Professional Documents
Culture Documents
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SAM’s Official
Journal !
The Journal of
Clinical Anesthesia
% 9*4>T%*U%Z@>"53*>.%
18BEVBE!6%% President
% Elizabeth Behringer, MD
VT@3*>@4+%V:#>"..@*2.%% elizabeth.behringer@cshs.org
B"J%O"KW">.% President-Elect
Thomas Mort, MD
-23">243@*24+%-23">".3.% tmort@harthosp.org
!NO%N22/4+%O""3@2Q%-2?@343@*2% Vice President
Maya Suresh, MD
14."%X"#*>36%Y4>P2Q*.#4.K%42T%YON%
msuresh@bcm.tmc.edu
YON%1/UU%ZP24K@5.%J@3=%N@>%?.%!4+@2"% Secretary
VFY@Q=3.%*U%3="%!NO%H*>/K% Irene Osborn, MD
Irene.osborn@mssm.edu
X".@T"23%X"?@"J%
Treasurer
N##+@543@*2%% Richard Cooper, MD
% richard.cooper@uhn.on.ca
Executive Director
Editor-In-Chief
Carin Hagberg, MD
Katherine Gil, MD
Carin.A.Hagberg@uth.tmc.edu
k-gil@northwestern.edu
9*4>T%O "K W">.%
Associate Editor Lauren Berkow, MD
Gail Randel, MD lberkow@jhmi.edu
g-randel@northwestern.edu Lorraine Foley, MD
ljfoley@comcast.net
Administrative Director Eugene Liu, MD
Anne-Marie Prince analiue@nus.edu.sg
amprince@peds.bsd.uchicago.edu Alonso Mesa, MD
Alonso.Mesa@moffitt.org
Gazette Layout Editor Arnd Timmerman, MD
Kathryn N. Gil atimmer@web.de
Ashutosh Wali, MD
awali@bcm.tmc.edu
Willis
Tower…
Chicago formerly
Theatre named
district Sears
sign Tower
2
2
Editorial Expressions ten do we hear the phrase in a potentially DA sce-
nario, “We should look first with a conventional la-
Dear fellow colleagues: Excitement is building! ryngoscope, to ‘evaluate’ the difficulty of intuba-
For stress-inducing, tension-building situations, few tion.” The difference to me here is that the video/
can beat having to deal with a difficult airway (DA). optical laryngoscopes usually give better laryngo-
But, our excitement is anticipation for the SAM An- scopic views with greater success and less morbidity,
nual Meeting starting on September 24th in Chicago. so why reverse engines? Imagine asking a surgeon to
There we can get expert advice for handling the DA use an older technique just to see if it can be done as
and see newer airway devices and techniques. well as a newer, improved one. Anyone have ideas
In this regard, interesting developments have tran- on these topics? Letters to the Editor are welcome!
spired: In the desire to optimally manage airways This Gazette issue has a number of articles that
with the latest devices, we have suffered disappearing discuss “changes in established techniques”. Dr.
skills. E.g. how often do “younger practitioners” per- Francisca Llobell details steps in the “Dénia model”
form blind nasal intubations or even insert soft nasal for DA identification, alerting, registration, and fol-
airways during difficult mask ventilation? low-up, in our International section. Dr. Davide Cat-
Many experienced practitioners feel that younger tano describes saline for supraglottic airway cuff in-
ones are less able to handle one of the oldest, most flation, comparing dynamics in LMA Unique™ and
prevalent techniques: face mask ventilation (FMV). Supreme.™ Another article, in our Resident’s Review
Chalk up this skill’s erosion to use of the laryngeal section (Dr. Ronen Harris), illustrates how measure-
mask airway (LMA). No more laborious FMV for up ment of intra-cuff pressure demonstrates the preva-
to two hours; dealing with the vagaries of trying to lence of cuff over-inflation and possible morbidity.
maintain a patent airway. The result is “disuse atro- For all airway enthusiasts, researchers, writers,
phy”. How can this be reversed? Although often and thinkers: please see guidelines in back issues of
requests are made for invasive techniques in other the Gazette via the SAM website and help fill our
realms for “educational purposes” that is not a con- pages. Also, please contact Dr. Meltem Yilmaz
cept to which many subscribe. But, use of FMV dur- (m_yilmaz@northwestern.edu) if you would like to
ing longer periods for “educational purposes” is one I write a synopsis of a session for the Gazette from the
would accept, as long as the patients are not precari- SAM meeting, for fellow
ous and my attention is not diverted by other duties. members unable to attend.
