Review about supraglottic

airway devices

Supervised by
Prof.Dr. Emad Abd El Moneim
Professor of anaesthesia and surgical ICU
Alexandria university

Submitted by
Mohamed Mo’men Abo El Seoud
4th year trainee
Egyptian fellowship of anaesthesia

Signature of supervisor
…………………………..

i
 LIST OF CONTENTS

LIST OF CONTENTS ................................................................................................ ii

LIST OF TABLES ......................................................................................................iii

LIST OF FIGURES .................................................................................................... iv

LIST OF ABBREVIATIONS..................................................................................... v

I. INTRODUCTION......................................................................................... 1

II. Supraglottic Airway Devices………………………………………….....9

III. REFERENCES…………………………………………………………….30

ii
 LIST OF TABLES
Table page
(1) Fastrack maneouvers guide 13

iii
LIST OF FIGURES
Figure page
(1) Upper airway anatomy: A.inferior turbinate B.Major nasal airway 9
C.vallecula D.Epiglottis E.Hyoid bone F.Hyoepiglottic ligament
G.Thyroid (laryngeal) cartilage
(2) Sites of airway obstruction in obtunded patient. In B. soft palate, tongue 4
and epiglottis when falling back toward the posterior pharyngeal wall
(3) A.median and lateral glossoepiglottic ligaments B.vocal folds 6
C.vestibular folds D.aryepiglottic ligaments E.posterior cartilages
F.interarytenoid notch G.esophagous H.piriform recess I.vallecula
J.epiglottis
(4) Alingment of the airway axes in B. optimizes the laryngeal view 7
(5) LMA classic 9
(6) proseal laryngeal mask airway 10
(7) Fastrack 10
(8) Insertion of the fastrack 11
(9) Insertion of the tube through the fastrack 11
(10) Removal of the fastrack after successful intubation 12
(11) Protex soft seal laryngeal mask 14
(12) Oesophageal tracheal combitube 14
(13) Laryngeal tube 15
(14) Laryngeal tube suction 16
(15) Perilaryngeal airway-cobra 16
(16) The SLIPA 17
(17) ELISHA 18
(18) Air-Q 18
(19) Baska Mask

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 LIST OF ABBREVIATIONS

µg microgram

ASA American Society of Anesthesiologists

BMI Body mass index

BMV Bag and mask ventilation

CLMA Laryngeal Mask Airway-Classic

cm centimeter

cmH2O Centimeter water

CO2 Carbon Dioxide

EAD Elisha Airway Device

ECG Electrocardiogram

ETC Oesophageal Tracheal Combitube

ETT Endotracheal Tube

EzT Easy Tube

F French

HP Hewlett Packard

HR Heart Rate

IIG Inter-Incisor Gap

ILA Intubating Laryngeal Airway

kg kilogram

LMA Laryngeal Mask Airway

LT Laryngeal Tube

LT-D Disposable Laryngeal Tube

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LTS Laryngeal Tube Suction

LTS-D Disposable Laryngeal Tube Suction

MABP Mean Arterial Blood Pressure

mg milligram

min minute

ml milliliter

mm millimeter

MMC Modified Mallampati classification

mmHg millimeter mercury

P value Probability value

PLA Perilaryngeal airway

PLMA ProSeal Laryngeal Mask Airway

PVC Polyvinyl Chloride

RSI Rapid sequence induction

SaO2 Arterial oxygen saturation

SD Standard Deviation

sec second

SLIPA Streamlined Linear of the Pharynx Airway

SMD Sterno-mental Distance

TMD Thyro-mental Distance

U.K. United Kingdom

US United States

Yrs years

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Supraglottic Airway Devices

INTRODUCTION
Airway management remains an important problem in the practice of anesthesia.
Interruption of gas exchange, for even a few minutes, can result in catastrophic outcomes
such as brain damage or death. Closed claims analysis has found that the vast majority (85%)
of airway related events involve brain damage or death, and as many as one third of deaths
attributable solely to anaesthesia have been related to inability to maintain a patent airway(1).
As anesthesiologists, we spend a respectable part of our career maintaining the airway.
Theoretically, every anesthesiologist should be familiar with, and well practiced in a variety
of the airway techniques that are available, so that when an airway problem occurs, it can be
managed with a solid armamentarium of information and experience. However, with the
rapid advancements in airway management technology, many of the newer airway devices
are foreign to most anesthiologists.

