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Success Rate of Intubation Using Conventional Flexomettalic Tube with the Intubating laryngeal Mask Airway (ILMA)
Bikash Agarwal, Balkrishna Bhattarai, Binay K Biswas, Sumati Joshi, Tasleem Roshan Rahman, Shweta Koirala ABSTRACT Background: The Ilma has become an essential component in airway management. It is used with its special flexomettalic tube. But the tube comes in limited number with the Ilma, and also the cost of buying it, limits its use. So we undertook this study to see the success rate of conventional reinforced tube when they are used with the Ilma. Patients & Methods: 80 patients were divided into 2 equal groups; in the first group (ILMA-TT) intubation was done using the special reinforced tube that is supplied with the Ilma and in the second group (RTT) using conventional Rusch flexomettalic tube. Intubation time, number of attempts for intubations, need of additional manipulations, failed intubation, esophageal intubation and incidence of complications were recorded. Results: The success rate of intubation was 100% and 97.5% in the ILMA-TT and the RTT group. More time was required to intubate using the conventional tube(p=0.06).The number of attempts required, esophageal intubations, adjusting maneuvers used and the incidence of complications were comparable among the two groups. Conclusions: The conventional flexomettalic latex tracheal tube can be safely used for tracheal intubation with comparable success rate via the ILMA. KEY WORDS: ILMA, Flexomettalic Tube
The Intubating laryngeal mask airway [ILMA, (Fastrach®), The Laryngeal Mask Company] has now become an indispensable component of airway equipments in modern anaesthetic practice and emergency care. It has been shown to be useful means of blind endotracheal intubations both in routine and difficult airway situations1-4 with high success rates in hospital, pre-hospital and difficult military environments5. Further, it has been shown to have reasonable success rates of blind tracheal intubation even in the hands of non-medical personnel6. A special reinforced endotracheal tube (ILMA-TT) has been made available by the manufacturer of ILMA to increase the success rate of tracheal intubation.1 However; the cost of this special tube is very high in the context of a developing country like Nepal. Buying such a costly new tube to replace the damaged one can be economically difficult and may not be always possible. This problem could be overcome if the conventional latex reinforced tube [(Silkolatex®, Rusch,Willy Rusch,Kermel,Germany) (RTT)] could be used with acceptable success rate via the ILMA. They have the advantage of being cheaper and easily available. But reports on the experience of the use of conventional tracheal tubes via the ILMA are limited. Keeping this in mind, this study was designed and carried out to compare the success rate of endotracheal intubation using ILMA-TT to that using Rusch reinforced tube (RTT) via the ILMA. PATIENTS AND METHODS Eighty adult ASA I and II patients of either sex, undergoing various surgical procedures were enrolled in the study after obtaining approval from the institutional research committee and written informed consent from each patient. Patients with anticipated difficult
airway [i.e.: reduced mouth opening <3 cms, Malampatti class 3 and 4] and those undergoing oral or emergency procedures were excluded from the study .The patients were randomly divided into either ILMA-TT or RTT group with 40 patients in each using sealed envelope technique. Patients’ demographic parameters (age, sex, height and weight) and airway characteristics (Malampatti class, thyromental distance, sternomental distance) were recorded in a preformed proforma following randomization. All the patients were premedicated with oral diazepam 0.2 mg kg-1, the night before and two hours prior to surgery. After preoxygenation with 100% oxygen for 3 minutes, anaesthesia was induced with intravenous injection of pethidine 1 mg kg-1 and propofol 2 mg kg-1. Injection vecuronium bromide 0.1mg kg-1 was administered intravenously for muscle relaxation and the patient’s lungs were manually ventilated using Bain’s circuit with facemask. Further anaesthesia was maintained with 1.5% isoflurane in oxygen. After clinically conforming adequate neuromuscular block, a pre-lubricated ILMA (size 3 for women and size 4 for men) was inserted and the cuff was inflated with recommended volume of air (20 ml for size 3 and 30 ml for size 4). Optimal position of the ILMA was verified by adequate chest expansion, square shaped capnograph and absence of audible leak on ventilation. In case of inadequate positioning, the ILMA was manipulated by pulling it out and reinserting again and adjusting it until no audible leak was heard. After confirming the adequacy of ventilation and correct position of the ILMA, the respective tracheal tubes were passed through the ILMA. In the ILMA-TT group, 7mm and 7.5mm internal diameter tubes supplied with the ILMA were used. The tube was first passed through the ILMA until the black
Drs. Bikash Agarwal, Assistant Professor, Balkrishna Bhattarai, Associate Professor, Binay K Biswas, Associate Professor, Sumati Joshi, Assistant Professor, Tasleem Roshan Rahman, Associate Professor, Shweta Koirala, Resident, Department of Anesthesiology & Critical Care, B.P.Koirala Institute of Health Sciences, (B.P.K.I. H. S), Dharan, Nepal. Correspondence: Dr. Bikash Agarwal, E-mail: firstname.lastname@example.org