Similarly, fear of another loss of skill has cropped
up, even among younger practitioner…i.e. erosion of Best regards,
conventional laryngoscopic intubation skill secon- Katherine S.L. Gil, M.D.
dary to video/optical laryngoscopes usage. How of- Editor-In-Chief
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4
rences happen in patient evaluation / diagnosis, and 7. Vigilance Post-extubation: Technique develop-
management. The ordinate (y), represents points of ment; systematic registry of new information
patient care. 8. End of Procedure: Revision and finalization of the
Table 1
Chronologically, these are the steps of the Dénia DA whole procedure; administration of a difficult airway
process (See Table 1 or website for details): card for the patient (fig. 2)
1. Inclusion: Steps needed for systematic evaluation Conclusions:
and registration of DA information including in- Anticipation based upon evaluation and diagnosis
formed consents. Create an alert. to detect the DA leads to the formation of a clinical
2. Activation: Each team member is contacted; the process or protocol for each subsequent action. The
alert is engaged and the responsible committee is in- development of a strategy of action according to the
formed; definite identification of the case is made. ASA-DA algorithm is followed by execution of the
3. Preparation: A thorough plan is made for airway plan in defining the personnel and equipment needs.
management of the patient. This process occurs under quality control with a con-
4. Pre-access: Previous protocols, materials, kits, and stant dynamic vigilance of the phases of develop-
the ASA-DA algorithm are gathered; the layout for ment. The process secures the registry of the patient
future management is designed. and revision of the actions taken. It forms the basis
5. Access: Development of the airway plan; system- of the patient’s future identification and care.
atic registry of all information. In summary, we try to evaluate, inform, prepare,
6. Extubation: According to protocol, an extubation document, and provide an ALERT: Difficult Airway!
strategy is formed with plans for delayed extubation We feel the DA should be given the same degree of
and ICU care. importance as patient allergies. See: www.cediva.eu
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6
Laryngospasm Associated with Tracheal Extubation
and LMA Insertion at Emergence
Stephanie Chiu, M4 and David T. Wong, MD
Glasgow Medical School, Glasgow, Scotland
7
0.3 mg/kg intravenously).2 In our case, administra- laryngospasm: Prevention and treatment. Curr Opin
tion of succinylcholine was effective, and endoscopic Anaesthesiol 2009; 22: 388-95
3
images showed relief of laryngospasm. Olsson GL, Hallen B. Laryngospasm during anaes-
References: thesia. A computer-aided incidence study in 136,929
1
Koga K, Asai T, Vaughn RS, Latto IP. Respiratory patients. Acta Anaesthesiol Scand 1984; 28: 567-75
4
complications associated with tracheal extubation. Holm-Knudsen RJ, Rasmussen LS. Paediatric
Timing of tracheal extubation and use of the laryn- airway management: Basic aspects. Acta Anaesthe-
geal mask during emergence from anaesthesia. An- siol Scand 2009; 53: 1-9
5
aesthesia 1998; 53: 540-4 Visvanathan T, Kluger MT, Webb RK, Westhorpe
2
Al-alami AA, Zestos MM, Baraka AS. Pediatric RN. Crisis management during anaesthesia: Laryn-
gospasm. Qual Saf Health Care. 2005; 14/3/e3
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8
A COMPARISON of the LMA UNIQUE™ and LMA SUPREME™
AIR VERSUS SALINE: A MANNEQUIN STUDY
Davide Cattano, M.D., Ph.D.†, Srikanth Sridhar, M.D.,
Meng Cheng*, M2, Jeremy R. Bates, M4, Carin A. Hagberg, M.D.
The University of Texas Medical School at Houston,
*
Baylor College of Medicine, Houston, Texas
(†sponsored by the Society of Airway Management 2009 Research Award)
9
of correlation and non-parametric test were applied as saline resulted in a flex point occurring at slightly
desirable (p <0.05). lower filling volumes than air (Fig. 4) for size 3, but
was unchanged for sizes 4 and 5.
