Newer Airway Devices.pdf

NEWER AIRWAY DEVICES WHAT IS NEW?

Dr.J.Edward Johnson.M.D., D.C.H., Professor KGMCH.

ANAESTHETIST AND AIRWAY

As Anaesthetists, it has been a part of our ‘DNA’ for years to believe that proficient and successful airway management is a prerequisite for any major surgical procedure.

AIRWAY

BASICS OF AIRWAY

• Supraglottic Airways

• Infraglottic Airways

OROPHARYNGEAL AIRWAYS

GREENBERG'S CUFFED OROPHARYNGEAL AIRWAY (COPA™) • Disposable device, which combines a Guedel airway with an inflatable distal high volume, lowpressure cuff and a 15 mm proximal adapter. • Create an effective airway without stimulating the larynx and can be used when facemask ventilation has proved to be difficult, as an adjunct to fiberoptic intubation, and with positive pressure ventilation. • The COPA is available in four sizes: 80, 90, 100, and 110, which refer to the distance measured in millimeters between the flange and distal tip. The COPA is made from polyvinyl chloride and is disposable.

4. SALT -SUPRAGLOTTIC AIRWAY LARYNGOPHARYNGEAL TUBE Tongue Blade and the Tube Securing Device

It is inserted similar to an OPA and then the endotracheal tube is placed through the device It accommodates ET Tube sizes of 6.5mm – 9.0mm (90% first-attempt success rate) S.A.L.T. needs lubrication

6. CHOU AIRWAY • Designed by the WUSCOPE • Oropharyngeal airway that includes a rigid outer tube and a flexible inner tube

• Two sizes of ChouAirway-Adult and Large-adult

VBM intubating airway

Optosafe airway

Berman airways

OVASSAPIAN Color-Coded Berman Airway

VS

BERMAN AIRWAY Ovassapian Airway

The Ovassapian airway is also used for oral fiberoptic intubation. It features some plastic ridges in its design which guide the ET tube in the midline. A disadvantage of this airway in comparison with the Berman airway is the fact that there is no 'channel' for the distal half of the airway, where it is pretty much just a flat plastic blade. This means that the Ovassapian airway does not create a channel for the fiberoptic bronchoscope to pass through the oropharynx. The tongue can still occlude the airway against the soft palate which causes poor visiblity during advancement of the fiberoptic scope..

MADgic AIRWAY (A temporary airway to facilitate fiber optic intubation)

SUPRAGLOTTIC AIRWAYS OLD - NEW

1ST AND 2ND GENERATION DEVICES • 1st generation

- simple airway tube

• 2nd generation - incorporates specific design features to improve safety by protecting against regurgitation and aspiration

(White, Cook and Stoddart, Pediatric Anesthesia: Volume 19, Issue Supplement s1, pages 55–65, July 2009)

Airway tube only 1st generation

Supraglottic Airways

Gastric channel/drain tube 2nd generation

Improved pharyngeal seal Integral bite block

THIRD GENERATION SUPRAGLOTTIC AIRWAY DEVICES? A selfenergizing or self-sealing cuff

The facility to intubate through The combination of a bite block and oesophageal drains

3 rd Generation 15

(British Journal of Anaesthesia, 115 (4): 633–642 (2015))

SUGGESTION • Retain the terms first and second generation SAD; • Add the suffix ‘i’ for those devices which enable intubation. (e.g. with success >50%); and • Include ‘d’ for direct intubation and • ‘g’ for guided intubation.