Airway anatomy:
A clear mental picture or “gestalt” of upper airway anatomy is an essential cognitive
underpinning to emergency airway management skills. This knowledge is important for the
following reasons:
A. Making decisions: Assessment of a patient’s airway anatomy is the foundation upon
which the airway plan is built. Can the patient be ventilated with bag-mask ventilation
(BMV)? Can the patient be intubated by direct laryngoscopy? If difficulty is
encountered, can rescue oxygenation occur via an extraglottic device or cricothyrotomy?
Based on this assessment, the clinician can decide how to proceed: with a rapid-sequence
intubation (RSI), an awake intubation, or primary surgical airway.
B. Structure and function: Knowledge of airway anatomy and its dynamic changes
facilitates the appropriate performance of airway opening skills and BMV. These skills
depend on an understanding of functional airway anatomy and how the tissues behave
with the patient in either the awake or obtunded state.
C. Landmark recognition: A sound three dimensional appreciation of the laryngeal inlet
and its surroundings is critical for optimal laryngoscopy. Anatomic structures adjacent
to the glottic opening, such as the epiglottis and paired posterior cartilages help provide
a “roadmap” to the cords. In addition, anatomic or pathologic variations in airway
anatomy must be understood and anticipated.
D. Spatial orientation: Particularly when using blind or indirect visual intubation
techniques, a clear mental image of the anatomy through which the instrument is
traveling is required. Problem solving through intubation with a lightwand or intubating
laryngeal mask airway is much easier with a solid appreciation of potential anatomical
barriers(2).

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Supraglottic Airway Devices

Functional airway anatomy

The Upper Airway
The immediate goal of airway management during resuscitation is to obtain a patent
upper airway and ensure adequate oxygenation. The upper airway may be defined as the
space extending from the nose and mouth down to the cricoid cartilage, while the lower
airway refers to the tracheobronchial tree.

The Nasal Cavity

During normal breathing in the awake state, inspired air travels through, and is
humidified by the nasal cavity. The nasal cavity is bounded laterally by a bony framework
which includes the three turbinates and medially by the nasal septum. Septal deviation occurs
commonly, and can impede passage of a nasal endotracheal tube, as can a hypertrophied
inferior turbinate. The space between the inferior turbinate and the floor of the nasal cavity,
termed the major nasal airway is oriented slightly downward. During an attempted nasal
intubation, the tube should therefore be directed straight back and slightly inferiorly. This
will help traverse the widest aspect of the nasal airway, beneath the inferior turbinate, while
avoiding the thin bone of the more superiorly located cribriform plate.
The nasal cavity is well vascularized, particularly at the anterior inferior aspect of the
nasal septum. Many authorities espouse directing an endotracheal tube’s bevel toward the
septum to minimize the potential for bleeding caused by traumatizing the vascular
Kiesselbach plexus. However, published case series suggest that significant bleeding with
nasal intubations is less frequent than commonly feared, occurring in under 15% of
cases(figure1).

Figure1: Upper airway anatomy : A.inferior turbinate B.Major nasal airway

C.vallecula D.Epiglottis E.Hyoid bone F.Hyoepiglottic ligament G.Thyroid
(laryngeal) cartilage(2)

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Supraglottic Airway Devices

The Naso- and Oropharynx and the Mandible

The nasal cavity terminates posteriorly at the level of the end of the nasal septum (the
nasal choanae). The space from here to the tip of the soft palate is referred to as the
nasopharynx. The oropharynx extends backward from the palatoglossal fold (arching from
the lateral aspect of the soft palate to the junction of the anterior two thirds with the posterior
one-third of the tongue), down to the epiglottis. The oro-and nasopharynx are common sites
of narrowing or complete airway obstruction in the obtunded patient, as the loss of tone in
muscles responsible for maintenance of airway patency allows for posterior movement of
soft palate, tongue, and epiglottis(3).
Although classic teaching has been that it is collapse of the tongue against the posterior
pharyngeal wall which causes functional airway obstruction in the obtunded patient, in fact,
significant airway narrowing or obstruction can occur in one or all of three locations(4).
• In the nasopharynx: as the soft palate meets the posterior pharyngeal wall.
• In the oropharynx: as the tongue moves posteriorly to lie against or near the soft palate
and posterior pharyngeal wall.
• In the laryngopharynx: as the epiglottis moves posteriorly toward the posterior pharyngeal
wall.
The mandible figures prominently in alleviating functional airway obstruction. The
horse-shoe shaped mandible extends superiorly via two rami to end in the coronoid process
and condylar head. The condylar head in turn articulates with the temporal bone at the
temporo-mandibular joint (TMJ), and allows for mouth opening by rotation. In addition,
anterior translation of the condyle at the TMJ permits forward movement of the mandible.
The latter is crucial for two reasons:
• As the inferior aspect of the tongue is attached to the mandible, anterior translation of the
jaw elevates the tongue away from the posterior pharyngeal wall, helping to attain a clear
airway in the obtunded patient (figure 2).
• During laryngoscopy, the laryngoscope blade moves the mandible forward, helping to
displace the tongue anteriorly and away from obstructing the line of sight view of the
laryngeal inlet.
In addition to forward movement of the mandible and tongue, a laryngoscope blade
also seeks to compress or displace the tongue into the bony framework of the mandible. This
is why individuals with small mandibles (so called receding chins) can present difficulty
with laryngoscopy.

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Supraglottic Airway Devices

Figure2: Sites of airway obstruction in obtunded patient. B.are soft palate, tongue and
epiglottis when falling back toward the posterior pharyngeal wall(2).

