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Discussion 2. B8501061 李又文. 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
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Discussion 2 B8501061 李又文
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 • 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