BSC OPERATION THEATER AND

ANAESTHESIA TECHNOLOGY
DEPARTMENT OF ANAESTHESIOLOGYSRM MEDICAL COLLEGE HOSPITAL AND
RESEARCH CENTER, POTHERI

SEMESTER VI - UNIT I
NEUROANAESTHESIA

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S.n Topic Book
o
1 Anatomy of brain PRINT HANDOUT

2 Blood supply of brain Ch. 2

3 Common neurosurgical procedures Ch. 14

4 Positions in neurosurgery Ch. 15

5 Positioning aids PRINT HANDOUT

6 Preoperative assessment of patients Ch. 12

7 Anaesthesia management in neuro surgery PRINT HANDOUT

8 Anaesthesia and Surgery for aneurysm Ch. 17

9 Anaesthesia and Surgery for brain trauma Ch. 23

10 Anaesthesia and Surgery for cervical spine PRINT HANDOUT

11 Anaesthesia and Surgery for microneurosurgery PRINT HANDOUT

12 Venous air embolism Ch. 18

13 Common intra-operative complications Ch. 7,16,18,19

14 Common postoperative complications Ch. 31

15 Anaesthetic drugs used in neurosurgery Ch. 8,9,10,11

16 Airway management using LMA and FOB PRINT HANDOUT

BOOK REFERENCE : SPECIFIED CHAPTERS FROM THE BOOK - SAUNDERS

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 TOPIC 1 : Anatomy of the Brain
The brain serves many important functions. It gives meaning to things that happen in the
world surrounding us. Through the five senses of sight, smell, hearing, touch and taste, the
brain receives messages, often many at the same time.The brain controls thoughts, memory
and speech, arm and leg movements and the function of many organs within the body. It also
determines how people respond to stressful situations (i.e. writing of an exam, loss of a job,
birth of a child, illness, etc.) by regulating heart and breathing rates. The brain is an
organized structure, divided into many components that serve specific and important
functions.The weight of the brain changes from birth through adulthood. At birth, the average
brain weighs about one pound, and grows to about two pounds during childhood. The
average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male
weighs about three pounds.

The Nervous System

The nervous system is commonly divided into the central nervous system and the peripheral
nervous system. The central nervous system is made up of the brain, its cranial nerves and
the spinal cord. The peripheral nervous system is composed of the spinal nerves that branch
from the spinal cord and the autonomous nervous system (divided into the sympathetic and
parasympathetic nervous system).

The Cell Structure of the Brain

The brain is made up of two types of cells: neurons and glial cells, also known as neuroglia
or glia. The neuron is responsible for sending and receiving nerve impulses or signals. Glial
cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form
myelin and facilitate signal transmission in the nervous system. In the human brain, glial
cells outnumber neurons by about 50 to one. Glial cells are the most common cells found in
primary brain tumors.When a person is diagnosed with a brain tumor, a biopsy may be done,
in which tissue is removed from the tumor for identification purposes by a pathologist.

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Pathologists identify the type of cells that are present in this brain tissue, and brain tumors
are named based on this association. The type of brain tumor and cells involved impact
patient prognosis and treatment.

The Meninges

The brain is housed inside the bony covering called the cranium. The cranium protects the
brain from injury. Together, the cranium and bones that protect the face are called the skull.
Between the skull and brain is the meninges, which consist of three layers of tissue that cover
and protect the brain and spinal cord. From the outermost layer inward they are: the dura
mater, arachnoid and pia mater.Dura Mater: In the brain, the dura mater is made up of two
layers of whitish, nonelastic film or membrane. The outer layer is called the periosteum. An
inner layer, the dura, lines the inside of the entire skull and creates little folds or
compartments in which parts of the brain are protected and secured. The two special folds of
the dura in the brain are called the falx and the tentorium. The falx separates the right and left
half of the brain and the tentorium separates the upper and lower parts of the
brain.Arachnoid: The second layer of the meninges is the arachnoid. This membrane is thin
and delicate and covers the entire brain. There is a space between the dura and the arachnoid
membranes that is called the subdural space. The arachnoid is made up of delicate, elastic
tissue and blood vessels of varying sizes.Pia Mater: The layer of meninges closest to the
surface of the brain is called the pia mater. The pia mater has many blood vessels that reach
deep into the surface of the brain. The pia, which covers the entire surface of the brain,
follows the folds of the brain. The major arteries supplying the brain provide the pia with its
blood vessels. The space that separates the arachnoid and the pia is called the subarachnoid
space. It is within this area that cerebrospinal fluid flows.

Cerebrospinal Fluid

Cerebrospinal fluid (CSF) is found within the brain and surrounds the brain and the spinal
cord. It is a clear, watery substance that helps to cushion the brain and spinal cord from
injury. This fluid circulates through channels around the spinal cord and brain, constantly
being absorbed and replenished. It is within hollow channels in the brain, called ventricles,
that the fluid is produced. A specialized structure within each ventricle, called the choroid
plexus, is responsible for the majority of CSF production. The brain normally maintains a
balance between the amount of CSF that is absorbed and the amount that is produced.
However, disruptions in this system may occur.

The Ventricular System

The ventricular system is divided into four cavities called ventricles, which are connected by
a series of holes, called foramen, and tubes.Two ventricles enclosed in the cerebral
hemispheres are called the lateral ventricles (first and second). They each communicate with
the third ventricle through a separate opening called the Foramen of Munro. The third

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ventricle is in the center of the brain, and its walls are made up of the thalamus and
hypothalamus.The third ventricle connects with the fourth ventricle through a long tube
called the Aqueduct of Sylvius.CSF flowing through the fourth ventricle flows around the
brain and spinal cord by passing through another series of openings.

