Direct and indirect low skill fibre-optic intubation: A randomised crossover manikin study of six supraglottic airway devices

Awake intubation is indicated in a patient with a difficult airway if attempts at maintaining or securing the airway after induction of general anesthesia may encounter difficulties or result in failure, and lead to patient harm. Consideration should also be given to compounding factors, e.g., patients with severe airway obstruction, or those at risk of rapid desaturation or gastric aspiration. In rare cases, a post induction 'cannot intubate, cannot oxygenate' (CICO) scenario may develop, which is associated with severe morbidity and mortality, and the need for emergency front-of-neck access [1,2]. Indications for awake intubation include: anticipated or known difficult airway, cervical Review ArticleAwake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as 'supraglottic airway guided' FBI (SAG-FBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu Auragain TM SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an 'awake test insertion' of the SAD, an 'awake look' at the periglottic region, and an 'awake test ventilation. ' In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.

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“…SAGFBI can be performed using either the direct or indirect method [57]. In our case series, we only used the direct method (see above).…”

Section: Discussionmentioning

confidence: 99%

“…The bronchoscope and SAD are then removed whilst keeping the AIC within the trachea, and only then is a tracheal tube railroaded over the AIC. This method is more complex, takes longer to perform and, when transitioning between the various steps involved, airway control and the ability to conventionally ventilate the patient are lost [57].…”

Section: Discussionmentioning

confidence: 99%

Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review

Lim

Wong

2019

Korean J Anesthesiol

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“…However, manikin studies showed no difference in SAGFBI times and success rates regardless of operator experience. [ 15 ] This supports junior anesthetists performing SAGFBI following failed intubation.…”

Section: Discussionmentioning

confidence: 59%

Comparison of glottic visualisation through supraglottic airway device (SAD) using bronchoscope in the ramped versus supine 'sniffing air' position: A pilot feasibility study

2020

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Background and Aims: Airway management in obese patients is associated with increased risk of difficult airway and intubation. After failed intubation, supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI) may be required. It is uncertain whether SAGFBI is best performed in the ramped versus conventional supine “sniffing air” position. We conducted a feasibility study to evaluate the logistics of positioning, compared glottic views, and evaluated SAGFBI success rates. Methods: We conducted a prospective, pilot study in patients with a body mass index (BMI) 30–40 kg/m 2 undergoing elective operations requiring tracheal intubation. All patients were placed in a ramped position. After induction, a supraglottic airway device (SAD) was inserted. A flexible bronchoscope was inserted into the SAD and a photograph of the glottic view taken. The patient was repositioned to the supine position. A second photograph was taken. SAGFBI was performed. Images were randomised and assessed by two independent anesthetists. Results: Of 17 patients recruited, 15 patients were repositioned successfully. There were no differences in glottic views observed in the two positions. SAGFBI was successful in 92.9% of patients (median time 91.5 s). Haemodynamic changes were noted in 42.7% of patients which resolved spontaneously. Conclusion: Our pilot study was completed within 5 months, achieved low dropout rate and protocol feasibility was established. SAGFBI was successfully and safely performed in obese patients, with a median time of 91.5 s. The time taken for SAGFBI was similar to awake intubation using FBI and videolaryngoscopy. Our study provided preliminary data supporting future, larger-scale studies to evaluate glottic views in the ramped versus supine positions.

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“…A manikin study comparing six SADs has reported higher success rate of fibreoptic aided tracheal intubation through Ambu® AuraGain™ than other devices. [ 17 ] This device is also made up of phthalate-free material. The phthalates are known to alter the endocrine system, interfere with steroid genesis and impede with luteal function in females.…”

Section: Discussionmentioning

confidence: 99%

A randomized comparative study of three supraglottic airway devices for controlled ventilation in anesthetized patients

Sharma¹,

Sharma²,

Gupta³

et al. 2021

Journal of Anaesthesiology Clinical Pharmacology

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Background and Aims: The LMA® ProSeal™, LMA® Supreme™ and Ambu® AuraGain™ are second-generation supraglottic airway devices (SADs) with integrated gastric access. In this study, we compared the clinical performance of these three devices in adults for controlled ventilation in anesthetized paralysed patients. Material and Methods: Two hundred and seventy adults, American Society of Anesthesiologists (ASA) Physical Status I-III, undergoing elective surgical procedures, were randomized into three groups with 90 patients in each: Group 1: LMA® ProSeal™, Group 2: LMA® Supreme™ and Group 3: Ambu® AuraGain™. All the three devices were evaluated for oropharyngeal seal pressure (OSP) and other parameters: ease and the number of attempts at device placement, fibreoptic laryngeal view and intraoperative and postoperative complications. Results: In the present study, the mean OSP was 38.9 ± 3.050 cm H 2 O in the LMA ProSeal™ group, 37.41 ± 4.097 cm H 2 O in LMA® Supreme™ group and 37.32 ± 3.740 cm H 2 O in Ambu® AuraGain™ group. The difference was found to be statistically significant (P = 0.006). The three groups were comparable for the ease of device insertion, number of attempts at device placement, fibreoptic laryngeal view, intraoperative and postoperative complications. Conclusion: In this study, we found that the LMA® ProSeal™ provided the highest OSP in comparison to the other two devices, even though this difference is not clinically relevant. The use of Ambu® AuraGain™ was associated with difficult and lowest first-time insertion success rate (P < 0.001) along with an increased incidence of airway trauma as compared to the other two SADs.

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Direct and indirect low skill fibre-optic intubation: A randomised crossover manikin study of six supraglottic airway devices

Cited by 10 publications

References 27 publications

Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review

Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review

Comparison of glottic visualisation through supraglottic airway device (SAD) using bronchoscope in the ramped versus supine 'sniffing air' position: A pilot feasibility study

A randomized comparative study of three supraglottic airway devices for controlled ventilation in anesthetized patients

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