A Reading on Malpositioning of Supraglottic Airway Devices: Preventive and Corrective

Strategies

In Partial Fulfillment of the Requirements

in RT 112: Airway Management

Submitted to:
Jandayan, Jeno L., RTRP
Clinical Instructor

Submitted by:
Bermudez,Celine Mickaela A.
BSRT 3C

Date Submitted:
November 9, 2020
 Title:
Malpositioning of supraglottic airway devices: preventive and corrective
strategies
Bibliography:

A. J. Van Zundert, C. M. Kumar and T. C. R. V. Van Zundert, Malpositioning of

supraglottic airway devices: preventive and corrective strategies. 2016,
https://www.bjanaesthesia.org.uk/article/S0007-0912(17)30351-3/pdf
Summary:

Airway management is one of the fundamental aspect for modern anesthesia

and plays a vital role for all patients undergoing general anesthesia. Supraglottic airway
devices (SADs) are increasingly used for managing airways which keeps the upper
airways open to provide unobstructed ventilation. Through the years researchers invest
time and effort in designing and remodeling the SAD to prevent aspiration and to
improve its functionality and safety for patients.

Contrary to the insertion of a tracheal tube, which is guided to the trachea under
direct vision through laryngoscope, the insertion of a SAD is virtually a ‘blind’ technique,
it relies on the skills of the practitioner to correctly and efficiently insert the device into
the hypopharynx. SAD routine includes auscultation of the lungs and gastric area,
capnogram, oxygen saturation, airway pressure, oropharyngeal leak pressure, and the
gold standard to evaluate its position using a fibreoptic scope, however the usage of
fibreoptic scope can only help to know if the SAD is correctly positioned. Thus, it does
not have the ability to change or reposition the malpositioned SAD.

Supraglottic airway devices are considered forgiving devices because even

trivially positioned SADs can still dispense adequate ventilation for the patients during
short procedures. Though it is a forgiving device, incorrect placement of SAD can result
to leakage and can cause obstruction of airway that can cause adverse effect.

Prevalence of complication such as airway trauma, obstruction, regurgitationm

gastric distention and etc. can likely to happen in line with an incorrect placed SAD. On
the other hand, Clinical Obstruction most likely to happen as a result from other causes,
such as laryngospasm and transient closure of glottis.
 Computed tomography (CT) scans shows that the epiglottis is posteriorly
deflected against the posterior pharyngeal wall in most 80% patients. Preferred size of
the device should be inserted into the hypopharynx which is the bottom part of the
pharynx and the distal tip of SAD esophagus whereas the tip of epiglottis is aligned with
the proximal part of the mask. Thereby, epiglottis should rest on the other side of the
cuff and the tube opening of the device opposes the entrance of the trachea.

If cuffed SAD is used, it should be filled with enough air to produce adequate seal
that allows both spontaneous and artificial ventilation and avoid hyperventilation and
hypoventilation. Related risks exists if inappropriate size of device is used. Non cuffed
SAD may possibly leak due to lack of adequate alignment and seal between seal and
the epiglottis.

Unfitting devices may result from use of an inappropriately small size,

hypoinflation of the cuff, or too deep insertion of the device. In the worst-case scenario,
down folding of the epiglottis may result in a leak or obstruct adequate ventilation
altogether, indicated by a very low oropharyngeal leak pressure and the absence of a
normal capnogram trace, the presence of high airway pressure, and the inability to
ventilate the patient. Anesthetists will then try to readjust the device or take it out
altogether and replace it with either another SAD or use a tracheal tube instead.

Selection of the correct SAD, the correct size, and all efforts to prevent aspiration
are all only secondary to the correct positioning of the device to the patient. The
epiglottis clearly plays a vital role in the correct positioning of any SAD. As down folding
of the epiglottis can occur with any of existing SADs, less ideal positioning may
generate problems in creating a patent airway. The primary role of healthcare
practitioner is to create a safe and effective patent airway.
Reactions
 Do you agree with the article/journal? Why?
- Yes, Supraglottic Airway Devices if placed correctly by a skillful practitioner can
have the upper airways open to provide unobstructed ventilation as it is
considered a blind technique and more complex compared to the usual
insertion of tracheal tube.
 Realizations? Insights?
- There a lot of techniques or ways to help the patient open up its airway, remove
blockage and help a patient breathe if they have collapsed lungs , heart failure or
trauma.
 Positive and negative impact of the article/ journal?
- The positive impact of the article is that it tackles about the use of supraglottic
airway device. It also states its preventive and corrective strategies on using SAD’s.
It usually up to the skill of the practitioner. It also tackles the importance of the
proper placement of the device and to avoid any adverse effect that can cause
discomfort to the patient.
 Respiratory Therapy implications of the article/ journal?
- Respiratory therapist are knowledgeable enough on how to relieve airway
obstruction through the use of special airways namely the Oropharyngeal airway,
Nasopharyngeal, Esophageal Gastric Tube Airway. Laryngeal Mask Airway,
Esophageal Tracheal Combitube, Double Lumen Endobronchial Tube.
A Reading on Expert Recommendations for Tracheal Intubation in Critically ill Patients
with Noval Coronavirus Disease 2019

In Partial Fulfillment of the Requirements

in RT 112: Airway Management

Submitted to:
Jandayan, Jeno L., RTRP
Clinical Instructor

Submitted by:
Bermudez, Celine Mickaela A.
BSRT 3C

Date Submitted:
November 9, 2020
Title:

Expert Recommendations for Tracheal Intubation in Critically ill Patients with

Noval Coronavirus Disease 2019

Bibliography:

Mingzhang Zuo, Yuguang Huang, Wuhua M, Zhanggang Xue , Jiaqiang Zhang,

Yahong Gong, Lu Che, Chinese Society of Anesthesiology Task Force on Airway
Management.

