SupraAD-1 and anaesthetic considerations .ppt

Supra ad and anaesthetic considerations

1. SUPRAGLOTTIC
AIRWAY DEVICES
DR. KUNAL KISHORE GUPTA
​
MODERATOR 1 DR. ADITYA KEJRIWAL
​
MODERATOR 2 DR. JANKI N THAKUR

2. SUPRAGLOTTIC
Airways that are intended to
open, secure & seal the
supraglottic area to provide
an unobstructed airway in
spontaneously breathing or
ventilated patients, typically
during anesthetic procedures
INFRAGLOTTIC
Below the glottis opening
Definitive airway- ET tube,
tracheostomy
Emergency airway -
cricothyrotomy

3. HISTORY
Dr Archie Brain - first
credited with
invention &
development of LMA
He first used a
Goldmans mask and
attached it a obliquely
cut endotracheal tube.
It was introduced in
1982.

4. CLASSIFICATION
1
st
and 2
nd
GENERATIONS
DEVICES
3
rd
GENERATION
SUPRAGLOTTIC AIRWAY
DEVICES?

5. INDICATION
SAD have been recommended as rescue airways
during DA management and in particular “cannot
intubate ,cannot ventilate” scenario
Alternative airway during GA specially in minor
surgeries & therapeutic or diagnostic procedures
like RT, endoscopy, ECT etc.
Cardiopulmonary resuscitation to secure the airway.
Essential part of difficult airway trolley.
Primary airway device when urgent airway patency is
required in lateral position.

6. CONTRAINDICATION
Limited mouth opening (< 2 fingers)
Local pathology in pharynx , larynx or upper airway.
Trismus, facial or upper airway trauma
Increase risk of aspiration- Morbid obese, > 14 week
pregnant, full stomach.
Prior opioid medication, delayed gastric emptying,
acute abdominal or thoracic injury, GERD, hiatus
hernia
Reduced lung compliance/increase work of breathing

7. ADVANTAGES OF THE SGAs
Avoidance of laryngoscope, less invasive means of
securing airway.
Increased ease of placement.
Can be placed in neutral position.
Higher success rate with inexperienced personnel.
Better tolerated by patients- less trauma, coughing
& post op sore throat.
Improved oxygen saturation during emergency
Improved hemodynamic stability.
Minimal increase in iop, icp during insertion.

8. DISADVANTAGES
Inadequate positive pressure ventilation.
Vascular compression and nerve damage.
Can cause laryngospasm if displaces
anteriorly.
More chances of aspiration of gastric
contents.

9. ROLE OF THE LMA IN ASA’S DIFFICULT
AIRWAY ALGORITHM.
LMA or any SAD now find its role in the management of
the difficult airway at 5 places in the ASA’s algorithm
either as:
Ventilatory devices
As a conduit to tracheal intubation

10. DAS guidelines for management of
unanticipated difficult intubation in adult

11. THE NEW 2022 ASA DIFFICULT AIRWAY
ALGORITHM

13. Avoid in patients who are un-fasted, or have factors
predispose to regurgitation.
Routinely test the cuff for defects before use.
Avoid lubricating the anterior surface of the mask, since
the lubricant may be aspirated.
Insert the LMA only when adequate depth of anesthesia
has been reached.
Avoid disturbing the patient during emergence from
anesthesia.
Keep the cuff inflated till the patient is awake.
If aspiration does occurs Dr. Brain AIJ recommends leaving the
LMA in place, tilting the patient’s head down and
suctioning through the LMA

14. LMA- Classic
Comprised of three main
components
Airway Tube
Mask
Inflation line
Designed to confirm contours of
hypopharynx with its lumen facing
the laryngeal opening.
Made of silicone, can be autoclaved
& reused many times.
Seal pressure =25cmH2O

15. SIZE SELECTION

16. PREPARATION PRIOR TO
INSERTION
Select proper size of LMA.
▶Inspect for any tear , blockage .
▶Slowly deflate the cuff to form a smooth flat wedge
shape .
▶Over inflate: look for leak.
▶Use a water soluble lubricant to lubricate the
posterior surface of LMA
▶Avoid excessive of lubricant & lignocaine jelly for
lubrication .

