Airway devices and adjuncts

A quick review on common airway devices and adjuncts

1. Airway Devices & Adjuncts Dr. Anoop James DNB Trainee, Emergency Medicine

2. Airway Devices

3. Airway Devices Supraglottic Devices Airway devices that facilitate oxygenation and ventilation without endotracheal intubation. Bridge between BMV and endotracheal intubation Useful in “ Cannot Intubate, Cannot Ventilate ” situations .

4. Supraglottic Devices Failed Intubation Surgical Airway

5. Dr. Archie Brain - credited with invention and development of LMA Airway Device Year Classic Laryngeal Mask Airway (cLMA) 1988 Combitube 1988 LMA Fastrach 1995 LMA Proseal 2000 Laryngeal Tube 2003 Air- Q 2004 I- Gel 2007 LMA Supreme 2007 Baska Mask 2012 Supraglottic Airway Devices - Genesis

6. First generation devices- simple airway tubes Classic LMA Flexible LMA Cobra PLA Second generation – includes drainage tubes ProSeal LMA I-Gel LMA Supreme SLIPA Third generation - cuffless , two drain tubes, small bowl Baska mask. Supraglottic Airway Devices – Evolution

7. Supraglottic Devices - Classification Cuffed Peri-laryngeal Sealers All LMAs Cuffed Pharyngeal Sealers Combitube King Laryngeal Tube (King LT) Cobra Peri-laryngeal Airway (PLA ) Cuffless Pre-shaped Sealers With Esophageal Sealing Baska Mask I-Gel Without Esophageal Sealing SLIPA AirQ - SP

8. Laryngeal Mask Airway (LMA)

9. 15 mm Connector Airway Tube Inflation Balloon Cuff Aperture Bar Classic LMA

10. Classic LMA cLMA Size Patient 1 Neonates/infants up to 5 kg 1.5 Infants between 5 and 10 kg 2 Infants/children between 10 and 20 kg 2.5 Children between 20 and 30 kg 3 Children 30 to 50 kg 4 Adults 50 to 70 kg 5 Adults 70 to 100 kg 6 Adults over 100 kg

11. Classic LMA Advantages Increased speed and ease of placement Improved hemodynamic stability Reduced anesthetic requirements Less coughing and sore throat Can be done by inexperienced personnel Disadvantages Low pressure seal – increased risk of gastric aspiration Suction not possible Tip may get folded causing obstruction Inadequate seal – PPV is difficult

12. Manual Vent ProSeal LMA Inflation Balloon Drain Tube Drain Tube Orifice Cuff Airway Tube Integrated Bite Block 15 mm Connector Internal Drain Tube

13. Classic LMA ProSeal LMA Modifications over classic LMA Larger and deeper bowl with no grille Gastric drainage tube running parallel to airway Larger deeper bowl and dorsal extension of cuff Bite block

14. LMA- ProSeal LMA Size Weight (kg) Max Cuff Inflation Volume (mL) Max. Fiberoptic Scope Size (mm) Max. gastric Tube Size (Fr) Length of Drain Tube (cm) Largest Tracheal Tube (ID in mm) 1.5 5 to 10 7 - 10 18.2 4.0 uncuffed 2 10 to 20 10 - 10 19.0 4.0 uncuffed 2.5 20 to 30 14 - 14 23.0 4.5 uncuffed 3 30 to 50 20 - 16 26.5 5.0 uncuffed 4 50 to 70 30 4 16 27.5 5.0 uncuffed 5 70 to 100 40 5 18 28.5 6.0 cuffed

15. ProSeal LMA

16. Classic LMA vs Proseal LMA Advantages Separate gastric tube port - for gastric access, checking correct positioning Bougie guided insertion f ETT Dorsal cuff -provides better seal and higher sealing pressures With drain tube occluded – less incidence of gastric aspiration Bite block. Can be used for both spontaneous and controlled ventilation

17. Classic LMA vs Proseal LMA * 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 . Disadvantages* More incidence of trauma Equivocal incidence of sore throat as compared to cLMA Slightly longer insertion time compared to cLMA 20% more airway resistance than classic airway in spontaneously breathing patients. Less suitable as an intubation device Requires a greater depth of anesthesia for insertion

