Professional Documents
Culture Documents
COM
lr
Professor, Department of Anesthesiology The University of Texas Medical School at Houston Director of Neuroanesthesia and Advanced Airway Management Memorial Hermann Hospital Houston, Texas President, Society for Airway Management
devices, several of which have been included in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm (Figure).1
Dr. Hagberg has disclosed that she has received education grants from Ambu A/S, Karl Storz Endoscopy, Smiths Medical; is a member of the speakers bureau for Ambu A/S, Cook Critical Care, Hospira, King Systems Corp, and LMA North America; and has received equipment support from Ambu A/S, Clarus Medical, Cook Critical Care, Hospira, Karl Storz Endoscopy, King Systems Corp, LMA North America, Mercury Medical, Olympus America, Smiths Medical, Tyco Healthcare, Verathon Medical, and Vital Signs.
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
rv
t
CARIN A. HAGBERG, MD
ed
20 06 ro du
.R
ep
ct
A common factor preventing successful tracheal intubation is the inability to visualize the vocal cords during the performance of direct laryngoscopy. Many devices and techniques are now available to circumvent the problems typically encountered with a difficult airway using conventional direct laryngoscopy.
A number of endotracheal tube (ET) guides (Table 1) have been used to aid in intubation, including the Portex Venn Tracheal Tube Introducer (Smiths Medical ASD, Keene, NH/Smiths Medical, Hythe, Kent, England) and, more recently, the Single-Use Bougie (Smiths Medical ASD), Frova Intubating Introducer (Cook Critical Care, Bloomington, Ind), the Aintree Intubation Catheter (Cook Critical Care), the Arndt Airway Exchange Catheter Set (Cook
te
1
d.
A N E S T H E S I O L O G Y N E W S M AY 2 0 0 7
A. AWAKE INTUBATION
lr ig ht s
2
Other options include (but are not limited to): surgery utilizing face mask or LMA anesthesia, local anesthesia infiltration, or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the emergency pathway. Invasive airway access includes surgical or percutaneous tracheostomy or cricothyrotomy.
Alternative noninvasive approaches to difficult intubation include (but are not limited to): use of different laryngoscope blades, LMA as an intubation conduit (with or without fiber-optic guidance), fiber-optic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. II Consider repreparation of the patient for awake intubation or cancellation of surgery.
Options for emergency noninvasive airway ventilation include (but are not limited to): rigid bronchoscope, esophagealtracheal Combitube ventilation, or transtracheal jet ventilation.
Adapted and reprinted with permission from the American Society of Anesthesiologists and Anesthesiology 2003;98:1269-1277.
Co
Succeed*
Cancel case
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
py ri gh t 20 .R
Consider feasibility of other options Invasive airway access* Fail From this point onward, repeatedly consider: 1. Calling for help 2. Returning to spontaneous ventilation 3. Awakening the patient
re se
rv
ed
06
ep
ro
du
ct
te
d.
1. Assess the likelihood and clinical impact of basic management problems: a. Difficult ventilation b. Difficult intubation c. Difficulty with patient cooperation or consent d. Difficult tracheostomy 2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management.
Critical Care), the Cook Airway Exchange Catheter EF (Cook Critical Care), and the Cook Airway Exchange Catheter EF Soft Tip (Cook Critical Care).
LIGHTED STYLETS
In the past several years, a number of lighted stylets have been developed, including light wands such as the Trachlight (Laerdal Medical Corp, Stavanger, Norway), and visual scopes, such as the Shikani Optical Stylet (SOS; Clarus Medical, Minneapolis), Flexible Airway Scope Tool (FAST; Clarus Medical), Levitan GLS (Clarus Medical), Bonfils Retromolar Intubation Fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany/Culver City, Calif), and the Brambrink Intubation Endoscope (Karl Storz Endoscopy). Light wands rely on transillumination of the tissues of the anterior neck to demonstrate the location of the tip of the ETa blind technique, unless combined with direct laryngoscopy (Table 2).3,4 The visual scopes, on the other hand, utilize fiber-optic imagery and allow indirect visualization of the airway. They also can be used alone or in conjunction with direct laryngoscopy.
lr ig ht s
LMA adequate*
Successful ventilation*
Co
a. Awake intubation vs intubation attempts after induction of general anesthesia b. Noninvasive technique for initial approach to intubation vs invasive technique for initial approach to intubation
Consider/Attempt LMA
py rv
re
ri
gh
se
ed
20
.R
06
Fail
ep
ro
du
ct
These laryngoscopes were designed to facilitate tracheal intubation in the same population that would be considered for flexible fiber-optic bronchoscopy, such as patients with limited mouth opening or neck movement. Relative to the flexible fiber-optic bronchoscopes (FOBs), they are more rugged in design, control soft tissue better, allow for better management of secretions, are more portable (with the exception of the new portable FOBs), and are not as costly. Intubation can be performed via the nasal or oral route and can be accomplished in awake or anesthetized patients (Table 4).9-11
The Laryngeal Mask Airway (LMA; LMA North America, Inc, San Diego) is the single most important development in airway devices in the past 25 years. Since its introduction into clinical practice, it has been used in more than 150 million patients worldwide with no reported deaths.12 Several new variants of the LMA Classic, or standard LMA, are available, including the
te
3
d.