Brain Components and Functions

BrainstemThe brainstem is the lower extension of the brain, located in front of the
cerebellum and connected to the spinal cord. It consists of three structures: the midbrain,
pons and medulla oblongata. It serves as a relay station, passing messages back and forth
between various parts of the body and the cerebral cortex. Many simple or primitive
functions that are essential for survival are located here.The midbrain is an important center
for ocular motion while the pons is involved with coordinating eye and facial movements,
facial sensation, hearing and balance.The medulla oblongata controls breathing, blood
pressure, heart rhythms and swallowing. Messages from the cortex to the spinal cord and
nerves that branch from the spinal cord are sent through the pons and the brainstem.
Destruction of these regions of the brain will cause "brain death." Without these key
functions, humans cannot survive.The reticular activating system is found in the midbrain,
pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to
pay attention to their environments and is involved in sleep patterns.Originating in the
brainstem are 10 of the 12 cranial nerves that control hearing, eye movement, facial
sensations, taste, swallowing and movements of the face, neck, shoulder and tongue muscles.
The cranial nerves for smell and vision originate in the cerebrum. Four pairs of cranial nerves
originate from the pons: nerves five through eight.

Cerebellum

The cerebellum is located at the back of the brain beneath the occipital lobes. It is separated
from the cerebrum by the tentorium (fold of dura). The cerebellum fine tunes motor activity
or movement, e.g. the fine movements of fingers as they perform surgery or paint a picture. It
helps one maintain posture, sense of balance or equilibrium, by controlling the tone of
muscles and the position of limbs. The cerebellum is important in one's ability to perform
rapid and repetitive actions such as playing a video game. In the cerebellum, right-sided
abnormalities produce symptoms on the same side of the body.

Cerebrum

The cerebrum, which forms the major portion of the brain, is divided into two major parts:
the right and left cerebral hemispheres. The cerebrum is a term often used to describe the
entire brain. A fissure or groove that separates the two hemispheres is called the great
longitudinal fissure. The two sides of the brain are joined at the bottom by the corpus
callosum. The corpus callosum connects the two halves of the brain and delivers messages
from one half of the brain to the other. The surface of the cerebrum contains billions of

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neurons and glia that together form the cerebral cortex.The cerebral cortex appears grayish
brown in color and is called the "gray matter." The surface of the brain appears wrinkled. The
cerebral cortex has sulci (small grooves), fissures (larger grooves) and bulges between the
grooves called gyri. Scientists have specific names for the bulges and grooves on the surface
of the brain. Decades of scientific research have revealed the specific functions of the various
regions of the brain. Beneath the cerebral cortex or surface of the brain, connecting fibers
between neurons form a white-colored area called the "white matter."The cerebral
hemispheres have several distinct fissures. By locating these landmarks on the surface of the
brain, it can effectively be divided into pairs of "lobes." Lobes are simply broad regions of
the brain. The cerebrum or brain can be divided into pairs of frontal, temporal, parietal and
occipital lobes. Each hemisphere has a frontal, temporal, parietal and occipital lobe. Each
lobe may be divided, once again, into areas that serve very specific functions. The lobes of
the brain do not function alone: they function through very complex relationships with one
another.Messages within the brain are delivered in many ways. The signals are transported
along routes called pathways. Any destruction of brain tissue by a tumor can disrupt the
communication between different parts of the brain. The result will be a loss of function such
as speech, the ability to read or the ability to follow simple spoken commands. Messages can
travel from one bulge on the brain to another (gyri to gyri), from one lobe to another, from
one side of the brain to the other, from one lobe of the brain to structures that are found deep
in the brain, e.g. thalamus, or from the deep structures of the brain to another region in the
central nervous system.Research has determined that touching one side of the brain sends
electrical signals to the other side of the body. Touching the motor region on the right side of
the brain would cause the opposite side or the left side of the body to move. Stimulating the
left primary motor cortex would cause the right side of the body to move. The messages for
movement and sensation cross to the other side of the brain and cause the opposite limb to
move or feel a sensation. The right side of the brain controls the left side of the body and vice
versa. So if a brain tumor occurs on the right side of the brain that controls the movement of
the arm, the left arm may be weak or paralyzed.

Cranial Nerves

There are 12 pairs of nerves that originate from the brain itself. These nerves are responsible
for very specific activities and are named and numbered as follows:

Olfactory: Smell

Optic: Visual fields and ability to see

Oculomotor: Eye movements; eyelid opening

Trochlear: Eye movements

Trigeminal: Facial sensation

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Abducens: Eye movements

Facial: Eyelid closing; facial expression; taste sensation

Auditory/vestibular: Hearing; sense of balance

Glossopharyngeal: Taste sensation; swallowing

Vagus: Swallowing; taste sensation

Accessory: Control of neck and shoulder muscles

Hypoglossal: Tongue movement

Hypothalamus

The hypothalamus is a small structure that contains nerve connections that send messages to
the pituitary gland. The hypothalamus handles information that comes from the autonomic
nervous system. It plays a role in controlling functions such as eating, sexual behavior and
sleeping; and regulates body temperature, emotions, secretion of hormones and movement.
The pituitary gland develops from an extension of the hypothalamus downwards and from a
second component extending upward from the roof of the mouth.

