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Supraglottic airways
- 1. Advancement in Supraglottic Airways Speaker-Dr Mohammed zahid yergatti, DA(DNB) Moderator- Dr Madhavi singh, MD
- 2. Definition • These areairway devices that facilitate oxygenation and ventilation without endotracheal intubation. Some also refer them as extraglottic
- 3. Classification Based on sealingmechanism • Perilaryngeal sealers- • All LMAs • I-Gel • Air- Q Intubating laryngeal airway • Pharyngeal sealers- • Combitube • Streamlined liner of pharynx airway(SLIPA) • Laryngeal tube • Both • Cobra perilaryngeal airway(cobra PLA)
- 4. Based on evolution •First generation devices- simple airway tubes • Classic LMA • Flexible LMA • CobraPLA • Second generation- with addition of drainage tubes • Proseal LMA • I-Gel • LMA supreme • SLIPA • Third generation- cuffless, two drain tubes, small bowl • Baska mask.
- 5. Timeline- few outof 17 variants • Classic laryngeal mask airway(cLMA)- 1988 • Esophagael tracheal combitube- 1988 • LMA fastrach- 1995 • LMA Proseal- 2000 • Laryngeal tube- 2003 • I-Gel- 2003 • Air-Q- 2004 • LMA supreme- 2007 • Baska mask ~2012
- 6. LMA- laryngeal maskairway • Dr archie brain is first credited with invention and development of LMA • He first used a goldmans mask and attached it a obliquely cut endotracheal tube. • It was introduced in 1988.
- 7. Classic LMA Main shortcomings- •Bending of tip, if we keep pushing during insertion it can push the epiglottis over larynx and cause obstruction of airway • Rotation and dislodgment of the bowl, • lesser sealing pressure, more risk of aspiration, inaccurate placement
- 8. Esophageal- tracheal combitube •PVC double lumen with two inflatable cuffs
- 9. • Ventilation eitherthrough tracheal or oesophageal port • Distal ballon either seals trachea or oesophageous.
- 10. advantages • Requires minimaltraining and minimal mouth opening • Useful in non fasted pts during emergency disadvantages • Only adult and small adult sizes available • Oesophagel trauma • Problems in maintaing seal with movement.
- 11. Porseal LMA Developed basicallyfor more better sealing pressure and acsess to oesophaeous. Modifications over classic LMA- Larger and deeper bowl with no grille Darinage tube running parallel to airway Larger deeper bowl and dorsal exension of cuff
- 12. Advantages over classicLMA • Gastric tube port- for gastric access, checking correct positioning, bougie guided insertion. • Dorsal cuff- better seal and airway pressure- not present in 2 ½ & below. – with drain tube occluded it prtected airway to soiling pressures of 68cm of H20* • Bite block • Strap/Hinge for hooking the bougie/introducer. *Evans NR, Gardner SV, James MF. ProSeal laryngeal mask protects against aspiration of fluid in the pharynx. Br J Anaesth 2002; 88: 584–7
- 13. Disadvantages over cLMA •More incidence of trauma, equivocal incidence of sore throat* • Slightly longer insertion time compared to cLMA. • 20% more airway resistance than cllasic airway. *Brimacombe J, Keller C, Fullekrug B, et al. A multicenter study comparing the ProSeal™ and Classic™laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology 2002; 96: 289–95.
- 14. Comparison of PLMAwith cLMA
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- 16. Laryngeal tube • Multiuse , single lumen • Two low pressure cuffs- distal and proximal • Two anterior oval ventilating ports between the cuffs.
- 17. advantages Easy insertion Minimal mouthopening required. High ventilation pressure can be used Can be used to intubate trachea disadvantages Airway obstruction- narrowing Trauma to pharynx Cuff rupture
- 18. I-Geltm • Single-use non-inflatablemask made of a gel-like thermoplastic elastomer. • Epiglottic rest to prevent epiglottic downfolding
- 19. • Gastric accesschannel (not present in size 1) • Built-in bite block • Buccal cavity stabiliser
- 20. Lisa Sohn •Razan Nour • Narasimhan Jagannathan-Update on Airway Devices Curr Anesthesiol Rep (2015) 5:147–155 DOI 10.1007/s40140-015-0100-2 • Advantages- – It has better anatomical fit and improves its airway seal as it approaches body temperature. – Less risk for injuries related to cuff hyperinflation and decreases the time for successful insertion. – i-gel in meta analysis has been found to be having greater airway leak pressures and superior fibreoptic views compared to other SGAs. – Wide lumen allows for airway rescue and assisted intubation. – Effective in prone position rescue.
