September 2010 Gazette

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SAMs OfficialJournal !

The Journal of Clinical Anesthesia

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Editor-In-Chief

Katherine Gil, [email protected]

Associate Editor Gail Randel, MD

[email protected]

Administrative Director Anne-Marie Prince

[email protected]

Gazette Layout Editor Kathryn N. Gil

Be sure to save the date!! September 24-26, 2010

PresidentElizabeth Behringer, MD

[email protected]

President-ElectThomas Mort, [email protected]

Vice PresidentMaya Suresh, MD

[email protected]

SecretaryIrene Osborn, MD

[email protected]

TreasurerRichard Cooper, MD

[email protected]

Executive DirectorCarin Hagberg, MD

[email protected]

Lauren Berkow, [email protected]

Lorraine Foley, [email protected]

Eugene Liu, [email protected]

Alonso Mesa, [email protected]

Arnd Timmerman, [email protected]

Ashutosh Wali, [email protected]

Willis Tower

formerly named Sears Tower

ChicagoTheatredistrict sign

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Dear fellow colleagues: Excitement is building!For stress-inducing, tension-building situations, fewcan beat having to deal with a difficult airway (DA).But, our excitement is anticipation for the SAM An-nual Meeting starting on September 24th in Chicago.

There we can get expert advice for handling the DAand see newer airway devices and techniques.In this regard, interesting developments have tran-

spired: In the desire to optimally manage airwayswith the latest devices, we have suffered disappearingskills. E.g. how often do younger practitioners per-form blind nasal intubations or even insert soft nasalairways during difficult mask ventilation?

Many experienced practitioners feel that younger ones are less able to handle one of the oldest, most

prevalent techniques: face mask ventilation (FMV).Chalk up this skills erosion to use of the laryngeal

mask airway (LMA). No more laborious FMV for upto two hours; dealing with the vagaries of trying tomaintain a patent airway. The result is disuse atro-

phy. How can this be reversed? Although oftenrequests are made for invasive techniques in other realms for educational purposes that is not a con-cept to which many subscribe. But, use of FMV dur-ing longer periods for educational purposes is one Iwould accept, as long as the patients are not precari-ous and my attention is not diverted by other duties.

Similarly, fear of another loss of skill has croppedup, even among younger practitioneri.e. erosion of

conventional laryngoscopic intubation skill secon-dary to video/optical laryngoscopes usage. How of-

ten do we hear the phrase in a potentially DA sce-nario, We should look first with a conventional la-ryngoscope, to evaluate the difficulty of intuba-tion. The difference to me here is that the video/optical laryngoscopes usually give better laryngo-scopic views with greater success and less morbidity,so why reverse engines? Imagine asking a surgeon touse an older technique just to see if it can be done aswell as a newer, improved one. Anyone have ideason these topics? Letters to the Editor are welcome!

This Gazette issue has a number of articles thatdiscuss changes in established techniques. Dr.Francisca Llobell details steps in the Dnia modelfor DA identification, alerting, registration, and fol-low-up, in our International section. Dr. Davide Cat-tano describes saline for supraglottic airway cuff in-flation, comparing dynamics in LMA Unique andSupreme. Another article, in our Residents Reviewsection (Dr. Ronen Harris), illustrates how measure-ment of intra-cuff pressure demonstrates the preva-lence of cuff over-inflation and possible morbidity.

For all airway enthusiasts, researchers, writers,and thinkers: please see guidelines in back issues of the Gazette via the SAM website and help fill our

pages. Also, please contact Dr. Meltem Yilmaz(m _ [email protected]) if you would like towrite a synopsis of a session for the Gazette from theSAM meeting, for fellowmembers unable to attend.

Best regards,

Katherine S.L. Gil,M.D.

