airway-.pdf

INDEPENDENTLY DEVELOPED BY MCMAHON PUBL ISH ING ANESTHES IOLOGY NEWS • MAY 2007 1

he practice of airway management

has become more advanced in recent

years. This advancement is demonstrat-

ed by the introduction of many new airway

devices, several of which have been included

in the American Society of Anesthesiologists

(ASA) Difficult Airway Algorithm (Figure).1

Management of the difficult airway remainsone of the most relevant and challenging tasksfor anesthesia care providers. Claims involvingairway management continue to comprise animportant aspect of the ASA Closed ClaimsProject database, which tracks all anesthesia-related insurance claims.2

This review focuses on several of the alterna-tive airway management devices/techniquesand their clinical applications, with particularemphasis on the difficult or failed airway.

Alternative Airway DevicesA common factor preventing successful tra-

cheal intubation is the inability to visualize thevocal cords during the performance of directlaryngoscopy. Many devices and techniques arenow available to circumvent the problems typi-cally encountered with a difficult airway usingconventional direct laryngoscopy.

ENDOTRACHEAL TUBE GUIDES

A number of endotracheal tube (ET) guides(Table 1) have been used to aid in intubation,including the Portex Venn Tracheal TubeIntroducer (Smiths Medical ASD, Keene,NH/Smiths Medical, Hythe, Kent, England) and,more recently, the Single-Use Bougie (SmithsMedical ASD), Frova Intubating Introducer(Cook Critical Care, Bloomington, Ind), theAintree Intubation Catheter (Cook Critical Care),the Arndt Airway Exchange Catheter Set (Cook

CARIN A. HAGBERG, MDProfessor, Department of Anesthesiology

The University of Texas MedicalSchool at Houston

Director of Neuroanesthesia and Advanced Airway ManagementMemorial Hermann Hospital

Houston, TexasPresident, Society for Airway Management

T

PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.COM•

Dr. Hagberg has disclosed that she has received education grantsfrom Ambu A/S, Karl Storz Endoscopy, Smiths Medical; is a memberof the speakers’ bureau for Ambu A/S, Cook Critical Care, Hospira,King Systems Corp, and LMA North America; and has received equipment support from Ambu A/S, Clarus Medical, Cook CriticalCare, Hospira, Karl Storz Endoscopy, King Systems Corp, LMA NorthAmerica, Mercury Medical, Olympus America, Smiths Medical, TycoHealthcare, Verathon Medical, and Vital Signs.

Current Concepts in the Management of The Difficult Airway

Copyright © 2006 McM

ahon Publishing Group unless otherwise noted.

All rights reserved. Reproduction in whole or in part w

ithout permission is prohibited.

INDEPENDENTLY DEVELOPED BY MCMAHON PUBL ISH ING2

A. AWAKE INTUBATION B. INTUBATION ATTEMPTS AFTER INDUCTION OF GENERAL ANESTHESIA

Succeed*

Initial intubationattempts successful*

Successfulintubation*

Cancelcase

Invasiveairway access*‡

Consider feasibilityof other options†

Fail

Airway approached bynoninvasive intubation

Airway secured by surgical access*‡

Initial intubationattempts unsuccessful

From this point onward, repeatedly consider:1. Calling for help2. Returning to spontaneous ventilation3. Awakening the patient

Face mask ventilation adequate

Invasive airway access*‡

Consider feasibilityof other options†

Awaken patient

Nonemergency pathwayVentilation adequate, intubation unsuccessful

Alternative approaches to intubation§

Fail after multipleattempts

Figure. Difficult airway algorithm.* Confirm ventilation, tracheal intubation, or LMA placement with

exhaled CO2.

† Other options include (but are not limited to): surgery utilizingface mask or LMA anesthesia, local anesthesia infiltration, orregional nerve blockade. Pursuit of these options usually impliesthat mask ventilation will not be problematic. Therefore, theseoptions may be of limited value if this step in the algorithm hasbeen reached via the emergency pathway.

‡ Invasive airway access includes surgical or percutaneoustracheostomy or cricothyrotomy.

§ Alternative noninvasive approaches to difficult intubation include(but are not limited to): use of different laryngoscope blades, LMAas an intubation conduit (with or without fiber-optic guidance),fiber-optic intubation, intubating stylet or tube changer, lightwand, retrograde intubation, and blind oral or nasal intubation.

II Consider repreparation of the patient for awake intubation orcancellation of surgery.

¶ Options for emergency noninvasive airway ventilation include(but are not limited to): rigid bronchoscope, esophageal-tracheal Combitube ventilation, or transtracheal jet ventilation.

Adapted and reprinted with permission from the American Societyof Anesthesiologists and Anesthesiology 2003;98:1269-1277.





Critical Care), the Cook Airway Exchange Catheter EF(Cook Critical Care), and the Cook Airway ExchangeCatheter EF Soft Tip (Cook Critical Care).

LIGHTED STYLETS

In the past several years, a number of lighted styletshave been developed, including light wands such asthe Trachlight (Laerdal Medical Corp, Stavanger,Norway), and visual scopes, such as the Shikani OpticalStylet (SOS; Clarus Medical, Minneapolis), FlexibleAirway Scope Tool (FAST; Clarus Medical), Levitan GLS(Clarus Medical), Bonfils Retromolar IntubationFiberscope (Karl Storz Endoscopy, Tuttlingen,Germany/Culver City, Calif), and the BrambrinkIntubation Endoscope (Karl Storz Endoscopy). Lightwands rely on transillumination of the tissues of theanterior neck to demonstrate the location of the tip ofthe ET—a blind technique, unless combined with directlaryngoscopy (Table 2).3,4 The visual scopes, on theother hand, utilize fiber-optic imagery and allow indi-rect visualization of the airway. They also can be usedalone or in conjunction with direct laryngoscopy.

RIGID LARYNGOSCOPES

It is beyond the scope of this review to discuss all ofthe laryngoscopes that have been manufactured; thus,only some of the most recently developed blades willbe described. Modifications of traditional laryngoscopeblades are primarily designed to overcome certainproblems associated with difficult airway management,such as limited mouth opening, anterior larynx, sternalspace restriction, small intraoral cavity, and immobileor unstable cervical spines (Table 3).5-8

INDIRECT RIGID FIBER-OPTIC LARYNGOSCOPES

These laryngoscopes were designed to facilitate tra-cheal intubation in the same population that would beconsidered for flexible fiber-optic bronchoscopy, suchas patients with limited mouth opening or neck move-ment. Relative to the flexible fiber-optic broncho-scopes (FOBs), they are more rugged in design, controlsoft tissue better, allow for better management ofsecretions, are more portable (with the exception ofthe new portable FOBs), and are not as costly.Intubation can be performed via the nasal or oral routeand can be accomplished in awake or anesthetizedpatients (Table 4).9-11

SUPRAGLOTTIC VENTILATORY DEVICES

The Laryngeal Mask Airway (LMA; LMA NorthAmerica, Inc, San Diego) is the single most importantdevelopment in airway devices in the past 25 years.Since its introduction into clinical practice, it has beenused in more than 150 million patients worldwide withno reported deaths.12 Several new variants of the LMAClassic, or standard LMA, are available, including the