The Lobes

Frontal Lobes

The frontal lobes are the largest of the four lobes responsible for many different functions.
These include motor skills such as voluntary movement, speech, intellectual and behavioral
functions. The areas that produce movement in parts of the body are found in the primary
motor cortex or precentral gyrus. The prefrontal cortex plays an important part in memory,
intelligence, concentration, temper and personality.The premotor cortex is a region found
beside the primary motor cortex. It guides eye and head movements and a person’s sense of
orientation. Broca's area, important in language production, is found in the frontal lobe,
usually on the left side

.Occipital Lobes

These lobes are located at the back of the brain and enable humans to receive and process
visual information. They influence how humans process colors and shapes. The occipital lobe
on the right interprets visual signals from the left visual space, while the left occipital lobe
performs the same function for the right visual space.Parietal LobesThese lobes interpret
simultaneously, signals received from other areas of the brain such as vision, hearing, motor,
sensory and memory. A person’s memory, and the new sensory information received, give
meaning to objects.Temporal LobesThese lobes are located on each side of the brain at about

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ear level, and can be divided into two parts. One part is on the bottom (ventral) of each
hemisphere, and the other part is on the side (lateral) of each hemisphere. An area on the
right side is involved in visual memory and helps humans recognize objects and peoples'
faces. An area on the left side is involved in verbal memory and helps humans remember and
understand language. The rear of the temporal lobe enables humans to interpret other
people’s emotions and reactions.

Limbic System

This system is involved in emotions. Included in this system are the hypothalamus, part of
the thalamus, amygdala (active in producing aggressive behavior) and hippocampus (plays a
role in the ability to remember new information).

Pineal Gland

This gland is an outgrowth from the posterior or back portion of the third ventricle. In some
mammals, it controls the response to darkness and light. In humans, it has some role in
sexual maturation, although the exact function of the pineal gland in humans is unclear

.Pituitary Gland

The pituitary is a small gland attached to the base of the brain (behind the nose) in an area
called the pituitary fossa or sella turcica. The pituitary is often called the "master gland"
because it controls the secretion of hormones. The pituitary is responsible for controlling and
coordinating the following:

Growth and development

The function of various body organs (i.e. kidneys, breasts and uterus)

The function of other glands (i.e. thyroid, gonads, and adrenal glands)

Posterior Fossa

This is a cavity in the back part of the skull which contains the cerebellum, brainstem and
cranial nerves 5-12.

Thalamus

The thalamus serves as a relay station for almost all information that comes and goes to the
cortex. It plays a role in pain sensation, attention and alertness. It consists of four parts: the
hypothalamus, the epythalamus, the ventral thalamus and the dorsal thalamus. The basal
ganglia are clusters of nerve cells surrounding the thalamus.

Language and Speech Functions

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In general, the left hemisphere or side of the brain is responsible for language and speech.
Because of this, it has been called the "dominant" hemisphere. The right hemisphere plays a
large part in interpreting visual information and spatial processing. In about one-third of
individuals who are left-handed, speech function may be located on the right side of the
brain. Left-handed individuals may need specialized testing to determine if their speech
center is on the left or right side prior to any surgery in that area.Many neuroscientists
believe that the left hemisphere and perhaps other portions of the brain are important in
language. Aphasia is simply a disturbance of language. Certain parts of the brain are
responsible for specific functions in language production. There are many types of aphasias,
each depending upon the brain area that is affected, and the role that area plays in language
production.There is an area in the frontal lobe of the left hemisphere called Broca’s area. It is
next to the region that controls the movement of facial muscles, tongue, jaw and throat. If
this area is destroyed, a person will have difficulty producing the sounds of speech, because
of the inability to move the tongue or facial muscles to form words. A person with Broca's
aphasia can still read and understand spoken language, but has difficulty speaking and
writing.There is a region in the left temporal lobe called Wernicke's area. Damage to this area
causes Wernicke's aphasia. An individual can make speech sounds, but they are meaningless
(receptive aphasia) because they do not make any sense.

TOPIC 5 : POSITIONING AIDS IN HEAD FIXATION

1. Pin (Mayfield) head holder

2. Radiolucent pin head holder
3. Horseshoe head rest
4. Foam head support (e.g., Voss, O.S.I., Prone-View)
5. Vacuum mattress (“bean bag”)
6. Wilson-type frame
7. Relton-Hall (four-poster) frame

1. Pin Skull Clamps

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The current gold standard for head fixation in neurosurgery is the Mayfield®
skull clamp. It is comprised of a mounting device, an arm, a clamp and three
skull pins. The mounting device which is typically made of stainless steel
attaches to the table and connects with the arm. The arm has a few joints to give
the device a high degree of freedom. It is typically made of a glass-infused
PEEK composite which is light (low density) and strong, and its joints are
typically made from powder-coated anodized aluminum. The clamp is attached
to the arm and is also typically made of glass-infused PEEK composite. It can
be rotated at the base to allow the head to be positioned and holds three skull
pins in place. The skull pins which are made of titanium or stainless steel hold
the head in place and are fixed to the clamp. These pins pierce partway into the
skull to make sure they are held in place. The amounts of pressure pins exert on
the skull are measured by spring loaded pressure gauges which are located at
the pin insertion points.The major problem with this device is the fact that it is
not suitable for young children which have much more fragile skulls. Skull
penetration and depression are common when this device is used in younger
children. There are specialized pins with a flat surface made of rigid plastic or
metal at the base of pin to prevent skull penetration. However, these pins can
cause skull depression when the hard base is pressed against the skull

2.3.2 Horseshoe Head Holders

Another commonly used technology for head fixation is the horseshoe head
holder. This device has the patient’s head rested in between the legs of a padded
horseshoe shaped device. Also the forehead can either contact the base of the
“U” or be exposed to the open surface depending on the need. The pads are
typically made of gels such as viscoelastic polymer Akton® [17].The major

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problems with this device is its stability. It does not provide nearly as much
stability as the pin head holder and therefore is not appropriate for surgeries
which require absolute stability such as those which use microscopes. It is more
commonly used for the surgeries where the stability is not extremely critical
such as hydrocephalus treatment [6]. However, during long surgeries,
prolonged contact with the device, lack of oxygen to the skin, and constant
pressure can cause skin necrosis or pressure sores which are discussed later.