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(British Journal of Anaesthesia, 115 (4): 633–642 (2015))

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1ST GENERATION SAD LARYNGEAL TUBE (LT) COBRA PERILARYNGEAL AIRWAY TULIP AIRWAY DEVICE

1. LARYNGEAL TUBE

Single pilot balloon Silicone (latex free)

Two ventilation outlet Distal

Kinked at an angle of 30-45° Connector of the tube is color-coded

esophageal cuff Proximal pharyngeal cuff

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LARYNGEAL TUBE

LARYNGEAL TUBE

Success rate of insertion 92–100% , Peak airway pressures up to 30 cm H2O

Size

Patients

Body size

Recommende d cuff volumes (ml)

Connector colour

0

Newborn

<5 kg

10

Clear

1

Infants

5–12 kg

20

White

2

Children

12–25 kg

35

Green

3

Adults: small

<155 cm

60

Yellow

4

Adults: medium

155–180 cm

80

Red

5

Adults: large

>180 cm

90

Purple

A & A May 2000 vol. 90 no. 5 1220-1222 Br. J. Anaesth. (December 2005) 95 (6): 729-736

2. COBRA PERILARYNGEAL AIRWAY (PLA) Single-use plastic device 15-mm standard adapter A rigid breathing tube A circumferential inflatable cuff proximal to the ventilation outlet portion (hypopharynx) Distal widened cobra head with soft grills (deflection of the epiglottis) An internal ramp in the COBRA head is designed to help guide a tracheal tube into the larynx when the device is used as an intubation conduit

COBRA (PLA) Spontaneous and controlled ventilation No effective protection against aspiration. Used as a rescue airway through which tracheal intubation can then be attempted.. Cobra PLUS – Temp monitoring and distal gas sampling. Success rate of insertion 93% , Peak airway pressure is 23 ± 6 cm H2O Anesth Analg. 2004 July; 99(1): 272–278

Adult & Paediatric ½,1,11/2

3. TULIP – AIRWAY DEVICES

Small

Medium

Large

Extra Large

40-60kg

60-80kg

80100kg

 100kg

< 60ml

60ml

> 60ml

> 70ml

40mm Hg

“One-size-fits-all adults” device Lowest cuff pressure device Latex free “Tulip was significantly easier to insert”

Anaesthesia Volume 64, Issue 7, page 807, July 2009

2ND GENERATION SAD I-GEL LARYNGEAL TUBE SUCTION II (LTS-II) STREAMLINED LINEAR PHARYNGEAL AIRWAY (SLIPA) BASKA MASK

1. I-GEL • The i-gel is a single use • Has a noninflatable cuff made from a gel-like thermoplastic Elastomer (SEBS) • Cuff is ‘anatomically shaped’ and the airway seal improves as the device warms to body temperature • For both spontaneous and controlled ventilation, and can be used as a conduit for tracheal intubation •

i-gel O2 Resus Pack - contains a modified igel with a supplementary oxygen port Insertion rates of 97–100% Seal pressures 20 to 32 cm H2O ANESTHESIA & ANALGESIA: Vol. 106, No. 4, April 2008

I-GEL Gastric Channel An integral gastric channel is present posterioriorly allowing direct suctioning or passage of a gastric tube. Epiglottic Blocking Ridge Is present on the superior anterior edge of the igel bowl, and is intended to reduce the possibility of epiglottic downfolding Integrated bite block and buccal stabilizer design to prevent rotation

Distal tip of gastric channel

2. LARYNGEAL TUBE SUCTION(KING LTS- D)

Primary Ventilatory Opening For Passage of fibroscope

Distal Opening of Gastric Access Lumen

LARYNGEAL TUBE- AIRWAY LARYNGEAL TUBE

LARYNGEAL TUBE SUCTION

G-LT (Gastro-Laryngeal Tube) - Allows introduction of endoscope through large esophageal lumen for upper gastrointestinal endoscopy

FINAL POSITION

3. Streamlined linear pharyngeal airway (SLIPA) 57

55 53

30

51

49

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SLIPA

•Cuffless • Anatomically preformed shape that lines the pharynx •Large internal volume – Allows collection of secretion, minimize Aspiration(50ml) First attempts for insertion 94.8% Sealing pressure 27.1 ± 2.9 mmHg 1/21/2019