Results:
Phase 1: Cuff Elastance Outside Mannequins
When assessing cuff elastance, the Unique™ had
higher cuff pressures than the Supreme™ at any given
cuff volume, regardless of whether air (Fig. 1) or sa-
line (Fig. 2) was used to fill the cuff.
10
Overall, there were no significant differences in cuff
seals or cuff pressures between the Unique™ and
Supreme™ in either the non-mannequin or inside-
mannequin setting.
Discussion:
Our goal was to provide basic research for future
In the TCA mannequin, elastance graphs for the tests in humans on whether saline might offer a better
Supreme™ are shown in Fig. 8. seal and better cuff stability. Essentially, changes in
volume and the type of filling medium affected the
Unique™ cuff pressure more so than the Supreme™.
This in turn warrants exercising more caution when
using the Unique™ when saline is used as the filling
medium.
The ideal cuff inflation pressure in humans should
not exceed 60 cm H2O, which usually is achieved
with 15 mL of air inflation in the Unique™ Size 4.
When comparing air vs saline in the Supreme™, cuff Closer examination of the elastance curve for the size
pressures generally increased at steeper rates with 4 Unique™ inflated with air inside the TCA does in-
saline than with air inside both mannequins (Fig. 5, deed show 15 mL of air achieving cuff pressures be-
6). This suggests that using saline increases the tween 50-100 cm H2O (Fig. 7). The elastance curve
elastance of the cuff in Supreme™. for the Supreme™ sizes 3 and 4 had similar results.
Inside the TCA, 15 mL of saline achieves cuff pres-
Phase 3: Cuff leak or minimum seal pressure sures between 100 and 150 cm H2O for the size 4
The last phase of the study was performed only in Unique™. Thus, a smaller volume of saline is needed
the TCA by documenting cuff volumes of air versus to fill the cuff in order to reach the 60 cm H2O of cuff
saline at which an oropharyngeal air leaks were de- pressure in the average device. Our data only reflects
tected using different PEEP levels. Saline showed that saline might achieve higher cuff pressures than
lower leak volumes than air in all devices at all PEEP air at a given volume both outside and inside manne-
levels (Fig. 9, 10). The Unique™ had overall lower quins. The use of saline resulted in flex points occur-
leak volumes than the Supreme™ at all PEEP levels ring earlier than air (higher elastance).
(Fig. 9, 10). In comparing saline versus air, oropharyngeal air
leaks were detected at lower cuff volumes through all
PEEP levels and for both devices, which indicates a
smaller volume of saline than air was needed to
maintain an oropharyngeal seal without any detect-
able air leaks.
A limitation of the study was the lack of informa-
tion on peripharyngeal pressure7 as opposed to in-
tracuff pressure, with resulting possible mucosal and
nerve injury. This necessitates further investigation.
Conclusion:
Saline provided higher intracuff pressures with
both LMA Unique™ and LMA Supreme™ within
mannequins. Despite lower compliance by saline at
higher inflation volumes, lower volumes are required
to achieve comparable airway leak pressures.
11
References:
1
Coorey A, Brimacombe J, Keller C. Saline as an alterna- ing manikins as patient simulators for the insertion of eight
tive to air for filling the laryngeal mask airway cuff. Br J types of supraglottic airway devices. Anaesthesia.
Anaesth. 1998;81:398-400. 2007;62:388-393.
2 5
Brimacombe J, Keller C. Laryngeal mask airway size Cook TM, Green C, McGrath, J, Srivatsava R. Evalua-
selection in males and females: ease of insertion, oro- tion of four airway training Airway Management Trainer
pharyngeal leak pressure, pharyngeal mucosal pressures, as patient simulators for the insertion of single use laryn-
and anatomical position. Br J Anaesth. 1999;82(5):703- geal mask airways. Anaesthesia. 2007;62:713-718.
6
707. Silsby J, Jordan G, Bayley G, Cook TM. Evaluation of
3
Ulrich-Pur H, Hrska F, Krafft P, Friehs H, Wulkersdorfer four airway training manikins as simulators for inserting
B, Köstler WJ, Rabitsch W, Staudinger T, Schuster E, the LMA Classic. Anaesthesia. 2006;61(6):576-9.