2.3
.3Combined Head Holder Devices

There are other devices that aim to solve the problems of the previous two
devices. One of them is the “multi-purpose” head holder which holds the head
using several gel pads as shown in figure 5. It also has interchangeable parts;
the pads can be exchanged for different shaped ones or pins can be put in place

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of the side gel pads [18]. According to our client, Dr. Cataltepe, this device is
too intrusive to be used and gets in the way of surgical procedures. In addition,
these devices can cause skin necrosis and pressure sores on its multiple contact
areas.

2.4 Patient Head Positioning and Fixation

Positioning of the patient is a critical step in neurosurgical care, and it begins

with fixation of the head. Appropriate head positioning helps the neurosurgeon
perform an effective operation and prevents serious complications. As infant
head is delicate and prone to prolonged pressures, the ideal positioning involves
balancing surgical comfort against the risks related to the desired intraoperative
position, particularly during long procedures [19].

There are 3 fundamental positions in neurosurgery: supine, lateral and prone.

 Supine position: this position is the most frequently utilized position in

neurosurgery. The head can be neutral straight or slightly turned. This position
allows access to the frontal, parietal and temporal lobes.

 Lateral oblique position: this position is used for surgical approach in the
temporal lobe, skull base and posterior fossa (near the brainstem and
cerebellum).

 Prone position: the head is placed neutral downward. This position is

commonly utilized for approaches to the occipital and suboccipital regions.

Among the three standard head positions, supine position is the simplest
positioning and easily achievable with any current head fixation devices. On the
other hand, prone position is the most difficult positioning and compatible with
fewer devices. It is also associated with more challenges in securing lines and
maintaining adequate ventilation, as well as increased risk of complications due
to prolonged pressure on the face and eye area [19].

No position is ideally safe for pin fixation as fontanelles and sutures are located
around the skull.Once the fixation position is determined, antiseptic solution is
applied on the surgical site as well as pin fixation site, if pin head holder is
used, to prevent surgical site infection. The two pins in the dual pin rocker

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should be equidistant from the centerline to achieve optimal stability. When the
pins are aligned to the desired position, the arms are squeezed together by
sliding the ratchet gear until the pins contact with the skull. The pins are
screwed into the skull by tightening the knobs, starting with the single pin and
then the dual pins. In most of current pin fixation devices, the knobs are
equipped with spring loaded force gauges to indicate the amount of applied

FOAM HEAD SUPPORT

forces.
VACUUM MATTRESS (“BEAN BAG”)

By molding to patients' bodies

without applying pressure, vacuum
mattresses reduce pressure point
tenderness and increase patient
comfort — a win-win for patients
and medics 13
VACUUM MATTRESS (“BEAN BAG”)

By molding to patients' bodies

without applying pressure, vacuum
mattresses reduce pressure point
tenderness and increase patient
comfort — a win-win for patients
and medics

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POSITIONING AIDS AND SUPPORTS
Relton-Hall (four-poster) frame

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 Wilson-type frame – for spine
surgery.

2.8 Complications Related to Head FixationThe use of current head fixation

devices in pediatric neurosurgery such as pin skull clamp and horseshoe
headrest have been reported with several complications. The most common
complications are pressure-related, including skull penetration and skull
depression caused by pin fixation and skin necrosis and pressure sores by the
headrest.

TOPIC 7 : ANESTHESIA MANAGEMENT IN

NEUROSURGICAL PROCEDURES

Preoperative medication
• Diazepam 5–15 mg orally if normal consciousness
• In children (>1 year) diazepam or midazolam 0.3–0.5 mg/kg orally (max. 15 mg)
• Regular oral antiepileptic drugs
• Betamethasone (Betapred 4mg/ml) with proton pump inhibitor in CNS tumor
patients
• Hydrocortison with proton pump inhibitor in pituitary tumors
• Regular antihypertensive (excluding ACE-inhibitors, diuretics), asthma and
COPD drugs and statins
• Insulin i.v., as needed, in diabetic patients, B-gluc aim 5–8 mmol/l

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Induction
• One peripheral i.v. cannula before induction, another 17-gauge i.v. cannula in
antecubital vein
after induction
• Glycopyrrolate 0.2 mg or 5 μg/kg (in children) i.v.
• Fentanyl 5–7 μg/kg. i.v.
• Thiopental 3–7 mg/kg i.v.
• Rocuronium 0.6–1.0 mg/kg i.v. or succinylcholine 1.0–1.5 mg/kg i.v.
• Vancomycin 1 g (or 20 mg/kg) i.v. in 250 ml of normal saline in CNS surgery,
otherwise
cefuroxime 1.5 g i.v.
• 15% mannitol 500 ml (or 1g/kg) as indicated
Pulmonary/airway management
• Oral endotracheal intubation
• Nasal fiberoptic endotracheal intubation under local anesthesia if anticipated
difficult airway or
instability in cervical spine
• Firm fixation of intubation tube by tape without jugular vein compression
• Access to endotracheal tube in every patient position
• FiO2 0.4–1.0 (in sitting position and during temporary clipping 1.0). SaO2 >95%,
PaO2 >13 kPa
• Normoventilation PaCO2 4.5–5.0 kPa with volume controlled ventilator, TV 7-
10 ml/kg, respiration
rate 10–15/min, no routine PEEP
• Mild hyperventilation (PaCO2 4.0–4.5 kPa) in primary surgery of TBI as needed
and to counteract the
vasodilatory e©ects of inhaled anesthetics
Maintenance of anesthesia
Normal ICP, uncomplicated surgery
• Sevoflurane (or isoflurane) in O2/N2O up to 1 MAC
• Fentanyl boluses (0.1 mg) or remifentanil infusion (0.125–0.25 μg/kg/min)
• Rocuronium as needed
High ICP, tight brain, emergency surgery
• Propofol-infusion (6–12 mg/kg/hour)
• Remifentanil infusion (0.125–0.25 μg/kg/min) or fentanyl boluses (0.1 mg)
• Rocuronium as needed
• No inhaled anesthetics
Termination of anesthesia
• Postoperative controlled ventilation and sedation is discussed in each case
separately
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• Normoventilation until removal of endotracheal tube, avoid hypertension
• Patient has to be awake, obey commands, breathe adequately and have core
temperature above
35.0–35.5 °C before extubation.

