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• W2615912305 abstract "Anaesthetists would not accept malpositioned tracheal tubes resulting in leak, inadequate ventilation, high airway pressures, or one-sided lung ventilation. Yet it is our impression that many, if not the majority, of surgeries are conducted with blindly placed and suboptimally sited supraglottic airway devices (SADs). The anaesthetic community appears to accept much lower standards for SAD placement than for tracheal tube placement. Blind insertion of SADs often results in suboptimal positioning in the oropharynx or hypopharynx. Studies involving magnetic resonance imaging, computed tomography, and lateral neck radiography have shown that the epiglottis is deflected posteriorly in >80% of patients after blind insertion of SADs,1Shorten GD Opie NJ Graziotti P Morris I Khangure M. Assessment of upper airway anatomy in awake, sedated and anaesthetised patients using magnetic resonance imaging.Anaesth Intensive Care. 1994; 22: 165-169Crossref PubMed Google Scholar reflecting several aberrant positions.2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar3Aoyama K Takenaka I Sata T Shigematsu A. The triple airway manoeuvre for insertion of the laryngeal mask airway in paralyzed patients.Can J Anaesth. 1995; 42: 1010-1016Crossref PubMed Scopus (42) Google Scholar Fibreoptic viewing also reveals that the epiglottis is deflected to suboptimal positions in 50–80% of insertions, and the epiglottis tip can be seen within the bowl of the SAD.4Moustafa MA Abdelhady MM. Fiberoptic assessment of the laryngeal mask airway (Laryseal) position after one hour of positive pressure ventilation: an observational study.J Clin Anesth. 2014; 26: 480-484Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 5Joshi S Sciacca RR Solanki DR Young WL Mathru MM. A prospective evaluation of clinical tests for placement of laryngeal mask airways.Anesthesiology. 1998; 89: 1141-1146Crossref PubMed Scopus (80) Google Scholar, 6Payne J. The use of the fibreoptic laryngoscope to confirm the position of the laryngeal mask.Anaesthesia. 1989; 44: 865Crossref PubMed Scopus (93) Google Scholar According to Brimacombe,2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar the anterior surface of the epiglottis is visible from the airway tube in 31% of patients, resulting in increased work of breathing and potentially obstructing tracheal intubation via the SAD if needed. Studies further suggest that blind insertion is far from ideal.7Van Zundert AAJ Gatt SP Kumar CM van Zundert TCRV. Vision-guided placement of supraglottic airway device (SAD) prevents airway obstruction – a prospective audit.Br J Anaesth. 2017; 118: 462-463Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 8Verma S Mehta N Metha N Metha S Verma J. Malpositioned LMA confused as foreign body in nasal cavity.Middle East J Anaesthesiol. 2015; 25: 351-354Google Scholar, 9Russo SG Cremer S Eich C et al.Magnetic resonance imaging study of the in vivo position of the extraglottic airway devices i-gel™ and the LMA-Supreme™ in anaesthetized human volunteers.Br J Anaesth. 2012; 109: 996-1004Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 10Cook T Woodall N Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1181) Google Scholar Simple cuff pressure measurement and oropharyngeal leak pressure (OPLP) are not enough. We therefore question the outcome of earlier studies that recommended measuring OPLP and intracuff pressure11Checketts MR Alladi R Ferguson K et al.Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland.Anaesthesia. 2016; 71: 85-93Crossref PubMed Scopus (321) Google Scholar because these are not valid if no information is provided about the position of the device. Clinical signs of incorrect SAD position include the following: (i) resistance to SAD insertion in the hypopharynx; (ii) SAD dislodgement during cuff insufflation; (iii) bite block malaligned with incisors; (iv) poor oropharyngeal airway seal (OPLP; intracuff pressure); (v) ineffective gas exchange (by observation of thoracic excursions and front of neck, inadequate tidal volume, low arterial O2 saturation, poor capnograph trace, high airway pressure, air leak); (vi) no drain tube patency; (vii) adverse suprasternal notch tap test (also known as the ‘Brimacombe bounce’; tapping the suprasternal notch or cricoid cartilage and observing simultaneous movement of a column of lubricant or a soap bubble membrane at the proximal end of the drain tube);2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar or (viii) fibreoptic inspection through airway tube and gastric drain tube; (video)laryngoscopy); or if required, expensive radiological methods. No particular SAD design guarantees a perfect position when inserted blindly into the hypopharynx. However, some SADs may be more prone to malpositioning than others. In our experience, the non-reinforced tip of the distal cuff of a first-generation SAD (LMA-Classic) frequently results in backwards deflection, which is hardly ever seen with reinforced-tip SADs. A circular or tubular breathing tube, as opposed to a more elliptical design, is more likely to sit less firmly in the hypopharynx and between the teeth and