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EDITORIAL
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 1-2

Ideal supralaryngeal device in obstetrics: Still a long way to go!


Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Web Publication4-Aug-2012

Correspondence Address:
Anjan Trikha
Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.99307

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How to cite this article:
Trikha A, Singh P M. Ideal supralaryngeal device in obstetrics: Still a long way to go!. J Obstet Anaesth Crit Care 2012;2:1-2

How to cite this URL:
Trikha A, Singh P M. Ideal supralaryngeal device in obstetrics: Still a long way to go!. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2018 Apr 25];2:1-2. Available from: http://www.joacc.com/text.asp?2012/2/1/1/99307

Approximately 1 in 250-300 parturients would have a difficult airway and these numbers are about eight times higher than the numbers seen in nonpregnant women. [1],[2] The complications associated with management of difficult airway among parturients are about 13 times higher than among the general population. [3] These numbers are from studies from the developed countries, but in our practice the incidence of difficult airway and "cannot ventilate cannot intubate" scenario in the developing countries is much lower; the probable reason being the lower body mass index and less weight gain during pregnancy in the developing and underdeveloped world. However, due to lack of published data from these countries it is natural for all to quote the incidence rates from the developed world. Nevertheless, managing difficult airway (unanticipated or anticipated) in parturients is a challenge and the availability of supralaryngeal or extralaryngeal devices has made the life of all anesthesiologists comfortable. This has led to a decrease in airway-related deaths due to general anesthesia in both parturients and general population.

There are many emergency airway devices available, which can be used to ensure adequate oxygenation and ventilation in a scenario of unrecognized difficult airway. The American Society of Anesthesiologists' Task Force on Management of the Difficult Airway suggests the use of two such devices (laryngeal mask airway and the combitube) in a situation of "cannot ventilate, cannot intubate". [4] It also recommends that the usage of airway rescue device should not be limited to only these two, implying that any such devices could be used for 'rescue airway management'.

The supraglottic laryngeal devices available can be grouped into four, depending on their basic structure and function: (i) devices without a conduit for esophageal drainage (Classic LMA TM , LMA Unique TM : LMA North America, San Diego, CA, USA and SLIPA TM : SLIPA Medical Ltd., Douglas, Isle of Man, UK), (ii) devices with a conduit for esophageal drainage (LMA ProSeal TM , LMA Supreme TM : LMA North America, San Diego, CA, USA and I-gel Intersurgical Ltd., Wokingham, UK), (iii) devices that facilitate intubation (LMA FasTrach TM : LMA North America, San Diego, CA, USA and Air-Q TM Cookgas, St. Louis, MO, USA), and (iv) devices with a conduit for esophageal drainage along with a balloon (Combitube: Covidien-Nellcor, Boulder, CO, USA, Laryngeal Tube [LTS, LTS-D TM ]: VBM Medizintechnik, Sulz, Germany, and EasyTube: Rüsch Teleflex Medical Company, Durham, NC, USA).

Logically, a device with an esophageal conduit would be better than one without. In the literature, only classical LMA, proseal LMA, LMA FasTrach, Combitube, and Laryngeal tube have been described to be useful as obstetric airway rescue devices in case reports and case series. [5],[6],[7],[8],[9],[10],[11],[12]

The present issue of the journal has a study regarding a similar device known as Baska Mask. [13] An earlier observational study with the same device was published a couple of months ago. [14] This device has many unique features; out of which, two are likely to be very useful in decreasing the possibility of aspiration - the cuff of this device is not a usual inflatable balloon but a membrane that inflates with every breath and this inflation pressure increases with increased inspiratory pressure (unlike all other extraglottis devices) and two gastric drain tubes. Eventually, Baska mask should also see widespread usage and finally be added to the long list of similar laryngeal devices available to an anesthesiologist for managing difficult airway both in parturients and in normal population.

