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Sads ppt

1. Supraglottic airway devices( sad’S ) PRESENTER :DR.LAXMI SORAGANVI MODERATER :DR.SANGAMESH SIR

2. OVERVIEW Introduction History Indication/contraindication Classification Complications Technique of insertion Individual description Summery

3. Supraglottic airways Airway that are intended to open ,secure and seal supraglottic area to provide an unobstructed airway in spontaneously breathing or ventilated patients, typically during anaesthetic procedures. TERMINOLOGY Supraglottic airway devices (SADs) –most commonly used Supraglottic airway (SGAs) Extra-glottic airway devices (EADs)

4. HISTORY AND EVOLUTION DR . Archie Brain developed LMA in 1981 In 1988 initial commercial devices was launched – cLMA 1997 : intubating LMA 2001 : pro seal LMA 2005 : LMA supreme 2007 : i -gel 2009 : paediatric i -gel

5. DISADVANTAGES OF THE ETT For insertion of ETT –requires rigid laryngoscopy concomitant hemodynamic changes damage to oropharyngeal structures post operative airway morbidity serious concerns SIMPLE AND EFFECTIVE ALTERNATE TO ENDOTRACHEAL INTUBATION IS SADs.

6. ADVANTAGES OF SADs Avoidance of laryngoscopy , less invasive means of securing airways . Increased ease of placement and faster . It can be placed in neutral position . Higher success rate with inexperienced personnel . Better tolerated by patients –less trauma , coughing and post-op sore throat. NMBA not mandatory . Improved hemodynamic stability . Minimal increase in IOP ,ICP during insertion

7. CLASSIFICATION SADs are conventionally classified based on following characteristics Whether it has an inflatable cuff or not. Location of the distal end in the relation to glottis. Whether it protects against aspiration . What is the sealing mechanism. PRESENCE OF AN INFLATABLE CUFF 1.Cuffed SDAs – cLMA ,PLMA 2.Uncuffed SADs – igel , baska mask LOCATION OF THE DISTAL END IN THE RELATION TO GLOTTIS 1.Supraglottic devices – seal around the glottic inlet and remain superior to the larynx. cLMA ,PLMA , Ambu mask . 2.Retroglotic devices – terminate in the upper esophagus , remain posterior to the glottis . LT , LTS

8. PROTECTION AGAINST ASPIRATION 1.First generation – simple airway tube that do not have specific design that aims at SADs reducing the risk of pulmonary aspiration of gastric contents. cLMA , ilma , flexible LMA 2.Second generation – incorporate specific features to improve positive pressure SADs ventilation and reduce risk of aspiration . PLAMS , Igel ,supreme , ambu aura , GAIN , Baska SEALING MECHANISM 1.Cuffed pharyngeal sealers – without oesophageal sealing : COPA ,COBRA with oesophageal sealing :LTs 2.Cuffed peri laryngeal sealers - non directional sealing :LMA Directional sealing : PLMAs

9. INDICATION OF SADs Used as alternative to tracheal intubation :routinely Introduction of SADs resulted in a paradigm shift in airway management anesthesia Typically for anesthetized patient breathing spontaneously ,now increasingly being used in patient who are paralyzed with NMBAs. Wide variety of elective surgeries (laparoscopic) , in different group of patients (obese , children). IN DIFFICULT AIRWAY –ELECTIVE AND EMERGENCY Difficult bag and mask ventilation PRIMARY AIRWAY DEVICE Difficult laryngoscopy and video laryngoscopy Difficult intubation RESCUE DEVICE Difficult invasive airway Diffcult emergency AID TO TRACHEAL INTUBATION

10. USED AS A SUBSTITUE FOR FACEMASK : Useful when mask fit is difficult as in –edentulous pt ,bearded pt , facial tumour , growths Used as a primary device for oxygenation , frees the hand of anaesthesia care giver. Used in reduced mouth opening. TRACHEAL INTUBATION AID : SADs placed for rescue of failed direct laryngoscopy /failed intubation. May be used for blind /fibro-optic bronchoscope – guided intubation Best for management of unanticipated difficult airway scenarios. DEVICES THAT AID INTUBATION : IGEL , Ambu mask , LMA fastrach , LMA protector ,block blaster LMA .

11. To aid tracheal intubation ,Aintree catheter may be used over FOB to access trachea through SAD, SADs then removed while keeping Aintree catheter in place ETT can be advanced over the Aintree catheter into trachea RESUSCITATION AND PREHOSPITAL AIRWAY MANAGEMENT : Tracheal intubation is more likely to be difficult in emergent situation . Failure rate is high ,often require cessation of chest compression for significant duration.