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
15-Fr ET introducer made 60 from a woven polyester base, with a coude tip (angled 35 degrees at its distal end). Also known as the gum elastic bougie. Color: golden brown.
Nondisposable and reusable. Size 5 Fr is single use. Has excellent memory properties. Coude tip effectively detects tracheal clicks to confirm correct placement. Part of a range of introducers, stylets, and guides for adults and pediatrics. Can be reused after cold water disinfection. Similar to Portex Venn Tracheal Tube Introducer, but hollow lumen allows oxygenation/ventilation. Single use.
lr ig
Co
ht
py rv
re
4
ri gh
New 15-Fr PVC ET intro70 ducer with coude tip. Has a hollow lumen that discourages reuse and is provided sterile. Color: ivory.
Single-Use Bougie (Smiths Medical ASD, Keene, NH/Smiths Medical International, Hythe, Kent, England) Frova Intubating Introducer (Cook Critical Care, Bloomington, Ind)
se
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
ed
20
.R
06
ep
Polyethylene 8- and 14-Fr 35, 65 AEC with angled distal tip and 2 side ports. Has a hollow lumen and is packaged with a stiffening cannula and removable RapiFit adapters. Color: blue.
Polyethylene 19-Fr AEC 56 allows passage of an FOB through its lumen. Has 2 distal side holes and is packaged with Rapi-Fit adapters. Color: light blue.
Polyethylene 8- and 14-Fr 50, 65, 78 Exchange of LMAs and AEC with a tapered end, ETs using an FOB. multiple side ports, packaged with a stiff wire guide, bronchoscope port, and Rapi-Fit adapters. Color: yellow. Polyethylene 11- and 14-Fr EF AEC that facilitates exchange of DLT of 4.0 mm or larger ID. Also comes in a soft-tipped version. Color: green.
ro
du
ct
te
d.
LMA Flexible (wire-reinforced flexible), LMA Unique (disposable), LMA Fastrach (intubating, reusable, and disposable), the LMA ProSeal (50% higher seal pressure, with gastric drain tube), the LMA CTrach (a Fastrach with integrated fiber optics), and most recently, the LMA Supreme (disposable ProSeal). Other supraglottic ventilatory devices (Table 5)13-16 include the Soft-Seal Laryngeal Mask (Smiths Medical ASD), the CobraPLA17 (Engineered Medical Systems, Indianapolis), the King Laryngeal Tube (King Systems Corp, Noblesville, Ind/VBM Medizintechnik GmbH, Sulz, Germany), and the Esophageal Tracheal Combitube (Tyco Healthcare/Mallinckrodt Nellcor Puritan Bennett, Pleasanton, Calif).
Medizintechnik GmbH, Sulz, Germany), the Manual Jet Ventilator (Instrumentation Industries, Bethel Park, Pa), and the Jet Ventilator (National Anesthesia Associates, Inc, San Marcos, Calif). The Enk Oxygen Flow Modulator (Cook Critical Care) is a new device that is recommended for use when jet ventilation is appropriate but a jet ventilator is not available.22 The Wadhwa Emergency Airway Device (Cook Critical Care) can also be used for TTJV.23,24 It is actually several devices in one (Table 6). It has an emergency nasopharyngeal airway catheter; a large diameter transtracheal needle for a cricothyrotomy procedure with the option for TTJV; and the main body of the device, which acts as a blow tube or 15-mm adapter.
lr ig ht
Co
py rv
re
ri
gh
Flexible fiber-optic intubation is a very reliable approach to difficult airway management and assessment. It has a more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited, as well as in patients of any age and in any position. Technological advances, including improved optics, battery-powered light sources, better aspiration capabilities, increased angulation capabilities, and improved reprocessing procedures, have been developed. Rescue techniques, such as direct laryngoscopy and placing a retrograde guidewire through the suction channel, may be used if the glottic opening cannot be located with the scope, or if blood or secretions are present.18 Insufflation of oxygen or jet ventilation through the suction channel may provide oxygen throughout the procedure, and allow additional time when difficulty arises in passing the ET into the trachea.19
RETROGRADE INTUBATION
Retrograde intubation (Table 6) is an excellent technique for securing a difficult airway either alone or in conjunction with other airway techniques.20 Every anesthesia care provider should be skilled in employing this simple, straightforward technique. It is especially useful in patients with limited neck mobility (ie, that is associated with cervical spine pathology, or in those who have suffered airway trauma). Recent advancements in the technique include the introduction of the Arndt Airway Exchange Catheter and needle holder to the preexisting retrograde intubation set.
