Supraglotticairwaydeviceanaesthsia-1 3.pptx

Sad

1. 1 SUPRAGLOTTIC AIRWAY DEVICES PRESENTER : Dr. Trilok Mahawar ​ (PG Resident) MODERATOR : Dr. Atul K r. Singh ( Associate Professor)

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 - I nvention & development of LMA He first used a Goldmans mask and attached it a obliquely cut endotracheal tube. It was introduced in 1982.

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

5. Based on sealing mechanism (MILLER’S CLASSIFICATION)– 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. Cuffed pharyngeal sealer:- Without esophageal sealing: COPA, PAX. With esophageal sealing: Combitube, LT, LTS. Cuff less preshaped sealer: - With esophageal sealing- Baska mask, i-gel. Without esophageal sealing- SLIPA , AirQ-SP.

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

7. 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 .

8. 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

9. 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.

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

11. 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

12. 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. If aspiration does occurs Dr. Brain AIJ recommends leaving the LMA in place, tilting the patient’s head down and suctioning through the LMA

13. 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

14. First Generation

15. 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

16. SIZE SELECTION

17. 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 .

18. 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.

19. 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.

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

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

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

31. 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.

32. THANK YOU