BRIDGES TO ESTABLISH AN EMERGENCY AIRWAY AND ALTERNATE INTUBATING TECHNIQUES
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.
References (57)
- et al.
Single compared to double-handed cricoid pressure for insertion of an LMA
Br J Anaesth
(1994) - et al.
Cricoid pressure and the LMA: Efficacy and interpretation
Br J Anaesth
(1994) - et al.
Cricoid pressure applied after placement of the laryngeal mask prevents gastric insufflation but inhibits ventilation
Br J Anaesth
(1996) - et al.
Appropriate size and inflation of the laryngeal mask airway
Br J Anaesth
(1998) - et al.
Cricoid pressure and the laryngeal mask airway
Br J Anaesth
(1993) - et al.
Cricoid pressure and the LMA: Efficacy and interpretation
Br J Anaesth
(1994) - et al.
Laryngeal mask airway and tracheal tube insertion by unskilled personnel
Lancet
(1990) - et al.
The eophageal tracheal Combitube: Preliminary results with a new airway for CPR
Ann Emerg Med
(1987) - et al.
Ventilation with the esophageal tracheal Combitube in cardiopulmonary resuscitation: Promptness and effectiveness
Chest
(1988) - et al.
Cuffed oropharyngeal airway (COPA) as an adjunct to fiberoptic tracheal intubation
Br J Anaesth
(1999)
A comparison of the laryngeal mask airway and Guedel airway bag and facemsk for manual ventilation following formal training
Anaesthesia
Cricoid pressure may prevent insertion of the laryngeal mask airway
Br J Anaesth
Cricoid pressure impedes positioning and ventilation through the laryngeal mask airway
Can J Anaesth
The laryngeal mask: A new concept in airway management
Br J Anaesth
Laryngeal mask airway and the ASA difficult airway algorithm
Anesthesiology
Insertion of the laryngeal mask airway: A prospective study of four techniques
Anaesth Intens Care
Cricoid pressure
Can J Anaesth
Single-compared to double-handed cricoid pressure for LMA insertion
Br J Anaesth
A comparison of the laryngeal mask airway and cuffed oropharyngeal airway in anesthetized adult patients
Anesth Analg
The Bullard laryngoscope for emergency airway management in morbidly obese parturient
Anesth Analg
Evaluation of the Bullard laryngoscope using the new intubation stylet: Comparison with conventional laryngoscopy
Anesth Analg
The Combitube elective anesthetic airway management in a patient with cervical spine fracture
Anesth Analg
The laryngeal mask airway and positive-pressure ventilation
Anesthesiology
The intubating laryngeal mask airway
Inter Anesth Clin
The Combitube: Esophageal/tracheal double lumen airway
Esophageal tracheal Combitube, endotracheal airway and mask: Comparison of ventilaroy pressure curves
J Trauma
Evaluation of esophageal tracheal combitube in cardiopulmonary resuscitation
Crit Care Med
The Upsher scope in routine and difficult airway management: A randomized, controlled clinical trial
Anesth Analg
Cited by (21)
Use of the McGrath <sup>®</sup> video laryngoscope and paediatric tube exchanger for endotrachial tube replacement in a patient with a difficult airway
2012, Revista Espanola de Anestesiologia y ReanimacionAdvanced Airway Techniques
2012, Emergency Medicine: Clinical Essentials, SECOND EDITIONAirway management equipment
2012, Ward's Anaesthetic EquipmentAirway Management in the Trauma Patient: How to Intubate and Manage Neuromuscular Paralytic Agents
2008, Current Therapy of Trauma and Surgical Critical CareA new approach to securing a difficult airway
2005, Journal of Clinical AnesthesiaCitation Excerpt :Effective management of a patient's airway is one of the most important skills for the anesthesiologist to master [1]. Numerous methods of securing difficult airways have been described, including various techniques using the laryngeal mask airway (LMA) and the fiberoptic bronchoscope (FOB) [2-6]. Each of these techniques has its own set of shortcomings, and even for practitioners who are adept at the use of such alternative devices, complications can arise [7].
Tongue engorgement with prolonged use of the esophageal-tracheal combitube
2004, Annals of Emergency MedicineCitation Excerpt :In a case report by Kuhnert et al3 and a literature review by Lam and Vavilala,4 the occurrence of glossal engorgement during neurosurgical procedures with endotracheally intubated patients appears related to lingual venous and arterial obstruction resulting from neck flexion, obesity, local compression of vessels, and prolonged duration. Mucosal pressures measured on the surface of the pharyngeal cuff of the Combitube inflated to 30 cm H2O were up to 3 times higher than mucosal perfusion pressure,6,7 suggesting that a properly inflated pharyngeal cuff exerts enough pressure on the mucosal tissue to compromise submucosal blood flow or cause ischemia-reperfusion injury. These pressure data, along with the risk factors associated with glossal engorgement during neurosurgical procedures, support our conclusion that the prolonged use of the Combitube contributed to glossal engorgement.
Address reprint requests to Lorraine J. Foley, MD, Department of Anesthesia, Winchester Hospital, 41 Highland Avenue, Winchester, MA 01890