INDEPENDENTLY DEVELOPED BY MCMAHON PUBL ISH ING 3

Successful ventilation*

Face mask ventilation not adequate

Consider/Attempt LMA

Emergency noninvasiveairway ventilation

Emergency invasiveairway access*‡

LMA not adequateor not feasible

LMA adequate*

Call for help

Emergency pathwayVentilation not adequate, intubation unsuccessful

Fail

If both face mask and LMA ventilationbecome inadequate

If both face mask and LMA ventilationbecome inadequate

1. Assess the likelihood and clinical impact of basicmanagement problems:

a. Difficult ventilation

b. Difficult intubation

c. Difficulty with patient cooperation or consent

d. Difficult tracheostomy

2. Actively pursue opportunities to deliver supple-mental oxygen throughout the process of diffi-cult airway management.

3. Consider the relative merits and feasibility ofbasic management choices:a. Awake intubation vs intubation attempts after

induction of general anesthesia

b. Noninvasive technique for initial approach tointubation vs invasive technique for initialapproach to intubation

c. Preservation of spontaneous ventilation vsablation of spontaneous ventilation

4. Develop primary and alternative strategies:






Table 1. Endotracheal Tube Guides

Name/Manufacturer Description Length, cm Clinical Applications Special Features

Portex VennTracheal TubeIntroducer(Smiths MedicalASD, Keene,NH/SmithsMedicalInternational,Hythe, Kent,England)

15-Fr ET introducer madefrom a woven polyesterbase, with a coude tip(angled 35 degrees at itsdistal end). Also known asthe gum elastic bougie.Color: golden brown.

Proven useful inpatients with an anteri-or larynx (grades 2b, 3,and 4) and those withlimited mouth opening.Can be used by slightlyprotruding through theET, or placing it directlyinto the glottis andthen placing an ET over it.

60 Nondisposable and reusable.Size 5 Fr is single use. Hasexcellent memory proper-ties. Coude tip effectivelydetects “tracheal clicks” toconfirm correct placement.Part of a range of introduc-ers, stylets, and guides foradults and pediatrics. Canbe reused after cold waterdisinfection.

Single-Use Bougie(Smiths MedicalASD, Keene,NH/SmithsMedicalInternational,Hythe, Kent,England)

New 15-Fr PVC ET intro-ducer with coude tip. Hasa hollow lumen that dis-courages reuse and is pro-vided sterile. Color: ivory.

Single-use productreduces the risk ofcross contamination.Otherwise, same asPortex Venn TrachealTube Introducer.

70 Similar to Portex VennTracheal Tube Introducer,but hollow lumen allowsoxygenation/ventilation.Single use.

Frova Intubating Introducer (Cook Critical Care, Bloomington, Ind)

Polyethylene 8- and 14-FrAEC with angled distal tip and 2 side ports. Has ahollow lumen and is pack-aged with a stiffening can-nula and removable Rapi-Fit adapters. Color: blue.

Facilitates endotrachealintubation and allowssimple ET exchange.Can also be used byplacing it first in the ET,with its tip protruding,or placing it directlyinto the glottis andthen placing the ETover it.

35, 65 Can be used in pediatricpopulation for ETs as smallas 3.0 mm. Hollow lumenallows oxygenation/ventila-tion in all sizes. Single use.

Aintree IntubationCatheter(Cook CriticalCare,Bloomington, Ind)

Polyethylene 19-Fr AECallows passage of an FOBthrough its lumen. Has 2distal side holes and ispackaged with Rapi-Fitadapters. Color: light blue.

Exchange of SGAs forETs !7.0 mm using anFOB. Its hollow lumenallows insertion of anFOB directly throughthe catheter so that theairway can be indirectlyvisualized.

56 Large lumen (4.7 mm)allows passage of FOB.Rapi-Fit adapters allow bothjet ventilation and ventila-tion with 15-mm adapter(anesthesia circuit or Ambubag). Single use.

Arndt AEC Set (Cook CriticalCare,Bloomington, Ind)

Polyethylene 8- and 14-FrAEC with a tapered end,multiple side ports, pack-aged with a stiff wireguide, bronchoscope port,and Rapi-Fit adapters.Color: yellow.

Exchange of LMAs andETs using an FOB.

50, 65, 78 Tapered end and multipleside ports. Rapi-Fit adaptersallow both jet ventilationand ventilation with 15-mmadapter (anesthesia circuitor Ambu bag). Single use.

Cook AEC EF (Cook CriticalCare,Bloomington, Ind)

Polyethylene 11- and 14-FrEF AEC that facilitatesexchange of DLT of 4.0mm or larger ID. Alsocomes in a soft-tippedversion. Color: green.

Exchange of DLTs. 100 Extra firm with 2 distal sideholes. The soft-tip versionoffers a more flexible tip tohelp minimize tracheal trau-ma. Rapi-Fit adapters asabove, but should be usedprimarily for jet ventilationbecause of length. Singleuse.

Abbreviation key for all tables is on page 19.





LMA Flexible (wire-reinforced flexible), LMA Unique(disposable), LMA Fastrach (intubating, reusable, anddisposable), the LMA ProSeal (50% higher seal pres-sure, with gastric drain tube), the LMA CTrach (aFastrach with integrated fiber optics), and mostrecently, the LMA Supreme (disposable ProSeal).

Other supraglottic ventilatory devices (Table 5)13-16

include the Soft-Seal Laryngeal Mask (Smiths MedicalASD), the CobraPLA17 (Engineered Medical Systems,Indianapolis), the King Laryngeal Tube (King SystemsCorp, Noblesville, Ind/VBM Medizintechnik GmbH, Sulz,Germany), and the Esophageal Tracheal Combitube(Tyco Healthcare/Mallinckrodt Nellcor Puritan Bennett,Pleasanton, Calif).

Special Airway Techniques

FLEXIBLE FIBER-OPTIC INTUBATION

Flexible fiber-optic intubation is a very reliableapproach to difficult airway management and assess-ment. It has a more universal application than anyother technique. It can be used orally or nasally forboth upper and lower airway problems and whenaccess to the airway is limited, as well as in patients ofany age and in any position. Technological advances,including improved optics, battery-powered lightsources, better aspiration capabilities, increased angu-lation capabilities, and improved reprocessing proce-dures, have been developed. Rescue techniques, suchas direct laryngoscopy and placing a retrogradeguidewire through the suction channel, may be used ifthe glottic opening cannot be located with the scope,or if blood or secretions are present.18 Insufflation ofoxygen or jet ventilation through the suction channelmay provide oxygen throughout the procedure, andallow additional time when difficulty arises in passingthe ET into the trachea.19

RETROGRADE INTUBATION

Retrograde intubation (Table 6) is an excellent tech-nique for securing a difficult airway either alone or inconjunction with other airway techniques.20 Everyanesthesia care provider should be skilled in employingthis simple, straightforward technique. It is especiallyuseful in patients with limited neck mobility (ie, that isassociated with cervical spine pathology, or in thosewho have suffered airway trauma). Recent ad-vancements in the technique include the introductionof the Arndt Airway Exchange Catheter and needleholder to the preexisting retrograde intubation set.