Such devices are important not only for cesarean sections but also for pregnant women presenting for obstetric-related interventions or nonobstetric surgery. Once the uterus becomes an intra-abdominal organ after 12 weeks of pregnancy, even a nonobstetric elective surgery in this population warrants special attention for aspiration and encountering a difficult airway. Many anesthesiologists prefer supralaryngeal devices in such short surgical cases though there are no standard guidelines available for their usage in such cases. Most of the studies in the literature have limitations regarding their actual use in obstetric population. Usually the results are extrapolated into this population from trials carried out on nonparturients. It is interesting to note that a choice of one device over the other is even lacking in nonobstetric population. However, there is a greater likelihood of finding a differential result in the obstetric population. These devices are intended to successfully tide over a difficult airway situation with an ability to give higher ventilation pressures. Both these situations are more frequent in obstetric population than in general population and thus studies conducted in obstetric subgroup may give more conclusive and informative results.

Most of the supralaryngeal devices have some unique features, which are deemed to be superior to the other devices available. The use of these supralaryngeal devices in obstetrics needs to be investigated on the following accounts-ease of insertion, first-time success rates of insertion, incidence of placement-related side effects like mucosal injury and sore throat, and finally incidence of aspiration. There is a need of some standard trials comparing these devices in the real time on parturients for airway rescue, but this is not likely to happen due to ethical concerns. Alternatively, a combination of data from parturients regarding ease of insertion and placement-related side effects and aspiration rates from comparable animal models could be utilized to reach a logical conclusion regarding the ideal supraglottis device for obstetric usage. It is unlikely that such information would be available to an anesthesiologist in the near future and till that time each anesthesiologist should individually decide the supralaryngeal 'Device' that is needed to be carried in pocket while practicing obstetric anesthesia.

 
  References Top

1.Boutonnet M, Faitot V, Keïta H. Airway management in obstetrics. Ann?Fr Anesth Reanim 2011;30:651-64.  Back to cited text no. 1
    
2.Heidegger T. Extubation of the difficult airway - An important but neglected topic. Anaesthesia 2012;67:213-5.  Back to cited text no. 2
[PUBMED]    
3.Barnardo PD, Jenkins JG. Failed tracheal intubation in obstetrics: A 6-year review in a UK region. Anaesthesia 2000;55:690-4.  Back to cited text no. 3
[PUBMED]    
4.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 2003;98: 1269-77.  Back to cited text no. 4
    
5.McDonnell NJ, Paech MJ, Clavisi OM, Scott KL. Difficult and failed intubation in obstetric anaesthesia: An observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth 2008;17:292-7.  Back to cited text no. 5
    
6.Anderson KJ, Quinlan MJ, Popat M, Russell R. Failed intubation in a parturient with spina bifida. Int J Obstet Anesth 2000;9:64-8.  Back to cited text no. 6
[PUBMED]    
7.Keller C, Brimacombe J, Lirk P, Pühringer F. Failed obstetric tracheal intubation and postoperative respiratory support with the ProSeal laryngeal mask airway. Anesth Analg 2004;98:1467-70.  Back to cited text no. 7
    
8.Bailey SG, Kitching AJ. The Laryngeal mask airway in failed obstetric tracheal intubation. Int J Obstet Anesth 2005;14:270-1.  Back to cited text no. 8
[PUBMED]    
9.Bullingham A. Use of the ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed intubation. Br J Anaesth 2004;92:903; author reply 904.  Back to cited text no. 9
[PUBMED]    
10.Sharma B, Sahai C, Sood J, Kumra VP. The ProSeal laryngeal mask airway in two failed obstetric tracheal intubation scenarios. Int J Obstet Anesth 2006;15:338-9.  Back to cited text no. 10
[PUBMED]    
11.Vaida SJ, Gaitini LA. Another case of use of the ProSeal laryngeal mask airway in a difficult obstetric airway. Br J Anaesth 2004;92:905; author?reply 905.  Back to cited text no. 11
    
12.Cook TM, Brooks TS, Van der Westhuizen J, Clarke M. The Proseal LMA is a useful rescue device during failed rapid sequence intubation: two additional cases. Can J Anaesth 2005;52:630-3.  Back to cited text no. 12
[PUBMED]    
13.Zundert TV, Gatt S. The Baska Mask®-A new concept in Self- sealing membrane cuff extraglottic airway devices, using a sump and two gastric drains: A critical evaluation. J Obstet Anaesth Crit Care 2012;2:23-30.  Back to cited text no. 13
  Medknow Journal  
14.Alexiev V, Salim A, Kevin LG, Laffey JG. An observational study of the Baska® mask: a novel supraglottic airway. Anaesthesia 2012;67:640-5.  Back to cited text no. 14
    




 

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