ACE, angiotensin-converting enzyme; CNS, central nervous system; COPD, chronic obstructive
pulmonary disease; FiO2,
inspired oxygen concentration; TV, tidal volume; MAC, minimum alveolar concentration; TBI,
traumatic brain injury;
PEEP, positive end-expiratory pressure; i.v., intravenous.

TOPIC 10 : ANESTHETIC CONSIDERATIONS FOR PATIENTS WITH

ACUTE CERVICAL SPINAL CORD INJURY

Introduction

Cervical spine injury (CSI) occurs in 0.9% to 3% of all patients with blunt
trauma, with a weighted average of 1.8% (Crosby et al., 1990; Casha et al.,
2011). Acute cervical spinal cord injury (CSCI) can cause significant morbidity
and mortality. Most of these patients will see an anesthesiologist, as patients
with CSCI often require emergent airway management (intubation) and
emergent surgery. Guidelines exist for the treatment of spinal cord injury (SCI),
but these include few details for anesthesiologists, even though they always
take part in patient management. Anesthesiologists may be able to prevent or
minimize secondary injury to the nervous system and improve patient outcome
by ensuring that they understand the pathophysiology of CSCI and make a
patient-specific plan during the perioperative period. In this review, we
highlight important factors for the optimal treatment of acute CSCI patients by
anesthesiologists during preoperative interviews, airway management,
induction administration, management during general anesthesia, and recovery
phases. We hope that such information will provide anesthesiologists with
useful information about CSCI, enabling them to provide optimal
management.Preoperative AssessmentHistoryFirst, it is necessary to determine
the cause of injury, if possible. This will enable the anesthesiologist to
anticipate likely injury patterns. For example, “rear end” motor vehicle
collisions usually result in damage to central cord syndrome patterns. Second,
the time span from injury to treatment is important as this dictates whether
prophylactic anticoagulation and hypothermia can be used. Additionally, the

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time course of treatment may signal the potential for complications that require
anesthesiologist management. Although the timing of decompressive surgery
was not given in some CSCI studies early surgery has been found to be feasible
and safe, and can improve clinical and neurological outcomes as well as reduce
medical costsPhysical examinationAn initial assessment of the airway,
respiration, and circulation of the patient should always be conducted prior to
evaluation of the spine. CSCI patients should be monitored in intensive care,
and hemodynamic instability and respiratory insufficiency should be managed.
Maintenance of mean arterial blood pressure (MAP) at 85 to 90 mmHg in the
first week following injury can improve spinal perfusion. Respiratory
insufficiency is common after CSCI. CSCI disrupts the function of the
diaphragm, muscles, accessory respiratory muscles, and abdominal muscles.
This can lead to the loss of vital capacity and expiratory force, predisposing
patients to atelectasis and the secretion retention, thus resulting in a high
incidence of pneumonia. Patients with CSCI above C3–5 often need respiratory
care. Intubation and ventilator support should be used if the patient has the
following conditions:(1) PaO2 < 60 mmHg (1 mmHg = 0.133 kPa),(2) PaCO2
> 45 mmHg, or(3)respiratory rate > 35 breaths per minute despite medical
managementIntranasal oxygen is usually sufficient for patients with CSCI
below C5. Neurological examination is thus necessary to designate the injured
segment of the spinal cord. Frankel classification (Table 1) concerns both motor
and sensory functions, and is associated with long-term prognosis. To exclude
“spinal shock”, it is not possible to diagnose patients until at least 24–48 hours
after injury.

Radiographic assessment

Radiographic images are widely used to evaluate CSI and SCI. For
symptomatic patients, the 2002 American Association of Neurological
Surgeons and Congress of Neurological Surgeons (AANSCNS) guidelines
recommended a 3-views cervical spine series. At present, high-quality computer
tomography (CT) has been recommended (Hadley et al., 2013). CT is ideal for
visualization of most fractures. Magnetic resonance imaging (MRI) allows
detailed visualization of the soft tissue structure, and is sufficiently sensitive to
reveal abnormal cord signals. MRI is optimal for detecting edema, hemorrhage,
and ligamentous injuries. MRI may be required in patients whose clinical
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presentation cannot be explained by plain film or CT. Radiographic imaging
can help anesthesiologists evaluate the level of SCI and cervical spine stability,
plan airway management, and determine whether a ventilator is necessary. Only
20% of traumatic injuries are limited to the cervical spine, and 25–50% of CSI
patients have associated head injuries (Sekhon et al., 2001). Patients with
additional organ damage are more likely to require emergency airway and
surgical interventions, and are also susceptible to secondary nerve injury.

Neuroprotection

Immobilization

To reduce secondary injury and mortality, spinal immobilization is widely

recommended for cervical spine or CSCI patients. Cervical collars, sandbags,
tape, and axial-traction devices are common. Used alone, collars cannot
effectively reduce spinal movement, and they may limit mouth-opening
movements.

Methylprednisolone.

Although not included in the 2013 guidelines, the 2002 guidelines

recommended a high dose of methylprednisolone for patients within eight hours
of the injury. Indeed, few has known the clinical benefits and various harmful
side effects of methylprednisolone , such as hyperglycemia, depression of the
immune system, gastrointestinal bleeding, and even death. If surgeons choose to
use methylprednisolone, the anesthesiologist should consider the management
of potential complications. GM-1 ganglioside was not recommended for
treatment of CSCI in the 2013 guidelines. Other substances, such as
thyrotropin-releasing hormone, have potential, but require further testing with
large clinical trials.