12. SADS are now recommended : Ease of insertion , less training required , less extension of the upper cervical vertebrae compared to direct laryngoscopy . TRACHEAL EXTUBATION AID : SADs may be placed after removal of ETT, or placed alongside the ET before its removal . This approach particularly helpful in situations like Airway and hemodynamic reflexes are not desired When surgical incisions prevent the application of face mask When vocal cord movements need to be observed as after thyroidectomy . PROCEDURES IN CRITICAL CARE : Adult and paediatric bronchoscopies. Percutaneous tracheostomies.

13. CONTRAINDICATIONS TO SUPRAGLOTTIC AIRWAY DEVICE USE Mnemonic for Contraindications RODS: Restricted mouth opening, Obstruction in upper airway, Disrupted upper airway, e.g. trauma, intraoral burns following caustic ingestion, Stiff lung (poor compliance).

14. PARTS COMMON TO SUPRAGLOTTIC AIRWAYS : AIRWAY TUBE : distal aperture proximal aperture INFLATABLE /INFLATED PART : mask and cuffs Back plate Inner aspect –bowl Inflatable cuff INFLATION LINE : Syringe port Metallic valve Inflation indicator ballon DRAINAGE TUBE

15. Classic laryngeal mask airway ( cLMA ) Low orolpharyngeal pressure(10-20cmH2o)produces gastric insufflation and offer zero protection against pulmonary aspiration.

16. Proseal LMA (PLMA)

17. INSERTION TECHNIQUE STEP 1 : size selection STEP 2 : inspection STEP 3 : check deflation and inflation of cuff then deflate STEP 4 : mounting and lubrication STEP 5 : position the airway STEP 6 : Insertion STEP 7 : cuff inflation STEP 8 : verify placement STEP 9 : securing the SDAs

18. STEP 1 : SIZE SELECTION Weight based selection –as per the manufacturer's guideline done. PATIENTS WEIGHT LARYNGEAL MASK SIZE <5kg 1 5-10kg 1.5 10-20 2 20-30 2.5 30-50 3 50-70 4 70-90 5 >100 6 If malposition or an inadequate seal then Larger size should be considered

19. STEP 2 : INSPECTION Visually inspect the SAD cuff for patency and integrity of airway tube connector tube bond , both apertures , markings . Inspect the tube to ensure that it is free of blockage /loose particles . STEP 3 : DEFLATION AND INFLATION Deflate the cuff to ensure that it will maintain a vacuum . Inflate the cuff to ensure that it does not leak , asymmetrical Slowly deflate cuff to form a smooth flat wedge shape which will pass easily around the back of the tongue and behind the epiglottis . Use the cuff deflator .

20. STEP 4 : MOUNTING AND LUBRICATION Mount on the insertion tool Use a water soluble lubricant . Lubricate just prior to insertion . Lubricate the back of the mask thoroughly . STEP 5 : POSITIONING OF THE AIRWAY Optimize position of head and neck –extend head and flex neck . Optimize positioning of device in mouth-avoid LMA fold over. -Ask assistant to pull the lower jaw downwards -visualize the posterior oral airway -ensure that cuff is not folding over in the oral cavity as it is inserted. FINGER INSERTION NOT NEEDED FOR PERFORMED DEVICES.

21. STEP 6 : INSERTION Grasp by the mounting tool by the dominant hand , keep the mouth open. Place tip of LMA against the inner surface of the patients upper teeth. Press the mask tip upwards against the hard palate to flatten it out . Move the LMA in a up and down motion to spread lubricant on the hard palate . Keep pressing backwards and downwards ,mask is advanced along the hard palate into the pharynx , ensure tip remains flattened and avoid the tongue . Once definitive resistance is felt ,in position, hold tube and remove introducer. Bougie-guided insertion-bougie placed into the oesophagus and PLMA is railroaded into place via the drain tube.

22. STEP 7 : CUFF INFLATION Should be inflated before fixation. Inflate the mask with the recommended volume of air. Do not over inflate the LMA . Do not touch the LMA tube while it is being inflated. Normally the mask should rise up slightly out of hypopharynx as it is inflated. Cuff inflation pressure should never exceed 60cmH2O CAREFUL INFLATION: Intracuff pressure increases as cuff volume increases. Pressure exerted on the pharynx by SAD higher than that of mucosal capillary perfusion pressure ,when cuff inflated with recommended maximum volume of air . Higher cuff pressure may pharyngeal mucosa pressure and that can cause mucosal ischemia and morbidity. Desirable to inflate the cuff with minimum volume of air which provides a seal around the mask. Inflate to ½ of the maximum recommended volume. Do not go below 1/4 th of the maximum recommended volume. MASK SIZE PT WEIGHT(kg) MAX.CUFF VOLUME OF AIR (ml) 1 Neonate/infant Upto 5kg 4 1.5 Infant 5-10 7 2 Infant/children 10-20 10 2.5 20-30kg 14 3 Children 30-50kg 20 4 Adult 50-70 30 5 Adult 70 -100 40

