Elsevier

Critical Care Clinics

Volume 16, Issue 3, 1 July 2000, Pages 429-444
Critical Care Clinics

BRIDGES TO ESTABLISH AN EMERGENCY AIRWAY AND ALTERNATE INTUBATING TECHNIQUES

https://doi.org/10.1016/S0749-0704(05)70121-4Get rights and content

The incidence of unanticipated difficult intubations ranges from 1% to 3%.46, 47 When patients cannot be intubated by direct laryngoscopy, other airway adjuncts are available. In this article, a number of alternatives to direct laryngoscopy are examined. These include the laryngeal mask airway (LMA; LMA North America, San Diego, CA), cuffed oropharyngeal airway (COPA; Mallinckrodt, St. Louis, MO), and Combitube (Kendall-Sheridan, Mansfield, MA), which have been designed to act as bridges to establish an airway. Other devices such as rigid stylets, the lightwand (a blind technique), and indirect fiberoptic rigid stylets such as the Bullard scope, Upsher scope, and Wu scope also are briefly discussed.

Section snippets

LARYNGEAL MASK AIRWAY

The laryngeal mask airway (LMA), first described in 1981 by Dr. Archie Brain at the London Hospital, Whitechapel, was intended as an alternative to the traditional facemask. It forms a direct end-to-end connection between the glottic opening and the mouth.8 After extensive modifications by the inventor, the LMA was first made commercially available in Europe in 1988 and was introduced in the United States in late 1992.

The LMA is made of medical grade silicone rubber and is latex free. It

INTUBATING LARYNGEAL MASK AIRWAY

The classic LMA has become a valuable tool for management of the difficult airway. It is not an optimal conduit for endotracheal tube placement because the classic LMA's long, narrow shaft admits only a 6.0-mm or smaller nasal RAE ETT. The mask aperture and glottic opening cannot be aligned easily because the shaft is not easy to manipulate. The aperture bars can obstruct the passage of the endotracheal tube through the LMA into the trachea.

To overcome these difficulties, Dr. Brain developed

CUFFED OROPHARYNGEAL AIRWAY

The cuffed oropharyngeal airway was first introduced by Greenberg and Toung in 1992.31 The COPA is an alternative to the LMA and a face mask–oral airway combination. It is a modified Guedel airway with a cuff at its distal end and a standard 15-mm connector at its proximal end to serve as an adapter for an anesthesia circuit or Ambu bag. The COPA is made from polyvinyl chloride for one-time use. The cuff is inflated by a one-way valve in the pilot balloon that emerges from the proximal end.

COMBITUBE

The Combitube (Kendall Sheridan Catheter Corp., Argyle, New York) is a modified esophageal obturator airway developed by Frass, Frenzer, and Zahler by adding an ETT to the original esophageal obturator airway (OEA) device.22 The Combitube has two lumens: an esophageal lumen (longer, blue tube no. 1) with an open upper end and a blocked distal end with perforations at the pharyngeal level, and a tracheal lumen (shorter, white tube no. 2) that is open at the distal end. There are two balloons;

LIGHTWAND

The lightwand or lighted stylet is an alternative tracheal intubating device for easy and difficult intubations, either nasal or oral. It is based on the principle of transillumination of the trachea and soft tissues of the neck. The lightwand consists of a bright light source at the tip of the stylet, a variable length shaft, and a handle. It is a lightweight, portable, and durable device. Like any other airway device, practice in insertion during nonemergent situations is required. (Fig. 5).

RIGID INDIRECT FIBEROPTIC INSTRUMENTS

Three devices that combine rigid laryngoscopy with fiberoptic intubation have been developed. These are the Bullard Scope (Circon Inc, Stanford, CT), the Wu scope (Achi Corp, Fremont, CA) and the Upsher scope (The Upsher Laryngoscope Corp, Foster City, CA). Each represents a viable option for tracheal intubations.

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    Address reprint requests to Lorraine J. Foley, MD, Department of Anesthesia, Winchester Hospital, 41 Highland Avenue, Winchester, MA 01890

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