17. INSERTION TECHNIQUE
Position: Neck flexed and head
extended.
Use non-inserting hand to stabilize
occiput.
Grasp like a pen with index finger
pressing the point where tube joins
mask.
Place tip of LMA against inner surface
of patient’s upper teeth.
Aperture facing forward, the tip
pressed upwards against hard palate.

Mask is advanced into pharynx to
ensure that tip remains flattened and
avoids tongue.

18. Neck is kept flexed and head
extended.
Continue pushing with index
finger and guide it downward.
Grasp tube firmly with other
hand & then withdraw index
finger.
Press gently downward with
other hand to ensure mask is
fully inserted.

19. Inflate the mask with the
recommended volume of air.
Normally it should be
allowed to rise up slightly
out of hypo pharynx as it is
inflated to find its correct
position.
Insert a bite-block or roll of
gauze to prevent occlusion
of the tube.
Now the LMA can be
secured.

21. OTHER METHODS OF
INSERTION
 Thumb index method.
Partial inflation method.
180 degree rotation method.
Laryngoscopy aided method.
Stylet or a bougie aided method.
Insertion from side of mouth opening.
In a patient with restricted mouth opening LMA can
be placed retromolar and subsequently LMA tube is
brought forward to lie centrally.

22. SIGNS OF CORRECT
PLACEMENT
slight outward movement of tube upon LMA inflation.
presence of smooth oval swelling in the neck around
thyroid and cricoid area, or no cuff visible in oral cavity.
Ventilate the patient while confirming equal breath
sounds over both lungs in all fields and the absence of
ventilatory sounds over epigastrium
Distal tip of silicone cuff- Upper esophageal sphincter
Sides of cuff- Pyriform fossa
Upper part of cuff -Tongue base

23. PROBLEMS
Failure to press the
deflated mask up against
hard palate or inadequate
lubrication or deflation
can cause the mask tip to
fold back on itself.
Folding mask tip may
progress, pushing the
epiglottis causing
mechanical obstruction .
inadequately deflated
mask may either –
1. Push down the epiglottis
2.Enter the glottis.

24. PROSEAL LMA
Reusable , silicon made , most
specialized modification of c-LMA.
Modifications:-
(i)oesophageal drain tube
(ii)posterior inflatable cuff
(iii)reinforced airway tube
(iv)integral bite block
(v)introducer
Higher leak pressure(35cm of H2O) than c-
LMA(25cm of H2O).
Size- in 7 sizes (1-5) like C-LMA with
drainage tube of 8, 10, 10, 14, 16, 16 &18
Fr respectively.

25. ADVANTAGES
Increased airway seal improves the PPV.
Decreased chance of aspiration-
1.Oesophageal opening is isolated from the airway. 2.Drain tube vents
gas leaked into the oesophagus.
3.On regurgitation drain tube vents the fluid & small solid particles
beyond the pharynx.
4.The large bulk of the PLMA reduces the space available for
regurgitated fluid to ‘pool’.
5.Increased oesophageal and pharyngeal seal decreases the risk
of any pooled fluid entering the laryngeal inlet.
Simple tests enable correct positioning of the PLMA to be confirmed.
The stomach may be accessed with an orogastric tube.

26. LMA - UNIQUE
Single use
PVC made
Cheaper.
Tube – stiffer
Cuff- less compliant
Less rise of intracuff
pressure with N2O.
Size same as cLMA.

27. LMA - SUPREME
Single use, PVC made 2
nd generation LMA.
Has features of P-LMA, I-LMA & LMA
unique.
(i)Large inflatable plastic cuff, but no
posterior cuff
(ii)Oesophageal drain tube
(iii)Preformed semi-rigid tube
(iv) Fins in the mask bowl to prevent
epiglottic obstruction
Pharyngeal seal is intermediate
between cLMA and PLMA( 26–30 cm
H2O)

28. ADVANTAGES
The reinforced tip reduces the risk of fold-over,
compared with the PLMA.
Anatomic curve that facilitates easy insertion.
A drain tube to allow gastric aspiration:
I.A high value / low pressure cuff which generates
higher seal pressure
II.A built-in bite block and fixation tab to help secure
the airway.
III.An oval airway cross section for improved stability
of the airway.