23. STEP 8 : VERIFY PLACEMENT AND FUNCTIONING Visual assessment of depth of insertion Relation of the integral bite block to the incisors . Ideally bite block lies between the teeth ,protrudes in case PLMA is inadequately inserted. Observe front of neck. unobstructed inspiratory and expiratory flow Assessed by manually ventilating patient , observing chest movements, capnography ,expired TV of >8ml/kg, evaluating compliance by feel of bag. Partial obstruction due to infolding of PLMA cuff of downfolding of epiglottis. Suprasternal notch tap test / brimacombe bounce test Confirms location of PLMA tip in oesophagus behind the cricoid cartilage. Tap the suprasternal notch or cricoid cartilage – observe simultaneous movement of a column of lubricant at the proximal end of drain tube. Drain tube must be patent for the test to be positive.

24. Gel displacement test place water soluble gel (0.5ml) at proximal end of drain tube to form a column of about 2.3cm. Min movement or gentle up/down movements indicates a normal position. Positive test is gel ejection with PPV – indicates a leak from drain tube , signifying improper seal of device with the hypopharynx . Passage of gastric tube through drain tube into stomach Verifies patency of drain tube – posterior folding of mask tip ruled out. AIRWAY SEALING PRESSURE: Oropharyngeal leak pressure pressure at which gas leak occurs around the device. It indicates the degree of airway protection. Method turn off the ventilator and close the APL valve of the circuit , fixed O2 flow of 3L/min started pressure from the breathing system increases. Manometer dial observed to note observed to note airway pressure at which the dial attains stability ,max pressure of 40cmH2O allowed . Audible noise over the patients mouth .

25. Auscultation just lateral to the thyroid cartilage for audible noise. Most 1 st generation SGDs develop on air leak during PPV of 16-20cmH2O. Most 2 nd generation devices maintain pharyngeal seals with pressures of 25-28cmH2O. Step 9 : securing the SAD Insert a bite block or role of gauze to prevent occlusion of the tube. Done normally soon after the cuff inflation. Removed after the removal of the device. Placed between the back teeth . Now LMA can be secured after bite block insertion – maxilla to maxilla , mandible to mandible .

26. DRAIN AND GASTRIC TUBE USES: Separates the alimentary and respiratory tracts . Allows escape of fluids from the stomach and reduces the risk of gastric insufflation and pulmonary aspiration. Determines its correct position. Permits monitoring DEVICE REMOVAL : bite block in place . Suctioning –if needed Cuff fully deflated. STERILIZATION : The PLMA is reusable and recommended product life is 40 sterilization. Steam autoclaving is recommended method of sterilizing this devices . Prepare for sterilization –cuff fully deflated and dry Track the number of sterilization.

27. PROBLEMS WITH LMA INSERTION : Failure to press the deflated mask up against the hard palate or inadequate lubrication or deflation can cause mask tip to fold back on itself. Once the mask tip has started to fold over ,this may progress ,pushing the epiglottis into its down-folded position causing mechanical obstruction.

28. If the tip is deflated and forward it can push down the epiglottis causing obstruction. If mask is inadequately deflated it may either push down the epiglottis penetrate the glottis

29. LARYNGEAL MASK AIRWAY UNIQUE LMA Unique is first single use SADs, disposable LMA . No risk of transmission of infection. Sizes available from 1-5 It is similar to LMA classic.

30. Soft seal LMA Similar to LMA unique Cuff is softer ,blunter and less permeable to N2O. Integrated inflation line. No epiglottic bar. Wider ventilation orifices. Size – 1-5

31. LMA CLASSIC EXCEL Epiglottic elevating bar and removable connector facilitate introduction of ETT through LMA . Available in sizes 3-5 , accommodates ETTs upto size 7.5mm. Its reusable up to 60 times.

32. LMA FLEXIBLE It’s a combination of the original LMA cuff with narrower ,longer ,wire reinforced flexible airway tube . Intubation is impossible –because of narrow and long tube. It can be positioned away from the surgical field without cuff displacement –because of its flexibility and extra length. in case of ENT /maxillofacial/dental procedures. Available in sizes 2-6.