Editor-In-Chief

Editorial Expressions

Cory Adams, CRNA (Maryland) Regianld Bulkley, M.D. (Illinois) Carmencita Castro, M.D. (Indiana) Eugene Cheng, M.D. (California) Peter H. Cheng, D.O. (California) Stephen Donahue, M.D. (Texas)

Charles Ducat, M.D. (New Zealand) Lunei Fitzsimmons, M.D. (Maryland)Joseph Goode, Jr, CRNA (Pennsylvania) Jeffrey Grass, M.D. (Ohio) Jeffrey Kurley, RN (New Mexico) Felipe Lara, M.D. (Brazil)Gayle Lourens, CRNA (Michigan) Gerald Maloney (Ohio) Issam Mardini, M.D. (Pennsylvania) Pezhman Mehrabian, M.D. (Canada) Jeff Mitchell (New York) Viki Mitchell (United Kingdom) Amina Mohideen, M.D. (Ohio) Mauricio Perilla, M.D. (Ohio) Didier Sciard, M.D. (Texas) Renato Terzi, M.D. (Brazil) Rohan Sundaralingam, M.D. (Illinois) Witold Waberski, M.D. (Connecticut) Wade Weigel, M.D. (Washington) Gina Whitney, M.D. (Tennessee)

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Introduction: This project involved a multidiscipli-nary systematic focus on patients to derive the essen-tial diagnostic evaluation of their degree of difficultairways (DA) and document airway management.For thirteen years at Dnia Hospital, Spain, we have

been organized as a group of professionals in teach-ing, investigation, and development of airway man-agement.

Beforehand, we didnt think it appropriate to de-velop such an approach because the DA patientsdidnt seem to present themselves with any great fre-quency in occurrence. The recent transformation of our hospital to a universal computerized system for recording patient history and physical examination

provided us with the tool to realize DA consequencesand occurrence rates and to tackle and implement

protocols geared toward DA patient care. Subse-quently, we realized that airway management of pa-tients with DA is very important in consideration of risks to patients and costs due to the high morbidity/mortality that may ensue.The Process of this project:

For this reason we designed an organized tool that permitted planning and coordination of the sequenceof medical procedures, nursing, and administrativeactions necessary to achieve maximum efficiency indealing with these patients. Documentation of multi-

ple points of patient data/information is the first stepin the process of identifying DA patients and they are

provided with an alerting wrist band (fig.1).

This band will accompany the patient through multi- ple phases during this process of airway manage-ment. This process is not meant to set specific tech-niques that must be used in DA patients or create analgorithm of management in specific cases of DA

patients.

Our objective is to systematize the evaluation,treatment, and documentation they have undergone tohelp these patients every time they are in contact witha health system. An important phase is to form acommittee of experts with at least one anesthesiolo-gist, surgeon, otolaryngologist, and surgical nurse.This team will daily assume responsibility to followthe patient over each 24-hour period. If this methodis patterned in other health care organizations, nodoubt employment of the process will depend ontheir available personnel.Questions and Answers:

1. Who is this system designed to reach? Funda-mentally, it is geared toward airway managementoperators, and assisting teams whether hospital-basedor not: nursing, critical care, operating room, primarycare, admissions departments, and pharmacy person-nel.

2. What patients are involved? Patients includedin this program would be anyone: Who has had documented DA with or without de-scriptions of strategies that were used Who has a DA according to criteria Whose DA was encountered unexpectedly.

Design of the evaluation/documentation matrix:(Table 1):The temporal matrix is a form that remains part of

the documentation of the patients clinical process. Itshould show evaluations, guidelines, tests, medicaltreatments, nursing care, and other actions related tothe patients airway in chronological sequence. Theabscissa (x), represents points in time, when occur-

Clinical Pathway for Diagnostic Evaluation of the Difficult Airwayin the 13 th Health Department in Dnia Hospital, Spain

(Presented at the Valentin Madrid Opening Lecture at the First Symposium on Difficult Airway Management in 2009Cediva Dnia Training Center and Anesthesia-ICU Department)

Francisca Llobell, MD, Patricia Marzal, MD, Daniel Paz, MD,Remedios Prez, MD, Isabel Estruch, MD, and Juan Cardona, MD

Cediva Dnia Training Center, Dnia Hospital, Spain

I SYMPOSIUM DE MANEJO DE VAIA AEREA


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rences happen in patient evaluation / diagnosis, andmanagement. The ordinate (y), represents points of

patient care.

Chronologically, these are the steps of the Dnia DA process (See Table 1 or website for details):1. Inclusion: Steps needed for systematic evaluationand registration of DA information including in-formed consents. Create an alert.2. Activation: Each team member is contacted; thealert is engaged and the responsible committee is in-formed; definite identification of the case is made.3. Preparation: A thorough plan is made for airway

management of the patient.4. Pre-access: Previous protocols, materials, kits, andthe ASA-DA algorithm are gathered; the layout for future management is designed.5. Access: Development of the airway plan; system-atic registry of all information.6. Extubation: According to protocol, an extubationstrategy is formed with plans for delayed extubation

and ICU care.