The Laryngopharynx
The laryngopharynx extends from the epiglottis down to the inferior border of the
cricoid cartilage. The laryngopharynx can be looked upon as a “tube within a tube,” with the
circular structure of the larynx located anteriorly within the larger pharyngeal tube. On either
side of the larynx, in the pharynx, are the piriform recesses, while the esophagus is located
posteriorly.
The larynx, which sits at the entrance to the trachea opposite the fourth, fifth, and sixth
cervical vertebrae, is a complex box like structure consisting of multiple articulating
cartilages, ligaments, and muscles. The major cartilages involved are the cricoid, thyroid,
and epiglottis, together with the smaller paired arytenoid, corniculate, and cuneiform
cartilages. Located anteriorly in the midline, the shield-shaped thyroid cartilage is attached
by the thyrohyoid membrane to the hyoid bone above, and articulates inferiorly with the
cricoid cartilage. The cricoid cartilage is a circular, signet-ring-shaped cartilage which marks
the lower border of the laryngeal structure. The hyoid bone and thyroid and cricoid cartilages
are all palpable in the anterior neck.
The vocal cords attach anteriorly to the inner aspect of the thyroid cartilage, and
posteriorly to the arytenoids cartilages, which in turn also articulate with the cricoid
cartilage. The cricoid cartilage is significant in airway management for a number of reasons:
A. Because of its rigid nature, application of posterior pressure on the cricoid cartilage can
occlude the underlying esophagus, helping to prevent passive regurgitation of gastric
contents.
B. It is the narrowest point of the airway in the pediatric patient (the glottic opening is
narrowest in the adult patient), and can be an area of potential obstruction due to swelling
(producing the clinical syndrome pediatricians call croup), or congenital or acquired
subglottic stenosis. Such narrowing of the subglottic space may block passage of even a
normally sized endotracheal tube (ETT).

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Supraglottic Airway Devices

C. The cricoid cartilage, together with the thyroid cartilage, is a landmark for locating the
cricothyroid membrane, an area of critical importance in performing an emergency
surgical airway.

The Laryngeal Inlet

The clinician should be very familiar with the component parts of the laryngeal inlet
which are visually presented at laryngoscopy. The paired vocal cords are the “target” for the
laryngoscopist, and are identified by their whitish color and triangular orientation.
Surrounding the vocal cords, the laryngeal inlet is bordered anteriorly by the epiglottis,
laterally by the aryepiglottic folds, and inferiorly by the cuneiform and corniculate tubercles
(cartilages), and the interarytenoid notch (figure 3).
The epiglottis projects upward and backward, behind the hyoid bone and base of
tongue, and overhangs the laryngeal inlet. The base of the superior surface of the epiglottis
is attached to the hyoid bone by the hyoepiglottic ligament, while the inferior surface
attaches to the thyroid cartilage via the thyroepiglottic ligament. The overlying mucosa on
the upper surface of the epiglottis sweeps forward to join the base of the tongue, with
prominences forming the median and paired lateral glossoepiglottic folds. The paired valleys
between these folds are called the vallecullae, although both vallecullae are commonly
referred to together as the vallecula.
To expose the vocal cords, the tip of a curved (e.g., Macintosh) laryngoscope blade
can be advanced into the vallecula until it engages the underlying hyoepiglottic ligament.
Pressure on this ligament with the blade tip helps evert (“flips up”) the epiglottis to achieve
a line of sight view into the larynx. Attempts to lift the tongue prematurely, before the
hyoepiglottic ligament is engaged at the base of the vallecula, will often result in an
inadequate view of the glottic inlet.
Clinicians preferring straight blade direct laryngoscopy usually elect to place the blade
beneath the epiglottis and directly lift it. Either way, the epiglottis is an important landmark
in airway management, and should be a source of reassurance, not anxiety. Indeed, it should
be actively thought by the laryngoscopist as a guide to the underlying glottic opening.
Originating laterally from each side of the epiglottis toward its base, the aryepiglottic
folds form the lateral aspect of the laryngeal inlet by sweeping posteriorly to incorporate the
cuneiform and corniculate cartilages. The corniculate cartilages overlie the corresponding
arytenoid cartilages, and appear as the characteristic “bumps” (tubercles) posterior to the
vocal cords. In practice, many clinicians refer to these prominences as the arytenoids.
Confusion can be avoided by referring to these tubercles collectively simply as the posterior
cartilages. The underlying arytenoids are anatomic hinges used by laryngeal muscles to open
and close the cords. Between and slightly inferior to the paired posterior cartilages lies the
interarytenoid notch (figure 3). With the cords in the abducted position, this notch widens to
a ledge of mucosa stretching between the posterior cartilages, but with the cords in a more
adducted position, the interarytenoid notch narrows simply to a small vertical line. This
notch lies slightly inferior to the posterior cartilages and is important during laryngoscopy
because in a restricted view situation, it may be the only landmark identifying the entrance
to the glottis opening above.