7
Frass M. Comparison of mucosal pressures induced by Keller C, Brimacombe J: Mucosal pressure and oro-
cuffs of different airway devices. Anesthesiology. pharyngeal leak pressure with the ProSeal versus laryngeal
2006;104(5):933-938. mask airway in anaesthetized paralyzed patients. Br J An-
4
Jackson KM, Cook TM. Evaluation of four airway train aesth. 2000;85(2):262-66.
!"#$%&'"#&$()*&+"&,*&"-&.&/"0(*+'&1"2&3(24.'&5.-.6*7*-+&8"77(++**9&&
:(;(+&<++=>??444@;.7<A@0"7&&
Unfortunately on June 17, 2010 SAM and its Forum lost chin lift maneuver. I then switched to a size 3 LMA
a giant/friend/champion/mentor/beacon/heart, and soul Unique which was easily inserted on the first pass.
and world-renowned icon in the field of airway man- Any similar experiences from Forum members? Any
agement, Dr. Andranik Ovassapian. This edition of E- suggestions/tips for problem solving?
lights includes his last recorded contribution to the Fo- Elizabeth Cordes Behringer, MD
rum. Participants remember he lead most discussions in
~ The rigid connection of the respiratory gas tubing
which he participated. His contributions were always
(with respect to the bowl of the mask) is the culprit be-
expected and highly appreciated. Very few dared to
challenge his statements that usually put an end to hind the inability to get the mask fully around the cor-
whatever discussion had taken place. Needless to say ner, as evidenced by the success with the LMA Unique.
The connection between the respiratory gas tubing and
the Forum will never be the same without his contribu-
tions, experience and wisdom, but as I am sure he the bowl of the mask needs to flex (to a variable degree,
would have said “the show must go on”. depending on the patient's anatomy) for the final phase
of LMA insertion to be complete. Solution? Mac 3 to
elevate the base of tongue and flatten the "angle of at-
•• As a frequent and generally successful user of the
Supreme LMA I am still occasionally puzzled by de- tack" to mask insertion. Mac 3…. the ultimate tongue
depressor for the most Supreme airway.
vice insertion difficulty in petite women. I planned to
James DuCanto, MD
use a size 3 LMA Supreme in a 53 year old (BMI 22)
women for an incision and drainage of a Right lower
~ A more aggressive triple-airway maneuver may also
extremity wound. On exam the patient had a small but
work. Pre-load the Supreme with a 14 F OG protruding
adequate two fingerbreadth mouth opening and was a
Mallampati 2. After confirming that a size 3 Supreme about 5-8 cm. Then use your McGrath (or GVL) to
was an appropriate size (by the Goldman Guedel test) place the Supreme, while watching the OG enter the
esophagus. Because of the Supreme's fixed curve, a lat-
the patient was induced with the head in neutral posi-
tion. After an easy initial insertion of the LMA I could eral approach may work best. I do this frequently for
not get it to seat well in the posterior pharynx despite teaching purposes (even for a Bailey maneuver). It's
also possible that the device just doesn't work all the
12
time. It's rigidity is a compromise to facilitate ease of Ranger scope, SGA (LMA, ILMA, supreme), bougie,
insertion by novices. melker kit, jet set, combitube, Airtraq. We started this
Allan Goldman, MD concept of “airway bag” about 14 years ago and at first
we were considered "airway geeks" and many times we
•• At my institution we have had discussions regarding got ridiculed, but we saved lives. It is not a perfect sys-
what airway equipment should be stocked in ICU’s. tem but is functional. We are always tweaking it to
In the past each ICU had a tackle box with a basic make improvements.