18. LMA Supreme Drain Tube AirwayTube Bite-block Pilot Balloon Valve Modified Cuff Drain Tube Orifice Unique Elliptical Rigid Airway Tube Reinforced Tip and Moulded Distal Cuff Moulded Fins Fixation Tab

19. Modifications of LMA Supreme Fixation Tab (FT) : Facilitates easy insertion and fixation of the LMA Visual guide to ‘correct’ size select - after inflation of the cuff, the FT should be 1.5–2 cm from the upper lip If distance is less, the size chosen may be too small If >3.0 cm from the upper lip the size chosen may be too large

20. Modifications of LMA Supreme 2. Airway Tube: Unique, flattened, firm, anatomically shaped airway tube - elliptical in cross-section Elliptical shape facilitates insertion in patients with reduced interdental space, without increasing the resistance to breathing Firm, anatomical shape facilitates easy insertion without placing fingers in the mouth Helps to minimize accidental rotation, once in place Lateral grooves on either side prevent kinking

21. Modifications of LMA Supreme 3. Drainage Tube: Runs from its rigid proximal end, through the middle of the airway tube, continues along the posterior surface of the cuff Equalizes the pressure between UES and atmosphere Vents gastrointestinal gases and liquids Serves as a conduit for the passage of nasogastric tube Indicator of correct tube positioning

22. Modifications of LMA Supreme 4. Cuff: Modified and enlarged inflatable cuff Enhances the anatomical fit into the pharynx Glottic seal pressures between cLMA and ProSeal LMA Moulded distal cuff - strengthens the tip and prevent it from ‘folding over’ during insertion Modified fins - prevent the epiglottis from becoming wedged in the airway

23. LMA Fastrach Airway Tube Handle Epiglottic Elevating Bar 15 mm Connector LMA Fastrach ETT Shaft

24. LMA Fastrach “ Intubating Laryngeal Mask Airway ” Uses: To facilitate tracheal intubation Can also be used as a primary airway device Rescue device for failed intubation Blind or fiberscopic guided insertion

25. LMA Fastrach Disadvantages : Pharyngeal pathology or limited mouth opening Cannot be used for intubation in patients below 30 kg Expensive & prolonged use is to be avoided The tracheal tube may be displaced downward or dislodged Unsuitable for use in the MRI unit Increased incidence of sore throat and difficulty swallowing Esophageal intubation

26. LMA Unique

27. LMA Flexible

28. LMA C-Trach

29. Proximal Cuff stabilizes tubes seals oro /nasopharynx King LT Distal Cuff seals esophageal inlet prevents gastric inflation Ventilation Holes lies in front of the larynx Pilot Balloon Radio Opaque Line 15 mm Connector Color coded to determine size Length Marker Ramp Passage of tube exchanger or fiberoptic bronchoscope

30. King LT Advantages : Easy insertion – less skill Minimal mouth opening required. High ventilation pressure can be used Can be used to intubate trachea

31. Combitube

32. Combitube “ Esophageal Tracheal Airway ” Blind insertion airway device (BIAD) Double lumen airway device designed for emergency ventilation of a patient when visualization of the airway and endotracheal intubation are not possible Ventilation can be achieved with either tracheal or esophageal placement of tube

33. Combitube Proximal Lumen (blue colored) - sealed at the end, contains fenestrations distal to the pharyngeal balloon Used in case of esophageal intubation (90% - 95 %) Distal Lumen (transparent) - ends beyond the distal cuff; similar to an ETT Used when trachea is intubated

34. Combitube

35. Combitube Advantages : Blind insertion without the need for light, laryngoscope, or direct visualization Effective ventilation and oxygenation with moderate protection against aspiration Proximal pharyngeal balloon provides better air seal Gastric contents can be aspired through lumen #2 when the device is in the esophagus

36. Combitube Disdvantages : Pediatric sizes not available Expensive Increased chance of laryngeal and tracheal injury Latex hypersensitivity (the pharyngeal balloon contains latex)

37. Combitube Contraindications : The patient has intact gag-reflex The patient is less than 5 feet tall or under 16 years old History of ingestion of caustic substance Burns involving the airway History of esophageal disease History of latex hypersensitivity