29. DISADVANTAGES
Drain tube runs through the middle of the
airway tube (rather than next to it in the
PLMA) dividing it into two narrow lumens.
This limits its use for airway inspection. and
for use as a conduit for intubation.
Being made of PVC, the SLMA may cause
more trauma than silicone devices.

30. GUARDIAN SUPREME AIRWAY
It is new silicone based single use extraglottic
airway device.
It forms a seal with the glottis for ventilation and
with hypopharynx for airway protection.
Provides a gastric drainage port.
In addition it has a port with suctioning material
from the hypopharynx and pilot balloon valve
with pressure logo ( Yellow< 40 cm H2O, Green
40-60 cm H2O and Red > 60 cm H2O), that
indicate visual intra-cuff pressure.

31. In addition it has a port with suctioning material
from the hypopharynx and pilot balloon valve
with pressure logo ( Yellow< 40 cm H2O, Green
40-60 cm H2O and Red > 60 cm H2O), that
indicate visual intra-cuff pressure.

32. FLEXIBLE LMA
Flexometallic tube- narrower & longer.
▶Has a rigid preformed angle at cuff.
▶Seal pressure = 20cmH2O
▶Introducer helps to stabilize airway tube
during insertion
▶ less incidence of dislodgement once placed.
▶More useful in head & neck surgeries, ENT
and upper torso procedures where need to
reposition the airway
▶Problems- Disruption of spiral reinforce
wire, Increased airway resistance , limits
endoscope & tracheal tube passage , unsuitable
for MRI.

33. AMBU AURA LMA
single-use LM with a preformed curve.
▶The Ambu Aura40 is the reusable,
silicone version.
▶The Ambu Aura-i designed to
facilitate intubation like ILMA.
▶3 parts- an airway tube, a mount area,
and a bowl including the inflatable cuff..
▶A reinforced tip reduces the risk of
folding back during insertion.
▶integrated inflation line and no
epiglottic bars at the airway orifice.

34. COBRA PERILARYNGEAL AIRWAY
(PLA)
single use, PVC made, latex free .
has a breathing tube with large inner
diameter to increase air flow.
Novel head design- Grill of soft bar with
Cobra head shape.
Bars allow ventilation & instrumentation.
Internal ramp to guide ETT
Proximal high volume low pressure cuff- seals
hypopharynx.
offers a more effective seal, and a better
fiberoptic score as the c-LMA.

35. LARYNGEAL TUBE
Cough pressure 60cmH2O
4 types - LT, LT-D, LTS-II, LTs-D

36. I-GEL
Novel SAD designed by UK
anaesthetist, Muhammed Nasir.
(i) Single use.
(ii) Cuffless: made of a soft
polymer and is shaped similarly to
an inflated LMA posteriorly with
its anterior shape designed to ‘fit
the perilaryngeal structures’.
(iii) Narrow-bore oesophageal
drain tube.
(iv) Short, wide-bore airway tube.
(v) Integral bite block
(vi) an epiglottic rest - reduces
possibility of epiglottis ‘down
folding’ and airway obstruction.

37. SIZE SELECTION

38. ADVANTAGES
1. Easy to insert: due to a combination of a
very low coefficient of friction when
lubricated & absence of cuff.
2. Wide lumen make it well worth for both
airway rescue and as a conduit for assisted
intubation.
3. A gastric channel allows for suctioning
and placement of a nasogastric tube.
4.Though oesophageal seal is low but
enough (according to the manufacturer).

39. STREAMLINED LINER OF THE
PHARYNGEAL AIRWAY ( SLIPA)
Plastic made, uncuffed, disposable ,2
nd
generation SAD.
▶Anatomically pre-shaped to line the
pharynx.
▶Hollow & boot shaped distal part-
1.Toe- rest in oesophageal entrance
2.Bridge- fits to pyriform fossa.
3.Heel- anchor in position & connect the
airway tube.
4.Two lateral bulges- relieve pressure on
hypoglossal& recurrent laryngeal n.
5.Large capacity chamber-stores regurgited
fluid.
Available in 6 sizes- : 47, 49, 51, 53, 55& 57
mm.