TRANSTRACHEAL JET VENTILATION

Transtracheal jet ventilation (TTJV) is a well-accept-ed method for securing ventilation in rigid and interven-tional bronchoscopy (Table 6).21 There are a number ofcommercial manual jet ventilation devices currentlyavailable, including the Manujet III Jet Ventilator (VBM

Medizintechnik GmbH, Sulz, Germany), the Manual JetVentilator (Instrumentation Industries, Bethel Park, Pa),and the Jet Ventilator (National Anesthesia Associates,Inc, San Marcos, Calif). The Enk Oxygen FlowModulator (Cook Critical Care) is a new device that isrecommended for use when jet ventilation is appropri-ate but a jet ventilator is not available.22 The WadhwaEmergency Airway Device (Cook Critical Care) can alsobe used for TTJV.23,24 It is actually several devices in one(Table 6). It has an emergency nasopharyngeal airwaycatheter; a large diameter transtracheal needle for acricothyrotomy procedure with the option for TTJV;and the main body of the device, which acts as a blowtube or 15-mm adapter.

CRICOTHYROTOMY

Cricothyrotomy (Table 7), a lifesaving procedure, isthe final option for “cannot-intubate, cannot-ventilate”patients according to all airway algorithms, whetherthey concern prehospital, emergency department,intensive care unit, or operating room patients.

In adults, needle cricothyrotomy should be per-formed with catheters at least 4 cm and up to 14 cm inlength. A 6-Fr reinforced fluorinated ethylene propy-lene Emergency Transtracheal Airway Catheter (CookCritical Care) has been designed as a kink-resistantcatheter for this purpose.

Percutaneous cricothyrotomy involves using theSeldinger technique to gain access to the cricothyroidmembrane. Subsequent dilation of the tract permitspassage of the emergency airway catheter. The MelkerCuffed Emergency Cricothyrotomy Catheter Set isavailable with a 5.0-mm cuffed airway catheter (CookCritical Care). A Portex (Smiths Medical) emergencycricothyrotomy kit is available (United Kingdom only)that uses a Veress needle and integral dilator to inserta 6.0-mm cuffed ET. The QuickTrach (VBMMedizintechnik GmbH) is available for children andadults in 2.0-mm and 4.0-mm IDs, respectively.

Surgical cricothyrotomy is performed by makingincisions through the cricothyroid membrane using ascalpel, followed by the insertion of an ET. This is themost rapid technique and should be used when equip-ment for the less invasive techniques is unavailable andspeed is particularly important.

TRACHEOSTOMY

Tracheostomy (Table 8) establishes transcutaneousaccess to the trachea below the level of the cricoid car-tilage.25 Emergency tracheostomy may be necessarywhen acute airway loss occurs in children younger than10 years of age or children whose cricothyroid space isconsidered too small for cannulation, as well as in indi-viduals whose laryngeal anatomy has been distortedby the presence of pathologic lesions or infection.26

Percutaneous dilatational tracheostomy is the mostcommonly performed tracheostomy technique, yet it is







Table 2. Lighted Stylets

Name/Manufacturer Description

Shikani OpticalStylet (SOS;Clarus Medical,Minneapolis)

High-resolution, stainlesssteel, malleable fiber-opticstylet that comes in a pre-formed J-shape. Has anadjustable tube stop andintegral oxygen port foroxygen insufflation.

Similar to flexible FOB.Can be used alone oras an adjunct tolaryngoscopy and isespecially useful forthose unable to main-tain skills with a bron-choscope.4

Adult(ETs !5.5mm ID).Pediatric (ETs 2.5-5.0 mmID).

Has the simple form of astandard stylet, plus theadvantage of a fiber-opticview and maneuverability ofits tip. Portable, rugged, andbetter maneuverability thanthe flexible FOB. Lightsources include battery-powered (4 AA-size), fiber-optic light source, or greenline laryngoscope handlewith adapter.

Flexible AirwayScope Tool (FAST;Clarus Medical,Minneapolis)

Flexible stylet with anondirectable tip.

Allows for visualizationduring intubationthrough ILMA or quickconfirmation of SGA orET placement.

Adult(ETs !5.0mm).

This device has been modi-fied with a tip that allows itto be used for nasal intuba-tion—FAST Plus (ClarusMedical, Minneapolis).

BonfilsRetromolarIntubationFiberscope (Karl StorzEndoscopy,Tuttlingen,Germany/CulverCity, Calif)

High-resolution rigid fiber-optic stylet with a fixed40-degree curved shape atthe distal end. Availablewith and without a work-ing channel for ease ofcleaning. Available with astandard eyepiece or witha DCI for video.

Able to elevate a large,floppy epiglottis andnavigate through theoropharynx of patientswith excessive pharyn-geal soft tissue.

3.5- and5.0-mmOD. ETmust be!0.5 mmlarger tofit.

Fixed-shaped shaft with anadjustable eyepiece thatallows ergonomic movementduring intubation, in addi-tion to an adapter for fixa-tion of ETs and oxygeninsufflation. Portable,rugged, and better maneu-verability than the flexibleFOB. Used with a battery-powered or fiber-optic lightsource.

Size Clinical Applications Special Features

Trachlight Stylet(Laerdal MedicalAS, Stavanger,Norway/Wappingers Falls,NY)

Consists of 3 parts: areusable handle, a flexiblewand, and a stiff,retractable stylet.

Although it can be usedfor routine intubations,it is especially useful insituations in which theFOB is unavailable (eg,in ambulances or out-side locations) or inwhich bronchoscopy isdifficult to perform (eg,when an airway isobscured by blood orsecretions or when apatient’s head cannotbe flexed or extended).

Availablein 3 sizes:adult,child, andinfant.Accom-modatesETs 2.5-10.0 mmID.3

Blind technique that can beused alone or in conjunctionwith other techniques.

Levitan GLS(Clarus Medical,Minneapolis)

Similar to the SOS, butdoes not have a movabletube stop.

Designed as an adjunctto direct laryngoscopy.Can also be used as astand-alone device sim-ilar to the SOS.

Adult(ETs !5.5mm).

Very similar to the SOS, butrequires the user to cut theET because it does not have amovable tube stop. Use eithera GreenLine laryngoscopehandle or an LED light source.

BrambrinkIntubationEndoscope (KarlStorz Endoscopy,Tuttlingen,Germany/CulverCity, Calif)

High-resolution semiflexi-ble fiber-optic stylet with a40-degree curved shape atthe distal end, 40x magni-fication, a fixed eyepiece, amovable ET tube holder,and an insufflation port.

Similar to BonfilsRetromolar IntubationFiberscope.

2.0-mmOD. ETmust be!0.5 mmlarger tofit.

Available with a standardeyepiece or a DCI for videocameras.

continues on page 7






Table 2. Lighted Stylets (continued)

Name/Manufacturer Description Size Clinical Applications Special Features

SensaScope(Acutronic MedicalSystems AG, Hirzel,Switzerland)

Hybrid S-shaped, semi-rigid fiber-optic intubationvideo stylet. Has a 3-cmsteerable tip that can beflexed in sagittal plane for75 degrees in both direc-tions with lever at proxi-mal end of device. Qualityof optics is similar to flexi-ble fiber-optic and rigidendoscopes, but has noworking channel.

Similar to BrambrinkIntubation Endoscope.

6.0-mm OD.ET must be>0.5 mmlarger to fit.

Offers an improved view ofglottis, simultaneous directand endoscopic views, fullvisual control over passage ofET, and confirmation of finalposition. No need for extremehead extension or forced trac-tion of laryngoscope. Can berapidly assembled to useimmediately. Not currentlyavailable in the United States.


