Advertisement

The effect of neck extension on success rate of blind intubation through Ambu® AuraGain™ laryngeal mask: a randomized clinical trial

  • Seokha Yoo
  • Sun-Kyung Park
  • Won Ho Kim
  • Min Hur
  • Jae-Hyon Bahk
  • Young-Jin Lim
  • Jin-Tae KimEmail author
Reports of Original Investigations

Abstract

Purpose

Although the use of fibreoptic guidance is recommended for tracheal intubation through supraglottic airway devices, it can also be performed in a blind manner. Based on the previous finding that a fibreoptic view of the vocal cords was better in the extended neck position than in the neutral position, we hypothesized that neck extension can better facilitate blind intubation through the Ambu® AuraGain™ laryngeal mask than the neutral position.

Methods

Patients undergoing general anesthesia were randomly assigned to the extension group or the neutral group. After induction of anesthesia, the AuraGain™ was placed in the oropharynx, followed by blind intubation through the AuraGain™ in the assigned neck position within a maximum of two attempts. The primary outcome was successful blind intubation through the AuraGain™ in the first attempt.

Results

Of 168 adult patients screened, 124 patients were enrolled and 121 patients were included in the final analysis (extension group, n = 59; neutral group, n = 62). The incidence of successful blind intubation on the first attempt was significantly higher in the extension group than in the neutral group (68% vs. 47%, respectively; relative risk [RR], 1.45; 95% confidence interval [CI], 1.05 to 1.99; P = 0.02). The overall incidence of successful blind intubation was also significantly higher in the extension group than in the neutral group (71% vs 50%, respectively; RR, 1.42; 95% CI, 1.06 to 1.92; P = 0.02). The time required for successful blind intubation and the incidence of hoarseness, cough, or sore throat at 24 hr after extubation did not differ between groups.

Conclusion

Neck extension can be used to facilitate blind intubation through the Ambu® AuraGain™ laryngeal mask. Considering the relatively high failure rate, blind intubation via the AuraGain™ should be used as an alternative, not as a first-line choice.

Trial registration

www.ClinicalTrials.gov (NCT03408431); registered 24 January 2018.

Effet de l’extension du cou sur le taux de succès d’intubation à l’aveugle à travers le masque laryngé Auragain™ d’Ambu®: étude clinique randomisée

Résumé

Objectif

Même si l’utilisation de l’endoscopie est recommandée pour l’intubation trachéale à travers des dispositifs pour voies respiratoires supraglottiques, elle peut être réalisée à l’aveugle. Considérant qu’il a été démontré que la vue endoscopique des cordes vocales était meilleure lorsque le cou est en extension que lorsqu’il est en position neutre, nous avons émis l’hypothèse que l’intubation en aveugle à travers le masque laryngé Auragain™ d’Ambu® pouvait être plus facile avec le cou en extension qu’avec le cou en position neutre.

Méthodes

Des patients subissant une anesthésie générale ont été randomisés dans un groupe « en extension » ou dans un groupe « position neutre ». Après induction de l’anesthésie, l’Auragain™ a été positionné dans l’oropharynx, avant une intubation à l’aveugle à travers l’Auragain™ dans la position assignée avec un maximum de deux tentatives. Le critère d’évaluation principal était la réussite de l’intubation à l’aveugle à travers l’Auragain™ à la première tentative.

Résultats

Sur les 168 patients adultes sélectionnés, 124 ont été recrutés et 121 patients ont été inclus dans l’analyse finale (groupe en extension, n = 59; groupe en position neutre, n = 62). L’incidence des intubations à l’aveugle réussies à la première tentative a été significativement plus élevée dans le groupe en extension que dans le groupe en position neutre (respectivement, 68 % contre 47 %; risque relatif [RR], 1,45; intervalle de confiance [IC] à 95 % : 1,05 à 1,99; P = 0,02). L’incidence globale des intubations à l’aveugle réussies a aussi été significativement plus élevée dans le groupe en extension que dans le groupe en position neutre (respectivement, 71 % contre 50 %; RR, 1,42; IC à 95 %, 1,06 à 1,92; P = 0,02). Le temps nécessaire à la réussite de l’intubation à l’aveugle et les incidences de voix rauque, de toux et de mal de gorge 24 heures après l’extubation étaient comparables entre les deux groupes.

Conclusion

Le positionnement du cou en extension peut faciliter une intubation à l’aveugle à travers le masque laryngé Auragain™ d’Ambu®. Considérant le taux d’échec relativement élevé, la technique d’intubation à l’aveugle au moyen de l’Auragain™ doit être utilisée comme une alternative et non en première intention.

Enregistrement de l’essai clinique

www.ClinicalTrials.gov (NCT03408431); enregistré le 24 janvier 2018.

Notes

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Associate Editor, Canadian Journal of Anesthesia.

Author contributions

Seokha Yoo contributed to the study design, data acquisition, data analysis, and writing the manuscript. Sun-Kyung Park and Min Hur contributed to this study by recruiting patients and acquiring data. Won Ho Kim contributed to this study by analyzing data and revising the manuscript. Jae-Hyon Bahk contributed to study conception and revised the manuscript. Young-Jin Lim contributed to study design and revised the manuscript. Jin-Tae Kim contributed to study conception and design, and revised the manuscript.

Funding

None declared.