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Supraglottic Airway Devices

Posterior to the laryngeal inlet lies the esophagus. It should be noted that the entrance
to the upper esophagus is not held open by any rigid structures, and at laryngoscopy is often
not seen at all. Conversely, when the esophageal entrance is seen, it can look like a dark,
(and sometimes inviting) opening. This highlights the importance to the laryngoscopist of
knowing the expected landmarks of the laryngeal inlet: the posterior cartilages, aryepiglottic
folds and overlying epiglottis flank the glottic opening, and not the esophagus.

Figure 3: A.median and lateral glossoepiglottic ligaments B.vocal folds C.vestibular

folds D.aryepiglottic ligaments E.posterior cartilages F.interarytenoid notch
G.esophagous H.piriform recess I.vallecula J.epiglottis(2).

Airway Axes
In the standard anatomic position, the axis of the oral cavity sits at close to right angles
to the axes of the pharynx and trachea. To obtain direct visualization during laryngoscopy,
this angle needs to be increased to 180°. The pharyngeal and tracheal axes can be aligned by
flexion of the lower cervical spine at the cervicothoracic junction, while alignment of the
oral and pharyngeal/tracheal axes then occurs with extension at the atlanto-occipital junction
and upper few cervical vertebrae(5).
Final visualization by line of sight is then achieved using the laryngoscope blade to
anteriorly lift the mandible and displace the tongue. This alignment of axes by proper
positioning before laryngoscopy reduces the need for tongue displacement required during
laryngoscopy, which may in turn reduce the amount of force required to expose the cords.
Where not contraindicated by C-spine precautions, the airway axes can be aligned before
laryngoscopy by placing folded blankets under the extended head to produce the “sniffing
position”.

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Supraglottic Airway Devices

Figure 4: Alingment of the airway axes in B. optimizes the laryngeal view(6).

The Lower Airway

The trachea extends from the inferior border of the cricoid cartilage to the level of the
sixth thoracic vertebra, where it splits into the left and right mainstem bronchus. The trachea
is 12 to 15 cm long in the average adult and is composed of C-shaped cartilages joined
vertically by fibroelastic tissue and completed posteriorly by the vertical trachealis muscle.
The anterior tracheal cartilaginous rings are responsible for the “clicking” sensation
transmitted to a clinician’s fingers following successful introduction and advancement of a
tracheal tube introducer (bougie)(7). The right mainstem bronchus is shorter and more vertical
than the left, making it a common location for the tip of an endotracheal tube that has been
advanced too far. Avoiding a right mainstem intubation will be aided by situating the ETT
no more than 23 cm at the teeth in males and 21 cm in females, reflecting the average teeth
to carina distance of 27 and 23 cm in the average male and female,

Surgical Airway Anatomy

One third of the trachea lies external to the thorax: the first 3–4 tracheal rings lie
between the cricoid and the sternal notch. These rings are the common location for elective
tracheotomies. Urgent percutaneous access to the trachea is more commonly achieved
through the relatively avascular and easily palpable cricothyroid membrane. located between
the cricoid and thyroid cartilages, the membrane is 22–30 mm wide and 9–10 mm high, in
the average adult. This means that the maximal outer diameter of a tube or cannula placed
through the cricothyroid membrane, as part of an emergent surgical airway, should be no
greater than 8.5 mm (the outside diameter [OD] of a #4 tracheostomy tube is 8 mm; the OD
of a #6 tracheostomy tube is 10 mm; and a 6.0 ID ETT has an OD of 8.2 mm). The average
distance between the midpoint of the cricothyroid membrane and the vocal cords above is
only 13 mm. The lower third of the membrane is usually less vascular than the upper third.
Emergency cricothyrotomies are performed after failure to intubate, in conjunction
with a failure to oxygenate by BMV or extraglottic device. Rarely, airway pathology may
mandate a primary cricothyrotomy or tracheotomy. It should be noted that developmentally,
the cricoid cartilage initially lies immediately beneath the thyroid cartilage. For this reason,
in the younger pediatric patient (i.e., up to age 8), there is no well-defined cricothyroid
membrane allowing easy access to the airway.

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Supraglottic Airway Devices

Airway innervation
Knowledge of the innervation of the airway is important to the airway manager
contemplating application of airway anesthesia to facilitate an “awake” intubation. The
posterior third of the tongue is innervated primarily by the glossopharyngeal nerve, as are
the soft palate and palatoglossal folds. Pressure on these structures can evoke a “gag”
response. The glossopharyngeal nerve can be blocked with small volumes of local anesthetic
injected at the base of the palatoglossal fold in the mouth, but also responds well to topically
applied anesthesia. The internal branch of the superior laryngeal nerve supplies the
laryngopharynx, including the inferior aspect of the epiglottis and the larynx above the cords.
It can be blocked topically by holding pledgets soaked in local anesthetic solution (e.g., 4%
xylocaine) in the piriform recesses.
Alternatively, it can be blocked by injecting a small volume of local anesthetic in the
proximity of the nerves as they pierce the thyrohyoid membrane, near the lateral aspects of
the hyoid bone.
Below the cords, sensation is provided by the recurrent laryngeal branch of the vagus
nerve(8).