CLM Laryngoscope Blade(Mercury Medical,Clearwater, Fla)

Flipper (Rusch Inc, Re-search Triangle Park, NC)

Heine Flex Tip Fiber-Optic LaryngoscopeBlade (Heine USA, Ltd,Dover, NH)

Flexible tip or levering fiber-optic MAC laryngoscopeblades are designed with ahinged tip controlled by alever at the proximal end.Designed to fit standardhandles.

Useful in patients with arecessed mandible anddecreased mouth opening.

Adultsizesonly.

A lever controls the tipangle through 70degrees during intuba-tion to lift the epiglottis,if necessary, to improvelaryngeal visualization.6


Dörges EmergencyLaryngoscope Blade(Karl Storz Endoscopy,Tuttlingen, Germany/Culver City, Calif)

Recently developed inEurope as a universal bladethat combines features ofboth the MAC and Millerlaryngoscope blades.

Blade is inserted into theoropharynx to the appro-priate depth, which corre-lates with the patient’s size.

One sizeonly forpatients >10 kg.

Has 10-kg and 20-kgmarkings on the blade.

HendersonLaryngoscope Blade(Karl Storz Endoscopy,Tuttlingen, Germany/Culver City, Calif)

A straight laryngoscopeblade that continues to bemodified in design; there hasbeen a resurgence of interestin the routine use of thisblade for tracheal intubation.

Routine or emergency usefor tracheal intubation.

Adultsize only.

Modified MAC Blades

When used with the para-glossal technique, a bet-ter view is obtained byoptimizing control of thesoft tissues and improv-ing the line of sight.5 Hasan improved tip and light,as well as a larger cross-sectional area.

Table 3. Rigid Laryngoscope Blades

continues on page 8

Rusch Truview EVO(Truphatek InternationalLtd, Netanya, Israel; distributed by Rusch Inc, Research TrianglePark, NC)

Indirect rigid laryngoscopewith specially designed 42-degree blade curvature; fitsonto all standard endoscopiccamera heads. Provides clear,unmagnified view of theglottis. Oxygen channel fordemisting, clearing secre-tions, and insufflation.

Similar to ViewmaxLaryngoscope.

Adult,pedi-atric,andneonatalsizes.

Rugged, portable, easyto maintain. Depth lineson the blade to guideinsertion. Can be usedwith all fiber-optic laryn-goscope handles.Designed to provideindirect laryngoscopywith continuous oxygeninsufflation.






Table 3. Rigid Laryngoscope Blades (continued)


Video Laryngoscopes

DCI Video LaryngoscopeSystem (Karl StorzEndoscopy, Tuttlingen,Germany/Culver City,Calif)

Video laryngoscope systemwith interchangeable laryngo-scope blades. Handles allow aDCI camera head to snaponto any standard eyepiecefiberscopes (flexible or semi-rigid). Required componentsinclude a camera control unit,xenon light source, and moni-tor. MediPack portable combi-nation video/lightsource/monitor unit is alsoavailable for use with thissystem.

Useful for anterior airways,obese patients, andpatients with limited mouthopening or neck extension.Additionally useful forteaching purposes, verifica-tion of ET position, aidingapplication of externallaryngeal manipulation, orpassage of an intubatingintroducer. Recommendstyletted or special ET. Mayalso be used for nasal intu-bation and ET exchange.

MAC 3,4,Dorges,and allMillerbladesizes.

The wide-angle cameraallows improved visuali-zation and video docu-mentation of laryngos-copy and intubation.Extreme positioning ofthe head is unnecessary.MAC #3 and #4 bladesprovide 45- and 60-degree angles of view,respectively.

GlideScope VideoLaryngoscopes (GVL)(Verathon Medical,Bothell, Wash)

Video laryngoscope offersimproved real-time view ofairway and tube placementthat enables quick intubationbecause it is operational inseconds. Includes high-reso-lution digital color camera,antifogging mechanism toresist lens contamination,nonglare color monitor, andblade with 60-degree bladeangle.8 Video output forremote display or recording.

Useful for difficult adultand pediatric airways,including obese patients,bloody or anterior air-ways, and patients withlimited neck mobility.7

Also useful for teachingpurposes.The more portable Rangermodel is ideal for prehos-pital, helicopter, ambu-lance, ER, ICU, and crashcart settings.

Large,mid-sized,andsmallbladesizes.

GVL single-use (Cobalt)or reusable. Rangermodel is compact,portable, and built tomilitary and EMS specifi-cations. Rugged,rechargeable, Li poly-mer battery; 1.5 lb.New GlideRite ET withsoft, curved, distal tip,and a rigid stylet that isfashioned to hugGlideScope blade shape,are offered with product.

continues on page 9

Viewmax LaryngoscopeBlade (Rusch Inc, Re-search Triangle Park, NC)

Laryngoscope blade thatincorporates an unmagnifiedoptic side port with prism ona modified MAC blade with a 20-degree anterior angleof view.

Same as DCI VideoLaryngoscope System.

Adultandpediatricsizes.

Distal prism enables a20-degree refractionand “fish eye” appear-ance. Can be used asMAC or Miller blade.

Modified MAC Blades

still considered invasive and can cause trauma to thetracheal wall. The Portex Ultraperc PercutaneousDilatational Tracheostomy Kit (Smiths Medical) incor-porates a unique introducer to aid smooth insertion ofthe tracheostomy tube over a Seldinger wire. In addi-tion, the Ciaglia Blue Rhino Percutaneous IntroducerKit (Cook Critical Care) has a flexible tip dilator for lesstraumatic insertion. The slippery hydrophilic coatingand tapered profile eliminate the need for multiplepasses with increasingly larger dilators.

Translaryngeal tracheostomy, a newer tracheostomytechnique, is considered to be safe and cost-effective,and it can be performed at the bedside.27 It may bebeneficial in patients who are coagulopathic.

Surgical tracheostomy is more invasive, and should

be performed on an elective basis and in a sterile envi-ronment.

ConclusionMost airway problems can be solved with relatively

simple devices and techniques, but clinical judgmentborn of experience is crucial to their application. Aswith any intubation technique, practice and routine usewill improve performance and may reduce the likeli-hood of complications. Each airway device has uniqueproperties that may be advantageous in certain situa-tions, yet limiting in others. Specific airway manage-ment techniques are greatly influenced by individualdisease and anatomy, and successful management mayrequire combinations of devices and techniques.






Table 3. Rigid Laryngoscope Blades (continued)


Video Laryngoscopes

Airtraq (Prodol MeditecSA, LLC, Vizcaya, Spain;distributed by KingSystems Corp,Noblesville, Ind)

Disposable optical laryngo-scope that provides magni-fied angular view of glottiswithout alignment of oral,pharyngeal, and trachealaxes. Includes guiding chan-nel to hold ET and direct ittowards vocal cords.Optional reusable cameracan be attached for viewingon external monitor. Sizesare color coded: regularadult has blue battery cover;small adult has green batterycover.

Intended to facilitate intu-bation in routine and diffi-cult airway situations.Useful in emergency set-tings, C-spine immobiliza-tion, fiberscope guidance,tube exchange, and for-eign body removal.

Twosizes:regularadult forETs 7.0-8.5 mm);smalladult forETs 6.0-7.5 mm.

Totally self-containeddisposable advancedairway device with built-in anti-fog system, andlow temperature lightsource. Can be usedwith standard ETs.Integral tracking channelallows ET to be directedwithout a stylet orbougie.