Transtracheal jet ventilation (TTJV) is a well-accepted method for securing ventilation in rigid and interventional bronchoscopy (Table 6).21 There are a number of commercial manual jet ventilation devices currently available, including the Manujet III Jet Ventilator (VBM
se
ed
CRICOTHYROTOMY
Cricothyrotomy (Table 7), a lifesaving procedure, is the final option for cannot-intubate, cannot-ventilate patients according to all airway algorithms, whether they concern prehospital, emergency department, intensive care unit, or operating room patients. In adults, needle cricothyrotomy should be performed with catheters at least 4 cm and up to 14 cm in length. A 6-Fr reinforced fluorinated ethylene propylene Emergency Transtracheal Airway Catheter (Cook Critical Care) has been designed as a kink-resistant catheter for this purpose. Percutaneous cricothyrotomy involves using the Seldinger technique to gain access to the cricothyroid membrane. Subsequent dilation of the tract permits passage of the emergency airway catheter. The Melker Cuffed Emergency Cricothyrotomy Catheter Set is available with a 5.0-mm cuffed airway catheter (Cook Critical Care). A Portex (Smiths Medical) emergency cricothyrotomy kit is available (United Kingdom only) that uses a Veress needle and integral dilator to insert a 6.0-mm cuffed ET. The QuickTrach (VBM Medizintechnik GmbH) is available for children and adults in 2.0-mm and 4.0-mm IDs, respectively. Surgical cricothyrotomy is performed by making incisions through the cricothyroid membrane using a scalpel, followed by the insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and speed is particularly important.
20
.R
06
ep
ro
du
ct
te
5
d.
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
Although it can be used Blind technique that can be for routine intubations, used alone or in conjunction it is especially useful in with other techniques. situations in which the FOB is unavailable (eg, in ambulances or outside locations) or in which bronchoscopy is difficult to perform (eg, when an airway is obscured by blood or secretions or when a patients head cannot be flexed or extended). Similar to flexible FOB. Can be used alone or as an adjunct to laryngoscopy and is especially useful for those unable to maintain skills with a bronchoscope.4 Has the simple form of a standard stylet, plus the advantage of a fiber-optic view and maneuverability of its tip. Portable, rugged, and better maneuverability than the flexible FOB. Light sources include batterypowered (4 AA-size), fiberoptic light source, or green line laryngoscope handle with adapter.
lr ig
Co
ht
py ri gh t
High-resolution, stainless steel, malleable fiber-optic stylet that comes in a preformed J-shape. Has an adjustable tube stop and integral oxygen port for oxygen insufflation.
s
6
re se
Flexible Airway Flexible stylet with a Scope Tool (FAST; nondirectable tip. Clarus Medical, Minneapolis) Levitan GLS (Clarus Medical, Minneapolis)
Bonfils Retromolar Intubation Fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany/Culver City, Calif)
Brambrink Intubation Endoscope (Karl Storz Endoscopy, Tuttlingen, Germany/Culver City, Calif)
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
rv
ed
20
.R
06
ep
Similar to the SOS, but does not have a movable tube stop.
High-resolution rigid fiberoptic stylet with a fixed 40-degree curved shape at the distal end. Available with and without a working channel for ease of cleaning. Available with a standard eyepiece or with a DCI for video.
High-resolution semiflexible fiber-optic stylet with a 40-degree curved shape at the distal end, 40x magnification, a fixed eyepiece, a movable ET tube holder, and an insufflation port.
ro
du
ct
te
continues on page 7
d.
Offers an improved view of glottis, simultaneous direct and endoscopic views, full visual control over passage of ET, and confirmation of final position. No need for extreme head extension or forced traction of laryngoscope. Can be rapidly assembled to use immediately. Not currently available in the United States.
lr
ig ht
Name/Manufacturer Drges Emergency Laryngoscope Blade (Karl Storz Endoscopy, Tuttlingen, Germany/ Culver City, Calif) Henderson Laryngoscope Blade (Karl Storz Endoscopy, Tuttlingen, Germany/ Culver City, Calif)
Modified MAC Blades CLM Laryngoscope Blade Flexible tip or levering fiber(Mercury Medical, optic MAC laryngoscope Clearwater, Fla) blades are designed with a hinged tip controlled by a Flipper (Rusch Inc, Research Triangle Park, NC) lever at the proximal end. Designed to fit standard Heine Flex Tip Fiberhandles. Optic Laryngoscope Blade (Heine USA, Ltd, Dover, NH) Rusch Truview EVO (Truphatek International Ltd, Netanya, Israel; distributed by Rusch Inc, Research Triangle Park, NC)
Co py ri rv ed se
re
gh
.R
ep
ro
Description
Recently developed in Europe as a universal blade that combines features of both the MAC and Miller laryngoscope blades.