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Supraglottic Airway Devices

Supraglottic airway devices

In the last years a number of supraglottic airway devices have been introduced in the
clinical practice of the airway management, trying to offer a simple and effective alternative
to the endotracheal intubation.
Supraglottic airway devices are devices that ventilate patients by delivering anesthetic
gases/oxygen above the level of the vocal cords and are designed to overcome the
disadvantages of endotracheal intubation as: soft tissue, tooth, vocal cords, laryngeal and
tracheal damage, exaggerated hemodynamic response, barotrauma, etc.
The advantages of the supraglottic airway devices includes: avoidance of
laryngoscopy, less invasive for the respiratory tract, better tolerated by the patients, increased
ease of placement, improved hemodynamic stability in emergence, less coughing, less sore
throat, hands free airway and easier placement by inexperienced personal.
The American Society of Anesthesiologists’ Task Force on Management of the
Difficult Airway suggests considering the use of the supraglottic airway devices (as
Laryngeal Mask Airway and the Combitube) when intubation problems occur in patients
with a previously unrecognized difficult airway, especially in a “cannot ventilate, cannot
intubate” situation. The European Difficult Airway Society suggests using the Laryngeal
Mask Airway or the Intubating Laryngeal Mask, in an unanticipated difficult tracheal
intubation(9).

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Supraglottic Airway Devices

 Laryngeal Mask Airway:

The Laryngeal Mask Airway (LMA), originally described by Brain has been
described as the missing link between the facemask and the tracheal tube and it has gained
widespread popularity. The LMA consists of two parts, the tube and the mask. Made of
medical grade silicone, it can be autoclaved and reused many times. It is designed to provide
an oval seal around the laryngeal inlet. LMA was first used at Royal Hospital London, UK,
in 1981 and since its introduction in clinical practice it has been used in more than 100
million patients worldwide with no reported deaths (figure 5).

Figure 5:LMA classic(10).

Advantages of the LMA over the endotracheal tube include: increased speed and ease
of placement, improved hemodynamic stability at induction and during emergence of
anesthesia; minimal increase in intraocular pressure following insertion; reduced anesthetic
requirements for airway tolerance; lower frequency of coughing during emergence;
improved oxygen saturation during emergence; and lower incidence of sore throat in adults.
LMA isn’t an ideal airway device because the low pressure seal may be inadequate for
positive pressure ventilation, and it does not protect the lungs from gastric contents
regurgitated into the pharynx.(11) In an attempt to overcome these disadvantages the Proseal
LMA was developed.

Proseal Laryngeal Mask Airway:

The Proseal Laryngeal Mask Airway (PLMA) (figure 6) is a new Laryngeal Mask
Airway with a modified cuff designed to improve its seal and a drainage tube for gastric tube
placement. These features are designed to improve safety of the LMA and broaden its scope
especially when used with positive pressure ventilation(12).

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Supraglottic Airway Devices

Figure 6: Proseal laryngeal mask airway(13)

It is a reusable device. The cuff is made of a softer material than the LMA Classic and
is designed to conform to the contours of the hypopharynx. While the LMA ProSeal may be
used with spontaneously breathing patients, it is designed for use with positive pressure
ventilation with and without muscle relaxants. The maximum airway seal pressure will vary
between patients, but is on average 10 cm H2O higher than the LMA Classic or up to 30 cm
H2O. However, it is more difficult to insert as the LMA, unless an introducer tool is used.

FastTrack – Intubating Laryngeal Mask Airway (ILMA):

FastTrack, a modification of the LMA is in use from 1997(figure7); designed as a
conduit for tracheal intubation and it has a success rate for endotracheal intubation of
approximately 93%. It has an epiglottic elevator bar at the mask aperture and a rigid
(stainless steal) anatomically curved shaft that follows the anatomical curve of the palate and
the posterior pharyngeal wall.
Fastrack has certain limitations. For example, the rigidity of its breathing tube makes
it inadvisable for prolonged use as a supraglottic airway for ventilation It also requires the
use of a special and expensive tracheal tube, adding to the overall cost. Finally, it is not
available in paediatric sizes(14)

Figure 7: Fastrack(13)

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Supraglottic Airway Devices

On insertion of the Fastrack, deflate the cuff of the mask and use a water soluble
lubricant on the posterior surface, rub the lubricant over the anterior hard palate.
Then, swing the mask into place in a circular movement maintaining contact against
the palate and posterior pharynx. And finally, inflate the mask without holding the tube or
the handle, to a pressure of about 60 cmH2O (figure 7)(15, 16).

Figure 8: Insertion of the fastrack(10).

To insert the endotracheal tube, hold the LMA Fastrack device handle while gently
inserting the lubricated endotracheal tube into the shaft, advance the endotracheal tube,
inflate the cuff and confirm intubation by adequate chest rise and appearance of capnography
waveform(figure 9)(15, 16).

Figure 9: Insertion of the tube through the fastrack(10).

To remove the device, remove the ETT connector and ease the LMA Fastrack out by
gently swinging the device handle caudally while concerning the use of special stabilizing
rod to keep the tube in place till it can grasped at the level of the incisors, finally remove the
device and replace the tube connector(15, 16)

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Supraglottic Airway Devices

Figure 10:Removal of the fastrack after successful intubation(10).