Pentax Airway Scope(Pentax, Tokyo, Japan)

New wireless video laryngo-scope with disposable trans-parent blade (PBLADE) thathas a suction port. Has a 12-cm cable with CCD cameraand 2.4-in LCD color monitor.

Similar to McGrath VideoLaryngoscope.

One sizeonly.

Green target symbol onmonitor display indi-cates direction of thetracheal tube tip. ThePBLADE has a suctionport through which asuction catheter can bepassed. ET is attachedto right side of theblade.

McGrath VideoLaryngoscope (LMANorth America, Inc, San Diego)

Fully portable wireless laryn-goscope with single-use dis-posable blades. Flat screenmonitor is mounted on thehandle.

Useful in patients withlimited mouth opening orhead and neck movement,and anterior airways;obese patients; patients in whom an increased hemo-dynamic response is aconcern; and for teachingpurposes.

Adjuststo fitmanyadultandpediatricsizes.

Highly portable andlightweight. Does notrequire an electrical out-let and is thus ideal forsettings outside the OR.Uses disposable bladesfor quick turnaroundbetween uses and forlimiting cross-contami-nation. An adjustableblade allows use of dif-ferent blade lengths onthe spot. Low-profileblade and disarticulatinghandle can accommo-date patients with verylimited mouth openingsand severe head andneck limitations. Themonitor is located onthe handle to remain ina more natural line ofsight with the patient.






Table 4. Indirect Rigid Fiber-Optic Laryngoscopes


Bullard EliteLaryngoscope(Gyrus ACMI,Southborough,Mass)

Most recent version of theBullard laryngoscope and the only indirect fiber-opticlaryngoscope that incorporatesattachable metal stylets.

Six methods of intu-bation have beendescribed.9,10 Usefulfor anterior airwaysand patients withlimited neck extension.

Adult andpediatricsizes (new-born/infantand child).

Has a working channel foroxygen insufflation, suc-tion, and instillation oflocal anesthetics. Can beused with a conventionallaryngoscope handle orfiber-optic light source.

UpsherScopeUltra (MercuryMedical,Clearwater, Fla)

Simplest in design of indirectrigid fiber-optic laryngoscopes.No detachable stylets or extraports. C-shaped delivery slot.Unlike the Bullard EliteLaryngoscope, there are nodetachable stylets or extraports along the right side of theinstrument.

Same as Bullard EliteLaryngoscope.

Adult sizeonly.

Has several improvementsfrom originalUpsherScope, includingbetter optics, an elongat-ed lower flange, andSteris compatibility. Mustbe used with UpsherUniversal handle or fiber-optic light source.

WuScope (Achi Corp, San Jose, Calif)

A combination laryngoscopethat has a rigid, curved,bivalved tubular blade incorpo-rated with a flexible fiberscope.The S-piece rigid blade portionconsists of a handle and 2 sizesof main-blade and bivalve ele-ments. There are 2 open chan-nels for the fiberscope and ET.11

Same as Bullard EliteLaryngoscope.

Using thesame fiber-scope andsame han-dle, adultor largeadult sizescan beassembled.

The fiber-optic mecha-nism consists of a fiber-optic endoscope. Thisfeature accounts for itsbetter visualizationcapacity and higher costthan the 2 aforemen-tioned scopes. Used witha battery-powered orfiber-optic light sourceand a suction catheter asan ET guide.

Table 5. Supraglottic Ventilatory Devices


LMA Classic (LMA NorthAmerica, Inc, SanDiego)

Supraglottic ventilatorydevice that consists of anoval inflatable silicone cuffin continuity with a wide-bore tube that can be con-nected to an Ambu bag oranesthesia circuit. Designedto fit the pharynx ofpatients of various weights.

Although originally developedfor airway management of rou-tine cases with spontaneousventilation, it is now listed inthe ASA Difficult AirwayAlgorithm as an airway ventila-tory device or a conduit forendotracheal intubation.1,13 Canbe used in both pediatric andadult patients in whom ventila-tion with a face mask or intuba-tion is difficult or impossible.Can also be used as a bridge toextubation14 and with pressuresupport or PPV.15

Adult andpediatricsizes 1-6,accom-modatingET 3.5-7.0mm.

Nondisposable andreusable.

continues on page 11






LMA Flexible (LMA North America, Inc, San Diego)

Original LMA cuff designattached to smaller-diame-ter, flexible armored tubethat allows repositioning ofthe tube without cuff dis-placement. New single-useversion is easier to insert.

Particularly useful in ENT/headand neck procedures.

Adult andpediatricsizes 2-6.

Both reusable anddisposable versionsnow available.Airway tube resistskinking and cuffdislodgment, andthus may be posi-tioned away fromthe surgical fieldwithout loss of seal.

LMA Unique (LMA North America, Inc, San Diego)

Original, disposable LMAdesign. Sterile, latex-free,available with or withoutsyringe and lubricant. Softcuff and airway tube allowfor conformity to patients’natural anatomy.

Same as LMA Classic. Includedin AHA 2000 Guidelines forCPR and Emergency MedicineCardiovascular Care.


Single use.

LMA Supreme(LMA NorthAmerica, Inc, San Diego)

Same features as the LMAProSeal. Design allowseasy insertion.

Same as LMA ProSeal.Adultsizes 3-5.

Same as LMAProSeal, but dispos-able.

LMA ProSeal(LMA NorthAmerica, Inc, San Diego)

Designed with a modifiedcuff and dual tubes toseparate the respira-tory/alimentary tracts. Hasa built-in bite block.

Same as LMA Classic exceptdrain tube also allows for evac-uation of stomach contents.

Adult and pediatricsizes 11⁄2-5.

Second cuff allowshigher seal for PPV.Reusable.


Table 5. Supraglottic Ventilatory Devices (continued)


LMA CTrach (LMANorth America,Inc, San Diego)

The LMA CTrach is aFastrach with built-in fiberoptics that allow for venti-lation, visualization, andintubation of the trachea.It includes an airway(made of silicone) that issimilar to the Fastrach,with an attachable light-weight viewer.

Useful in unanticipated andanticipated difficult airways.Allows for continuous ventila-tion during intubation attempts.Provides a direct view of thelarynx and real-time visualiza-tion of the ET passing throughthe vocal cords.

Adultsizes 3-5forpatients!30 kg.ComeswithFastrachETs 6.0-8.0 mm.

Reusable only.Comes with 3 air-ways, a viewer,charger, 5 ETs, andstabilizer rods.

LMA Fastrach(LMA NorthAmerica, Inc, San Diego)

Consists of a maskattached to a rigid stain-less steel tube curved toalign the barrel aperture tothe glottic vestibule. Theset includes an LMA with astainless steel shaft cov-ered with silicone(reusable version) and asingle movable epiglotticelevating bar, ET stabilizer,and silicone wire-rein-forced ET. The single-useFastrach is made from PVCand includes a disposablewire-reinforced ET.

Useful for ventilation and intu-bation. Designed for blind oro-tracheal intubation but can beused in conjunction with lightedstylets, FOB, or Flexible AirwayScope Tool. FOB recommendedwhen using PVC ET.

Adultsizes 3-5that canaccom-modatespecial ETs 6.0-8.0 mm.

Both reusable anddisposable versionsnow available. Canbe utilized as ablind or visuallyguided technique.Benefits includeability to intubatewith larger ET andremove the deviceeasily over the ET.