38. Epiglottic Rest i -GEL Distal Part of Drainage Tube Proximal Part of Drainage Tube 15 mm Connector Bite Block Non-inflatable Cuff

39. i -GEL Second generation supraglottic airway device – 2007 ( Intersurgical ) Mask made of medical grade thermoplastic elastomer - Styrene Ethylene Butadiene Styrene (SEBS) Adapts to patients airway - anatomical seal of the pharyngeal, laryngeal and peri-laryngeal structures Provides effective seal without a cuff

40. i -GEL Soft, gel-like, non-inflatable cuff, designed to provide an anatomical impression fit over the laryngeal inlet. The shape, softness and contours accurately mirror the peri-laryngeal anatomy - no cuff inflation is required. Compression and displacement trauma are significantly reduced or eliminated.

41. i-GEL Firmness of material – facilitates easy insertion Tip design – prevent folding back of tip edge Epiglottic rest – prevents downfolding of epiglottis Buccal stabilizer and broad mask – provides stability, reduce kinking and midline positioning Gastric channel – helps to vent gastric secretions

42. i-GEL

43. i -Gel Advantages : Better anatomical fit – less compression trauma Less risk for injuries related to cuff hyperinflation Easy insertion - reduces the time for successful insertion Greater airway seal pressures and superior fibreoptic views as compared to other SGAs* Wide lumen allows for airway rescue and assisted intubation Effective in prone position ventilation *Lisa S Razan N Narasimhan J, Update on Airway Devices Curr Anesthesiol Rep. (2015) 5:147–155

44. Airway Rescue With i-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 * * Dingeman RS, Goumnerova LC, Goobie SM. The use of a laryngeal mask airway for emergent airway management in a prone child, Anesth Analg . 2005 Mar; 100(3):670-1

45. SLIPA - Streamlined Liner of the Pharynx Airway Plastic uncuffed disposable Hollow boot shaped distal part Anatomically fits pharynx Toe rests in esophageal entrance Bridge fits in pyriform fossa Heel – anchors to soft palate Large size prevents aspiration of regurgitated fluid

46. Advantges Better airway sealing pressures for PPV Cuffless Disadvantages More traumatic Occupies space upto soft palate.

47. Baska Mask 3 rd generation supraglottic airway device Smaller bowl compared to other LMAs - less risk of including oesophageal opening Adjustable tab in shaft to increase angulation - allows 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

48. BaskaMask

49. Supraglottic Airway Guided ET Intubation and Fibre Optic Laryngoscopy

50. Infraglottic Airways Supraglottic Access Infraglottic Access Endotracheal Tube Fibre optic devices Cricothyroidotomy Tracheostomy Retrograde Intubation

51. Endotracheal Tube Universal Connector Pilot Balloon Inflation Tube One-way valve Radio-opaque line PVC Tube Cuff Murphy’s Eye

52. Endotracheal Tube Machine end – Universal Connector Tracheal end – Atraumatic Beveled Tip Murphy’s eye – Murphy’s Tip ET Tube

53. Types of Endotracheal Tube Cuffed Uncuffed Double lumen

54. Markings on an ET Tube The markings are situated on the bevel side above the cuff & are read from patient end to machine end

55. Markings on an ET Tube ID – Inner Diameter OD – Outer Diameter Type of tube – Oral/nasal IT – Implant Tested Single use Name of manufacturer Markings for length of insertion Indicator for position of vocal cords “ Conformité Européenne ”  European Conformity - indicates conformity with health, safety, and environmental protection standards for products sold within the European Economic Area (EEA)

56. Requirements of an Ideal ET Tube Smoothness of outer surface to avoid damage to mucosa Smooth & non- wettable inner surface. Non-inflammable Transparent Easily sterilizable Non-kinking

57. Requirements of an Ideal ET Tube Sufficiently strong - to allow thin wall framework Thermoplasticity - to conform to anatomic passage and to be self centering within the trachea. Non reactive with lubricants or anesthetic agents Latex free Non injurious catheter tip

58. ET Tube Cuff The cuff is an inflatable sleeve near the patient end of ETT. The cuff material should be strong and tear resistant but thin, soft and pliable. Cuffs are usually made of the same material as the ETT.