a sample size of 33 patients in each group was calculated. intubation was possible in the second attempt in 6 patients and in the third attempt in 2 patients. The data was analyzed with SPSS version 10 (SPSS Inc.23 156.89 seconds in the RTT group(p =0.02 26/14/0/0 25/15 RTT n-40 35±7. Chicago. Adjusting maneuvers and Complications ILMA-TT n-40 n-40 Intubation success: 40 Attempts for intubation 1/2/3: 32/4/4 Intubation time (SECS) 16.12 Esophageal intubations 6 Adjusting maneuvers used 8 CHANDY’S 6 REINSERTION 2 Trauma 4 Sore Throat 5 RTT 39 31/6/3 20.68±1.70±5. 6 and 2 in RTT group.61 1. out of the 8 patients in whom intubation was not possible in first attempt. sex.AGARWAL B: ET AL: ILMA AND CONVENTIONAL FLEXOMETALLIC TUBE 404 mark of the ILMA –TT could still be seen and it was checked if there was any resistance to further push. Intubation was possible in 4 of these 8 patients with the first manipulation technique and only in 4 patients third attempt was required for intubation. number of attempts for intubations. Table 1 Demographic and Airway Characteristics Parameters Age (yrs) [Mean ± SD] Sex (M: F) Weight (kgs) [Mean ±SD] Height (cms) [Mean ±SD] Sternomental distance (cms) [Mean ± SD] Thyromental distance (cms [Mean ± SD] Malampati class 1/2/3/4 ASA grade 1/2 ILMA-TT n-40 35. RESULTS Age.06 0. In the RTT group.037 24:16 57.0%) in ILMA-TT group and 39 (97. If no resistance was felt then the tubes were passed beyond the black mark of the ILMATT till adequate length was in. second and third attempts in 32.40±1. Intubation was possible in 79 out of total 80 patients.After successful intubation of the trachea. weight. If intubation was unsuccessful after all these attempts .68±1. Out of 9 patients in whom intubation was not possible in first attempt in RTT group.84 5.89 7 9 7 2 4 6 P value 1.00 1.73 5. considering the errors and possible failure of procedure. 40 patients in each group were taken. IL). need of additional manipulations. 4 and 4 patients respectively while the same was possible in 31. intubation was possible in first. Assuming a power of 80%.50±5.78±5. If this second attempt was also unsuccessful then third attempt of intubation was made after pulling the ILMA out and reinserting it again.The mean time required for intubation in the ILMA-TT group was 16.05 152. If there was difficulty in negotiating the tubes through the ILMA or when esophageal intubation was suspected (inadequate chest expansion. If no resistance was felt. no breath sound on auscultation and absent capnograph tracing) the tracheal tube was removed and further attempts were made subsequently by adopting the following manipulations in order.1. Overall. Germany) size 28 and 30 Fr was used for female and male patients respectively.00 1.8 Tracheal intubation . Rusch. In ILMA-TT group. The tubes were passed through the ILMA till 15 cm mark on the tubes and checked whether there was any resistance to further push. the universal connector of the ILMA-TT and the RTT was removed. First. Successful tracheal intubation in both the groups was confirmed by evidence of adequate ventilation (bilateral chest expansion and breath sounds on auscultation) and square shaped capnograph. esophageal intubation and incidence of complications including drop in oxygen saturation. the endotracheal tube was not negotiable through the ILMA. esophageal intubation had occurred in 7 patients and in the remaining 2 patients. High overall success rate of tracheal intubation has been reported with its use via ILMA in large number of patients.12 seconds as compared to 20.08±10. Variables recorded included intubation time (from the insertion of tracheal tube to the confirmation of intubation with the capnograph). the tubes were passed beyond 15cm mark till adequate length of the RTT was in. 10 patients in second attempt and 6 patients in third attempt. Of these 9 patients. . In the ILMA –TT group. In one patient intubation was not possible through the ILMA even after third attempt and intubation was done under direct laryngoscopy . There was no statistical difference in the need of manipulations and maneuvers between the groups.70±5.28±7.00 1.08±10. the ILMA was pulled towards the intubator holding its metal handle (Chandy’s maneuver)7 and attempt of advancing the tube further while rotating it.68±1.03 22:18 53. The ILMA was then removed while stabilizing the tracheal tube with the stabilizer (supplied by the ILMA manufacturer). all 40 (100.95±9. trauma and sore throat were similar in both the groups (Table 2).63 10. failed intubation. in 6 patients esophageal intubation had taken place and in 2 it was difficult to negotiate the endotracheal tube. The incidence of esophageal intubation.67 DISCUSSION The specially designed endotracheal tube is supplied by the manufacturer of the ILMA to enhance the success rate of intubation. no further attempts were made and intubation was done using direct laryngoscopy .00 0.46±10.5%) in RTT group.00 1. latex reinforced endo-tracheal tube (SilkolatexTM. tracheal intubation was possible in 63 patients in first attempt. The tracheal tube was fixed at appropriate mark with adhesive tape after verifying equal bilateral air entry and reconfirming it with capnography.05 was considered significant. ‘α’ error of 5% and an expected difference in the primary outcome (overall success of intubation) between the groups of 25%. height and airway characteristics were comparable in both the groups (Table 1).00 0.061).05 28/12/0/0 30/10 Table 2 Intubation data. A ‘p’ value <0. Continuous data were compared using‘t’ test and values expressed in proportion were analyzed using Chi-square or Fisher’s exact with Yates’ correction.58 11. trauma (indicated by blood staining of the tracheal tube which was judged after extubation of the trachea) and sore throat (documented postoperatively in the ward).