Saudi J Anaesth. 2011 Jul-Sep; 5(3): 270–276

4. BASKA MASK Open to atmosphere Loops assist in securing the mask Attachment for suction

Bite block Tab for manually curving the mask for easy insertion

Sump reservoir

Journal of Obsteric Anaethesia and Critical Care: Year : 2012 | Volume : 2 | Issue :1 | Page : 23-30

Self-sealing membrane cuff extraglottic airway devices, using a sump and two gastric drains

Advanced Self Sealing Variable Pressure Cuff

Superior Gastric Reflux Drainage

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BASKA MASK - FEATURES

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The bowl of the LMA/ Proseal/ Fastrach/ Air Q is large- Baska it’s small A tab on the Baska Mask which can increase its angulation for easy negotiation Baska mask by adding a second gastric channel which is left open to ambient atmosphere to nearly equilibrate the pressure in the sump cavity to atmospheric Baska mask is a cuffless device with a membranous bowl which inflates with each positive pressure and then deflates to atmospheric levels during passive expiration.

Enlarging the size of gastric channel opening by its fish mouth type in Baska mask. The oropharyngeal leak pressure was above 30 cm H 2 O in all patients and the maximum of 40 cm H 2 O was 35 1/21/2019 achieved in 82% of the patients

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3GLM A non-inflatable cuff, which adapts to the anatomy with positive pressure. It has two gastric tube channels for redundancy.

Insertion success rate was 92.5% Mean oropharyngeal seal pressure was 27 cm H2O 37

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LMA FOR INTUBATION LMA-CTRACH AIR-Q LMA CLASSIC EXCEL BLOCK BUSTER LMA

More recent version ILMA which incoporates two fibreoptic bundles. (light guide and image), detachable colour screen and light source.

1. LMA CTRACH

LMA CTrach is designed to minimize the head and neck extension required.

With the exception of the detachable screen it is fully autoclavable Disadvantages • Poor image quality •The view may be obstructed by secretions, lubricant, or blood •Cannot be used easily in the patient with a limited mouth opening

98.9% first attempt success rate for endotracheal intubation

Br. J. Anaesth. (March 2006) 96 (3): 396-400

2. AIR-Q (INTUBATING LARYNGEAL AIRWAY AND COOK GAS ) Advantages: • Designed as intubating conduit • No aperture bars

• Shorter, allows ETT to reach vocal cords • Accommodates conventional ETT • Can be left in situ during case which may be utilized during emergence Six sizes available 1.0, 1.5, 2.0, 2.5, 3.5 & 4.5

3. LMA CLASSIC EXCEL Advantages:

• Removable 15mm connector aids in ETT passage • Epiglottic elevator bar • No aperture bars

BLOCK BUSTER LMA

Average Seal Pressure > 30 cm H2O

Intubation success rate 90%

OTHER SAD EASYTUBE PHARYNGEAL AIRWAY EXPRESS (PAXPRESS)

ELISHA

1. EASYTUBE

The EasyTube is new disposable, PVC, double-lumen, latex-free, supra-glottic airway device It has a close design to the Combitube Allows ventilation in either esophageal or tracheal position EasyTube had a better fiberoptic view and a shorter time to achieve an effective airway

2. PHARYNGEAL AIRWAY EXPRESS (PAXPRESS) Available only in one adult size A single use device, conceptually similar to the Laryngeal Tube

While it also has a proximal cuff to seal the oropharynx, instead of a lower cuff, its distal end consists of a series of corrugated plastic gills designed to sit in the hypopharynx and proximal oesophagus.