59. ET Tube Cuff Provides a seal between tube & tracheal wall to prevent aspiration of gastric contents Prevents air-leak Serves to center the tube in trachea Can be high volume - low pressure system or low volume - high pressure system

60. ET Tube Cuff Normal recommended cuff pressure - Damage to tracheal mucosa - >30 cm H 2 O Total obstruction of tracheal blood flow - >50 cm H 2 O Usually 10 ml of air is sufficient for adequate cuff pressure 20 – 30 cm H 2 O

61. Factors Affecting Cuff Pressures Positive pressure ventilation Ventilation with N 2 O Bronchoconstriction Laryngeal spasm Edema Sedation Neuromuscular blockade Reduced core temperature Time Changes in body position Increase in cuff pressure Decrease in cuff pressure Athiraman U, Gupta R, Singh G. Endotracheal cuff pressure changes with change in position in neurosurgical patients. Int J Crit Illn Inj Sci. 2015 Oct-Dec;5(4)

62. THE GUIDELINES TO DETERMINE THE SIZE OF ETT: Ideal tube in average adult male – 8.5mm ID Ideal tube in an average adult female - 7.5mm ID. Age is recognized as the most reliable indicator of appropriate ETT size for children. 3 months & less ------ 3 mm ID 3 - 9 months ------ 3.5 mm ID Older than 1 year ------ ID in mm = (16 + age in years)/4

63. Younger than 6 years --- 3.5 + age in years/3 = ID in mm Older than 6years --- 4.5 + age in years / 4 = ID in mm Choosing a tube whose external diameter is same width as the patient's distal end of little finger THE GUIDELINES TO DETERMINE THE SIZE OF ETT:

64. Principles of ET Tube Internal diameter – Smaller tubes offer greater resistance Length – Increase in length of tube increases airway resistance Configuration - Abrupt change in the diameter and direction increases the resistance

65. Suction Catheters

66. Ideal Suction Catheter Size Measured in French (French/3.14 = size in mm) Diameter of catheter < ½ inner diameter of tube Infants 6 - 8 Fr 2 – 6 years 10 Fr 7 – 15 years 12 Fr >16 years 12 - 14 Fr Size 10 ETT 14 Fr Size 8 ETT 12 Fr Size 6 ETT 10 Fr

67. Ideal Suction Pressures Adult – -100 to -120 mmHg Child – -80 to -100 mmHg Infant – -60 to -80 mmHg

68. Hazards of Suctioning Trauma Hypoxia – Arrhythmias, Cerebral hypoxia Vagal Stimulation Atelectasis Infection Bronchospasm Raised ICP Stimulation of gag Reflex

69. Guedel’s Oropharyngeal Airway

70. OROPHARYNGEAL AIRWAY Sizes Length (mm) 000 30 00 40 50 1 60 2 70 3 80 4 90 5 100 Sizes available Colour coding

71. OROPHARYNGEAL AIRWAYS Uses – To maintain open airway Prevent endotracheal tube occlusion Prevent tongue bite Facilitate suction Conduit for passing devices into oropharynx Obtain a better mask fit Contraindications – Intact gag reflex Oropharyngeal growth

72. Bougie Eschmann Stylet / Endotracheal Tube Introducer Gum Elastic Bougie - neither made of gum nor is it elastic Made from beige colored resin covering a  fiberglass core Size – 15 Fr or 5mm diameter Total length – 60 – 70 cm Distal tip angulation - 30-45 degrees

73. “Kiwi Grip”

74. Bougie Tracheal intubation - in difficult airways or during CPR Tracheal intubation via supraglottic airway device Surgical airway (cricothyrotomy) Selective endobronchial intubation Confirmation of endotracheal tube position Endotracheal tube exchange Bougie-assisted intercostal catheter insertion

75. Spotters….

76. 1. Non–cuffed Endotracheal Tube

77. 2. Nasopharygeal Airway

78. 3. RAE Tube (Ring, Adair and Elwyn)

79. 4. Laryngoscope

80. Questions?

81. Thank You