Hypothermia

Moderate hypothermia has been used to target several neurological disorders,

including traumatic brain injury and SCI, in a variety of experimental and
clinical situations. Deep and sustained hypothermia may lead to complications,
including coagulopathy, cardiovascular instability, and infection. Systemic
introduction of moderate hypothermia (33°C) appears to be safe and provides

20
some benefits in terms of long-term functional recovery. At present, mild
hypothermia or low normothermia have been widely accepted in the
management of CSCI patients. Some studies have focused on local
hypothermia, but clinical application has been limited due to the small number
of samples and the lack of randomization and control.

Airway Management

The primary objective when managing the airway in a CSCI patient is to

minimize neck movement while rapidly and efficientlysecuring the airway.All
basic airway maneuvers have effects on the injuredneck (Aprahamian et al.,
1984). Mask ventilation is a commonlyused method, and moves the cervical
spine more thanany other method (Hauswald et al., 1991). Although
cricoidpressure is safe in CSI patients (Donaldson et al., 1997), othertypes of
movement or force may enhance injury.Direct laryngoscopy induces the
greatest motion at thecraniocervical junction, moderate motion at the C1 to
C2joints, and causes minimal displacement below C4 in healthypatients (Sawin
et al., 1996). Direct laryngoscopy can still cause spinal movement during
manual in-line immobilization(MILI) involving a cervical collar and traction,
althoughthe movement magnitude is small and within physiologicalrange in the
injured spine model (Gerling et al., 2000; Lennarsonet al., 2001). Different
laryngoscope blades (Macintosh,McCoy, and Miller) are comparable in terms
of theirinfluence on spinal movement during direct laryngoscopy(Hastings et
al., 1995; MacIntyre et al., 1999; Gerling et al.,2000).MILI is most frequently
used during airway management,and is applied to limited head and neck
movement.

AlthoughMILI improves laryngoscopic grade in some patients, it increasesthe

failure rate of successful intubations within thefirst 30 seconds.Compared with
collar immobilization, MILI reduces total spinalmovement (Majernick et al.,
1986; Watts et al., 1997) andimproves laryngeal visualization (Heath et al.,
1994; Gerlinget al., 2000) during oral tracheal intubation. When MILI is
inplace, the front portion of the collar can be removed to allowfor larger
openings, thereby facilitating airway interventions.MILI is recommended as an
airway intervention standard inknown or suspected cervical injury
patients.Video laryngoscopy is an alternative to conventionaldirect

21
laryngoscopy. Several studies have compared videoand direct laryngoscopy,
with conflicting results. One studyrevealed that video laryngoscopy prolonged
intubation time(Wetsch et al., 2012). The Airtraq intubation device
reducedcervical motion (Hirabayashi et al., 2007; Maruyama et al.,2008) and
facilitated intubation (Maharaj et al., 2007; McElwainet al., 2011), while the
GlideScope prolonged intubationtime. One study reported that the GlideScope
reducedmoment in a particular cervical segment (Turkstra et al.,2005), while
another reported no difference in cervical segmentmovement (Robitaille et al.,
2008). Other devices suchas the fiberoptic laryngoscope (Bullard) (Watts et al.,
1997;Gerling et al., 2000) and gum elastic bougie (Nolan et al.,1993; Nocera et
al., 1996) are important adjuncts during laryngoscopyin patients with suspected
CSCI, as these devicescan minimize cervical spine movement.

Laryngeal mask airways can cause some posterior displacementat upper

cervical levels (Keller et al., 1999; Kiharaet al., 2000). Although the above-
listed techniques may stillproduce movements in the cervical spine, this should
notprevent them from being used to save lives (Brimacombe etal., 2000). In the
“cannot intubate, cannot ventilate” scenario,surgical airway or
cricothyroidotomy must be performed.Although neurological deterioration has
been reportedin CSI patients with direct laryngoscopy (Hastings et al.,1991,
1993; Muckart et al., 1997), most studies find no deteriorationcaused by direct
laryngoscopy or other airwaymaneuvers (Rhee et al., 1990; Scanell et al., 1993;
Shatneyet al., 1995). A wake-up cannula can be neurologically testedafter
intubation and positioning. However, it requires aco-operative patient.
Intubations performed on patients whoare awake are not better than those
performed in sleepingpatients (Crosby et al., 1990; Suderman et al.,
1991).When faced with CSI patients in stable situations
(breathingspontaneously with stale vital signs), most anesthesiologistsopt to
perform awake fiberoptic bronchoscopeintubation (Rosenblatt et al., 1998;
Jenkins et al., 2002).However, this technique requires adequate training and
timefor intubation, and is difficult to perform in the presence ofblood, vomit,
secretions, or distorted anatomy. In emergencysituations, most anesthesiologists
rely on direct laryngoscopywith MILI for CSI patients. Hence, for each CSCI
patient, ananesthesiologist may select an airway management methodbased on
previous experience and the patient status.

22
Induction

There are no specific rules regarding the use of anestheticfor induction. Caution
should be used during inductionwith propofol, benzodiazepines, or barbiturates,
becausethese drugs may cause severe hypotension in patients withhypovolemia.
Kematine may increase axial pressure, but thiseffect can be balanced by the
parallel use of hypnotics suchas propofol.Between three days to nine months
following CSCI, patientsshould avoid depolarizing muscle relaxants such as
succinylcholine,as these can trigger fatal hyperkalemia (Cooperman,1970).
Non-depolarizing muscle relaxants are preferable becausethey do not increase
axial pressure or induce fasciculation.Stimulation of airway tissue can lead to
deep bradycardia,hypotension, and cardiac arrest (Yoo et al., 2003)