Soft-SealLaryngeal Mask(Smiths MedicalASD, Keene,NH/SmithsMedicalInternational,Hythe, Kent,England)

Similar in shape to theLMA Unique, but differs inits one-piece design, inwhich the cuff is softer andthere is no “step” betweenthe tube and the cuff, anintegrated inflation line, noepiglottic bars on the ante-rior surface of the cuff, anda wider ventilation orifice.

Same as LMA Classic. Allowseasy access for flexible fiber-optic devices.


If intubationbecomes necessaryor desired, willaccommodate upto a 7.5-mm ET.Single use.

Ambu AuraOnce (formerly theAmbu LaryngealMask; Ambu Inc,Glen Burnie, Md)

A laryngeal mask with aspecial built-in curve thatreplicates natural humananatomy. It is molded inone piece with an integrat-ed inflation line and noepiglottic bars on the ante-rior surface of the cuff.

Same as LMA Classic. Allowseasy access for flexible fiber-optic devices.


Anatomically cor-rect curve and rein-forced tip thatfacilitates place-ment. If intubationbecomes necessaryor desired, recom-mend intubationover Aintree AEC.Single use.

Ambu AuraOnceStandard (AmbuInc, Glen Burnie,Md)

Similar to LMA Unique but without epiglottic barson the anterior surface ofthe cuff.

Same as Ambu AuraOnce.Adult andpediatricsizes 1-5.

Single use.Available only inthe United States.

Air-Q DisposableLaryngeal Mask(Cookgas LLC, St.Louis; distributedby Mercury Medi-cal, Clearwater,Fla)

Same features as Air-QReusable Laryngeal Mask,except disposable.

Same as Air-Q ReusableLaryngeal Mask.

Adultsizes (1.5,2.5, 3.5,and 4.5)that canaccom-modateETs 5.0-8.5 mm.

Same as Air-QReusable LaryngealMask, but dispos-able.

Air-Q ReusableLaryngeal Mask,formerly theIntubatingLaryngeal Airway(Cookgas LLC, St.Louis; distributedby MercuryMedical,Clearwater, Fla)

Hypercurved intubatinglaryngeal airway thatresists kinking, and remov-able airway connector.Anterior portion of mask isrecessed; a larger maskcavity allows intubationusing standard ETs. Air-Qremoval after intubation isaccomplished by using Air-Q reusable removal stylet.

Similar to both LMA Classic andFastrach. Allows easy access forflexible fiber-optic devices.

Adultsizes (2.5, 3.5,and 4.5)that canaccom-modateETs5.5–8.5mm.

Designed to mini-mize folding of thecuff tip on inser-tion. Same use andbenefits as LMAClassic andFastrach.

Ambu Aura40(Ambu Inc, GlenBurnie, Md)

Same design as the AmbuAuraOnce, but reusable.


Same as AmbuAuraOnce, butreusable.

Ambu Aura40Standard (AmbuInc, Glen Burnie,Md)

Similar to the LMA Classic.No epiglottic bars on theanterior surface of the cuff.


Reusable. Availableonly in the UnitedStates.










CobraPLUS(EngineeredMedical Systems,Indianapolis)

Similar to the CobraPLA.Includes temperature mon-itor (all sizes) and distalgas sampling (pediatricsizes only: 1⁄2, 1, and 11⁄2).

Same as LMA Classic. An added benefit is theability to measure coretemperature. In addi-tion, distal CO2 can bemonitored in the pediatric population.

Adult andpediatricsizes 1⁄2-6.

Similar to CobraPLA butPLUS allows monitoringof the patient’s coretemperature. In neona-tal and infant patients,PLUS has the ability toincrease the accuracy of end-tidal CO2 andvolatile gas analysis.

CobraPLAPerilaryngealAirway(Engineered Med-ical Systems,Indianapolis)

Large ID laryngeal tube,which is soft and flexible indesign with a tapered, stri-ated tip. Now has an im-proved distal curve, softertube, and softer head. Ithas a high-volume, low-pressure oropharyngealcuff.

Same as LMA Classic.Adult andpediatricsizes 1⁄2-6.

Disposable. If intubationbecomes necessary ordesired, will accommo-date up to an 8.0-mmET. Single use.


SLIPAStreamlined Linerof the PharynxAirway (SLIPAMedical Ltd,London)

Similar to the LMA Unique. Same as LMA Classic.Six adult sizesthat relate tothe dimensionacross thyroidcartilagecornu: 47, 49,51, 53, 55, 57mm.

Its hollow structureallows storage of regur-gitant liquids, minimiz-ing aspiration risk.1

More confident place-ment by first-timeusers.2 Single use. Notavailable in the UnitedStates.

KING LT-D (KingSystems Corp,Noblesville,Ind/VBM Medizin-technik GmbH,Sulz, Germany)

Same design as the KINGLT, except disposable.

Same as KING LT.Adult sizes(3-5).Pediatricsizes (2, 2.5)available mid-2007.

Same as KING LT, butdisposable. Also avail-able in an EMS kit.

KING LT (KingSystems Corp,Noblesville,Ind/VBM Medizin-technik GmbH,Sulz, Germany)

Multi-use, latex-free, sin-gle-lumen silicon tube withoropharyngeal andesophageal low-pressurecuffs, 2 ventilation outlets,insertion marks, and ablind distal tip (almost likea single-lumen, shortenedCombitube).16 Color-codedconnectors for each size.

Same as LMA Classic,but with ventilatoryseal characteristics likethose of LMA ProSeal.

Sizes 2-5availableworldwide;sizes 0-1available outsideUnited Statesand Canada.

Easily inserted, possibleaspiration protection,and allows both positivepressure ventilation andspontaneous breathing.Nondisposable andreusable (up to 50times).

KING LTS (KingSystems Corp,Noblesville,Ind/VBM Medizin-technik GmbH,Sulz, Germany)

Double-lumen laryngealtube that incorporates asecond (esophageal)lumen posterior to theventilation lumen.

Same as KING LT,except that it has asecond lumen forgastric access, similarto LMA ProSeal.

Adult sizes(3-5); pedi-atric sizes (0, 1, 2, 2.5).

Allows easy passage ofa gastric tube to evacu-ate stomach. Distal tipreduced in size to facili-tate insertion.








EsophagealTrachealCombitube (TycoHealthcare/MallinckrodtNellcor PuritanBennett,Pleasanton, Calif)

A disposable double-lumentube that combines the features of a conven-tional ET with those of anesophageal obturator air-way. Has a large proximallatex oropharyngeal bal-loon and a distal esoph-ageal low-pressure cuffwith 8 ventilatory holes inbetween.

Same as LMA Classic.Appropriate for prehos-pital, intraoperative,and emergency use.Especially useful forpatients in whom directvisualization of thevocal cords is not pos-sible, patients withmassive airway bleed-ing or regurgitation,limited access to theairway, and patients inwhom neck movementis contraindicated.

Two adultsizes. 41 Fr:height >5 ft.37 Fr: height 4-6 ft.

Ventilation is possiblewith either tracheal oresophageal intubation.Distal cuff seals off theesophagus to preventaspiration of gastriccontents. Allows pas-sage of an orogastrictube when placed in theesophagus. Single use.

ChouAirway (Achi Corp, SanJose, Calif)

Adjustable oropharyngealairway of 2-piece construc-tion. The rigid outer tubeserves as a conduit for andprotects the flexible innertube, which creates apatent air passage fromthe mouth opening to theglottis.