A straight laryngoscope Adult Routine or emergency use blade that continues to be size only. for tracheal intubation. modified in design; there has been a resurgence of interest in the routine use of this blade for tracheal intubation.
Indirect rigid laryngoscope with specially designed 42degree blade curvature; fits onto all standard endoscopic camera heads. Provides clear, unmagnified view of the glottis. Oxygen channel for demisting, clearing secretions, and insufflation.
ct
Blade is inserted into the Has 10-kg and 20-kg oropharynx to the appromarkings on the blade. priate depth, which correlates with the patients size.
When used with the paraglossal technique, a better view is obtained by optimizing control of the soft tissues and improving the line of sight.5 Has an improved tip and light, as well as a larger crosssectional area.
Useful in patients with a A lever controls the tip recessed mandible and angle through 70 decreased mouth opening. degrees during intubation to lift the epiglottis, if necessary, to improve laryngeal visualization.6
Rugged, portable, easy to maintain. Depth lines on the blade to guide insertion. Can be used with all fiber-optic laryngoscope handles. Designed to provide indirect laryngoscopy with continuous oxygen insufflation.
continues on page 8
te
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
d.
lr ig
Co
ht
py rv
still considered invasive and can cause trauma to the tracheal wall. The Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit (Smiths Medical) incorporates a unique introducer to aid smooth insertion of the tracheostomy tube over a Seldinger wire. In addition, the Ciaglia Blue Rhino Percutaneous Introducer Kit (Cook Critical Care) has a flexible tip dilator for less traumatic insertion. The slippery hydrophilic coating and tapered profile eliminate the need for multiple passes with increasingly larger dilators. Translaryngeal tracheostomy, a newer tracheostomy technique, is considered to be safe and cost-effective, and it can be performed at the bedside.27 It may be beneficial in patients who are coagulopathic. Surgical tracheostomy is more invasive, and should
Video Laryngoscopes DCI Video Laryngoscope System (Karl Storz Endoscopy, Tuttlingen, Germany/Culver City, Calif)
re
8
ri
Video laryngoscope system with interchangeable laryngoscope blades. Handles allow a DCI camera head to snap onto any standard eyepiece fiberscopes (flexible or semirigid). Required components include a camera control unit, xenon light source, and monitor. MediPack portable combination video/light source/monitor unit is also available for use with this system.
Useful for anterior airways, obese patients, and patients with limited mouth opening or neck extension. Additionally useful for teaching purposes, verification of ET position, aiding application of external laryngeal manipulation, or passage of an intubating introducer. Recommend styletted or special ET. May also be used for nasal intubation and ET exchange.
The wide-angle camera allows improved visualization and video documentation of laryngoscopy and intubation. Extreme positioning of the head is unnecessary. MAC #3 and #4 blades provide 45- and 60degree angles of view, respectively.
gh
se
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
ed
20 ro
.R
06 du
ep
Video laryngoscope offers improved real-time view of airway and tube placement that enables quick intubation because it is operational in seconds. Includes high-resolution digital color camera, antifogging mechanism to resist lens contamination, nonglare color monitor, and blade with 60-degree blade angle.8 Video output for remote display or recording.
ct
Conclusion
Most airway problems can be solved with relatively simple devices and techniques, but clinical judgment born of experience is crucial to their application. As with any intubation technique, practice and routine use will improve performance and may reduce the likelihood of complications. Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require combinations of devices and techniques.
te
d.
lr
ig ht
Airtraq (Prodol Meditec SA, LLC, Vizcaya, Spain; distributed by King Systems Corp, Noblesville, Ind)
Co py ri gh t rv se ed .R
re
New wireless video laryngo- One size scope with disposable trans- only. parent blade (PBLADE) that has a suction port. Has a 12cm cable with CCD camera and 2.4-in LCD color monitor. Disposable optical laryngoscope that provides magnified angular view of glottis without alignment of oral, pharyngeal, and tracheal axes. Includes guiding channel to hold ET and direct it towards vocal cords. Optional reusable camera can be attached for viewing on external monitor. Sizes are color coded: regular adult has blue battery cover; small adult has green battery cover.
