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Re: Training in the use of different airway management systems
- Serge-K NDOKO, Gilles DHONNEUR (22 January 2007)
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Training in the use of different airway management systems
- Awanee Kumar (14 January 2007)
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Primary Use of LMA CTrach for Airway Management of Morbidly Obese Patients
- Gilles Dhonneur (3 November 2006)
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cTrach: a valuable aid for daily practice in bariatric surgery
- Davide Cattano (27 October 2006)
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Serge-K NDOKO Jean Verdier University Hospital of Paris (APHP), 93143, Bondy-Paris 13 School of Medicine, Gilles DHONNEUR
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In response: We read with great interest your letter and considered your concern about training with devices for tracheal intubation. What emerges from your survey is the lack of confidence expressed by trainees after a standard educational program. Indeed, confidence of trainees is the key point. How trainees get confident with an airway management device? We believe that mastering of techniques on manikin is just one of the ways to get comfortable but confidence comes later with clinical experience or particular learning environment. In our University Hospital of Paris (Jean VERDIER) we have developed a specific educational and training program in order to accelerate trainees’ confidence at using intubating laryngeal masks (ILMAs: Fastrach and CTrach) for tracheal intubation. We have focused our difficult airway management teaching program on two specific techniques that are: tracheal intubation by using ILMAs and trans-tracheal oxygenation. Before manipulating difficult airway devices there is a prerequisite for all trainees in our department; this is to demonstrate, in clinical situations, that trainees are skilled with face mask ventilation and standard tracheal intubation using Macintosh laryngoscope (including positioning manoeuvres, external laryngeal manipulations, gum elastic bougie assistance). We are particularly fussy on this important point. This stage of direct laryngoscopy and face mask ventilation skill acquisition needs to be systematically cleared with a senior expert working in the obesity surgery unit before evolving to other airway management techniques. The first step of our teaching program begins with presentation of the algorithms, procedures and alternative techniques proposed in our department in case of difficult airways. Difficult airway scenarios are presented and explained. Characteristics and place of ILMAs are described. Then trainees are allowed participating to manikin workshops and manipulations until they strictly master tracheal intubation with ILMAs. The second step of our learning program is exclusively dedicated to teaching (in daily standard clinical situations) CTrach preparation, insertion, ventilation and viewing optimizing maneuvers. All maneuvers and manipulations are gently performed initially with “four hands” under the supervision of an experienced senior until the trainee feels able to perform independently the entire tracheal intubation process. The learning curve using CTrach in such conditions is quite short. After 7 to 10 accompanied tracheal intubations most trainees feel comfortable with CTrach. During the third part of the learning program, trainees must demonstrate their ability at tracheal intubation with the Fastrach (the viewer of the CTrach is not available). This stage is performed under the supervision of the anaesthesiologists covering the obesity surgery. After completion of 5 to 10 successful blind tracheal intubation in morbidly obese patients, we observed that trainees felt confident with both ILMAs. We believe that adding a viewing system during the learning process of the Fastrach reduces the duration of the learning process and increases confidence with the Fastrach. This observation confirms previous data obtained in a large group of emergency physicians learning ILMAs use. We showed that the primary choice of CTrach versus Fastrach to learn the process of intubation with ILMAs influenced Fastrach tracheal intubation characteristics during a simulation program. When viewing was accessible during the learning process, performance of blind intubation with the Fastrach increased. Finally, the environment is very important for trainee’s confidence. Our centre is specialized in the evaluation of new airway management devices. Consequently, a culture of teaching in this area has grown. Almost everyday, trainees have the opportunity to ventilate and intubate safely normal weight and obese patients using not only ILMAs but also other intubating devices. This strategy is costly. We have been using 4 kits of CTrach since one year and half, which means that almost 300 patients were placed an ILMA. In conclusion, we believe that trainee’s ILMAs confidence acquisition requires, first, a specific environment, second, a particular learning strategy based on accompanied clinical practice and finally, some money! Serge Ndoko and Gilles Dhonneur Conflict of Interest:None declared |