The guide of the LMA Fastrack maneuvers include (15, 16):

1. Optimize the airway prior to intubation:

Position the LMA Fastrack for the least resistant, most compliant airway by:

 Grasping the handle of the device and gently ventilating the patient.
 Sqeezing the bag, and gently rotating the handle in and out and side to side until
ventilation is optimized.
 Gently lifting the handle anteriorly (in a similar fashion as a laryngoscope) and begin
passing the lubricated ETT.

2. Correct placement:
Insert ETT and inflate cuff, verify end-tidal co2

3.Overcoming: the resistance on advancing the ETT into the Fastrack:

The resistance which are felt at different levels while advancing the ETT, their causes
and methods to overcome are shown in table 1.

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 Supraglottic Airway Devices

Table (1): Fastrack maneuvers guide(10).

Resistance level The cause Method to overcome the resistance

2cm beyond the Tube impaction on Rotating the ETT bevel may overcome the
15cm mark on the vestibular wall impaction
ETT(transverse line)
2cm beyond the Epiglottis downfolded Without deflating the Reoptimize and
15cm mark on the cuff swing the device reattempt intubation
ETT(transverse line) outward 6cm and
reinsert it

3cm beyond the LMA Fastrack too small Epiglottis is out of reach Use larger one
15cm mark on the of the EEB (epiglottic
ETT(transverse line) elevating bar)

Immediately with the ETT LMA Fastrack too large In patients with normal Use smaller one
depth marker still visible, thin necks
or just a few mm into the
LMA Fastrack tube

4cm beyond the 15cm LMA Fastrack too large In patients with wide Use smaller one
mark on the short neck
ETT(transverse line)

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Supraglottic Airway Devices

Portex Soft Seal Laryngeal Mask

The single use Portex Soft Seal Laryngeal Mask is a new supraglottic device similar
to the single-use LMA –unique.

Figure 11: Protex soft seal laryngeal mask(17).

The difference between the two devices consists in the design of the ventilation orifice
of the Portex Soft Seal Laryngeal Mask, as well as its more eliptical cuff. The ventilation
orifice of the Portex Soft Seal Laryngeal Mask is wider and it is characterized by the absence
of mask aperture bars (figure 11)(18).

Esophageal-Tracheal Combitube
The Esophageal-Tracheal Combitube (ETC) is an easily inserted double lumen/ double
balloon supraglottic airway device, that allows for ventilation independent of its position
either in the esophagus or the trachea (figure 12). Blind insertion results in successful
esophageal intubation in nearly all patients. The major indication of the ETC is a back-up
device for airway management. It is an excellent option for rescue ventilation in both in and
out of the hospital environment, as well as in immediate life threatening cannot ventilate,
cannot intubate situations. The advantages of the Combitube include rapid airway control
without the need for neck or head movement, minimized risk for aspiration, firm fixation of
the device after inflation of the oropharyngeal balloon and that it works equally well in either
tracheal or esophageal position(19).

Figure 12: Oesophageal tracheal combitube(13)

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Supraglottic Airway Devices

EasyTube
The EasyTube is new disposable, polyvinyl-chloride, double-lumen, latex-free, supra-
glottic airway device. It has a close design to the Combitube, intended to be more friendly
to use. Allows ventilation in either esophageal or tracheal position, however it is expected
to enter the esophagus in most cases. However, the EasyTube had a better fiberoptic view
and a shorter time to achieve an effective airway, with similar ventilatory performances with
the ETC(20).

Laryngeal Tube
The Laryngeal Tube (LT) is a multiuse, latex-free, single-lumen silicon tube and
consists of an airway tube with an approximate angle of 130, an average diameter of 1.5 mm
and two low pressure cuffs (proximal and distal) with two oval apertures placed between
them which allows ventilation. The distal balloon (esophageal balloon) seals the airway
distally and protects against regurgitation. The proximal balloon (oropharyngeal balloon)
seals both the oral and nasal cavity (figure13). When the LT is inserted, it lies along the
length of the tongue, and the distal tip is positioned in the upper esophagus. During
ventilation, air passes into the pharynx and from there over the epiglottis into the trachea,
since the mouth, nose and esophagus are blocked by the balloons (11).

Figure 13 :Laryngeal tube(13)

Laryngeal Tube Suction

The newly introduced Laryngeal Tube Suction is a further development of the
Laryngeal Tube which allows better separation of the respiratory and alimentary tracts
(figure 14). The LTS is a latex-free, double lumen silicon tube where in one lumen is used
for ventilation and the other for decompression, suctioning and gastric tube placement(21).

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Supraglottic Airway Devices

Figure 14 :Laryngeal tube suction(13)

Airway – Perilaryngeal Cobra

The Perilaryngeal –Airway COBRA (PLA) is a single use, PVC mode, latex free
supraglottic airway device, designed to be positioned in the hypopharynx opposite to the
laryngeal inlet. It has a breathing tube with a large inner diameter to increase air flow. In
the proximal end it has a standard 15 mm connection and in the distal end a ventilatory hole
which is surrounded by a novel head design. The novel head design facilitates ventilation
though the slotted openings that prevents the soft tissue and the epiglottis to obstruct the
ventilatory hole (figure 15).