In conjunction with aface mask, it is placedorally to facilitate andmaintain spontaneousor assisted breathing.

Adult (10-13cm) and largeadult (13.5-16.5 cm)sizes.

The inner tube is longerthan other common oralairways, and thus capa-ble of reaching beyondthe base of the tonguein patients with a shortramus or large tongue.Single use.

KING LTS-D (KingSystems Corp,Noblesville,Ind/VBM Medizin-technik GmbH,Sulz, Germany)

Same as KING LTS, exceptdisposable.

Same as KING LTS.Adult sizes(3-5)

Same as KING LTS, butdisposable. Also avail-able in an EMS kit.

Intersurgical i-gel(Intersurgical,Wokingham,England)

Disposable supraglotticairway with noninflatablecuff designed to match theperilaryngeal anatomy.Incorporates an integralbite block and gastricchannel.

Similar to other supra-glottic airways, exceptdrain tube allows evac-uation of stomachcontents.

Adult sizes(3-5) that canincorporateET sizes 6.0-8.0 mm andnasogastrictube sizes 12-14 Fr.

Noninflatable cuffallows easy and rapidinsertion, minimal riskfor tissue compression,and stability after inser-tion. Gastric channelallows suctioning ofstomach contents,insertion of a nasogas-tric tube, and facilita-tion of venting.Epiglottis blocker mini-mizes the risk forepiglottis downfolding.Buccal cavity stabilizerreduces the risk for mal-position and aids inser-tion. Single use.Available only in theEuropean Union.






Table 6. Special Airway Techniques


Cook RetrogradeIntubation Set (Cook CriticalCare,Bloomington, Ind)

Complete set includes 14-Fr Arndt Airway ExchangeCatheter with Rapi-Fitadapter.

Excellent technique forsecuring a difficult air-way, either alone or inconjunction with otheralternative airway tech-niques. Especially use-ful in patients with lim-ited neck mobility orpatients who have suf-fered airway trauma.

110 cm Packaged as a com-plete kit with every-thing needed to per-form a retrogradeintubation. The recent-ly added Arndt AirwayExchange Catheterallows for patient oxy-genation and facili-tates placement of anET. Disposable.

ErgoMask (KingSystems Corp,Noblesville, Ind)

Face mask with contouredfinger/thumb grip.

Intended to facilitateone-handed mask ven-tilation. Encouragesproper chin lift to openairway. Allowsimproved control ofmask seal.

Medium adultsize.

Ventilation port off-center facilitates usewith small hand andimproves mask seal.

Face Mask Ventilation

Retrograde Intubation


Manujet III (VBMMedical, Inc,Noblesville, Ind)

Complete set including 4-m pressure hose, Luerlock connecting tubing,bronchoscope adapter,Endojet adapter withEndojet catheter, and jetventilation catheter.

Well-accepted methodfor securing ventilationin rigid and interven-tional bronchoscopy.Because airflow is gen-erally unidirectional, itis important that airhas a route to escape(unobstructed airway).

Jet ventilationcatheters canaccommodateadults, chil-dren, andinfants.

Packaged as a com-plete kit with every-thing needed to per-form transtracheal jetventilation. TheEndojet adapter allowsjet ventilation on anET, LMA, or face mask.The catheter can bepushed forwardthrough the ET or LMAas far as required, andcan be fastened with ascrew. Includes a pres-sure regulator.Reusable.

Manual JetVentilator(InstrumentationIndustries, Bethel Park, Pa)

Complete set includes anon/off valve, 6 ft of high-pressure tubing, and 4 ft ofsmall-bore tubing.

Same as Manujet III.Jet ventilationcatheters canaccommodateadults andchildren.

Offered with and with-out a regulator gauge.

Enk Oxygen FlowModulator Set (Cook CriticalCare,Bloomington, Ind)

Complete set including 15-g needle with reinforcedFEP catheter, syringe (5 cc), connecting tubing,and Enk oxygen flow mod-ulator with trachealcatheter connector.

Same as Manujet III JetVentilator.Recommended for usewhen jet ventilation isappropriate, but a jet ventilator isunavailable.

7.5 cm (2.0-mm ID).

Packaged as a com-plete set with every-thing needed to per-form transtracheal jetventilation.Disposable.

Transtracheal Jet Ventilation






Table 6. Special Airway Techniques (continued)


WadhwaEmergencyAirway Device (Cook CriticalCare,Bloomington, Ind)

Single device that lookssimilar to a pen. At oneend of the “pen” is a nee-dle with a 9-Fr cricothyro-tomy catheter. On theother end is a nasopharyn-geal airway catheter.

Can be used for a nee-dle cricothyrotomy,transtracheal jet venti-lation, or as a nasalcatheter.

Cricothyrotomycatheter: 6.0 cm.

Nasopharynge-al catheter: 9.5 cm (7.0-mm ID).

The componentsrequire some pre-assembly. Onceassembled, it is easyto transport to off-sitelocations and isintended for use inemergencies. Themain body of thedevice acts as a blowtube or 15-mmadapter. Disposable.


All in One

Table 7. Cricothyrotomy


MelkerEmergencyCricothyrotomyCatheter Set(Cook CriticalCare,Bloomington, Ind)

Complete set includingsyringe (10 cc), 2- to 18-gauge introducer needleswith TFE catheter (shortand long), 0.038-in diame-ter Amplatz extra-stiffguidewire with flexible tip,scalpel, curved dilator withradiopaque stripe, and PVCairway catheter. Also avail-able in a SpecialOperations kit, whichincludes all of the above ina slip peel-pouch and 2 airway catheters.

Same as EmergencyTranstracheal AirwayCatheter. Intendedto be used with theSeldinger techniquevia the cricothyroidmembrane; however,it has the capabilityto be used as a sur-gical cricothyrotomy.

Standard kit: 3.8 cm (3.5mm-ID), 4.2 cm (4.0-mm ID),and 7.5 cm(6.0-mm ID).Special kit: 4.2 and 7.5 cm.

Packaged as a completekit with everythingneeded to perform apercutaneous cricothyro-tomy. The SpecialOperations kit comes in aslip peel-pouch for easytransport to off-site loca-tions. Also good for usein the operating room. Itcomes with 2 differentlysized airway catheters toreduce the number ofkits needed in the field.Disposable.

EmergencyTranstrachealAirway Catheter(Cook CriticalCare,Bloomington, Ind)

6-Fr reinforced fluorinatedethylene propylenecatheter.

A lifesaving proce-dure that is the finaloption for “cannot-ventilate, cannot-intubate” patients in all airway algorithms.

5.0 and 7.5 cm. Designed to be kinkresistant specifically forthe purpose of needlecricothyrotomy.

Melker CuffedEmergencyCricothyrotomyCatheter Set(Cook CriticalCare,Bloomington, Ind)

Same as Melker EmergencyCricothyrotomy CatheterSet.

Same as MelkerEmergencyCricothyrotomyCatheter Set.

9.0 cm (5.0-mm ID).

Same as MelkerEmergency Cricothyrotomy Catheter Set.

Needle

Percutaneous







QuicktrachEmergencyCricothyrotomyDevice (VBMMedizintechnikGmbH, Sulz,Germany)

Complete kit includes air-way catheter, stopper, nee-dle, and syringes thatcome preassembled.


Adult (4.0-mmID) and child(2.0-mm ID).