7. Vigilance Post-extubation: Technique develop-ment; systematic registry of new information8. End of Procedure: Revision and finalization of the

Table 1

whole procedure; administration of a difficult airwaycard for the patient (fig. 2)Conclusions:

Anticipation based upon evaluation and diagnosisto detect the DA leads to the formation of a clinical

process or protocol for each subsequent action. Thedevelopment of a strategy of action according to theASA-DA algorithm is followed by execution of the

plan in defining the personnel and equipment needs.

This process occurs under quality control with a con-stant dynamic vigilance of the phases of develop-ment. The process secures the registry of the patientand revision of the actions taken. It forms the basisof the patients future identification and care.In summary, we try to evaluate, inform, prepare,document, and provide an ALERT: Difficult Airway!We feel the DA should be given the same degree of importance as patient allergies. See: www.cediva.eu

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Dear SAM Forum members,

The deadline for preregistration for the 14th annualmeeting and workshops is rapidly approaching. Pre-registration will be closed when space is full or onSeptember 9, 2010 at the latest. SAM needs your help in making the 2010 annual meeting both a scien-tific and financial success for the Society.

Please consider forwarding information about the2010 annual meeting to interested colleagues in An-esthesiology, Emergency Medicine, Critical Care,Surgery or Pre-hospital Medicine.

This year's meeting will feature special tributes tofounding president, Andranik (Andy) OvassapianM.D. Dr. John Doyle (Cleveland Clinic/ Past SAMPresident) will deliver a special lecture, highlightingthe breadth of Andy's contributions to the advance-ment of airway management, on Friday, September 24th. In addition, Will Rosenblatt, M.D. (Yale Uni-versity/Past SAM President) is hosting a tribute toAndy at the Saturday evening social event at the Met-ropolitan Club in Chicago.

Please check out the newly revised SAM website:www.samhq.com for registration information for the2010 Annual Meeting

Alternatively, please contact the University of Mass-

achusetts Medical School, Office of ContinuingMedical Education:Telephone Registration 508-856-1671, Fax 508-856-6838, and on-line: www.umassmed.edu/cme/events

Please join us in Chicago for the preeminent scien-tific meeting concerning airway management. Your support of the annual meeting insures the continuedgrowth of SAM and its mission to support multi-disciplinary international education and research inthe field of Airway Management.

We look forward to seeing you there!

President, SAM Elizabeth C. Behringer, M.D.Executive Director, SAM Carin A. Hagberg, M.D.Program Chair, 2010 Annual Meeting

Gail Randel, M.D.Program Co-Chair, 2010 Annual Meeting

Lauren Berkow, M.D.

A short remembrance of Dr. Ovassapian will be heldon Saturday night at the meeting reception. SAMmembers who would like to relate a short story abouta significant interaction with Dr. Ovassapian may beinvited to speak. If you're interested in speaking,

please e-mail [email protected]. A very lim-ited number of members will be accommodated. Wehope you will bring to the remembrance a specificstory about how Andy touched your life or of anevent that illustrates his persona.

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In patients prone to reactive airway responses,removal of a tracheal tube followed by insertion of asupraglottic airway at emergence has been suggestedto reduce coughing and bronchospasm. 1 We describea case in which the above strategy was employed andlaryngospasm ensued. Endoscopic images showinglaryngospasm and its reversal with succinylcholinewere captured.

The case involved a 90 year-old 72 kg female witha 100 pack-year smoking history and severe chronicobstructive pulmonary disease, who underwent sur-gery for fractured femur repair. As she declined spi-nal anesthesia, general anesthesia with tracheal intu-

bation was performed. Intraoperatively, tracheal suc-tion was performed once, and moderate amounts of clear secretions were obtained.

The plan for emergence was to allow her to wakeup smoothly with a supraglottic airway. At the end of the case, neuromuscular blockade reversal was given,inhalational anesthesia was maintained, positive pres-sure ventilation was applied, and propofol 20 mg wasgiven. The patients tracheal tube was removed and asize 3 LMA Classic TM was inserted. Subsequently,manual ventilation became difficult, and the airway

pressure was noted to be greater than 50 cm H 2O.