PAXPRESS

3. AIRWAY MANAGEMENT DEVICE (AMD)

• It was designed as a re-usable extra-glottic airway device and has an integral sterilization tag • Similar to Laryngeal Tube but has a separate pilot balloon for each cuff • Once in position it allows to aspirate secretions from the upper oesophagus via an aperture that opens when the distal cuff is deflated • Insertion of the AMD required more attempts and caused a greater number of complications . It is no longer marketed in the UK Br. J. Anaesth. (2003) 91 (5): 672-677

3. ELISHA (EAD) The Elisha’s uniqueness consists of its ability to combine three functions in a single device: • Ventilation • Intubation (blind and/or fiberopticaided) • Gastric tube insertion The ventilation channel (VC) and the intubation channel (IC) are side-by-side, whereas the gastric tube channel (GTC) has an outlet located in the distal end of the device The VC and the IC have a partitioning wall between them, but join at the ventilation outlet situated in front of the laryngeal inlet The EAD has two high-volume, low-pressure balloons: a proximal balloon which seals the oropharynx and nasopharynx and a distal balloon which seals the esophagus A New Supraglottic Airway, the Elisha Airway Device: A Preliminary Study. Anesth Analg 2004;99:124–7

LMA® GASTRO™ CUFF PILOT™ – FOR SAFE ENDOSCOPY

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BJA. February 2018Volume 120, Issue 2, Pages 353–360

GASTRO-LARYNGEAL TUBE

Maximum 13.8 mm diameter endoscope

60 cmH20

The Gastro Laryngeal Tube has the advantages of not requiring neuromuscular blocking drugs, Not subjecting the patient to direct laryngoscopy with all its possible hemodynamic consequences; It allows both spontaneous and mechanical ventilation, it protects the airways from reflux or inhalation of gastric content, It reduces extubation, recovery and discharging time and it Does not require improved anesthesiological skills for positioning.

GASTRO LARYNGEAL TUBE

ENDOTRACHEAL TUBES

WHAT’S NEW?

SHILEY™ EVAC ENDOTRACHEAL TUBE WITH TAPERGUARD™ CUFF To prevent Ventilator-Associated Pneumonia (VAP)

SHILEY™ EVAC ENDOTRACHEAL TUBE WITH TAPERGUARD™ CUFF • Subglottic secretion drainage (SSD) helps remove oral and/or gastric secretions from above the endotracheal tube cuff TAPERED-CUFF ADVANTAGES

• Reduces the area of tracheal impact • Reduces intracuff pressure required to obtain an adequate seal • Provides more uniform pressure distribution • Reduces microaspiration by as much as 90%

BRANDT™ TRACHEAL TUBE • The Brandt Anaesthesia Tube is designed to prevent intracuff pressure from increasing above 25 mmHg (33 cmH2O), by virtue of the cuff communicating through the inflation line with a pilot balloon that is more compliant and of higher volume. • The incidence of postoperative sore throat in patients intubated with this new tube (15%) was significantly lower than that after intubation with a standard Mallinckrodt tube (60%)

KIMBERLY-CLARK - MICROCUFF SUBGLOTTIC ETT The Microcuff ET’s unique cuff is made of an advanced microthin polyurethane material that allows the channels formed upon cuff inflation to ‘self-seal’ within the trachea, increasing protection against fluid leakage into the lungs. MICROCUFF Subglottic ETT features an ergonomic subglottic suction valve and integrated rinse port, enabling controlled rinsing and suctioning of the lumen in a single cycle, without the need to open the suction circuit and for the first time enables the use of saline for clearing the lumen.

THE VIVASIGHT-DL DOUBLE-LUMEN TUBE WITH INTEGRATED CAMERA The VivaSight-DL double-lumen tube with integrated camera Dean, Caroline; Dragnea, Dragos; Anwar, Sibtain; Ong, Cheng European Journal of Anaesthesiology (EJA)33(4):305-308, April 2016.

THE VIVASIGHT-DL DOUBLE-LUMEN TUBE WITH INTEGRATED CAMERA The VivaSight-DL double-lumen tube with integrated camera Dean, Caroline; Dragnea, Dragos; Anwar, Sibtain; Ong, Cheng European Journal of Anaesthesiology (EJA)33(4):305-308, April 2016.

WORLD'S FIRST INTUBATION ROBOT Kepler Intubation System (KIS)

KEPLER INTUBATION SYSTEM (KIS) • The world's first robotic intubation in a patient was performed at the Montreal General Hospital earlier in April, 2011by Dr. Hemmerling. • "The KIS allows us to operate a robotically mounted videolaryngoscope using a joystick from a remote workstation," • "This robotic system enables the anaesthesiologist to insert an endotracheal tube safely into the patient's trachea with precision."

