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Discussion 2

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

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  1. Discussion 2 B8501061 李又文

  2. 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.

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

  4. AFOI

  5. Intubation Laryngeal Mask Airway

  6. 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?

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

  8. 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

  9. 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

  10. 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

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

  12. 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

  13. 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.

  14. 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

  15. 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

  16. 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%

  17. 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

  18. 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

  19. Thank you very much!

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