20 06 M ct
Similar to McGrath Video Laryngoscope. Two sizes: regular adult for ETs 7.08.5 mm); small adult for ETs 6.07.5 mm. Intended to facilitate intubation in routine and difficult airway situations. Useful in emergency settings, C-spine immobilization, fiberscope guidance, tube exchange, and foreign body removal.
ep
ro
du
te
d.
lr ig
Co py rv
Simplest in design of indirect Adult size rigid fiber-optic laryngoscopes. only. No detachable stylets or extra ports. C-shaped delivery slot. Unlike the Bullard Elite Laryngoscope, there are no detachable stylets or extra ports along the right side of the instrument.
ht
Same as Bullard Elite Has several improvements Laryngoscope. from original UpsherScope, including better optics, an elongated lower flange, and Steris compatibility. Must be used with Upsher Universal handle or fiberoptic light source.
10
re
ri
gh
se
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
t .R
ed
A combination laryngoscope that has a rigid, curved, bivalved tubular blade incorporated with a flexible fiberscope. The S-piece rigid blade portion consists of a handle and 2 sizes of main-blade and bivalve elements. There are 2 open channels for the fiberscope and ET.11
20
06
ep
Using the Same as Bullard Elite The fiber-optic mechasame fiber- Laryngoscope. nism consists of a fiberscope and optic endoscope. This same hanfeature accounts for its dle, adult better visualization or large capacity and higher cost adult sizes than the 2 aforemencan be tioned scopes. Used with assembled. a battery-powered or fiber-optic light source and a suction catheter as an ET guide.
ro
du
ct
Although originally developed Nondisposable and for airway management of rou- reusable. tine cases with spontaneous ventilation, it is now listed in the ASA Difficult Airway Algorithm as an airway ventilatory device or a conduit for endotracheal intubation.1,13 Can be used in both pediatric and adult patients in whom ventilation with a face mask or intubation is difficult or impossible. Can also be used as a bridge to extubation14 and with pressure support or PPV.15
te
continues on page 11
d.
Original LMA cuff design Adult and Particularly useful in ENT/head attached to smaller-diame- pediatric and neck procedures. ter, flexible armored tube sizes 2-6. that allows repositioning of the tube without cuff displacement. New single-use version is easier to insert.
Both reusable and disposable versions now available. Airway tube resists kinking and cuff dislodgment, and thus may be positioned away from the surgical field without loss of seal. Single use.
lr ig ht s
Co
LMA Unique (LMA North America, Inc, San Diego) LMA ProSeal (LMA North America, Inc, San Diego) LMA Supreme (LMA North America, Inc, San Diego) LMA Fastrach (LMA North America, Inc, San Diego)
LMA CTrach (LMA The LMA CTrach is a North America, Fastrach with built-in fiber Inc, San Diego) optics that allow for ventilation, visualization, and intubation of the trachea. It includes an airway (made of silicone) that is similar to the Fastrach, with an attachable lightweight viewer.
py ri gh t .R
Original, disposable LMA design. Sterile, latex-free, available with or without syringe and lubricant. Soft cuff and airway tube allow for conformity to patients natural anatomy. Designed with a modified cuff and dual tubes to separate the respiratory/alimentary tracts. Has a built-in bite block. Same features as the LMA ProSeal. Design allows easy insertion. Adult and Same as LMA Classic. Included pediatric in AHA 2000 Guidelines for sizes 1-5. CPR and Emergency Medicine Cardiovascular Care.
re se
rv
ed
Consists of a mask attached to a rigid stainless steel tube curved to align the barrel aperture to the glottic vestibule. The set includes an LMA with a stainless steel shaft covered with silicone (reusable version) and a single movable epiglottic elevating bar, ET stabilizer, and silicone wire-reinforced ET. The single-use Fastrach is made from PVC and includes a disposable wire-reinforced ET.
20
06
ep
Adult and Same as LMA Classic except pediatric drain tube also allows for evacsizes uation of stomach contents. 112-5.
ro
du
ct
11
te
d.
Similar in shape to the Adult and Same as LMA Classic. Allows LMA Unique, but differs in pediatric easy access for flexible fiberits one-piece design, in sizes 1-5. optic devices. which the cuff is softer and there is no step between the tube and the cuff, an integrated inflation line, no epiglottic bars on the anterior surface of the cuff, and a wider ventilation orifice. A laryngeal mask with a Adult and Same as LMA Classic. Allows special built-in curve that pediatric easy access for flexible fiberreplicates natural human sizes 1-5. optic devices. anatomy. It is molded in one piece with an integrated inflation line and no epiglottic bars on the anterior surface of the cuff.