SUBGLOTTIC DEVICES

NEEDLE CRICOTHYROIDOTOMY Melker kit

Quick-trach Cricothyrotomy Kits

CRIC – CRICOTHROTOMY SYSTEM

LIFE STAT

Supraglottic Mask Airways

Supraglottic Mask Airways Manufacturer

AES, Inc. • Ultra CPV Supraglottic Mask Airways with Gastric Access • UltraFlex CPV Intersurgical Ltd Ambu Inc. • i-gel • AuraStraight LMA North America, Inc • AuraOnce •LMA-ProSeal • AuraFlex • LMA-Supreme GE Healthcare/Vital Signs King System/VBM Medizintechnik GmbH • Vital Seal • King/VBM King System/ • King/VBM LTS-D VBM Medizintechnik Gmb • VBM LTS II • King LAD • VBM G-LT (Gastro-Laryngeal Tube) • King LAD Flexible Nellcor (Covidien) Inc. Supraglottic Airway Devices for LMA North America Inc • Esophageal Tracheal Combitube One-Step Intubation • LMA Classic Teleflex Medical • LMA Unique Ambu Inc. • Rusch EasyTube • LMA flexible • Aura-i Pulmodyne Cookgas LLC • Cobra PLA Anesthesia-analgesia • air-Q/ILA • Cobra PLUS February 2012 • Volume 114 • Number 2 LMA North America, Inc Smith Medical • LMA Fastrach • Portex Soft Seal SLIPA Medical Ltd. • LMA Classic Excel • SLIPA Teleflex Medical

Which one to choose? 66

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EDITORIAL VIEW -ANAESTHESIA New devices should go through a three-stage process Stage 1: devices are evaluated on the bench and in specifically designed manikins Stage 2: a rigorous pilot study takes place to determine whether the device is effective and safe

Stage 3: the device is compared in a randomized controlled trial against the current gold standard for the procedure it is expected to be used for (in the case of supraglottic airways, the classic LMA)

Airway Device Evaluation Project Team (ADEPT) - DAS

SR 1a RCT

DAS’ ADEPT GUIDANCE

1b

Single RCT

Minimum criterion - there must be at least one source of ‘Level 3b’ trial evidence

All or nones 2 a SR of Cohorts 2b Single Cohort 2c Out comes Research SR of Case Control Study 3a 1c

3b 4 5 68

Single Case Control Study

Case Series Expert Opinion (Anaesthesia. 2011 Aug; 66(8):726-37)

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THE DIFFICULT AIRWAY SOCIETY ‘ADEPT’ GUIDANCE

Patients must be protected from untested devices that do not perform to an acceptable standard

RELATIONSHIP BETWEEN TECHNOLOGY AND HUMAN ERROR • Airway management-associated morbidity and mortality remain a sad reality for us as a scientific and academic society despite introduction of a plethora of airway tools. • NAP4 data represented the very first clear demonstration of the fact that airway management accidents are not always linked to a missing (hi-tech) device, but rather to misuse of available devices

We would need to abandon

The temptation of intubation at any cost in favour of oxygenation at any cost

LET OUR MOTTO BE:

Humans come before tools, Strategy before instruments and Target before devices

THANK YOU Chinese philosopher Lao Tzu says, ‘Mastering others is strength. Mastering yourself makes you fearless’

Almeida G, Costa AC, Machado HS (2016) Supraglottic Airway Devices: A Review in a New Era of Airway Management. J Anesth Clin Res 7:647 74

1/21/2019 Sharma, Bimla, Chand Sahai, and Jayashree Sood. “Extraglottic Airway Devices: Technology Update.” Medical Devices (Auckland, N.Z.) 10 (2017): 189–205. PMC. Web. 17 July 2018.