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Awanee Kumar, SHO, Anaesthesia
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Dear editor, I read with great interest the paper by G. Dhonneur and colleagues on tracheal intubation of morbidly obese patients: LMA CTrachTM vs direct laryngoscopy. It was very impressive that they were not only successful in tracheal intubation of all patients using LMA CTrachTM (CT) but also were able to view the advancing tracheal tube through the glottis; In the direct laryngoscopy group (DL) 17% of patients with Cormack and Lehane grade 3 required a gum elastic bougie to assist tracheal intubation resulting in total and partial blind intubations. The fact that they included only morbidly obese patients in their group, who have a further increased incidence of difficult airway, makes it more impressive. The down side being the average duration of tracheal intubation being 119 seconds in DL group and 176 seconds in CT group. Previous papers by F.G.C. Liu and Timmerman and colleagues, using CT, showed 100% success rate in ventilation of patients and a 96 % success rate in tracheal intubation either blindly or viewing the tracheal tube passing through the vocal cords. In a study by Baskett, P.J.F. involving ILMA in multicentre trial with 500 patients showed a success rate of 90 % in tracheal intubation. In all these trials most of the failures in tracheal intubation using CT and ILMA happened in the first 20 attempts of inserting the airway device by the concerned anaesthetist as per the manufacturer’s recommendations. This clearly indicates that more the experience one has in these devices more likely is the success in achieving a safe and definitive airway. My concern is the level of competency achieved by trainees in Anaesthesia in handling these airway devices. I recently conducted a survey among 20 trainees at different levels of training regarding the level of competency achieved by trainees in different airway devices. The survey is summarized in the Table View Image . This was conducted at Royal Berkshire Hospital, Reading who have been the pioneers and a leading force in the invention and use of airway devices like Classic LMATM, ILMA and CT. Most of the trainees replied that though they were trained in the use of the devices, they were not confident of using ILMA, Fibreoptic intubation (FOI) and CT in an emergency situation. They expressed a need for more training in these devices. NOTE:Please could the table be attached here.(Table 1.0) •16 trainees did not receive any formal training in LMA CTrach •14 of the 20 trainees felt a need for more training in the use of FOI technique. •8 of the trainees felt though they were trained in ILMA and Fibre optic system they were not confident using it independently and in an emergency situation. The survey group was small and there is a need for a larger study regionally and nationally. It is difficult to deny the fact that there is a necessity for more training in the use of the above mentioned airway devices. A. Kumar Royal Berkshire Hospital Department of Anaesthesia awaneekumar@doctors.org.uk References 1G. Dhonneur, S.K. Ndoko, A. Yavchitz, A. Foucrier, C. Fessenmeyer, C. Polliand, X. Combes and L. Tual Tracheal intubation of morbidly obese patients: LMA CTrach™ vs direct laryngoscopy. Br J Anaesth 2006; 97(5): 742-5 2E. H. C. Liu1,2,*, R. W. L. Goy2 and F. G. Chen1,2 The LMA CTrachTM, a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients. Br J Anaesth 2006; 96 (3) : 396- 400 3A. Timmermann*, S. Russo and B. M. Graf. Evaluation of the CTrachTM—an intubating LMA with integrated fibreoptic system. Br J Anaesth 2006; 96: 516-21 P.J.F. Baskett, M.J.A. Parr, J.P. Nolan. The intubating laryngeal mask; Results of multicentre trial with experience of 500 cases. Anaesthesia 1998; 53: 1174-79 Conflict of Interest:None declared |
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Gilles Dhonneur, Head of Anaesthesia and Intensive Care Department Jean Verdier University Hospital of Paris (APHP), 93143, Bondy-Paris 13 School of Medicine
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In response: I read with interest the letter you have sent to the Journal. I fully agree with you. I am sure that a size 5 LMA CTrach™ available would have allowed you a safe tracheal intubation while viewing the tube entering the glottis of his 350 pounds gentleman. Since the end or our randomized trial (1) we have continued using the LMA CTrach™ in morbid obeses, and 100 patients were successfully intubated without arterial oxygen desaturation. Moreover, we made more radical our difficult airway management. For all morbid obese patients requiring nocturnal CPAP for obstructive sleep apnea syndrome, LMA CTrach™ was used as a primary airway management device just after induction of anesthesia and pressurized preoxygenation. This strategy allowed us preventing arterial oxygen desaturation and securing the airway in all patients. We observed in this particular category of patients that a clear view of glottis was obtained in only 40% cases when attaching the viewer after ventilation optimization, but finally maneuvers (down up and down and