Discussion 2 B8501061 李又文

ANESTH ANALG 2001;92:1342-6 Hwan S. Joo, etc. The Intubation Laryngeal Mask Airway after induction of General Anesthesia versus Awake Fiberoptic Intubation in patients with difficult airways ANESTH ANALG 2001;92:1342-6 Hwan S. Joo, etc.

Abbreviations TI: Tracheal intubation AFOI: Awake fiberoptic intubation ILMA: Intubation laryngeal mask airway

AFOI

Intubation Laryngeal Mask Airway

AFOI AFOI is the “gold standard” for p’t with suspected or proven difficult airways. ASA “difficult airway algorithm” suggests difficult airways should be intubated awaked. What should we do for patients who are not cooperative or those who refuse AFOI?

Disadvantages of AFOI Oxygen desaturation Tachycardia Hypertension Life threatening AFOI requiring emergency surgical airway has been reported 55% incidence of patient discomfort

ILMA ILMA allows confirmation of oxygenation and ventilation before tracheal intubation. Normal airways: 99% ventilation success rate 97-99% TI success rate Difficult airways: Numerous case reports after failed laryngoscopy and failed FOB intubation

Hypothesis Patients with difficult airways could be successfully and safely intubated after induction of anesthesia using ILMA Patients would be more satisfied with TI after induction of anesthesia

Material and Method Prospective and randomized study ASA class I-III Patient who required AFOI based on clinical predictors or history of prior difficult intubations AFOI: 18 ILMA: 20

Including Multiple and failed laryngoscopies Cormack > Grade 3 Mallampati > Grade 3 Retrognathia Thyromental distance < 6 cm Limited c-spine movement

Excluding Unstable c-spine Morbid obesity (BMI>35) History of difficult ventilation At risk for aspiration of gastric contents Mouth opening < 2.5 cm Pathological abnormalities of the airway

Primary anesthesiologist: fully trained anesthesiologist Study investigators experienced with both AFOI and ILMA(>50 cases of each) Study investigators intervened when patient became hemodynamically unstable or primary anesthesiologist was unsuccessful after 20min using either method or if 4 TI attempt was required in the ILMA group.

ILMA group First: a single blind TI attempt Second: FOB guidance without ILMA adaptation Third: Reinsert the ILMA and with FOB guidance Fourth: study investigator take over with and ILMA reinserted with FOB guide Fifth: ILMA failure, awake patient for FOI

Results Faster induction times in ILMA (672 ± 545s) than AFOI group (972 ± 331s) AFOI group : all successfully intubated ILMA group : all successfully ventilated; 50% blind TI ; 25% intubated with FOB guidance without changing ILMA; 15% changing ILMA with FOB guidance; 10% intubated by study investigator

Oxygenation Minimum oxygen saturation was higher in ILMA at 97.5 vs AFOI at 94.5 AFOI group : oxygen saturation decreased to 62% and 84% in two patients in the ILMA: one patient decreased to 85%

Questionnaire Primary anesthesiologist : More comfort with the method of AFOI More experienced with AFOI Predict higher patient satisfaction in ILMA group Postoperative patients : more satisfied with ILMA induction no recall of TI in ILMA no difference in sore throat and hoarseness

Conclusion For calm and cooperative patient: no definite advantages other than patients comfort for using ILMA over AFOI Patient who refuse AFOI or not cooperate may be candidates for TI with ILMA Experience should be gained before attempting to use ILMA in patient with difficult airways

Thank you very much!