Packaged as a completekit with everything need-ed to perform a percuta-neous cricothyrotomy—even the necktape andconnecting tube. Theremovable stopper isused to prevent a “too-deep” insertion and avoidthe possibility of perfo-rating the rear trachealwall. The conical needletip allows for the smallestnecessary stoma andreduces the risk forbleeding. Easily trans-ported to off-site loca-tions. Disposable.

Table 7. Cricothyrotomy (continued)


Percutaneous

Combination Percutaneous and Surgical

There is no special kit for a surgical cricothyrotomy. It is performed by making an incision through the cricothy-roid membrane using a scalpel, followed by the caudad insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and when speed is particularly important.

Surgical

Melker UniversalEmergencyCricothyrotomyCatheter Set(Cook CriticalCare,Bloomington, Ind)

Same as Melker CuffedEmergencyCricothyrotomy CatheterSet for percutaneous tech-nique. Also includes forsurgical technique: tra-cheal hook, safety scalpel,Trousseau dilator, andblunt curved dilator.


9.0 cm (5.0-mm ID).

One half of the tray is the same as MelkerCuffed EmergencyCricothyrotomy CatheterSet for the percutaneoustechnique. The other halfof the tray includes allitems necessary to per-form a surgical emer-gency cricothyrotomy.






Table 8. Tracheostomy


Ciaglia Blue RhinoPercutaneousIntroducer Set(Cook CriticalCare,Bloomington, Ind)

Complete kit includes24.0-, 26.0-, and 28.0-Frloading dilators and Shiley6 or 8 PERC disposabledual cannula tracheostomytube. A tray version isavailable that includeslidocaine, connector,iodophor PVP swabs,drape, and suture.

Same as PortexUltrapercPercutaneousDilatationalTracheostomy Kit.

74 mm (6.4-mm ID); 79 mm(7.6-mm ID)

Packaged as a completekit with everything need-ed to perform a percuta-neous dilatational tra-cheostomy. The singledilator with a hydrophiliccoating and flexible tipresults in a simpler, lesstraumatic insertion. Theguidewire has a Safe-T-Jtip to reduce trauma.Disposable.

ShileyTracheoSoft XLTExtended-LengthTracheostomyTubes (TycoHealthcare/MallinckrodtNellcor PuritanBennett,Pleasanton, Calif)

Available in 4 ISO sizes(5.0-, 6.0-, 7.0-, 8.0-mmID). Each size offers thechoice of cuffed or cufflessstylets, and proximal ordistal extensions. Comeswith disposable inner can-nula; replacements sold inpackages of 10.

Flexible dual cannulatube for patientswith unusual anato-my. Proximal lengthextension for thicknecks; distal lengthextension for longnecks, trachealstenosis, or malacia.

90 mm (5.0-mm ID); 95 mm(6.0-mm ID);100 mm (7.0-mm ID); 105mm (8.0-mmID)

The only fixed flangeextended-length tubewith disposable innercannula. Flexible innercannula conforms to theshape of the outer can-nula. Sixteen configura-tions to fit a wide varietyof patients. Disposable.

Portex UltrapercPercutaneousDilatationalTracheostomy Kit(Smiths MedicalASD, Keene,NH/SmithsMedicalInternational,Hythe, Kent,England)

Complete set with or with-out a tracheostomy tube.

Establishes transcu-taneous access tothe trachea belowthe level of cricoidcartilage. Allows forsmooth insertion ofthe tracheostomytube over aSeldinger wire.

70.0 mm (7.0-mm ID); 75.5mm (8.0-mmID); 81.0 mm(9.0-mm ID).

Packaged as a completekit with everything need-ed to perform a percuta-neous dilatational tra-cheostomy. The dilator is single-staged and pre-lubricated with anergonomic handle tofacilitate insertion.Disposable.

Percutaneous Dilatational

Surgical

Surgical tracheostomies are performed by making a curvilinear skin incision along relaxed skin tension linesbetween sternal notch and cricoid cartilage. A midline vertical incision is then made dividing strap muscles anddivision of thyroid isthmus between ligatures is performed. Next, a cricoid hook is used to elevate the cricoid. Aninferior-based flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is thensutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of anellipse of anterior tracheal wall. Finally, the tracheostomy tube is inserted, the cuff is inflated, and it is securedwith tape around the neck or stay sutures.






References 1. American Society of Anesthesiologists Task Force on Manage-

ment of the Difficult Airway. Practice guidelines for managementof the difficult airway: an updated report by the American Societyof Anesthesiologists Task Force on Management of the DifficultAirway. Anesthesiology. 2003;98:1269-1277.

2. Miller C. Management of the difficult intubation in closed malprac-tice claims. American Society of Anesthesiologists Newsletter.2000;64:13-19.

3. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet trachealintubation: A review. Anesth Analg. 2000;90:745-756.

4. Frass M, Kofler J, Thalhammer F, et al. Clinical evaluation of a newvisualized endotracheal tube (VETT). Anesthesiology. 1997;87:1262-1263.

5. Henderson JJ. The use of paraglossal straight blade laryngoscopyin difficult tracheal intubation. Anaesthesia. 1997;52:552-560.

6. Tuckey JP, Cook TM, Render CA. Forum. An evaluation of the lev-ering laryngoscope. Anaesthesia. 1996;51:71-73.

7. Cooper RM. Use of a new videolaryngoscope (GlideScope) in themanagement of a difficult airway. Can J Anaesth. 2003;50:611-613.

8. Agro F, Barzoi G, Montecchia F. Tracheal intubation using aMacintosh laryngoscope or a GlideScope in 15 patients with cervicalspine immobilization (letter). Br J Anaesth. 2003;90:705-706.

9. Gorback MS. Management of the challenging airway with theBullard laryngoscope. J Clin Anesth. 1991;3:473-477.

10. Bjoraker DG. The Bullard intubating laryngoscopes. AnesthesiolRev. 1990;17:64-70.

11. Wu T, Chou HC. A new laryngoscope: the combination intubatingdevice. Anesthesiology. 1994;82:1085-1087.

12. Verghese C. Airway management. Curr Opin Anaesthesiol.1999;12:667-674.

13. Benumof JL. Laryngeal mask airway and the ASA difficult airwayalgorithm. Anesthesiology. 1996;84:686-699.

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18. Gupta B, McDonald JS, Brooks HT, Mendenhall J. Oral fiberopticintubation over a retrograde guidewire. Anesth Analg. 1989;68:517-519.

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Abbreviation KeyAEC, airway exchange catheter

AHA, American Heart Association

ASA, American Society of Anesthesiologists

CCD, charge-coupled device

CLM, Corazelli, London, McCoy

CPR, cardiopulmonary resuscitation

DCI, direct couple interface

DLT, double-lumen tubes

EF, extra firm

EMS, emergency medical service

ENT, ear, nose, and throat

ET, endotracheal tube

FOB, fiber-optic bronchoscope

Fr, French

ID, internal diameter

ILMA, intubating laryngeal mask airway

ISO, International Standards Organization

LCD, liquid crystal display

LED, light-emitting diode

LMA, laryngeal mask airway

MAC, Macintosh

OD, outer diameter

PERC, percutaneous low-pressure cuffed tracheostomy tube

PPV, positive pressure ventilation

PVC, polyvinyl chloride

PVP, polyvinylpyrrolidone

SGA, supraglottic airway

TFE, tetrafluoroethylene





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