Her end-tidal carbon dioxide level (PetCO 2) was zeroand her oxygen saturation (SpO 2) dropped to 85%.Performance of an up-down maneuver, application of

positive pressure ventilation (PPV), positive end ex- piratory pressure (PEEP), and propofol 50 mg, wereunsuccessful in achieving lung ventilation, and her SpO2 decreased to 80%. A flexible fibreoptic bron-choscope from a difficult airway cart in the room wasinserted via an elbow connector into the LMA. Theglottic opening appeared closed by either edematousvocal cords or adduction of the false cords, suggest-ing laryngospasm (Figure 1, left side). Succinylcho-

line 20 mg was administered, after which ventilation became possible and the PetCO 2 waveform becamevisible. After 1 minute her SpO 2 increased to 97%and endoscopic imaging showed an open glottis withno evidence of laryngeal or supraglottic edema (Fig-ure 1, right side). The laryngeal mask airway wassuccessfully removed when the patient was awak-ened.

Figure 1. (Left) Endoscopic image of the glottic and su- praglott ic region during laryngospasm showing closure of the glottic opening (black arrows) and approximation of supraglottic structures, specifically the false vocal cordsand the arytenoids (A). (Right) Endoscopic image of theglottic and supraglottic region after administration of suc-cinylcholine, demonstrating a patent glottic opening (whitearrows). A=arytenoids, FC=false cords.

Laryngospasm occurs more commonly duringemergence than during induction of anesthesia. 2 The

overall incidence of laryngospasm has been reportedto be 0.87%, a figure that almost doubles in pediatric patients (0-9 years) and triples in infants (0-3months). 3 Laryngospasm involves adduction of thevocal cords and approximation of the false vocalcords and arytenoids above the level of the vocalcords. 2, 4 It may be precipitated by nearby irritants(secretions, blood, regurgitated material, volatileagents), airway manipulation including suctioning,and inadequate anesthesia. 2, 5 In our case, laryn-gospasm was likely caused by the stimulation of tra-cheal tube extubation, LMA insertion under inade-

quate levels of anesthesia, or the presence of secre-tions.Recommended management of laryngospasm in-

cludes applying jaw thrust, delivering 100% oxygen, positive pressure ventilation with PEEP/PPV, deep-ening the level of anesthesia intravenously (e.g. pro-

pofol 1 mg/kg), suctioning (if periglottic fluid sus- pected), and/or administering succinylcholine (0.1-

Laryngospasm Associated with Tracheal Extubationand LMA Insertion at Emergence

Stephanie Chiu, M4 and David T. Wong, MDGlasgow Medical School, Glasgow, Scotland


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Introduction:Initial studies on saline use for Laryngeal Mask

Airway (LMA) cuffs demonstrated more stable cuff pressures and similar oropharyngeal leak pressures. 1

The LMA Classic (LMA North America, Inc.)made of silicone was the original and has since givenway to newer devices, designed to improve place-ment and anatomical seal. Use of the LMA in posi-tive pressure ventilation (PPV) requires higher oro-

pharyngeal leak pressures than under spontaneousventilation. 2 Applying PPV above the leak pressurewould endanger patient to risks of esophageal or gas-tric insufflation, regurgitation, and aspiration.

Risks of LMA use include sore throat, hypoglossaland lingual nerve injury, and poor perfusion withsubsequent edema and congestion of the pharyngealwall. 3 One potential option to overcome cuff pressure

problems and improve airway sealing would be to fillthe cuff with saline. This studys purpose was to as-sess mechanical features of the new disposable LMASupreme and the LMA Unique during cuff infla-tion utilizing normal saline versus air in order to as-sess an experimental model.

Materials and Methods:Experimental and control groups were divided

based on use of saline or air to fill cuffs using bothUnique and Supreme devices.Phase 1 : Cuff elastance was determined outside themannequin by serially re-inflating them with air after complete emptying. After each 5 mL of air, cuff

pressures were checked with an arterial line monitor.These data points were recorded with sizes 3, 4, and5 for each device until a maximum volume 5 mLgreater (25, 35, and 45 mL, respectively) than themanufacturers suggested maximum volume. Withthe same methodology, but using saline to fill eachcuff, data was obtained after every 5 mL of inflationin a similar way for both devices.