selection of laryngoscope blades and tubes. This was Thomas Mort, MD
abandoned because no one took ownership of restock-
ing, cleaning, etc. We currently have a disposable •• The optimal approach to difficult airway manage-
laryngoscope and some tubes in each crash cart but ment and failed DL for emergency intubations in
people are reluctant to break the seal on the cart due ED/ICU's is unclear. There are obviously big consid-
to the patient charge that is produced. We have a well- erations regarding cost effectiveness and skill of the
stocked airway bag that our anesthesia resident brings provider. It seems to me that a separate algorithm for
to codes, intubations and extubations with anesthesia these environments is needed and the algorithms for
stand-by. What is done at other institutions? What operative airway management carry
airway equipment is stocked in your ICUs, and limitations (can't just wake them up and cancel the
whether it is in every ICU or just select units? Who is case, don't necessarily have an "airway cart"). What
responsible for purchasing, checking, restocking and is lacking is data to guide these algorithms as many of
cleaning the equipment. our rescues (FOI, rigid video, extraglottic airway)
Allan Klock, MD have been poorly evaluated in these settings. Anyone
know of any literature for ICU/ED of large series or
~ We carry "boxes” to the Sites. We have two types prospective evaluation of rescue techniques? If so, it
Adult (red and much larger} and Peds (gray and can guide some new algorithms. If not, I see an op-
smaller). When we are called we usually get a sense of portunity...
whether it is an adult or Pedi situation, but there are Michael Aziz, MD
times when we take both boxes. Each box is stock with
emergency meds, laryngoscope handles and blades, col- ~ I am going to play "devil's advocate" in defense of
orimetric ETCO2 detectors, AEC's and LMA's and Su- the ASA DA guidelines. The current ASA Practice
preme's, ETT's, stylets (appropriate for each box), FOB, Guidelines on the Management of the Difficult Airway
Bullard, Glidescope, and other non-disposibles, Jet ven- are Evidence Based, therefore the recommendations of
tilator, Intubating Oral Airways, Cricothyrotomy sets, these guidelines (including the algorithm) are either
nebulizers. Used non-disposable equipment are returned literature based and/or the opinion of the ASA task
to central supply for "sterilization" (Hospital pays for force and their expert consultant group. Furthermore it
this and for the techs) Boxes are restocked by resident- is statistically analyzed. There is a reasonable amount of
attending team each call and after each use. literature in the ICU to suggest that the ASA Practice
Francis Stellaccio, MD Management guidelines are applicable outside the OR
setting (Mort TC: J Clin Anesth. 2004 Nov;16(7):508-
~We have difficult Airway Cart’s in ICUs and in the 16).
ED. This took “several years” to get together. As with I believe that the issue is one of publicity. I do not think
the code cart it is somewhat easier to have, it all there we need additional algorithms to explore this issue.
than to carry it on your shoulders.... Many ER physicians and Many ICU physicians are un-
Charles Watson, MD familiar with the ASA DA Guidelines. Spreading the
word to colleagues who manage the airway outside the
~ All ICU/ED/ PACU areas as well as a few high traffic OR in addition to broader studies of the ASA DA
surgical floors/medical wards, and all remote locations Guidelines in the Non-OR setting are warranted. As a
(GI suite, cardiac catheterization lab, neuro radiology, multidisciplinary society, SAM remains an ideal forum
interventional radiology, MRI) have the same DA cart for this goal.
as the OR. Portable battery FOB are on the carts Elizabeth Cordes Behringer M.D.
(suboptimal but good in a pinch). FOB towers with dig-
itial capabilities are available within a few minutes of ~ I fully agree with Dr. Behringer's statements regard-
waiting time. Anesthesia stocks all carts. An “Airway ing the ASA difficult airway guidelines. Although at
team” carries the "yellow airway bag" that contains a first glimpse they look simple, the reality is they need to
13
be studied many times to fully understand them and be from case to case and individual to individual. As all of
able to apply them properly. These guidelines cover all us know, there also is more than one way to approach or
aspects of airway management from the evaluation and manage any particular difficult airway. The proper se-
decision making to the mechanical act of securing the lection and plan of action is critical. The ASA guide-
airway. For each individual case scenario the basics of lines is not a recipe from cook book and does not tell
the airway management remains the same, however the the practitioner what device to use and does not provide
approach, equipment used, medications used will vary step-by-step description of each technique.
Andy Ovassapian, MD
(SIC)
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14
but it was unstated if this collection was blinded… I no difference in pharyngolaryngeal complications
assume it was. even though one group had ~30mmHg LMA intra-
cuff pressures and the other had ~180mmHg.