79: 699-703. flexible latex or silicone) through the ILMA have been reported with varying success rates. 6) Levitan RM. and chemical environment. 4) Minville V. . Use of the intubating laryngeal mask airway by medical and non-medical personnel.10 Kundra et al 10 reported success rate of nearly eighty-two percent of tracheal intubation with the use of Rusch latex armored tube which is lower than our success rate of nearly ninety-eight percent with the same tube. biological. 99: 1873. in a developing country like Nepal. 24(4): 403-405 405 It can be concluded that the conventional autoclavable. Kannan S. Use of the Intubating LMA-Fastrach in 254 patients with difficult to manage airways . Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear. J Med Assoc Thai 2004. reusable. It maintained the direction and did not bend posteriorly (Fig 1). major concerns about this special tube are its cost and availability. et al. 3) Ramachandran K. Horatanarung D. Ho AC. The ILMA may become useless once the tube gets damaged or becomes functionless.1. Laryngeal mask airway and the difficult airway. Curr Opin Anaesthesiol. Mil Med 2003. Am J Emerg Med. This may have further contributed to less esophageal intubations and better success rate in our study. Wongswadiwat M et al. 2) Thienthong S. However. Anesth Analg 2005. An experience with intubating laryngeal mask airway for difficult airway management: report on 38 cases. 9) Lu PP. Ochroch EA. The same reasons may explain lower incidence (17%) of esophageal intubations in our study as compared to their incidence of nearly thirty percent. 87: 1234-8. Guyen LN. Cuenca PJ. flexible reinforced latex tracheal tube can be safely used for ztracheal intubation with comparable success rate via the ILMA if the recommended silicone tracheal tubes supplied with the ILMA are not available. Stuart S. 5) Wedmore IS. Uses of various other endotracheal tubes (PVC. 95: 1175-81 8) Caponas G.Rotation of the tube while advancing it and use of smaller sized tubes in RTT group may have helped us in better negotiating the tube into the trachea. 7) Ferson DZ. Although we also found similar (40º) emerging angles of both ILMA-TT and RTT to the plane of ILMA cuff as shown by Kundra et al. Br J Anaesth 1997. Verghese C. The Intubating LMA : a comparison of inserting techniques with conventional tracheal tubes .J Anaesth Clin Pharmacol 2008. Talbo TS. Anaesth Intensive Care 2002. Development of a new device for intubation of the trachea. Longer mean time required for intubation in the RTT group in our study could be because of RTT being much softer and more flexible than the ILMA-TT and taking more time to negotiate through the ILMA. Intubating laryngeal mask airway. we did not find buckling of the RTT when pushed ahead in contrast to their finding. However. this longer time may be of very little clinical significance. Shyr MH.The Intubating laryngeal mask airway I. Conventional tracheal tubes for intubation through the Intubating laryngeal mask airway. Samii K.Anesthesiology 2001. Conventional reinforced latex tracheal tubes are not associated with increased complication rates and have the advantages of being less expensive and readily available. 30: 551-69. Yang CH.Can J Anesth 2000. Sujata N. Rosenblatt WH. 100: 284-8. Figure 1 The Rusch fexomettalic tube maintaining its emergence angle as it is advanced through the ILMA with this special tube was possible in all the patients in our study also. Difficult airway in obstetrics using ILMA-FastrachR. REFERENCES 1) Brain AIJ. Anesth Analg 2004. Addy EV et al. 47: 849-53 10) Kundra P.9. Hollander JE. 2000. Ravishankar M. Coustet B. 2004. Fourcade O. 18: 12-6. Johansen MJ. 17: 4913. 168: 876-9. particularly.
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