Phase 2 : Using the Laerdal Airway ManagementTrainer (LAMT, Laerdal Medical) and the TruCorpAdvanced (TCA, TruCorp Ltd., Northern Ireland)mannequins, 4-6 cuff elastance was also tested withonly size 3 and 4 LMAs used (according to manufac-turers recommendations (since size 5 devices weretoo large). The LAMT is a simple conduit with ahigher oropharyngeal volume while the TCA has lessoropharyngeal volume and an inflatable tongue. Tocreate more physiologic soft tissue pressure condi-tions, we fully deflated the TCA tongue and re-inflated it with 40 mL of air. The devices within thetwo mannequins were serially re-inflated with air or saline in increments of 5 mL, again to a maximumvolume 5 mL greater than the manufacturers maxi-mum suggested filling volume (sizes 3 and 4, 25 and35 mL, respectively). Cuff pressures were deter-mined at each 5 mL increment.

Phase 3 : The oropharyngeal seal was tested. Usingthe TCA, each device was inserted and a fiberoptic

bronchoscope was passed into each device to assessits proper placement to ensure a consistent Cormack-Lehane grade I view of the larynx. Once the devicewas placed into the mannequins mouth, the cuff wasinflated with saline (experimental group) or air (con-trol group) as done previously (size 3 and 4, 25 and35 mL, respectively). Airflow of 2 L/min was con-nected to the device with PEEP up to 30 cm H 2O. Subsequently the cuff was slowly deflated until anaudible oropharyngeal air leak was detected and thevolume was recorded. The cuff volume was then in-creased incrementally by 1 mL until the leak was nolonger audible, so as to confirm the volume at whichthe leak occurred. The methodology was then re-

peated at PEEP levels of 5 cm H 2O decrements.For each volume-pressure and volume-leak pres-sure/PEEP point the mean of two measurements wasrecorded and rounded to the closest number. Analysis

A COMPARISON of the LMA UNIQUE and LMA SUPREME AIR VERSUS SALINE: A MANNEQUIN STUDY

Davide Cattano, M.D., Ph.D. , Srikanth Sridhar, M.D.,Meng Cheng *, M2, Jeremy R. Bates, M4, Carin A. Hagberg, M.D.

The University of Texas Medical School at Houston,

*Baylor College of Medicine, Houston, Texas

(sponsored by the Society of Airway Management 2009 Research Award)


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In the TCA mannequin, elastance graphs for theSupreme are shown in Fig. 8.

When comparing air vs saline in the Supreme , cuff pressures generally increased at steeper rates withsaline than with air inside both mannequins (Fig. 5,6). This suggests that using saline increases theelastance of the cuff in Supreme .

Phase 3: Cuff leak or minimum seal pressure The last phase of the study was performed only in

the TCA by documenting cuff volumes of air versussaline at which an oropharyngeal air leaks were de-tected using different PEEP levels. Saline showedlower leak volumes than air in all devices at all PEEP

levels (Fig. 9, 10). The Unique

had overall lower leak volumes than the Supreme at all PEEP levels(Fig. 9, 10).

Overall, there were no significant differences in cuff seals or cuff pressures between the Unique andSupreme in either the non-mannequin or inside-mannequin setting.

Discussion:Our goal was to provide basic research for futuretests in humans on whether saline might offer a better seal and better cuff stability. Essentially, changes involume and the type of filling medium affected theUnique cuff pressure more so than the Supreme .This in turn warrants exercising more caution whenusing the Unique when saline is used as the fillingmedium.

The ideal cuff inflation pressure in humans shouldnot exceed 60 cm H 2O, which usually is achievedwith 15 mL of air inflation in the Unique Size 4.