Figure 15 : Perilaryngeal airway-cobra(22).

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Supraglottic Airway Devices

Above the head, the device has a balloon surrounding the tube like a ring. This balloon
when inflated closes the nasopharynx and pushed the roof of the tongue anteriorly,
preventing air leakage. PLA offers a more effective seal, and a better fiberoptic score as the
LMA(23).

Slipa - Streamlined Pharynx Airway Liner

The SLIPA is a hollow, preformed, soft plastic, blow-molded, boot-shaped airway,
which lines the pharynx. No cuff is necessary for the device to seal in the pharynx because
the shape of the SLIPA is similar to that of a pressurized pharynx (24) .

Figure 16 : The SLIPA(25)

Elisha
The Elisha’s uniqueness consists of its ability to combine three functions in a single
device: ventilation, intubation (blind and/or fiberoptic-aided) without interruption of
ventilation, and gastric tube insertion. It has three separate channels for ventilation,
intubation, and 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 VC has a standard
15 mm connector located on the proximal end of the device. The IC allows passage of an 8.0
mm ID endotracheal tube (ET) for blind or fiberoptic-guided intubation (figure17).

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Supraglottic Airway Devices

Figure17 : ELISHA(26).
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. Both
balloons are inflated through a single pilot port with 50 cc of air resulting in an intra-balloon
pressure of approximately 70 cm H2O(26).

Air-Q ILA
The Air-Q Intubating Laryngeal Airway (ILA, Cookgas LLC, Mercury Medical,
Clearwater, FL, USA) is a new supraglottic airway device that in addition to allowing for
airway maintenance under general anaesthesia, it allows for tracheal intubation with a cuffed
ETT(up to 8.5 mm IDs) blindly or fiberoptic-guided in both adults and pediatric patients
(figure 18)(27).

Figure18 : Air-Q(25).
Air-Q ILA maneuvers guide from cookgas.com include:
A. Selecting the Proper Size and Pre-Insertion Suggestions
 Sizing the air-Q® Blocker correctly is very important. Typically, LMA Supreme size 2.5
cross-references to air-Q size 2.5, LMA 3.0 to air-Q Blocker 3.5, and LMA 4 & 5 to air-
Q Blocker 4.5).

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Supraglottic Airway Devices

 Look at the patient’s Ideal Body Weight (IBW), not the patient’s actual weight. If, for
instance, a 5’2”, 125 lb. woman has an IBW of 50 – 60 kg, the appropriate size would be
3.5.
 Visualize the patient, especially the facial structures and laryngeal area. Small structures
should guide you to smaller air-Q Blocker sizes, etc.
B. Insertion Suggestions(28)
 Elevate the tongue
 If insertion is forced the epiglottis may down-fold or become lodged into the keyhole
opening.
 The patient will still be able to breathe without difficulty, but intubation is more difficult.
Jaw Lift is the best way to do this and is very easy to do. Performing a jaw lift also makes
sliding the air-Q Blocker into the pharynx much easier as well.
 Doing a jaw lift during insertion is important with all Supraglottic airways, not just the
air-Q Blocker.
 Prior to insertion, lubricate both the front and back of the air-Q Blocker.
 Be sure to lubricate the ridges within the mask cavity also.
 If the patient’s mouth is dry the air-Q Blocker ridges can get hung up on the back of the
tongue during placement.
 Proper lubrication only takes a few seconds. When using the Blocker tube or NG tube
through the guide channel, make certain that you lubricate the top of the guide channel
and the Blocker tube or NG tube thoroughly.
 Place the air-Q Blocker with the red tab on the pilot balloon in place.
 Once placed, remove the red tab and inflate with 2 – 5 cc of air or just until you get a
nice, firm bounce on the pilot balloon.
 Keeping the red tab in place during insertion keeps the valve open allowing the mask to
adjust easily and conform to the pharyngeal space.
C. Minimizing Leaks(28)
 If the clinician hyper-extends the head during placement, put the head in the neutral
position after placement. This is better for the patient overall and helps minimize leaks.
 With the air-Q® Blocker inflated, pull the air-Q Blocker back 1/4 – 1/2 inch. This can
help to correctly place it.
 Again, it is important to use a jaw lift during insertion. If not done during the original
insertion, ask the clinician to remove air from the mask, back the air-Q Blocker out about
3 – 4”, then re-insert using a jaw lift.
 Try a different size of air-Q Blocker. If you use a 3.5, and the patient looks a little big, go
up to a size 4.5. If you use a 4.5, and the patient looks a little small, go down to a 3.5.