Summary:

Coronavirus Disease 2019 (COVID-19), caused by a novel coronavirus (SARS-

CoV-2), is a highly contagious disease originated in Wuhan, Hubei Province of China in
December 2019. It moved rapidly and infected people throughout China and even
spread to different countries around the globe as it is considered an airborne disease.
Patients with suspected COVID 19 have mild symptoms such as fever, fatigue and
cough. In severe cases, patients may develop acute respiratory distress syndrome
(ARDS), septic shock, metabolic acidosis and coagulopathy that may lead to death if
not treated.

The new strain of Corona Virus is known to be transmitted via droplets, direct
contact to a positive patient, and natural aerosol from human to human.
Anesthesiologists who came in contact to patients who are under endotracheal
intubation have high risk of acquiring nosocomial infections as endotracheal intubation
is considered a high risk aerosol producing procedures. During airway management, an
enhanced tight droplet or airborne proof PPE is vital to every health care providers that
will come in contact to the patient. A good airway assessment before airway intervention
is a must.

Awake intubation to patients with normal airway is not needed and should be
avoided as it would only cause discomfort to the patient. Whereas, good preparation of
airway devices and detailed intubation plans should be done for patients with difficult
airways.
 Endotracheal intubation in needed to performed when a patient with persisting
respiratory distress and hypoxemia are present even after high flow nasal oxygenation
or non –invasive ventilation for 2 hours. Infection control is of top priority as
endotracheal intubation is a high risk procedure as secretions, blood, droplets and
aerosols can spread. Intubation procedure should be done in an airborne isolation
room. Personal Protective Equipment (PPE) such as fit test N95 mask, hair cover,
protective cover all, gown gloves, face shields, goggles and shoe covers should be
strictly implemented to worn by health care practitioner dealing endotracheal intubation.

Performing an effective rapid airway assessment before airway intervention is

vital as it may aid pre intubation planning of the patient. This includes the patient’s past
history of difficult airway, mouth opening , thyromental distance of < 6cm . mobility of the
head and neck, circumference of neck and modified Malampati Test. Usage of
disposable airway management tools is recommended to lower the risk of passing the
virus from patient to patient. Airway management tools such as video laryngoscope with
disposable blades, Disposable seeing optical stylet or disposable video endotracheal
tube, Disposable second-generation intubating laryngeal mask, Prepare devices for
needle or scalpel cricothyroidotomy.

Awake bronchoscopic trans - nasal intubation is recommended for anticipated

difficult airway. If it fails, oral intubation can be done. Enhanced PPE is needed and
health precautionary measures should be observed to inhibit cough reflexes. Topical
anesthesia or Lidocaine spray can be used with cautions as it may generate contagious
aerosol droplets. Cricoid pressure by an experienced assistant can be applied to
prevent gastroesophageal reflux and aspiration. If tracheal intubation fails, a second-
generation laryngeal mask should be placed immediately. If the second-generation
laryngeal mask is placed properly and satisfactory ventilation is achieved, then tracheal
intubation can be achieved through the laryngeal mask with the guidance of fibreoptic
bronchoscope. If tracheal intubation, face-mask ventilation, and second-generation
laryngeal mask airway (LMA) all have failed, proceed to invasive cricothyroidotomy
immediately to ensure ventilation
 After a successful intubation, proper placement of EET is confirmed through a
clear detection of trachea ring or bulge by bronchoscopy. All the airway devices must be
collected in double-sealed bags and implement proper disinfection during disposal.
Appropriate cleaning and disinfection of equipment and environment surfaces is
mandatory to reduce transmission by the indirect contact route.
Reactions
 Do you agree with the article/journal? Why?
- Yes, Tracheal Intubation is an approved way of providing breathing support to
severe COVID 19 patients, It supports the patient’s breathing so the body can
survive as the immune system fights the virus.
 Realizations? Insights?
- Intubation plays an important role on helping severe COVID 19 patients in this time
of pandemic in order for them to have patent airways as this disease is very
rampant nowadays not only in the Philippines but also worldwide. It is very useful to
permit air to pass freely to and from the lungs in order to ventilate the lungs thus
making the patient breath more efficiently.
 Positive and negative impact of the article/ journal?
- The positive impact of the chosen journal is that it acknowledge the importance of
the tracheal intubation on severe COVID 19 patients. It explained the procedure in a
clear, concise and in depth manner. It explained the importance of usage of the
PPE’s of health care practitioner, risks, indications and contraindications
 Respiratory Therapy implications of the article/ journal?
- Though in the Philippines Respiratory Therapists are not allowed to perform
intubation alone, RT’s are on the side to assist the physician in the procedure they
are knowledgeable on the proper execution of the procedure and also knows its
indications and contraindications of the procedure.