33. Intubating LMA/LMA Fastrach FT-LMA is an intubating laryngeal airway intended to provide both ventilation and consistent ability to pass an ETT blindly into the trachea. It was first developed by Dr.A BRAIN in 1997 in response to difficulty to intubate through cLMA . Available size 3,4 and 5 Reusable and disposable version available. Indication-anticipated/unanticipated difficult intubation. And in cervical spine injury. size Weight (kg) Cuff inflation volume (ml) 3 30-50 20 4 50-70 30 5 70-100 40

34. LMA SUPREME Elliptical airway tube –intubation is not possible. Fins prevent epiglottis from obstructing airway lumen. Drain tube –for evacuation of gastric contents, and monitor correct positioning of LMA. LMA supreme can be easily introduced without the need for introducer tool. Bite block –prevents tube damage and obstruction by patient biting. Fixation tab-prevents proximal displacement ,this enhances seal around upper oesophageal sphincter Sterile and single use only Available size 1-5 .

35. LMA PROTECTOR It is a silicone device that incorporates features from previous laryngeal masks. It presents a central tube larger than other models and two lateral drainage pipes. The sleeve incorporates a new system of “traffic light” that allows continuous monitoring of the cuff pressure during use.

36. LMA CTrach Its based on ILMA with two in-built fibreoptic channels one to convey light form one to convey image to viewer. It has an epiglottis elevating bar , elevates the epiglottis during passage of ETT. Fibro optic system is sealed and robust , and can be autoclaved . Rechargeable battery ,provides 30 min of continues use. Indication – achieving and maintain an airway in difficult intubation situation.

37. AMBU LARNGEAL MASK (AURAONCE) Built-in anatomical correct curve for easy atraumatic insertion. Reinforced tip resists folding over during insertion and plugs upper oesophageal sphincter. Cuff and airway tube moulded as single unit –no separation. Extra soft cuff ensures best possible seal with less mucosal pressure. Available size 1-6

38. AIR-Q/INTUBATING LARYNGEAL AIRWAY Developed by DR.Daniel cook and introduced in 2004. Used as SADs or conduit for intubation. For tracheal intubation ,the ET is advanced to a depth of 12-15cm so the tip of the tube is close to air-q opening. Success of blind intubation is higher.

39. PHARYNGEAL SEALERS: Its cuffed pharyngeal sealer without an oesophageal ballon. It is named so because the distal part resembles the hood of cobra, when positioned properly cobra head sits over glottis and seals off hypopharynx. Soft grill prevents epiglottis from downfolding . grill allows passage of ETT . Circumferential cuff rests in hypopharynx at vallecula , when inflated ,it lifts the base of tongue exposing glottic aperture , and seals airway. Size ½ -8 COBRA PERILARYNGEAL AIRWAY

40. LARYNGEAL TUBE AND LARYNGEAL TUBE SUCTION Cuffed pharyngeal sealers with oesophageal balloon. LT : Two cuffs(pharyngeal and oesophageal ) Single balloon for inflation of both cuffs Both cuffs have high volume and low pressure to avoid ischemic damage and provide good seal. LTS is double lumen silicon version of LT. Additional lumen for insertion gastric tube allowing suction. Lumen opens at oesophageal end . Size 0-5 , are colour coded.

41. ESOPHAGEAL–TRACHEAL COMBITUBE Cuffed pharyngeal sealer with oesophageal balloon. It has double lumen tube that has two balloon, two tubes , and two separate inflation lines. There is ventilation with combitube regardless of whether the distal tip is in oesophagus (common 95%) or trachea (rare). Works similar to conventional ETT . Size 37F –shorter patient 41F – patient taller than 152cm Recommended for use only in patient taller than 4.5feet. EASY TUBE disposable ,polyvinyl chloride latex free SAD. Similar to combitube .

42. CUFFLESS PRESHADPED SEALERS SLIPA is latex free slipper shaped device. Made of stiff medical grade thermoplastic material to facilitate easy insertion. After insertion it warms up to body temperature and softens , improving seal and comfort . Chamber -50ml capacity to accommodate secretion prevent aspiration. Connector is colour coded for size . STREAMLINED LINER OF THE PHARYNX AIRWAY (SLIPA)

43. IGEL I-GEL is cuffless, sterile ,latex free SAD. Made of soft, gel like medical grade thermoplastic elastomer. Available sizes -1-5 A standard 15 mm connection to the anesthetic system or patient connection, A port of entry for the gastric channel—the port is independent of the main 15 mm connection and is located on the right hand side of the connector wing. An integral bite block—this function is provided by the distal(below the wing) part of the connector, which runs through the center of the proximal part of the buccal cavity stabilizer. To reduce the possibility of the airway channel occluding—the junction of the distal tip to the body of the connector is V-shaped, which significantly reduces the risk of kinking. A guide to correct positioning—the integral part of the bite-block is marked with a horizontally placed black line, which signifies the optimum position of the teeth while the device is in situ (not applicable to the pediatric sizes)

44. Non-inflatable cuff fits peri laryngeal framework , mirroring the shape of the epiglottis, aryepiglottic folds , pyriform fossa , perithyroid , pericricoid , posterior cartilage , and spaces , Easy visibility of key product information—this includes size and recommended weight.