D. Intubation Tips: Lubrication

 Prior to intubation, lubricate the OETT generously and lubricate the inner portion of the
air-Q Blocker airway tube by sliding the OETT up and down within the air-Q Blocker
airway tube several times.
 If it is still a little sticky, then remove the OETT and place a little more lubricant near the
end of the OETT and replace the OETT into the air-Q Blocker airway tube.
 This will really lubricate the tube well which is the secret to easy passage within the air-
Q Blocker. Again, all this just takes a few moments, but is very important. If the tubes

26
Supraglottic Airway Devices

are not lubricated well, the clinician will find it harder to tell when he/she enters the
trachea or hits an obstruction.

E. Intubation Tips: Difficult Visualization

 If use of Fiber Optics does not immediately allow a view of the opening to the trachea
and cords, the epiglottis is most likely down-folded (partially shut) or sitting within the
air-Q Blocker’s keyhole opening into the mask. This usually happens when a jaw lift has
not been done during insertion(29).
 The epiglottis can then get caught by the keyhole tunnel structure. This can partially close
the epiglottis (obstructs the view entirely), or entrap the epiglottis within the keyhole
opening.
 Alternatively, a bimanual external jaw lift will usually expose the glottis for visualization.
This can usually be alleviated by performing the “Klein Maneuver.” Deflate the air-Q
Blocker, and pull the air-Q Blocker back about 2 – 3 inches. Next, reinsert the air-Q
Blocker using a lower jaw lift. This will generally lift the epiglottis up and into the proper
position.
F. Intubation Tips: Bougie Insertion(30)
 It is important to lubricate the bougie so it slides easier, giving the clinician better tactile
feedback while passing the bougie.
 First place the ET tube through the air-Q Blocker airway tube approximately 12 – 15 cm,
but not completely into the patient. This is called pre-loading the ET tube.
 The ET tube is much smaller than the air-Q Blocker airway tube and will help to keep the
bougie centered and help to guide it toward the glottic opening.
 If the clinician passes the bougie alone through the air-Q Blocker before the ET tube is
inserted, it is much more likely that the bougie will spin off center during placement.
 The air-Q Blocker airway tube is much larger than the ET tube and also is oval- shaped,
giving the bougie much more room to move off center.
 Next, insert the bougie through the ET tube with the tip pointing anterior, and gently pass
the bougie forward feeling for obstruction to further passage.
 Do Not Force the bougie. If it goes into the trachea, it will go quite easily.
 If it does not, it is probably off to one side or the other, or hitting the epiglottis as described
above. (Remember this is very delicate tissue!)
 Feel over the cricoid area of the neck during passage, a nurse or medic can do this for
you.
 A scraping sensation will usually be felt as the bougie passes over the cricoid ring. It takes
a little practice to get the feel of this.
 Once the bougie passes into the trachea, advance the ET tube into the trachea using the
bougie as a guide.
 Note: Sometimes the bougie, or any type of stylet for that matter, can be properly placed
within the trachea, but one is unable to pass the ET tube. In this case, the ET tube is
probably hung up on the lower aspect of the inlet.
 If this happens it usually helps to deflate the air-Q Blocker cuff and apply cricoid pressure
while passing the ET tube. Also turning the ET tube ¼ turn to the left (counterclockwise)
will help by placing the bevel of the ET tube facing down.
 If this does not help, try a smaller ET tube.

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Supraglottic Airway Devices

 This obstruction to passing the ET tube is not a specific problem to the air-Q Blocker;
this happens occasionally with all stylet intubations and intubation devices.
 If the bougie does not go into the trachea easily, it usually misses to one side or the other.
 It usually misses to the right. Pull the bougie back a few centimeters, twist the bougie
slightly to the left if you believe it missed to the right, and try to pass again.
 With a little practice, one can usually “walk” the bougie slowly over to the midline and
into the trachea.
 This does take some practice. Remember, the bougie will advance quite easily when you
enter the trachea, DO NOT FORCE the bougie.
 Hint: A helper feeling over the cricoid area of the neck can often feel the bougie if it
misses to one side or the other. Remember if the epiglottis is causing an obstruction, this
can lead to unsuccessful attempts with the bougie as well.

Baska Mask
Figure 19 : Baska mask

The Baska mask was designed by Australian anesthetists Kanag and Meena Baska.
The Baska mask obviates the need for an orogastric tube and replaces this with a sump and
two drains.

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Supraglottic Airway Devices

The Baska mask brings together features of:

1. LMA ProSeal i e. high seal pressure, gastric access port and bite block, which facilitate
ventilation, provide airway protection, and minimize airway obstruction, respectively;

2.LMA-Supreme
i e. oval shaped, anatomically curved airway tube which incorporates a gastric
tube;

3. gel
i-e. a gel-like cuff instead of an inflatable balloon; and

4. Slipa
i e. a cuffless, anatomically pre-shaped sealer with a sump reservoir.

The last three have an incorporated bite block to protect the airway.

The Baska Mask presents with a bite block throughout the entire length of the airway tube.
The oval-shaped airway tube matches the shape of the mouth and reduces rotation within the
pharynx.

http://www.joacc.com/article.asp?issn 2249-4472;year 2012; volume 2;issue 1 spage 23

epage 30

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Supraglottic Airway Devices

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Thank you

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