.Intraoperative

NeurophysiologicalMonitoring

Although intraoperative neurophysiological monitoring isnot mentioned in the

guidelines, several studies have focusedon this method with respect to SCI
patients. Intraoperativeneurophysiological monitoring is useful for evaluating
deteriorationof spinal cord function; thus enabling correctionof risk factors such
as patient location (e.g., neck positionand shoulder position), hypotension,
hypothermia, and surgery-related factors.Somatosensory evoked potential
(SSEP) is the most widelyused monitoring pattern in spinal surgery. SSEP
directlymonitors the dorsal column-medial lemniscus pathway,but not directly
to the cortical spinal cord. Thus, SSEP mayprovide false negatives in patients
with anterior spinal syndrome.The key limitation of SSEP monitoring is the
timerequirement for data summation. Thus, irreversible nervedamage can occur
before the monitoring data can be analyzed.In addition, SSEP has low
sensitivity to nerve rootinjury. When monitoring SSEPs, total intravenous
anesthesiaor balanced anesthesia with low concentrations of volatileanesthetics
may be preferable (Loughnan et al., 1995).Motor evoked potentials and muscle
motor evoked potentialscan be used to monitor motor pathways during
spinesurgery. Since stimulation induces movement, volatile anestheticsand
nitrous oxide should be avoided; and when monitoringmotor evoked potentials,
a total intravenous techniquewithout muscle relaxation is advised (Taniguchi et

23
al., 1993).Direct waves are generated by transcranial stimulation andare directly
monitored at the level of the spinal cord. Directwaves are relatively resistant to
anesthetic effects and permitthe use of neuromuscular block paralysis.During
spinal cord surgery, spontaneous electromyographyis widely used to monitor
selective nerve root function.This monitoring prohibits the use of
neuromuscular blockades,but allows the use of volatile anesthetics.Triggered
electromyography is used to assess the accuracyof pedicle screw placement.
The main limitation of triggeringelectromyography is the high rate of false
positive alarms.As with other forms of electromyography,
neuromuscularblockade is prohibited.

Maintenance of Anesthesia

No convincing data have shown any advantages of one anesthetic agent or

technique over another. It is crucial that the regimen used enables the
maintenance of adequate spinalcord perfusion. Ventilation should be adjusted to
maintainnormocapnia. With undisturbed CO2 reactivity in the spinalcord
perfusion, as exhibited in most patients, excessive hyperventilation may reduce
blood flow to areas with inadequateperfusion.

Hyperglycemia must be avoided in patients with severehead trauma. Similarly,

a blood glucose concentration above200 mg/dl must be treated aggressively in
acute SCI, becausehyperglycemia is associated with poor neurologic
outcomes(Drummond et al., 1989).Cardiovascular SystemIn acute CSCI, the
sympathetic nerve fibers in the superiorganglion can be physically or
functionally disrupted, leadingto reduced vascular tone and unbalanced vagal
hyperactivity.

Cardiovascular abnormalities, including bradycardia,

hypotension,supraventricular arrhythmias, and cardiac arrest, arecaused by
autonomic nervous system imbalance.Bradycardia: In the acute post-injury
stage, 64–77% of patientsexperienced bradycardia with CSCI, especially
thosewith high cervical (C1–5) lesions. Bradycardia peaks at fourdays after
injury, and may persist in acute CSI patients fortwo weeks, during which period
a positive sinus rhythmdrug or pacemaker may be required (Lehmann et al.,
1987;Bilello et al., 2003). Atropine is effective in increasing heartrate. Some

24
procedures, such as oropharyngeal suction andendotracheal intubation, might
increase vagal tone and causecardiac arrest. Therefore, these should be carried
out withatropine on hand in case of bradycardia.Isoprenaline can increase sinus
rhythm, but generally leadsto arrhythmia. Thus, it is not widely used at present.
Salbutamolis a β2-adrenergic receptor agonist used for treatmentof asthma. It
has a small but direct effect on β1-adrenoceptors,and can increase cardiac
output and heat rate

Hypotension: Systemic hypotension frequently occursafter hemorrhage and

neurogenic shock. Neurogenic shock resulting from the loss of central
supraspinal sympatheticcontrol and vasodilatation can lead to hypotension and
inadequatetissue perfusion (Wuermser et al., 2007). Systemichypotension
reduces spinal cord perfusion pressure andcontributes to secondary neurologic
injury. It has been suggestedthat MAP be maintained within 85–90 mmHg,
andsystolic blood pressure kept above 90 mmHg for the firstseven days.Except
for hypotension related to hypovolemia, excessivefluid administration is
associated with cardiac failure, electrolyteabnormalities, coagulopathy,
significant edema (includingairway edema), and prolonged hospitalization in
thepostoperative intensive care (Rosenthal et al., 1999). Agentswith inotropic,
chronotropic, and vasoconstrictive propertiesshould be used to maintain blood
pressure. Hence, dopamine,norepinephrine, or epinephrine with their α1-
andβ1-agonist properties are acceptable options. Phenylephrineworks as a α1-
receptor agonist with minimal β1 effects,which may lead to reflex bradycardia.
The use of dobutaminefor treating SCI is limited due to its effect on
vasodilationand the possible risk of reflex bradycardia (Nockels, 2001).Acute
blood loss leads to hypotension, which requires fluidmanagement. Optimal fluid
therapy for SCI patients is unknown.5% dextrose in water and 0.45% normal
saline madefrom hypotonic crystalloids should be avoided, as these
mayexacerbate spinal cord swelling. Cardiac output monitoringdevices may
improve intraoperative fluid delivery and mayreduce morbidity resulting from
excessive fluid administration.