If intubation becomes necessary or desired, will accommodate up to a 7.5-mm ET. Single use.
lr ig
Co
ht
py rv
12
re se
Ambu AuraOnce (formerly the Ambu Laryngeal Mask; Ambu Inc, Glen Burnie, Md)
Ambu Aura40 (Ambu Inc, Glen Burnie, Md) Ambu Aura40 Standard (Ambu Inc, Glen Burnie, Md) Air-Q Reusable Laryngeal Mask, formerly the Intubating Laryngeal Airway (Cookgas LLC, St. Louis; distributed by Mercury Medical, Clearwater, Fla)
Air-Q Disposable Laryngeal Mask (Cookgas LLC, St. Louis; distributed by Mercury Medical, Clearwater, Fla)
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
ri gh ed
Anatomically correct curve and reinforced tip that facilitates placement. If intubation becomes necessary or desired, recommend intubation over Aintree AEC. Single use. Single use. Available only in the United States.
20
.R
06
ep
Similar to LMA Unique but without epiglottic bars on the anterior surface of the cuff.
Similar to the LMA Classic. Adult and Same as Ambu AuraOnce. No epiglottic bars on the pediatric anterior surface of the cuff. sizes 1-6. Hypercurved intubating laryngeal airway that resists kinking, and removable airway connector. Anterior portion of mask is recessed; a larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using AirQ reusable removal stylet. Same features as Air-Q Reusable Laryngeal Mask, except disposable. Adult sizes (2.5, 3.5, and 4.5) that can accommodate ETs 5.58.5 mm.
ro
du
ct
te
continues on page 13
d.
Large ID laryngeal tube, Adult and which is soft and flexible in pediatric design with a tapered, stri- sizes 12-6. ated tip. Now has an improved distal curve, softer tube, and softer head. It has a high-volume, lowpressure oropharyngeal cuff. Similar to the CobraPLA. Adult and Includes temperature mon- pediatric itor (all sizes) and distal sizes 12-6. gas sampling (pediatric sizes only: 12, 1, and 112).
Disposable. If intubation becomes necessary or desired, will accommodate up to an 8.0-mm ET. Single use.
lr ig ht s
Co
SLIPA Streamlined Liner of the Pharynx Airway (SLIPA Medical Ltd, London)
KING LT (King Systems Corp, Noblesville, Ind/VBM Medizintechnik GmbH, Sulz, Germany)
KING LT-D (King Same design as the KING Systems Corp, LT, except disposable. Noblesville, Ind/VBM Medizintechnik GmbH, Sulz, Germany) KING LTS (King Systems Corp, Noblesville, Ind/VBM Medizintechnik GmbH, Sulz, Germany) Double-lumen laryngeal tube that incorporates a second (esophageal) lumen posterior to the ventilation lumen.
py ri gh se rv t ed .R
re
Same as LMA Classic. An added benefit is the ability to measure core temperature. In addition, distal CO2 can be monitored in the pediatric population.
Similar to CobraPLA but PLUS allows monitoring of the patients core temperature. In neonatal and infant patients, PLUS has the ability to increase the accuracy of end-tidal CO2 and volatile gas analysis.
Multi-use, latex-free, single-lumen silicon tube with oropharyngeal and esophageal low-pressure cuffs, 2 ventilation outlets, insertion marks, and a blind distal tip (almost like a single-lumen, shortened Combitube).16 Color-coded connectors for each size.
20
06 M du ct
Sizes 2-5 available worldwide; sizes 0-1 available outside United States and Canada. Adult sizes (3-5). Pediatric sizes (2, 2.5) available mid-2007. Adult sizes (3-5); pediatric sizes (0, 1, 2, 2.5).
ep
ro
13
te
d.
KING LTS-D (King Same as KING LTS, except Systems Corp, disposable. Noblesville, Ind/VBM Medizintechnik GmbH, Sulz, Germany)
lr ig
Co
ht
Esophageal Tracheal Combitube (Tyco Healthcare/ Mallinckrodt Nellcor Puritan Bennett, Pleasanton, Calif)
A disposable double-lumen tube that combines the features of a conventional ET with those of an esophageal obturator airway. Has a large proximal latex oropharyngeal balloon and a distal esophageal low-pressure cuff with 8 ventilatory holes in between.
Two adult sizes. 41 Fr: height >5 ft. 37 Fr: height 4-6 ft.
Same as LMA Classic. Appropriate for prehospital, intraoperative, and emergency use. Especially useful for patients in whom direct visualization of the vocal cords is not possible, patients with massive airway bleeding or regurgitation, limited access to the airway, and patients in whom neck movement is contraindicated. In conjunction with a face mask, it is placed orally to facilitate and maintain spontaneous or assisted breathing.
Ventilation is possible with either tracheal or esophageal intubation. Distal cuff seals off the esophagus to prevent aspiration of gastric contents. Allows passage of an orogastric tube when placed in the esophagus. Single use.
py rv
14
re
ri
gh
se
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
ed
20
.R
06
ep
M ct
Adult (10-13 cm) and large adult (13.516.5 cm) sizes. Adult sizes (3-5) that can incorporate ET sizes 6.08.0 mm and nasogastric tube sizes 1214 Fr.