Closer examination of the elastance curve for the size4 Unique inflated with air inside the TCA does in-deed show 15 mL of air achieving cuff pressures be-tween 50-100 cm H 2O (Fig. 7). The elastance curvefor the Supreme sizes 3 and 4 had similar results.Inside the TCA, 15 mL of saline achieves cuff pres-sures between 100 and 150 cm H 2O for the size 4Unique . Thus, a smaller volume of saline is neededto fill the cuff in order to reach the 60 cm H 2O of cuff

pressure in the average device. Our data only reflectsthat saline might achieve higher cuff pressures thanair at a given volume both outside and inside manne-

quins. The use of saline resulted in flex points occur-ring earlier than air (higher elastance).In comparing saline versus air, oropharyngeal air

leaks were detected at lower cuff volumes through allPEEP levels and for both devices, which indicates asmaller volume of saline than air was needed tomaintain an oropharyngeal seal without any detect-able air leaks.

A limitation of the study was the lack of informa-tion on peripharyngeal pressure 7 as opposed to in-tracuff pressure, with resulting possible mucosal andnerve injury. This necessitates further investigation.

Conclusion:Saline provided higher intracuff pressures with

both LMA Unique and LMA Supreme withinmannequins. Despite lower compliance by saline athigher inflation volumes, lower volumes are requiredto achieve comparable airway leak pressures.


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References:1Coorey A, Brimacombe J, Keller C. Saline as an alterna-tive to air for filling the laryngeal mask airway cuff. Br JAnaesth. 1998;81:398-400.2Brimacombe J, Keller C. Laryngeal mask airway sizeselection in males and females: ease of insertion, oro-

pharyngeal leak pressure, pharyngeal mucosal pressures,and anatomical position. Br J Anaesth. 1999;82(5):703-707.3Ulrich-Pur H, Hrska F, Krafft P, Friehs H, Wulkersdorfer B, Kstler WJ, Rabitsch W, Staudinger T, Schuster E,Frass M. Comparison of mucosal pressures induced bycuffs of different airway devices. Anesthesiology.2006;104(5):933-938.4Jackson KM, Cook TM. Evaluation of four airway train

ing manikins as patient simulators for the insertion of eighttypes of supraglottic airway devices. Anaesthesia.2007;62:388-393.5Cook TM, Green C, McGrath, J, Srivatsava R. Evalua-tion of four airway training Airway Management Trainer as patient simulators for the insertion of single use laryn-geal mask airways. Anaesthesia. 2007;62:713-718.6Silsby J, Jordan G, Bayley G, Cook TM. Evaluation of four airway training manikins as simulators for insertingthe LMA Classic. Anaesthesia. 2006;61(6):576-9.7Keller C, Brimacombe J: Mucosal pressure and oro-

pharyngeal leak pressure with the ProSeal versus laryngealmask airway in anaesthetized paralyzed patients. Br J An-aesth. 2000;85(2):262-66.

Unfortunately on June 17, 2010 SAM and its Forum losta giant/friend/champion/mentor/beacon/heart, and souland world-renowned icon in the field of airway man-agement, Dr. Andranik Ovassapian. This edition of E-

lights includes his last recorded contribution to the Fo-rum. Participants remember he lead most discussions inwhich he participated. His contributions were alwaysexpected and highly appreciated. Very few dared tochallenge his statements that usually put an end towhatever discussion had taken place. Needless to saythe Forum will never be the same without his contribu-tions, experience and wisdom, but as I am sure hewould have said the show must go on.

As a frequent and generally successful user of the Supreme LMA I am still occasionally puzzled by de-vice insertion difficulty in petite women. I planned to

use a size 3 LMA Supreme in a 53 year old (BMI 22)women for an incision and drainage of a Right lower extremity wound. On exam the patient had a small but adequate two fingerbreadth mouth opening and was a

Mallampati 2. After confirming that a size 3 Supremewas an appropriate size (by the Goldman Guedel test)the patient was induced with the head in neutral posi-tion. After an easy initial insertion of the LMA I could not get it to seat well in the posterior pharynx despite

chin lift maneuver. I then switched to a size 3 LMAUnique which was easily inserted on the first pass.

Any similar experiences from Forum members? Anysuggestions/tips for problem solving?

Elizabeth Cordes Behringer, MD~ The rigid connection of the respiratory gas tubing(with respect to the bowl of the mask) is the culprit be-hind the inability to get the mask fully around the cor-ner, as evidenced by the success with the LMA Unique.The connection between the respiratory gas tubing and

the bowl of the mask needs to flex (to a variable degree,depending on the patient's anatomy) for the final phaseof LMA insertion to be complete. Solution? Mac 3 toelevate the base of tongue and flatten the "angle of at-tack" to mask insertion. Mac 3. the ultimate tonguedepressor for the most Supreme airway.