might be dislocated more easily than an ellipsoid one as a result of rotation in the sagittal plane. A bite block (ideally built into the SAD design) provides better fixation once a good position is achieved.2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar In general, a ‘second-generation’ SAD, incorporating separate ventilation and gastric channels, a bite block, and a reinforced tip, is more likely to result in the following: (i) a safer airway, reducing the risk of aspiration; and (ii) a more efficacious airway with a much better position, providing a more patent airway than first-generation SADs without gastric access channel.12Cook TM Kelly FE. Time to abandon the ‘vintage’ laryngeal mask airway and adopt second-generation supraglottic airway devices as first choice.Br J Anaesth. 2015; 115: 497-499Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar, 13Cook TM. Third generation supraglottic airway devices: an undefined concept and misused term. Time for an updated classification of supraglottic airway devices.Br J Anaesth. 2015; 115: 633-634Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 14Cook TM Kelly FE. Abandoning use of 1st generation SAD – a reply.Anaesthesia. 2016; 71: 979-981Crossref PubMed Scopus (2) Google Scholar, 15Cook TMA. further plea for a unified classification of supraglottic (extraglottic) airway devices.Br J Anaesth. 2016; 117: 136-137Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Even with second-generation devices, we advocate visual verification to exclude malpositioning. The i-gel SAD is designed anatomically to fit the perilaryngeal and hypopharyngeal structures without an inflatable cuff. The LMA-Supreme and i-gel differ significantly with regard to in situ position and spatial relationship with adjacent structures assessed by magnetic resonance imaging, despite similar clinical and fibreoptic findings. Whereas the LMA-Supreme (longer cuff with tapered tip) protrudes deeper into the upper oesophageal sphincter, the i-gel (wider cuff with blunter tip) causes a greater dilatation of the upper oesophageal sphincter and compresses the tongue more, thus increasing the risk of aspiration, glottis narrowing, airway resistance, and soft-tissue morbidity.9Russo SG Cremer S Eich C et al.Magnetic resonance imaging study of the in vivo position of the extraglottic airway devices i-gel™ and the LMA-Supreme™ in anaesthetized human volunteers.Br J Anaesth. 2012; 109: 996-1004Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Complications of suboptimally positioned SADs include the following:2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar16Van Zundert TCRV Hagberg CA Cattaneo D. Inconsistent size nomenclature in extraglottic airway devices.Minerva Anestesiol. 2014; 80: 692-700PubMed Google Scholar (i) ventilatory failure, including insufficient tidal volume, air leak, and airway obstruction; (ii) airway or tissue trauma (sore throat, hoarseness, dysphagia, dysphonia, or arytenoid dislocation); (iii) nerve injuries (hypoglossal, lingual, or bilateral vocal cord palsy); and (iv) difficulties using the SAD as an intubation conduit. Suboptimal or malpositioned SADs are 26 times more likely to be associated with gastric insufflation and subsequent aspiration.8Verma S Mehta N Metha N Metha S Verma J. Malpositioned LMA confused as foreign body in nasal cavity.Middle East J Anaesthesiol. 2015; 25: 351-354Google Scholar According to the Fourth National Audit Project (NAP4), aspiration of gastric contents was involved in the majority (most frequently with first-generation SADs) of SAD-related complications, and a second-generation device would be preferable for prevention.10Cook T Woodall N Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1181) Google Scholar17Cook TM MacDougall-Davis SR. Complications and failure of airway management.Br J Anaesth. 2012; 51: i68-i85Abstract Full Text Full Text PDF Scopus (287) Google Scholar18Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 828-848Abstract Full Text Full Text PDF Scopus (1150) Google Scholar From an anatomical perspective, optimal positioning of a correctly sized SAD should include the following: (i) the distal tip of the cuff rests against and blocks the upper oesophageal sphincter; (ii) the cuff occupies the entire hypopharynx and lies immediately behind the cricoid cartilage, anterior to the second to seventh cervical vertebrae; (iii) the sides of the cuff face the pyriform fossae; (iv) the epiglottis is flattened between the anterior surface of the proximal cuff (on which it rests on the outer side of the cuff) and the posterior surface of the pharyngeal portion of the tongue, with the tip of the epiglottis aligned with the rim of the proximal cuff; and (v) producing two adequate seals, with the gastrointestinal tract (distally with the oesophageal entrance) and with the respiratory tract (the glottis opening opposing the distal opening of the airway tube). The closer the match between the shape of the SAD cuff and the pharynx and larynx, the better the seal produced by the airway device.2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar The tongue might improve the seal—potentially closing the gap, preventing an air