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- 22. • Large inflatableplastic cuff no post cuff. • Finns in the mask of bowl to prevent epiglottic obstruction. • Pharyngeal seal intermediate between cLMA and Proseal LMA. LMA supreme
- 23. Advantages • Reinforced tip-less chance of folding. • Anatomic curve facilitates insertion • Oval cross section for improved stability. disadvantages • Drain tube runs through the middle of airway dividing it into narrow two lumens- limiting its use for intubation, airway inspection. • PVC is more harder and more traumatic than silicone.
- 24. SLIPA-Streamlined Liner ofthe Pharynx Airway • Plastic uncuffed disposable • Hollow boot shaped distal part • Anatomically fits pharynx – Toe rests in oseophageal entrance – Bridge fits in pyriform fossa – Heel – anchors to softpalate – Large size prevents aspiration of regurgitated fluid
- 25. advantges • Greater airwaysealing pressue for PPV • cuffless disadvantages • More trauma • Prone to airway variability as occupies pace upto softpalate.
- 26. Baska mask • 3rdgeneration supraglottic irway • Smaller bowel compared to other LMAs- less risk of including oesophageal opening • Adjustable tab in shaft to increase angulation to allow easy negotiation of oropharyngeal curve • Double gastric channel- one channel is open to air so less chance of oesophageal wall impinging the gastric opening during suction
- 29. • Bigger distalgastric channel opening so more larger particulate can be sucked out • During extubation – if pt bites the bowl the gastric channels can be opened for airway. • Cuffless- membranous bowl which inflates during each positive pressure.
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- 31. • The meaninsertion time was lesser than PLMA* • It had higher sealing pressures than PLMA- 29.98+- 8.51 vs 24.5+-6.19 cm of H2O* *Sharifa Ali Sabeeh Al-Rawahi et al- ORIGINAL ARTICLE – A comparative analysis of the Baska® Mask vs. Proseal® laryngeal mask for general anesthesia with IPPV- Anaesthesia, Pain & Intensive Care-ISSN 1607-8322, ISSN (Online) 2220-5799
- 32. Role in difficultairway algorithm • Clear recommendation by Difficult airway society 2015 guidelines in both anticipated and unanticipaed difficult airway.
- 33. • Specially importantin can’t intubate, can’t ventilate situations • Laryngeal mask exchange recommended in at risk extubations* *DAS 2015 guidelines
- 34. Airway rescue withproseal LMA case reports
- 35. Airway rescue withi-gel • i-gel is established in emergency airway control. Case reports are present where it has been used for airway rescue when cLMA and PLMA have failed* • I-gel has been used for airway rescue in prone position** *Anaesthesia, 2008, 63, pages 1010–1026- Use of an i-gelTM for airway rescue **The use of a laryngeal mask airway for emergent airway management in a prone child. Dingeman RS, Goumnerova LC, Goobie SM Anesth Analg. 2005 Mar; 100(3):670-1
- 36. Supraglottic airway guidedET intubation and fibre optic laryngoscopy • LMA fastrach • LMA proseal • LMA supreme • I-gel • Air q • Ambu aura • Slipa
- 37. Comparing fibreoptic viewsthrough supraglottic airways* (1) full view of glottis (2) vocal cords, arytenoids, and inferior surface of epiglottis visible (3) only superior surface of epiglottis visible (4) no part of epiglottis or larynx visible *BioMed Research International Volume 2015 (2015), Article ID 201898, 8 pages http://dx.doi.org/10.1155/2015/201898Comparison of Five 2nd-Generation Supraglottic Airway Devices for Airway Management Performed by Novice Military Operators
- 38. DAS guidelines forfibreoptic intubation with Supraglottic airway video