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C H A P T E R 6 ADVANCED AIRWAY MANAGEMENT You ham attempted to intubate apMientrnko was in severerespiratory distressbut were unsuccessful Help has been called but is over 20 minutes away* You try to ventilate thepatient with thebagand mask but this is not effective and the saturation levels are falling. What should you do? DAVE NEILIPOVITZ AND WILLIAM GALLAGHER Basic airway management skills are some ofthe most important skills one can develop. Unfortunately, there are occasions when these skills will be insufficient to manage a patient's airway. Many different devices are available to facilitate intubation and airway management when the basic skills are not sufficient. Acomplete review ofthese devices isnot feasible here nor is it practicalfor the physician who performs only the occasional intubation. The goal in this chapter is to introduce some useful devices. A physician should chose only a couple ofthe devices and become proficient with their use. Do not try to learn how to use anew device during a crisis. However, familiarity with a special airway device can save the day (and the patient) in a situation when the usual devices and techniques fail. The chapter will also present the reader with various suggestions for specific problem situations. • Laryngeal Mask Airway A. LMA Classic™ (LMA™) The LMA™ is a specialized airway device that when properly placed will rest above the vocal cords (Figure 6.1).1 The LMA™ does not protect the patient from gastric aspiration and is therefore not a substitute for an endotracheal tube (ETT).2 Theutility of the LMA™ is that it can be used to ventilate and oxygenate a patient in whom intubation or mask ventilation is not successful. Insertion of an LMA™ is relatively easy with a very steep learning curve. 45 Figure 6.1 - Laryngeaj_Mask_Airway The Laryngeal Mask Airway (LMA™) is designed to encompass the glottic opening. The photograph is of the LMA Classic™, which is a reusable device. The blue pilot balloon is typically inflated with approximately 20-30 ml of air. B. Intubating Laryngeal Mask Airway Theintubating laryngeal mask airway or ILMA (LMA Fastrach™) is a modified LMA™ that allows blind intubation of the trachea (Figure 6.2).5 '6 The ILMA differs from the traditional LMA™ in that it comes with an insertion handle. The ILMA is mounted on the handle and lubricated. TheILMA is inserted into the mouth and passed against the palate, around the tongue, in a motion similar to the insertion of a laryngoscope. Once inserted, the handle is then removed. The ILMA can now be used in a similar fashion to a traditional LMA™. However, the additional advantage of the ILMA is that an ETTcan be inserted through the lumen. An ETTis not easily inserted through the traditional LMA™ because it has a web-like inner opening. The insertion of an ETTthrough the ILMA can be done blindly by simply passing it through the lumen. Although Agro5 et al. and Baskett6 et al. Although numerous insertion techniques have been described, only two will be discussed in this review. The LMA™ should be lubricated and deflated. The first technique involves pushing the solid side of the LMA™ up towards the top ofthe head along the hard palate. The LMA™ will slide against the palate and then down along the posterior pharynx. Advance the LMA™ until there is considerable resistance.The LMA™ is then inflated until the pilot balloon is firm or with 20-35 ml of air (amount varies depending upon the size of the LMA™). A second technique is very similar to the placement of an oral airway. The LMA™ is initially inserted upside down and then flipped as it is passed down along the posterior pharynx. The LMA™ is then inflated. Regardlessof the insertion technique, the black line on the tubeof the LMA™ should alwaysbe facing the upper incisors once it is in position. The laryngoscope may be used to help place an LMA™. The value of the LMA™ lies in the fact that it is usually veryeasyto insert. In addition, it canprovide a considerably better airway than a mask alone and can rescue the doctor and patient from a critical situation.3 -4 However, the LMA™ does not provide airway protection against gastric aspiration.3 The need forhigh airwaypressures to effectively ventilate a patient will limit the usefulness of an LMA™ because the pressures will risk gastric insufflation. Figure 62- Intubating Laryngeal Mask Air^^ Figure 6.2 is a photograph of an intubating laryngeal mask airway or LMA Fastrach...

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