leak—by forming an effective plug above the epiglottis–proximal cuff junction, which can be evaluated during the withdrawal of the laryngoscope. From a functional perspective, a well-sealed SAD should result in the following: (i) a functional barrier from soiling by secretions from below and gas and secretions from above, preventing aspiration and gastric insufflation (barring second-generation SADs, as the gastric drain tube and oesophagus neatly align themselves with one another); (ii) adequate gas exchange, facilitating spontaneous breathing or mechanical ventilation; and (iii) no trauma to the airway. Poor anatomical positioning after blind SAD insertion leads to specific deficiencies in function, as there is a link between form and function. Anaesthetists can improve deficient function using video-guided insertion techniques.7Van Zundert AAJ Gatt SP Kumar CM van Zundert TCRV. Vision-guided placement of supraglottic airway device (SAD) prevents airway obstruction – a prospective audit.Br J Anaesth. 2017; 118: 462-463Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar19Van Zundert AAJ Kumar CM Van Zundert TCRV. Malpositioning of supraglottic airway devices: preventive and corrective strategies.Br J Anaesth. 2016; 116: 579-582Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar We propose: (i) a grading system for SAD positions; and (ii) standardized manoeuvres to correct suboptimal positions. Suboptimal positions of SADs occur for several reasons: cuff hyperinflation/hypoinflation, use of too small or too large SADs, too deep or too superficial insertion, downfolding of the epiglottis, rotation of the SAD cuff in a sagittal plane, glottis distortion, backward folding of SAD cuff, proximal SAD cuff misplacement, and SAD cuff folding that results in airway gas leaks. Van Zundert and colleagues7Van Zundert AAJ Gatt SP Kumar CM van Zundert TCRV. Vision-guided placement of supraglottic airway device (SAD) prevents airway obstruction – a prospective audit.Br J Anaesth. 2017; 118: 462-463Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar recently revealed, using direct viewing by videolaryngoscopy, that 71% of SADs were initially malpositioned (but soon corrected). All malpositions could be corrected by applying jaw thrust and lifting the chin. This improved insertion conditions by elevating the epiglottis from the insertion path and increased the anteroposterior diameter of the pharynx. These manoeuvres also corrected temporary ventilatory failure attributable to airway obstruction. The Difficult Airway Society (DAS) guidelines10Cook T Woodall N Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1181) Google Scholar on the management of unanticipated difficult intubation in adults considers ‘blind’ airway management techniques unreliable and associated with a high incidence of airway trauma. The advent of videolaryngoscopy19Van Zundert AAJ Kumar CM Van Zundert TCRV. Malpositioning of supraglottic airway devices: preventive and corrective strategies.Br J Anaesth. 2016; 116: 579-582Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar and other direct viewing methods21Zhao L Zhang J Zhou Q Jiang W. Comparison of a new visual stylet (Discopo)-guided laryngeal mask airway placement vs conventional blind technique: a prospective randomized study.J Clin Anesth. 2016; 35: 85-89Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar allows visual confirmation of the positioning of any airway device, including SADs. We propose a grading system for use with video-guided insertion and standardized manoeuvres to correct identified suboptimal positioning, and provide a flow chart that summarizes suggested interventions for both first- and second-generation SADs. There are three grades of SAD positions (Fig. 1) after insertion.19Van Zundert AAJ Kumar CM Van Zundert TCRV. Malpositioning of supraglottic airway devices: preventive and corrective strategies.Br J Anaesth. 2016; 116: 579-582Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Grade I is a perfectly seated SAD of the correct size, with the epiglottis resting on the outside of the device, a normal capnogram, good air entry on auscultation of both lungs, and normal values for oropharyngeal leak pressure (OPLP >25 cm H2O), intracuff pressure (40–60 cm H2O), and haemoglobin oxygen saturation by oximetry [peripheral oxygen saturation (SpO2) >95%]. Grade I is uncommon with blind insertion of SADs, with the majority showing a Grade II or III position, as discussed above. Grade II is a marginally positioned SAD, clinically recognized by airway leak, abnormal capnogram of varying degree, diminished ability to access air entry in both lungs, and lower values for OPLP [there are differences in OPLP between first-generation SAD (i.e. within 20 cm H2O) and second-generation SAD (i.e. within 25 cm H2O)], intracuff pressure (<40 cm H2O), and eventually, SpO2 <95%. Even cuffless SADs can result in a leak because of malpositioning. There may be cuff folding over backwards, distortion of the cuff with foldings, choice of ‘too small’ a size of SAD, insertion too deep, or cuff hypoinflation. The actions to be taken include a change to a directly viewed reinsertion technique (e.g. videolaryngoscope) and