Results: Seet et al felt that a safe, relatively inexpensive
Of the 203 patients enrolled, three were excluded intervention could have a large impact on the fre-
because they required an endotracheal tube … two in quency of pharyngolaryngeal complications. The
the PLG, one in the RCG. manometer costs ~ $100, and would presumably have
Using the chi-square test, comparisons were made costs associated with its upkeep. However, if it sig-
of the primary outcome variable: the incidence of nificantly decreases the incidence of pharyngolaryn-
composite pharyngolaryngeal adverse events defined geal adverse events, it may be quite a bargain (as the
as any combination of sore throat (independent of authors argue.)
swallowing), dysphonia (difficulty/pain with speak- The positive aspects of the study were that it was
ing), or dysphagia (difficulty/pain with swallowing) double-blinded, had a relatively large sample size,
at the one, two, or 24-hour points. had a simple design, and examined adverse events
Regarding age, gender, height, weight, anesthetic over time.
duration, LMA size, number of insertion attempts, Lack of standardization of the method of LMA
ease of LMA insertion, attending experience, and use insertion was a potential limitation.
of suctioning, etc, the groups were statistically simi- The initial LMA intra-cuff pressure for both
lar. groups was 112-114 mmHg, well over the manufac-
Initially, the groups had statistically similar intra- turer’s recommended upper limit of 44mmHg, sug-
cuff pressure readings: RPG mean 112 ± 59 mmHg, gesting that in many cases LMAs are significantly
RCG mean 114 ± 57 mmHg. With deflation, the over-inflated.
PLG’s pressure dropped to 40 ± 6 mmHg. The inci- I believe that anesthesiologists need either further
dence of composite pharyngolaryngeal events was training or perhaps just a reminder that we may be
significantly lower in the PLG versus the RCG routinely overinflating our LMA cuffs.
(13.4% vs. 45.6%, p<0.0001). Sore throat was lower Regarding the authors’ assertion that the routine
in the PLG at two and 24 hours, dysphonia at one use of manometers after LMA insertion should be-
hour, and dysphagia at one, two, and 24 hours. Pa- come “best practice”, I believe that more research is
tient satisfaction scores were identical between needed before this can be firmly established.
groups.
References:
1
Resident Discussion: LMA™ Airway Instruction Manual, LMA North
Excessive intra-cuff pressure can adversely affect America Inc., San Diego 2005
2
mucosal perfusion. However, in the literature it is Rieger A, Brunne B, Striebel HW. Intra-cuff pres-
controversial whether limiting LMA cuff pressure sures do not predict laryngopharyngeal discomfort
leads to a decrease in pharyngolaryngeal complica- after use of the laryngeal mask airway. Anesthesiol-
tions. Reiger et al2 studied two groups where LMA ogy. 1997;87:63-67
removal was performed in asleep patients and found
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15
M
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http://www.samhq.com
Discounted subscription rate
to the Journal of Clinical Anesthesia
is available for SAM members as listed below:
SAM Membership Application: (Please Print Legibly) Dues for 2011 must be turned in ASAP
LAST NAME………………………………………………………………………………………………...
FIRST NAME……………………………………………………………………………….…….…........
DEGREE(S)…………………………………………………………………………………………………
SPECIALTY………………………………………………………………………………….………………
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EMAIL…………………………………………………………………….…………………………………
I wish to thank _______________________________________for encouraging me to join SAM.
Please fill in box for appropriate category:
! Physician Member…………………………………………………$100
! Retired Physician.………………………………………….…....….. 75
! CRNA………………………………………………………………... 75
! Individual / Industry Representative………………...……..…….. 75
! Paramedic / EMT / Flight Nurse /Technologist………….……… 50
! Resident / Fellow…………..……………………………………..... 50
! Journal of Clinical Anesthesia (Domestic) …………...…………. 78
! Journal of Clinical Anesthesia (International) ……………………100
! TOTAL……………………………………………………………...$____
! I wish to contribute an additional $____ towards SAM membership for a clinician from a
developing nation.
If you wish to pay by check, please make checks payable to Society for Airway
Management. PO Box 946, Schererville, IN 46375 USA or FAX to (773) 834-3166
Or we accept:
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(To avoid costs of processing international checks, please make payment with a credit card. Thank you)
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