Over time there has been multiple ways to tackle difficult airway scenarios. Needless to say, appropriate airway gadgets are carefully chosen according to the surgery and patient characteristics. But what if these certain techniques fail? Then, what next? The inability to efficiently manage a difficult airway is the major cause of morbidity and mortality in anaesthetic practice. Here, we discuss 4 different case scenarios of difficult airway management. case reports:Case 1 was a pediatric patient with TMJ ankylosis, with mouth opening 4mm, in whom we used the fibreoptic technique. Case 2- A failed fibreoptic attempt in a case of recurrent Ca oral cavity where we secured the airway using Airtraq videolaryngoscope. Case 3- A patient with post burn contracture over front of neck and anterior shoulder where we decided to use intubating laryngeal mask airway for securing airway and Case 4- An obese female patient posted for hysterolaparoscopy where we used the Laryngeal Mask Airway Supreme. Conclusion: Effective usage of newer drugs, equipment and airway gadgets by technically skilled personnel, with sound clinical judgement are essential factors in reducing airway related adverse scenario and it is of utmost importance to keep these alternate gadgets handy and to be proficient with its usage.

Comparative evaluation of ease of tracheal intubation using Airtraq and intubating laryngeal mask airway with cervical spine immobilization

Tracheal intubation in cervical spine injury patients with application of Manual In Line Stabilization (MILS) of the cervical spine in neutral position is a challenge for the anesthesiologist since it makes visualization of the larynx more difficult using conventional laryngoscopy. Our study was conducted to compare ease of intubation using Airtraq and Intubating laryngeal mask airway(ILMA) in simulated cervical spine injury patient using MILS. 100 ASA I/II patients (without cervical spine injury), aged 18-60 years were randomly allocated in two groups -Group A: Airtraq (n=50), Group I: ILMA (n=50). General anaesthesia was given as per standard protocol in all the patients, after that MILS was applied and patients intubated using Airtraq in group A and ILMA in group I with neck in neutral position. Time taken for intubation, number of attempts for intubation, ease of intubation with Airtraq/ILMA, hemodynamics and complications were compared.The mean time taken for intubation in the Group A was 12.6 ± 6.6 seconds and in the Group, I was 85.8 ± 36.6 seconds (p<0.001). Number of intubations attempts in Group A was significantly less as compared to the Group I (p= 0.027).Airtraq is a safer and faster alternative when compared to ILMA in patients with simulated cervical spine injury using manual in line stabilization.

Hemodynamic Responses during Insertion of Laryngeal Mask Airway versus Conventional Intubation

Aim: To determine the hemodynamic response during insertion of laryngeal mask airway versus conventional intubation. Study design: Randomized controlled trial. Place and duration of study: Department of Anaesthesia, Jinnah Postgraduate Medical Centre, Karachi from 9th June 2016 to 10th December 2016. Methodology: One hundred and fifty-eight patients were enrolled, and they were divided in two groups; Group A (laryngeal mask airway) and patients falling in group B (conventional method). Baseline haemodynamic parameters were noted, and all patients were induced with propofol 2mg.kg 1. In group B, succinylcholine 1.5mg.kg-1 was used to facilitate intubation. After induction appropriate size endotracheal tube or laryngeal mask airway were inserted for airway control. For first five minutes after intervention, analgesics and any other stimulation were avoided, in order to prevent any haemodynamic alteration. All airway interventions were done by anaesthesiologist who had more than 5 years post fellowship experience. Mean arterial pressures were recorded. Initial haemodynamic parameters were measured when the patient enter the operating room and then second reading taken just after induction of anaesthesia, third reading recorded one minute and fourth reading 5 minutes after the intervention (i.e., after passing either endotracheal tube or laryngeal mask airway). Results: The average mean arterial pressure during process of intubation of patients in Group laryngeal mask airway group was 105.21±5.90 while in conventional group the average mean arterial pressure was 102.21±4.29 with P-value=0.001. Conclusion: Intubation through intubating laryngeal mask airway is accompanied by minimal cardiovascular responses than those associated with direct laryngoscopic tracheal intubation, so it can be used for patients in whom a marked pressor response would be deleterious. Keywords: Intubating laryngeal mask airway, Conventional laryngoscopy, Hemodynamic responses, Airway morbidity,

Anaesthesia for Reconstruction Surgery Post Mandibulectomy in a Patient with a Predicted Difficult Airway: A Case Report

Introduction: Mandibular surgeries, edentulous mandible, use of dentures, and aging all predispose to residual mandibular ridge resorption and thinning. The edentulous state of the mandible makes the tongue occlude the upper airway. All these, contribute to difficulty in managing the airway. An adequate pre-operative review helped classify this index patient as high risk for difficult airway and adequate steps were taken to facilitate optimal airway management.Case report: We present a 53 years old woman with mandibular deformity, anterior neck mass and inadequate mouth opening who has had a segmental mandibulectomy and a soft tissue closure of reconstruction plate. She was scheduled for mandibular reconstruction.She was successfully intubated using a size 4.5 Intubating Laryngeal Mask Airway (ILMA) through which a size 6.0 ID classic endotracheal tube was introduced for ventilation. A gum elastic bougie was then inserted through the endotracheal tube, both the ILMA and classic endotracheal tube were withdrawn. An armored tube size 6.5 ID was then rail roaded.Conclusion: The successful anaesthetic management of this difficult airway patient was facilitated by a thorough pre-anaesthetic plan, concise and skilled anaesthetic management strategy with a well organized team work.

TRACHEAL INTUBATION DURING MANUAL INLINE STABILISATION: COMPARISON OF INTUBATING LARYNGEAL MASK AIRWAY™ VERSUS TRACHLIGHT®

Introduction: Airway management with unstable cervical spine is a major challenge to anesthetist. Conventional direct laryngoscopy causes substantial movement of cervical spine and can cause neurological decit. Newer devices like Intubating Laryngeal Mask Airway(ILMA) and Trachlight avoid cervical spine movement. To compare rate of successful tracheal Aim: intubation with Intubating Laryngeal Mask Airway™ with Trachlight® in anaesthetised and paralysed adults with manual in line stabilization Method and Materials: 50 patients were included in the study and allocated in two groups. In the ILMA group ,patients were ventilated and then intubated through the ILma. IN the Trachlight group, patients were intubated using trachlight. Success rate , time taken for intubation and post operative sore throat and hoarseness of voice were compared between the two groups. Results: In the ILMA group,21 patients could be adequately ventilated in the rst attempt and 4 in second attempt. 12 patients could be successfully intubated. 9 patients could be intubated in the rst attempt and 3 patients in second attempt. In the Trachlight , 24 patients could be intubated in the rst attempt and one patient in second attempt. Intubation time was 14.08 ± 2.23 seconds in the ILMA group whereas in Trachlight group it was 26.48 ± 9.13 seconds(p value of <0.0001) In healthy anaesthetized,paralysed adults with manual in line stabiliz Conclusion: ation Trachlight assistance at tracheal intubation provides high rst attempt success.ILMA is an effective ventilation device, but an unacceptably high failure rate at blind tracheal intubation.