Adjustable oropharyngeal airway of 2-piece construction. The rigid outer tube serves as a conduit for and protects the flexible inner tube, which creates a patent air passage from the mouth opening to the glottis.
Disposable supraglottic airway with noninflatable cuff designed to match the perilaryngeal anatomy. Incorporates an integral bite block and gastric channel.
ro
du
te
d.
Face Mask Ventilation ErgoMask (King Systems Corp, Noblesville, Ind) Face mask with contoured finger/thumb grip. Medium adult size. Intended to facilitate one-handed mask ventilation. Encourages proper chin lift to open airway. Allows improved control of mask seal. Ventilation port offcenter facilitates use with small hand and improves mask seal.
lr ig ht s
Co
Retrograde Intubation Cook Retrograde Intubation Set (Cook Critical Care, Bloomington, Ind) Transtracheal Jet Ventilation Manujet III (VBM Medical, Inc, Noblesville, Ind) Manual Jet Ventilator (Instrumentation Industries, Bethel Park, Pa) Enk Oxygen Flow Modulator Set (Cook Critical Care, Bloomington, Ind)
py ri gh se
Complete set includes 14Fr Arndt Airway Exchange Catheter with Rapi-Fit adapter. 110 cm
re
Excellent technique for securing a difficult airway, either alone or in conjunction with other alternative airway techniques. Especially useful in patients with limited neck mobility or patients who have suffered airway trauma.
Packaged as a complete kit with everything needed to perform a retrograde intubation. The recently added Arndt Airway Exchange Catheter allows for patient oxygenation and facilitates placement of an ET. Disposable.
rv
ed
20
.R
06 M ct
Jet ventilation catheters can accommodate adults, children, and infants. Jet ventilation catheters can accommodate adults and children.
ep
ro
Complete set including 4-m pressure hose, Luer lock connecting tubing, bronchoscope adapter, Endojet adapter with Endojet catheter, and jet ventilation catheter.
Complete set includes an on/off valve, 6 ft of highpressure tubing, and 4 ft of small-bore tubing.
Complete set including 7.5 cm 15-g needle with reinforced (2.0-mm ID). FEP catheter, syringe (5 cc), connecting tubing, and Enk oxygen flow modulator with tracheal catheter connector.
du
15
te
d.
lr ig
Co
ht
py ri gh rv se ed
s
16
Table 7. Cricothyrotomy
re
Needle
Name/Manufacturer
Emergency 6-Fr reinforced fluorinated Transtracheal ethylene propylene Airway Catheter catheter. (Cook Critical Care, Bloomington, Ind) Percutaneous Melker Emergency Cricothyrotomy Catheter Set (Cook Critical Care, Bloomington, Ind)
Melker Cuffed Same as Melker Emergency 9.0 cm Emergency Cricothyrotomy Catheter (5.0-mm ID). Cricothyrotomy Set. Catheter Set (Cook Critical Care, Bloomington, Ind)
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
t 20 06 M ro ep
Description Complete set including syringe (10 cc), 2- to 18gauge introducer needles with TFE catheter (short and long), 0.038-in diameter Amplatz extra-stiff guidewire with flexible tip, scalpel, curved dilator with radiopaque stripe, and PVC airway catheter. Also available in a Special Operations kit, which includes all of the above in a slip peel-pouch and 2 airway catheters.
.R
du
ct
te
continues on page 17
d.
lr ig ht s
Co
Surgical
There is no special kit for a surgical cricothyrotomy. It is performed by making an incision through the cricothyroid membrane using a scalpel, followed by the caudad insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and when speed is particularly important.
Combination Percutaneous and Surgical Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Critical Care, Bloomington, Ind)
py rv
re se
ri gh t 20 06 M du ct
9.0 cm (5.0-mm ID). Same as Melker Emergency Cricothyrotomy Catheter Set.
ed
.R
ep
ro
Same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for percutaneous technique. Also includes for surgical technique: tracheal hook, safety scalpel, Trousseau dilator, and blunt curved dilator.
17
te
d.