James DuCanto, MD

~ A more aggressive triple-airway maneuver may alsowork. Pre-load the Supreme with a 14 F OG protrudingabout 5-8 cm. Then use your McGrath (or GVL) to

place the Supreme, while watching the OG enter theesophagus. Because of the Supreme's fixed curve, a lat-eral approach may work best. I do this frequently for teaching purposes (even for a Bailey maneuver). It'salso possible that the device just doesn't work all the

BMI = Body mass indexMac = MacIntosh bladeGVL = Glidescope videolaryngoscopeOG = Orogastric tubeICU= intensive care unitAEC = Airway exchange catheter FOB = Fiberoptic bronchoscopeED/ER = Emergency department/RoomDL = Direct laryngoscopy

E LIGHTS OF THE SAM FORUMFelipe Urdaneta, M.D.

MRVAMC/University of Florida

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time. It's rigidity is a compromise to facilitate ease of insertion by novices.

Allan Goldman, MD

At my institution we have had discussions regarding what airway equipment should be stocked in ICUs.

In the past each ICU had a tackle box with a basicselection of laryngoscope blades and tubes. This wasabandoned because no one took ownership of restock-ing, cleaning, etc. We currently have a disposablelaryngoscope and some tubes in each crash cart but

people are reluctant to break the seal on the cart dueto the patient charge that is produced. We have a well-stocked airway bag that our anesthesia resident bringsto codes, intubations and extubations with anesthesiastand-by. What is done at other institutions? What airway equipment is stocked in your ICUs, and whether it is in every ICU or just select units? Who isresponsible for purchasing, checking, restocking and cleaning the equipment.

Allan Klock, MD

~ We carry "boxes to the Sites. We have two typesAdult (red and much larger} and Peds (gray andsmaller). When we are called we usually get a sense of whether it is an adult or Pedi situation, but there aretimes when we take both boxes. Each box is stock withemergency meds, laryngoscope handles and blades, col-orimetric ETCO2 detectors, AEC's and LMA's and Su-

preme's, ETT's, stylets (appropriate for each box), FOB,Bullard, Glidescope, and other non-disposibles, Jet ven-

tilator, Intubating Oral Airways, Cricothyrotomy sets,nebulizers. Used non-disposable equipment are returnedto central supply for "sterilization" (Hospital pays for this and for the techs) Boxes are restocked by resident-attending team each call and after each use.

Francis Stellaccio, MD

~We have difficult Airway Carts in ICUs and in theED. This took several years to get together. As withthe code cart it is somewhat easier to have, it all therethan to carry it on your shoulders....

Charles Watson, MD

~ All ICU/ED/ PACU areas as well as a few high trafficsurgical floors/medical wards, and all remote locations(GI suite, cardiac catheterization lab, neuro radiology,interventional radiology, MRI) have the same DA cartas the OR. Portable battery FOB are on the carts(suboptimal but good in a pinch). FOB towers with dig-itial capabilities are available within a few minutes of waiting time. Anesthesia stocks all carts. An Airwayteam carries the "yellow airway bag" that contains a

Ranger scope, SGA (LMA, ILMA, supreme), bougie,melker kit, jet set, combitube, Airtraq. We started thisconcept of airway bag about 14 years ago and at firstwe were considered "airway geeks" and many times wegot ridiculed, but we saved lives. It is not a perfect sys-tem but is functional. We are always tweaking it to

make improvements. Thomas Mort, MD

The optimal approach to difficult airway manage-ment and failed DL for emergency intubations in

ED/ICU's is unclear. There are obviously big consid-erations regarding cost effectiveness and skill of the

provider. It seems to me that a separate algorithm for these environments is needed and the algorithms for operative airway management carrylimitations (can't just wake them up and cancel thecase, don't necessarily have an "airway cart"). What is lacking is data to guide these algorithms as many of our rescues (FOI, rigid video, extraglottic airway)have been poorly evaluated in these settings. Anyoneknow of any literature for ICU/ED of large series or

prospective evaluation of rescue techniques? If so, it can guide some new algorithms. If not, I see an op-