References

  1. 1.
    Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115: 827-48.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118: 251-70.CrossRefPubMedGoogle Scholar
  3. 3.
    Brain AI, Verghese C, Addy EV, Kapila A. The intubating laryngeal mask. I: development of a new device for intubation of the trachea. Br J Anaesth 1997; 79: 699-703.Google Scholar
  4. 4.
    Artime CA, Altamirano A, Normand KC, et al. Flexible optical intubation via the Ambu Aura-i vs blind intubation via the single-use LMA Fastrach: a prospective randomized clinical trial. J Clin Anesth 2016; 33: 41-6.CrossRefPubMedGoogle Scholar
  5. 5.
    Kleine-Brueggeney M, Theiler L, Urwyler N, Vogt A, Greif R. Randomized trial comparing the i-gel™ and Magill tracheal tube with the single-use ILMA™ and ILMA™ tracheal tube for fibreoptic-guided intubation in anaesthetized patients with a predicted difficult airway. Br J Anaesth 2011; 107: 251-7.CrossRefPubMedGoogle Scholar
  6. 6.
    Halwagi AE, Massicotte N, Lallo A, et al. Tracheal intubation through the I-gel™ supraglottic airway versus the LMA Fastrach™: a randomized controlled trial. Anesth Analg 2012; 114: 152-6.CrossRefPubMedGoogle Scholar
  7. 7.
    Theiler L, Kleine-Brueggeney M, Urwyler N, Graf T, Luyet C, Greif R. Randomized clinical trial of the i-gel™ and Magill tracheal tube or single-use ILMA™ and ILMA™ tracheal tube for blind intubation in anaesthetized patients with a predicted difficult airway. Br J Anaesth 2011; 107: 243-50.CrossRefPubMedGoogle Scholar
  8. 8.
    Karim YM, Swanson DE. Comparison of blind tracheal intubation through the intubating laryngeal mask airway (LMA Fastrach™) and the Air-Q™. Anaesthesia 2011; 66: 185-90.CrossRefPubMedGoogle Scholar
  9. 9.
    Erlacher W, Tiefenbrunner H, Kastenbauer T, Schwarz S, Fitzgerald RD. CobraPLUS and Cookgas air-Q versus Fastrach for blind endotracheal intubation: a randomised controlled trial. Eur J Anaesthesiol 2011; 28: 181-6.CrossRefPubMedGoogle Scholar
  10. 10.
    Ruetzler K, Guzzella SE, Tscholl DW, et al. Blind intubation through self-pressurized, disposable supraglottic airway laryngeal intubation masks: an international, multicenter, prospective cohort study. Anesthesiology 2017; 127: 307-16.CrossRefPubMedGoogle Scholar
  11. 11.
    Yoo S, Park SK, Kim WH, et al. Influence of head and neck position on performance of the Ambu® AuraGain™ laryngeal mask: a randomized crossover study. Minerva Anestesiol 2019; 85: 133-8.CrossRefPubMedGoogle Scholar
  12. 12.
    Tang MY, Tang IP, Wang CY. Optimal Size AMBU® laryngeal mask airway among Asian adult population. Med J Malaysia 2014; 69: 151-5.PubMedGoogle Scholar
  13. 13.
    Tan SM, Sim YY, Koay CK. The ProSeal laryngeal mask airway size selection in male and female patients in an Asian population. Anaesth Intensive Care 2005; 33: 239-42.CrossRefPubMedGoogle Scholar
  14. 14.
    Kim JT, Jeon SY, Kim CS, Kim SD, Kim HS. Alternative method for predicting optimal insertion depth of the laryngeal tube in children. Br J Anaesth 2007; 99: 704-7.CrossRefPubMedGoogle Scholar
  15. 15.
    Tazeh-Kand NF, Eslami B, Mohammadian K. Inhaled fluticasone propionate reduces postoperative sore throat, cough, and hoarseness. Anesth Analg 2010; 111: 895-8.PubMedGoogle Scholar
  16. 16.
    Gaszynski T. Blind intubation through Air-Q SP laryngeal mask in morbidly obese patients. Eur J Anaesthesiol 2016; 33: 301-2.CrossRefPubMedGoogle Scholar
  17. 17.
    Kleine-Brueggeney M, Nicolet A, Nabecker S, et al. Blind intubation of anaesthetised children with supraglottic airway devices AmbuAura-i and Air-Q cannot be recommended: a randomised controlled trial. Eur J Anaesthesiol 2015; 32: 631-9.CrossRefPubMedGoogle Scholar
  18. 18.
    Liu EH, Goy RW, Lim Y, Chen FG. Success of tracheal intubation with intubating laryngeal mask airways: a randomized trial of the LMA Fastrach and LMA CTrach. Anesthesiology 2008; 108: 621-6.CrossRefPubMedGoogle Scholar
  19. 19.
    Ye L, Liu J, Wong DT, Zhu T. Effects of tracheal tube orientation on the success of intubation through an intubating laryngeal mask airway: study in Mallampati class 3 or 4 patients. Br J Anaesth 2009; 102: 269-72.CrossRefPubMedGoogle Scholar
  20. 20.
    Lu PP, Yang CH, Ho AC, Shyr MH. The intubating LMA: a comparison of insertion techniques with conventional tracheal tubes. Can J Anesth 2000; 47: 849-53.CrossRefPubMedGoogle Scholar
  21. 21.
    Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology 2001; 95: 1175-81.CrossRefPubMedGoogle Scholar
  22. 22.
    Brain AI, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II: a preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997; 79: 704-9.Google Scholar

Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  1. 1.Department of Anesthesiology and Pain Medicine, Seoul National University HospitalSeoul National University College of MedicineSeoulKorea

Personalised recommendations