40. BASKA MASK

42. INTUBATING LMA
 modification of c-LMA.
A rigid (stainless steel) anatomically
curved, short & wide bored shaft that
follows anatomical curve of palate &
post pharyngeal wall.
An epiglottic elevator bar at mask
aperture
Armoured flexible ET tube with a
longitudinal and a horizontal black
line- coincides with epiglottic
elevating bar.
 Stabilizer Rod of 25cm.
Seal pressure=60cmof H2O max.
Body
weight
ILMA sizeAir
volume
Tracheal
Tube
30-50kg 3 20ml 7mm
50-70kg 4 30ml 7.5mm
70-100kg 5 40ml 8mm

43. LMA C-Trach
Enables combined ventilation,
visualization& intubation.
⚫High first attempt intubation success
rate of 91%.
⚫Fiberoptic technology allows real time
visualization of glottic opening & of ET
tube passing through vocal cords.
⚫Ideal in rescue/difficult airway situations
⚫Completely portable and wireless
system - weighs less than 8 ounces.
⚫Easy to learn and very effective

44. AIR-Q
(INTUBATING LARYNGEAL AIRWAY AND COOK GAS )
Designed as intubating conduit
No aperture bars
Shorter, allows ETT to reach
vocal cords
Accommodates conventional
ETT
Can be left in situ during case
which may be utilized during
emergence

45. ESOPHAGEAL- TRACHEAL
COMBITUBE
PVC double lumen SAD with 2 inflatable
balloons
2 Lumens : tracheal and pharyngeal
Proximal balloon- seals oral &
nasal cavity
Distal balloon - seals either
esophagus or trachea, depending on
which of these ETC has been sited.
Size- 37 Fr for height up to 5 ft.
41 Fr for height above 5.5 ft.
Between 5-5.5ft – either of these.

48. Classification based on evolution
1
st
generation devices 2
nd
generation devices
Classic LMA
Flexible LMA
Laryngeal tube
 Cobra PLA
Proseal LMA
 I-Gel
 LMA supreme
 SLIPA
3
rd
generation devices- Baska mask

49. Based on sealing mechanism (MILLER’S CLASSIFICATION)–
1.Cuffed perilaryngeal sealer:-
Non-directional non esophageal Sealers- cLMA, Flexible LMA, LMA unique.
Directional Non-esophageal sealing- Fastrach LMA, ALMA.
Directional esophageal sealing- Proseal LMA, Supreme LMA.
2.Cuffed pharyngeal sealer:-
Without esophageal sealing: COPA, PAX.
With esophageal sealing: Combitube, LT, LTS.
3.Cuff less preshaped sealer: -
With esophageal sealing- Baska mask, i-gel.
 Without esophageal sealing- SLIPA , AirQ-SP.

50. BASED ON THE NUMBER OF LUMEN-
1. Single Lumen Devices:-
LMA-classic, LMA-unique, LMA-flexible, I LMA, C-trach,
Laryngeal Tube, SLIPA
2. Double Lumen Devices:-
Proseal LMA, Combitube, I gel , Laryngeal Tube
Suction, Airway Management Device(AMD)
3 . Triple Lumen Devices:-
Elisha Airway Device(EAD)

51. SEALING PRESSURES OF DIFFERENT SADs

52. SOME IMPORTANT FEATURES OF THE
PRESENT DAY SUPRAGLOTTIC
AIRWAY DEVICES

53. CONTINUE….

54. SUMMARY
Recent advances in SAD design have significantly enhanced the
clinical utility.
SADs play an important role in rescue ventilation in
DA(DMV,DL,TI).
Can be used as conduit for intubation and bronchoscopy.
Can be used by paramedics with adequate training to secure
airway.
Knowledge about indications and contraindications and features
of device essential for their appropriate use.
Correct insertion technique must be carefully followed to ensure
optimal positioning.
Concerns such as pulmonary aspiration of gastric contents
remain, necessitating careful patient selection, device selection.
Checks for function and position should be done everytime the
device is placed.

55. If you are not willing to learn, No one
can help you!
If you are determined to learn, No one
can stop you!
THANK
YOU!

56. Questions