Discussions for Module 10 : Recent Developments in Supraglottic Airway

Questions are answered by module author: John Doyle MD Ph.D. FRCPC

 

Question:

You used the example of a prolapsed cord as an example of an obstetric emergency in which the anesthesia choices are limited. I disagree. As long as the obstetrician can lift the fetal head off the umbilical cord restoring blood flow, all choices are on the table. This is the one ob "emergency scenario" in which the anesthetist should not be rushed into making a choice that could potentially harm the mother/child. A spinal is an excellent choice provided the cord blood flow is maintained measured by FHR provided that it can be successfully performed in less than 5 minutes. In my opinion, this is the one scenario in which you should not be rushed. Pretty much all other ob emergencies would have been a better choice to use as your example.

January 8, 2014 8:59:34 AM, 

Dr. Doyle replies:

I agree that as long as the obstetrician can lift the fetal head off the umbilical cord to restore fetal blood flow the urgency of the situation is diminished. The problem is that this is not always the case.

Question:

in c -section full stomach would medications used i.e. ketamine that allow spontaneous respiration be better then drug that make mechanical ventilation necessary(in a patient at risk for aspiration)?

December 31, 2013 9:50:20 PM, 

Dr. Doyle replies:

In any patient at significant risk for aspiration the prudent course would be to use the supraglottic airway as a conduit for tracheal intubation. Failing that, applying cricoid pressure with the supraglottic airway in place would be expected to be helpful to close off the esophagus and thereby reduce the risk of regurgitaion. As to whether spontaneous respiration  is safer than mechanical ventilation  in an unconscious patient with an unprotected airway, I know of no study that indicates that this is the case.

Question:

Is the use of LMA Fastrach advisable in situations such as emergency caesarian sections where difficult intubation is encountered? Can you enlighten me on the use of gum elastic bougie and tell me how useful is this device in an emergency setting?

April 3, 2010 2:10:43 PM, A.L.S.

Dr. Doyle replies:

The LMA Fastrach and similar supraglottic devces can be of value in emergency caesarian sections where difficult intubation is encountered because one can ventilate the patient between attempts at intubation through the LMA Fastrach. Some experts recommend using a fiberoptic bronchoscope with the LMA Fastrach to make the process even easier. More information is available at http://www.anesthesia-analgesia.org/content/105/1/294.1.full

The gum elastic bougie is another tool to facilitate intubation. Here is a description of its use (http://metrohealthanesthesia.com/edu/airway/gumElasticBougie.htm): "The gum elastic bougie can be used whenever you encounter difficult orotracheal intubation. The technique is as follows: with adequate anesthesia, the operator performs direct laryngscopy and maintains adequate laryngoscopic force to optimize the glottic view. Backwards pressure over the thyroid cartilage can also be employed to improve the view. The operator then introduces the bougie into the patient's mouth and gently advances it through the glottic opening (Grade II view) or anteriorly under the epiglottis (Grade III view) until clicks from the tracheal rings or hold up is felt. With the operator still maintaining laryngoscopic force, a 2nd operator then threads a tracheal tube over the bougie and advances it to a depth of 20-24 cm while maintaining proximal control over the 60 cm long bougie. Occasionally, the bougie and tracheal tube may need to be rotated 90o for the tube to pass. It is relatively easy to insert a bougie through the glottic opening when only the epiglottis (Grade III view) or tip of the arytenoids (Grade II view) can be visualized. Tracheal placement is confirmed using capnography. Auscultation of the lungs is done to insure mid-tracheal position." 

 

Question:

Can we use LMA safely during laproscopic surgery?

Feb. 8, 2010 4:51:45 PM, J.

Dr. Doyle replies:

The answer is "it depends". I would consider using the LMA only when the patient is lean, when there is a good clinical indication, and when other favorable factors are present. Recognize that this is not currently the "standard of care" in Canada and the USA.

Still, a number of studies are supportive of this practice. For instance, Natalini et al (J Clin Anesth. 2003 Sep; 15(6):428-32.) conducted a prospective, controlled, randomized, nonblinded clinical study that was supportive of patients undergoing mechanical ventilation during laparoscopic surgery using the regular LMA and the LMA Proseal. The authors emphasized the importance of using a gastric tube in such patients.

A 2010 review from Sweden (Minerva Anestesiol. 2010 Jan; 76(1):38-44) offers additional commentary on this controversial issue. The article is available free online at http://www.minervamedica.it/en/journals/minerva-anestesiologica/article.php?cod=R02Y2010N01A0038

Question:

I would like to know the advantages of ILA in sizes of 4.5/3.5/2.5 over convetionally used supraglottic airways(5/4/3/2/1/).

Mar. 7, 2010 2:18:21 AM, .A.


Dr. Doyle replies:

The advantage of the ILA family of supraglottic airways is that they were specifically designed to allow easy intubation through the device. Most other supraglottic airwways were not designed with this goal in mind.

Question:

I am very concerned about using LMA proseal in pts who are at high risk for aspiration and regurgitation. I know there are some Anesthetists who would think other wise. Please write me your input about this. Thanks in advance.

Feb. 28, 2009 4:23:18 PM C.A.


Dr. Doyle replies:

Patients at high risk for aspiration and regurgitation undergoing general anesthesia should ordinarily be intubated. Where intubation is not possible, the LMA ProSeal has design features which would be expected to offer superior airway protection compared to conventional supraglottic airway devices.


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