use of corrective manoeuvres. These manoeuvres include the following: (i) jaw thrust to correct initial downfolding of the epiglottis; (ii) adjustment of the position of the distal oesophageal cuff; (iii) changing the SAD to a device with a reinforced tip configuration if the cuff folds over backwards persistently; (iv) using a different size, type, or brand of SAD; (v) using a larger size of SAD or reinflating the cuff to an intracuff pressure of 40–60 cm H2O if cuff hypoinflation is observed; and (vi) change to a silicone-cuffed SAD, instead of a polyvinyl chloride one, when folding in the cuff is causing an air leak. Grade II obtained with blind insertion should be regarded as unacceptable, but if no improvement is possible even with directly viewed insertion, it might be reasonable to proceed with caution or use alternative airway management methods, such as tracheal intubation. Grade III is clinically unacceptable. It is detected by a severe gas leak, airway obstruction, or both, with an abnormal, odd, or even absent capnogram, inadequate ventilation of both lungs, and low values for both intracuff pressure (<40 cm H2O) and, eventually, SpO2 (<92%). In patients where the SAD is too large, the device is too superficial, or the cuff is hyperinflated, the problem might be corrected by using a smaller SAD or deflation of the cuff to an intracuff pressure of 40–60 cm H2O. If the epiglottis is completely downfolded in the bowl of the device or double folded sideways, a major leak or airway malobstruction will ensue, resulting in a very low OPLP, sometimes approaching zero, requiring corrective manoeuvres such as jaw thrust. If jaw thrust does not correct the malposition, a railroad technique (e.g. using a gum elastic bougie, an Aintree intubation catheter, or Frova tube-changer)2Brimacombe JR. Laryngeal Mask Anesthesia – Principles and Practice. 2nd Edn. Saunders, Philadelphia, PA, USA2005Google Scholar or repositioning using Magill forceps might correct the malposition. In the event that the distal cuff of the device lies between and across the vocal cords, a major leak will result, with an OPLP of 0 cm H2O. Jaw thrust should be applied with the aim of relocating the tip of the SAD. If the epiglottis lies within the bowl of the SAD but does not result in a leak or the leak is minimal, there is minimal or no airway obstruction, and the epiglottis is in the upright position and not downfolded, the function of the SAD is usually adequate, which allows us to proceed with surgery (Grade I). If the videolaryngoscope demonstrates that the epiglottis is positioned in the bowl of the device, one cannot readily differentiate between an epiglottis in the upright, partly downfolded, or completely downfolded position. The only way to exclude downfolding or otherwise of the epiglottis in the bowl of the SAD is by inserting a fibreoptic scope through the ventilating channel of the SAD. Grade III needs immediate correction. In reality, most, if not all, Grade II and III malpositions should be corrected promptly even if there is no immediate adverse clinical outcome. A Grade III-positioned SAD is extremely likely to result in an adverse outcome (e.g. airway obstruction), which precludes continuing with surgery and can be considered as a ‘failed’ SAD. Further studies should elaborate on specific incidences and causes of malpositioning across a broader range of SADs. Anaesthetists should aspire to improving the quality of SAD insertions; it is unacceptable to have patients breathing noisily, partly obstructed via a misplaced SAD, or SAD cuff inflation pressures that are dangerously high (or unmeasured). Poor fits should not be accepted. Blind insertion results in a poor fit, whereas direct vision improves placement with videolaryngoscopy, facilitating functional and anatomical optimization. Any placement Grade of II or III should be regarded as a misplaced or ‘failed’ SAD. As the way forward is direct viewing, manufacturers are encouraged to develop SAD-specific viewing tools to facilitate correct insertion. Until such a time, videolaryngoscopy is the tool of choice. More than 40 yr ago, Brain22Brain AIJ. The laryngeal mask – a new concept in airway management.Br J Anaesth. 1983; 55: 801-805Abstract Full Text PDF PubMed Scopus (779) Google Scholar suggested the use of a laryngoscope to view and adjust the position of his then newly invented laryngeal mask airway. However, using a Macintosh laryngoscope has historically been regarded as defeating part of the purpose of using a SAD, which is to avoid the adverse haemodynamic effects of laryngoscopy. Videolaryngoscopes offer a fresh alternative,20Kelly FE Cook TM. Seeing is believing: getting the best out of videolaryngoscopy.Br J Anaesth. 2016; 117: i9-13Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar and the time is ripe to follow Brain's early advice to check and correct malpositioned SADs by direct viewing." @default.
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• W2615912305 title "‘Failed supraglottic airway’: an algorithm for suboptimally placed supraglottic airway devices based on videolaryngoscopy" @default.
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