lateral-medial- lateral) resulted in glottis exposition and tracheal intubation under the control of the view in all patients. This strategy allowed us teaching seniors but also residents performing these important optimizing view maneuvers. After learning these maneuvers with the LMA CTrach™ in clinical conditions we observed that residents were more efficient at performing blind tracheal intubation with the LMA Fastrach™, than those whom learning process was conducted with the ILMA on manikin. This data confirms that LMA CTrach™ is not only an efficient airway device but also an interesting airway management teaching tool. Our experience with the LMA CTrach™ has brought us safety in the morbid obese airway management. However, in order to tone down a little LMA praises, we regret this company cannot provide us a size 5 LMA CTrach™ equipped with a longer airway tube which might have simplified or maneuver in some cases. Indeed, some male patients required a very deep insertion (viewer connector just emerging from the oral cavity between the teeth) of the mask in the pharynx in order to obtain optimal view of the glottis. Moreover, we were distributed in France a very poor quality plastic disposable tracheal tube. Due to exaggerated flexibility a turnaround of the atraumatic distal end was observed when the tip of the tube contacted the elevating epiglottic bar. This resulted in some tubes misdirected (under the view) into pyriform fossea when arythenoids are placed first plan in high position in the screen. Laryngeal manipulations in these circumstances resolved this problem. Finally, we have switched LMA Fastrach to LMA CTrach ™ in our unexpected difficult airway management algorithm (2). Ref 1. Dhonneur G et al., Br J Anaesth 2006;97:742-745, Combes X et al. 2004;100: 1056-50 Conflict of Interest:None declared |
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Davide Cattano
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Dear Editor, the recent article by Dhonneur and collegues, opens the everlasting discussion about how important is for the anesthesiologist to control the airway for possible difficult ventilation in elective as well as in emergency situations. Morbidly obesity, and I mean for sure BMI over 40-45 kg/m2, (far over the suggested one risk factor of 26, ref 1) challenges more the scenario involving difficult ventilation than the difficult intubation (2). LMA has been proved a valuable device (3), and besides the reluctance by some fibreoptic affectionated, it remains valuable both as an airway aid and as a definite airway. Recently I had the chance of having a cTrach available for managing a difficult airway in a obese patient. An over 350 pounds gentleman, scheduled for general anesthesia, Cath Lab interventional cardiology ablation of an arrhythmic bundle, with Mallampati 1 but a severe reduction in neck mobility, a nice beard and a thick neck, was planned to be anaesthetised (for his anxiety) in preferance to an awake fibreoptic intubation. The patient was placed over the OR bed supine but in ramped position and the head in the best sniffing position possible. Besides 5 minutes of 100% O2 preoxygenation, his saturation dropped fast to 75% after induction with Propofol and SuccinylCholine, and the Bag Mask Ventilation was barely sufficient to maintain a 95% saturation with oral airway and double hands. So I decided for a LMA disposable (promptly available in our regular anesthesia cart), and after the placement, ventilation and saturation was fine. A fibreoptic cart was then accessed, ILMA acquired and help requested. Unfortunatly besides three successful attempts to visualize the cords through the fibrescope, but not to pass a 6.0 (able to pass through the LMA but too short to maintain seal below the traheal inlet) and 7.0 (unable to pass the LMA barrs) endotracheal tubes, and after two unsuccessful attempts through a ILMA (unable to visualize the laryngeal inlet besides Chandi manuouver and up and down replacements), the case was decided to be cancelled and the patient scheduled for an awake fibreoptic on another occasion. The patient woke up without any airway morbidity and was informed of the complication. A cTrach LMA available may have offered a better choice. More randomized clinical trials are necessary to establish the confirmed reliabilty of this valuable device to be used in regular practice in patients at risk of difficult ventilation when endotracheal intubation is requested under general anesthesia, but so far, it has been demonstrated a wise aid by the clinical practice, as the work by Dhonneur just showed. Ref: 1.Langeron O et al.Anesthesiology 2000, 92: 1229-36 2.Brodsky BJ et al. Anesth Analg 2002; 94: 732-6 3.Combes X et al Anesthesiology 2004; 100: 1146-50 Davide Cattano, MD Assistant Professor of Anesthesiology, Department of Surgery School of Medicine, University of Pisa, Pisa, Italy Clinical Instructor of )Anesthesiology Department of Anesthesiology School of Medicine, Washington University of St Louis 660 South Euclid Avenue Campus Box 8054 St Louis MO 63110-1056 office 314 362 2345 fax 314 362 1185 cattanod@msnotes.wustl.edu Conflict of Interest:None declared |
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