45. ELISHA AIRWAY DEVICE (EAD) Made of latex free medical grade silicone. Has three separate channel for ventilation ( vc ), intubation( ic ), gastric tube insertion. VC and IC are side by side with partitioning wall in between , but they join at ventilator outlet in front of laryngeal inlet . EAD has two high volume , low pressure balloons, proximal seals oro and nasopharynx , distal seals oesophagus.

46. BASKA MASK AIRWAY Newer SAD similar to LMA. Has noninflatable cuff that is continuous with the airway , gets inflated with PPV, reducing chance of gastric insufflation and aspiration. Distal opening sits in upper oesophagus ,dorsal surface of cuff is made in a way that directs the oropharyngeal contents towards side channel . Size  3-green ,4-yellow ,5-red , 6-blue.

47. SUPRAGLOTTIC AIRWAY DEVICES IN SPECIAL SITUATIONS 1. Laryngeal mask airway in prone position: The use of the Classic™ LMA in the prone position is controversial, but the ProSeal ™ LMA may be more suitable as it forms a better seal and provides access to the stomach. 2. Laryngeal mask airway in the obstetric patient: The LMA is a part of the difficult airway algorithm for the obstetric difficult airway. When tracheal intubation has failed ,ventilation with mask and cricoid pressure, or with a LMA or SAD [e.g. Combitube , intubating LMA ( Fastrach ™)] should be considered for maintaining an airway and ventilating the lungs. The LMA is to be used only as a rescue device in obstetric patients as parturients have delayed gastric emptying and are prone for aspiration pneumonitis. 3. Laryngeal mask airway in CPCR: Supraglottic airways that have been studied in cardiac arrest are the LMA, the esophageal–tracheal tube ( Combitube ) and the LT or King LT ,appear to be able to provide ventilation that is as effective as that provided with a bag and mask or an ETT.

48. 4. Laryngeal mask airway in obesity : The LMA is contraindicated in grossly or morbidly obese patients because of the increased risk of regurgitation and the requirements for high airway pressure ventilation. However, it is indicated for airway rescue in emergency situations and the ProSeal ™ LMA may be used as a temporary ventilatory device before laryngoscope guided tracheal intubation. 5. Laryngeal mask airway in laparoscopy: The LMA ProSeal ™ and Supreme™ offers a cuff that allows a higher seal pressure than the LMA Classic™, and a drain tube that allows venting of the stomach contents, and blind insertion of standard gastric tubes. All these factors are designed to reduce gastric insufflation, regurgitation and subsequent pulmonary aspiration. These properties of the LMAs (LMA ProSeal™and LMA Supreme™) offer greater protection with regard to aspiration pneumonitis. Since 2002, several clinical studies have recommended their use for laparoscopic surgery. Only SAD devices which offer higher seal pressures and the provision for passing gastric tubes should be recommended for use in laparoscopic surgery.

49. TOTALTRACK VLM The Totaltrack ® Video Laryngeal Mask (VLM) was designed by Dr. Pedro Acha , whose previous design was the Airtraq . It could be defined as a 3rd generation disposable Supraglottic Airway Device (SAD) allowing intubation with a direct view and continuous ventilation since the device is introduced into the patient's mouth while adding the possibility of intubation keeping with ventilation. The VLM concept can itself integrate several functions that previously mentioned devices do separately. This includes keeping the airway permeable, ventilating/oxygenating, separating the digestive tract from the respiratory tract, and intubating under continuous viewing “without stopping ventilation”. In cases of a failed intubation attempt, VLM can continue optimal ventilation/oxygenation while the operator thinks about the next step of the strategy. VLM can integrate functions that other devices on their own cannot provide to the patient.

50. REFERENCES : UNDERSTANDING ANESTHETIC EQUIPMENTS AND PROCEDURES AND PRACTICAL APPROACH –D.K.BAHETI , VANDANA V LAHERI. 1 ST EDITION. WARDS ANAESTHETIC EQUIPMENTS. ADREW J DAVEY AND ALI DIBA . 6 TH EDITION Recent Advances in Anesthesiology, Vol. 3

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