portunity...Michael Aziz, MD

~ I am going to play "devil's advocate" in defense of the ASA DA guidelines. The current ASA PracticeGuidelines on the Management of the Difficult Airwayare Evidence Based, therefore the recommendations of

these guidelines (including the algorithm) are either literature based and/or the opinion of the ASA task force and their expert consultant group. Furthermore itis statistically analyzed. There is a reasonable amount of literature in the ICU to suggest that the ASA PracticeManagement guidelines are applicable outside the OR setting (Mort TC: J Clin Anesth. 2004 Nov;16(7):508-16).I believe that the issue is one of publicity. I do not think we need additional algorithms to explore this issue.Many ER physicians and Many ICU physicians are un-familiar with the ASA DA Guidelines. Spreading theword to colleagues who manage the airway outside the

OR in addition to broader studies of the ASA DAGuidelines in the Non-OR setting are warranted. As amultidisciplinary society, SAM remains an ideal forumfor this goal.

Elizabeth Cordes Behringer M.D.

~ I fully agree with Dr. Behringer's statements regard-ing the ASA difficult airway guidelines. Although atfirst glimpse they look simple, the reality is they need to


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be studied many times to fully understand them and beable to apply them properly. These guidelines cover allaspects of airway management from the evaluation anddecision making to the mechanical act of securing theairway. For each individual case scenario the basics of the airway management remains the same, however the

approach, equipment used, medications used will vary

from case to case and individual to individual. As all of us know, there also is more than one way to approach or manage any particular difficult airway. The proper se-lection and plan of action is critical. The ASA guide-lines is not a recipe from cook book and does not tellthe practitioner what device to use and does not provide

step-by-step description of each technique.Andy Ovassapian, MD(SIC)

Introduction:How much air should be introduced into the cuff

of the laryngeal mask airway (LMA) after insertion?Until recently, my answer would have been vague,enough to prevent a leak, perhaps. Although themanufacturer of the LMA North America recom-

mends limiting intra-cuff pressure to 44mmHg (60cm H 2O), 1 I suspect that many of us wouldnt knowthis number, let alone know what it feels like.

Study Type:Double-blinded randomized control trial.

Hypothesis:That the routine use of manometry to limit LMA

intracuff pressure to less than 44 mmHg, may reducethe incidence of pharyngolaryngeal adverse events.

Methods:After approval from the Hospital Ethics Board,

203 patients undergoing outpatient orthopedic,urologic, ophthalmologic, plastic, and general surger-ies under general anesthesia were enrolled. Inclusioncriteria: age 18-80 years, ASA PS Class I-III. Exclu-sion criteria: recent upper respiratory tract infection,contraindication to LMA use such as body mass in-

dex >40 kg/m 2, symptomatic hiatus hernia or gastro-esophageal reflux disease.

Group randomization was computer-generated.One group was designated the pressure-limitinggroup (PLG), meaning that shortly after anestheticinduction, a research assistant recorded cuff pressure

with a hand-held Pressostabil manometer, and if nec-essary, deflated it to achieve a pressure between 40-44 mmHg. The other group, termed the routine caregroup (RCG), had LMA intra-cuff pressure recorded

but not adjusted. Both groups had standardized meth-ods for induction (propofol and fentanyl), ventilation(spontaneous), maintenance (desflurane in air/O 2 at0.8-1.4 MAC), analgesia (fentanyl) , and LMA re-moval (when the patient was sufficiently awake toopen his or her mouth to command).

The method for LMA insertion differed accordingto each attending anesthesiologists preference. Thisanesthesiologist was blinded to the group and cuff

pressures.A research assistant, blinded to the group, col-

lected data 1, 2, and 24 hours post-operatively to de-termine symptoms and satisfaction scores (using a

predetermined questionnaire). Data collected in-cluded: demographics, anesthesiologist experience,information on anesthetic techniques, LMA inser-tion/removal, and post-operative pain requirements,

by Ronen Harris, M.D. Northwestern University Feinberg School of Medicine

Chicago, Illinois

Use of Manometry for Laryngeal Mask Airway Reduces PostoperativePharyngolaryngeal Adverse Events: A Postoperative, Randomized Trial

Seet E, Yousaf F, Gupta S, Subramanyam R, Wong D, Chung F.Anesthesiology. 2010;112(3):652-7

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Documents

September 2010 Gazette