Table 8. Tracheostomy
Name/Manufacturer Description Size Clinical Applications
Special Features
Percutaneous Dilatational Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit (Smiths Medical ASD, Keene, NH/Smiths Medical International, Hythe, Kent, England) Complete set with or without a tracheostomy tube. 70.0 mm (7.0mm ID); 75.5 mm (8.0-mm ID); 81.0 mm (9.0-mm ID). Establishes transcutaneous access to the trachea below the level of cricoid cartilage. Allows for smooth insertion of the tracheostomy tube over a Seldinger wire. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The dilator is single-staged and prelubricated with an ergonomic handle to facilitate insertion. Disposable.
lr ig
Co
ht
py rv
18
re
ri
gh t
Complete kit includes 74 mm (6.424.0-, 26.0-, and 28.0-Fr mm ID); 79 mm loading dilators and Shiley (7.6-mm ID) 6 or 8 PERC disposable dual cannula tracheostomy tube. A tray version is available that includes lidocaine, connector, iodophor PVP swabs, drape, and suture.
Ciaglia Blue Rhino Percutaneous Introducer Set (Cook Critical Care, Bloomington, Ind)
Shiley TracheoSoft XLT Extended-Length Tracheostomy Tubes (Tyco Healthcare/ Mallinckrodt Nellcor Puritan Bennett, Pleasanton, Calif)
Surgical
Surgical tracheostomies are performed by making a curvilinear skin incision along relaxed skin tension lines between sternal notch and cricoid cartilage. A midline vertical incision is then made dividing strap muscles and division of thyroid isthmus between ligatures is performed. Next, a cricoid hook is used to elevate the cricoid. An inferior-based flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall. Finally, the tracheostomy tube is inserted, the cuff is inflated, and it is secured with tape around the neck or stay sutures.
se
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
ed
Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The single dilator with a hydrophilic coating and flexible tip results in a simpler, less traumatic insertion. The guidewire has a Safe-T-J tip to reduce trauma. Disposable.
20
.R
06
ep
Available in 4 ISO sizes (5.0-, 6.0-, 7.0-, 8.0-mm ID). Each size offers the choice of cuffed or cuffless stylets, and proximal or distal extensions. Comes with disposable inner cannula; replacements sold in packages of 10.
ro
du
ct
te
d.
Abbreviation Key
AEC, airway exchange catheter AHA, American Heart Association ASA, American Society of Anesthesiologists CCD, charge-coupled device CLM, Corazelli, London, McCoy CPR, cardiopulmonary resuscitation DCI, direct couple interface
EMS, emergency medical service ENT, ear, nose, and throat ET, endotracheal tube FOB, fiber-optic bronchoscope Fr, French ID, internal diameter ILMA, intubating laryngeal mask airway ISO, International Standards Organization LCD, liquid crystal display LED, light-emitting diode
LMA, laryngeal mask airway MAC, Macintosh OD, outer diameter PERC, percutaneous low-pressure cuffed tracheostomy tube PPV, positive pressure ventilation PVC, polyvinyl chloride PVP, polyvinylpyrrolidone SGA, supraglottic airway TFE, tetrafluoroethylene
lr ig ht s
1.
Co
References
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269-1277.
2. Miller C. Management of the difficult intubation in closed malpractice claims. American Society of Anesthesiologists Newsletter. 2000;64:13-19. 3. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: A review. Anesth Analg. 2000;90:745-756.
4. Frass M, Kofler J, Thalhammer F, et al. Clinical evaluation of a new visualized endotracheal tube (VETT). Anesthesiology. 1997; 87:1262-1263. 5. Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia. 1997;52:552-560. 6. Tuckey JP, Cook TM, Render CA. Forum. An evaluation of the levering laryngoscope. Anaesthesia. 1996;51:71-73.
7. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anaesth. 2003;50:611-613.
8. Agro F, Barzoi G, Montecchia F. Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization (letter). Br J Anaesth. 2003;90:705-706. 9. Gorback MS. Management of the challenging airway with the Bullard laryngoscope. J Clin Anesth. 1991;3:473-477.
10. Bjoraker DG. The Bullard intubating laryngoscopes. Anesthesiol Rev. 1990;17:64-70.
11. Wu T, Chou HC. A new laryngoscope: the combination intubating device. Anesthesiology. 1994;82:1085-1087. 12. Verghese C. Airway management. Curr Opin Anaesthesiol. 1999;12:667-674.
13. Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology. 1996;84:686-699.
14. Patel P, Verghese C. Delayed extubation facilitated with the use of a laryngeal mask airway in the intensive care unit. Anaesthesia. 2000;55:396.
py rv
re
ri
gh t 20 .R 06 ep M ro du ct
se
ed
15. Brimacombe J, Keller C, Hormann C. Pressure support ventilation versus continuous positive pressure with the laryngeal mask airway: a randomised, crossover study of anesthetized adult patients. Anesthesiology. 2000;92:1621-1623. 16. Dorges V, Ocher H, Wenzel V, Schmucher P. The laryngeal tube: a new simple airway device. Anesth Analg. 2000;90:1220-1222.
19
te
d.
Co lr ig
py ht s
ri
gh re se
rv
20 ed
06 .R
M ep
te
d.