Major blood loss can lead to transfusions. In additionto the known risks of
transfusing blood components, includingpotential transfusion reactions and
alloimmunization, aswell as the risk of contagion, the cost of blood
replacementmust be evaluated. Several techniques have been used tominimize
25
intraoperative blood loss, including erythrocyteaugmentation, intraoperative
antifibrinolytic administration,the use of topical hemostatic agents,
intraoperative bloodsalvage, and postoperative blood salvage (Bess et al.,
2006).Because it may exacerbate secondary SCI, hypotensive anesthesiashould
be avoided in SCI patients.

Coagulopathy can occur during spine surgery after a largenumber of blood

transfusions. When performing multilevel instrumentation, significant blood
loss should be anticipated. Homeostasis assays should be used to assess
ongoing bloodloss during surgery. Standard coagulation tests are too slow for
use with actively bleeding patients. However, viscoelasticpoint-of-care
coagulation assays have a rapid turn-around timetable 1 Frankel classification
of spinal cord injury patients

Frankel grade Definition

A Complete injury, no motor or sensory function below the level of injury

B Incomplete injury, no motor function

C Incomplete injury, motor function useless, sensory incomplete

D Incomplete injury, motor function useful, sensory incomplete

E Incomplete injury, motor function normal, sensory normal

Management in the Intensive Care Unit

All patients with acute SCI, especially those with severe CSCI, should be
managed in the intensive care unit for adequate neurological, cardiac,
hemodynamic, and respiratory monitoring. Life threatening cardiovascular
instability and respiratory insufficiency may be transient and episodic, and may
recur in the first 7–10 days after injury (Ripken et al.,2013). When deciding
whether to immediately extubate patients postoperatively, anesthesiologists
should considerthe extent of the surgery, surgical complications, such
asrecurrent laryngeal nerve injury, the duration of surgery,prone position,
degree of blood loss and subsequent fluidresuscitation, and the ease of
intubation. For CSCI patients,respiratory insufficiency may occur not only
immediately atpostoperation, but may also be delayed.These patients have a

26
very high risk of thromboemboliccomplication. Thus, active prophylaxis is
recommendedfor three months, using a combination of low-molecular-weight-
heparins and a rotating bed, elastic or pneumaticcompression stockings, or
electrical stimulation (Dhall et al.,2013a).Patients will have increased caloric
requirements after SCI.Therefore, appropriate nutritional support should be
provided.It is safe for SCI patients to meet caloric and nitrogen requirements,
and such nutritional support can even reducethe deleterious effects of
consumptive processes.

Early enteralnutrition (within 72 hours) is safe, but does not affectneurological

outcomes (Dhall et al., 2013b).CSCI patients carry an increased risk of
respiratory and/or urinary tract infections, especially with the use of
methylprednisolone.Other complications, such as occult peritonitis,may also
occur and require attention.ConclusionsAcute CSCI is a severe injury.
Anesthesiologists managingpatients with acute CSCI should make themselves
aware ofthe relevant pathophysiology and provide specialized careto improve
patient outcomes. They are advised to communicateeffectively with surgeons,
plan well in advance, andexecute their plan at each step of the preoperative
interview,airway management, induction, maintenance of anesthesia,and
postoperative intensive care. In-depth CSCI researchis underway to provide
more efficient neuroprotective andneuroregenerative solutions for the future.

TOPIC 16 - Laryngeal Mask Airway and Fibroptic bronchoscope

Laryngeal mask airways (LMA) are supraglottic airway devices. They may be used
as a temporary method to maintain an open airway during the administration of
anesthesia or as an immediate life-saving measure in a patient with a difficult or
failed airway. Laryngeal mask airways were introduced into clinical practice in the
1980s where they were initially used predominantly in the operating room. Since
then, their use has become more widespread in the intensive care unit, emergency
department, and field settings. This activity describes the indications,
contraindications, and techniques involved in placing a laryngeal mask airway and
highlights the role of the interprofessional team in the management of patients with
difficult airways.
Objectives:

27
  Outline the technique for laryngeal mask airway use.
 Describe the indications for laryngeal mask airways.
 Review the complications of laryngeal mask airways.
 Explain the importance of well-coordinated teamwork and clear
communicatioto facilitate appropriate use of laryngeal mask airways in
patients with difficult airways.
Access free multiple choice questions on this topic.

Introduction
Laryngeal mask airways (LMA) are single-use or reusable supraglottic airway
devices which may be used as a temporary method to maintain an open airway
during the administration of anesthesia or as an immediate life-saving measure in a
difficult or failed airway as outlined in the difficult airway algorithm published by
many societies of anesthesiology worldwide. Introduced into clinical practice in
the 1980s, they were initially used predominantly in the operating room but have
become widely used in the intensive care unit, emergency department and field
settings. LMAs are easier to use and more effective than a bag-valve-mask in the
hands of basic life support providers and may be used as an alternative to
intubation by advanced life support providers. Some models may be used as a
conduit to facilitate endotracheal intubation.[1][2][3]

Anatomy and Physiology

Supraglottic devices, like the LMA, are designed to be inserted blindly through the
mouth and into the hypopharynx to seal around the glottic opening allowing for
ventilation. The mnemonic RODS can be used to predict difficulty in either placing
an extraglottic device or in providing adequate gas exchange through one. RODS
stands for Restriction, Obstruction/Obesity, Disrupted or Distorted anatomy,
and Short thyromental distance. Restriction refers to both increased airway
resistance - extraglottic devices have lower leak pressures than endotracheal tubes -
as well as restricted mouth opening insufficient to allow for passage of the device.
Patients with upper or lower airway obstruction due to a tumor or foreign
body may make passage of or ventilation through the device difficult or
impossible. Obese patients may have a redundant tissue, making it more difficult to
seat the device in place, and the increased ventilatory pressures required in obese
patients may increase the likelihood of a leak. Distortion or disruption of the
airway from the midline makes the device less likely to seat properly. Small

28
mandibular spaces, assessed by shortened thyromental distance, are associated with
difficult use to extraglottic devices due to the position of the tongue.

Indications
LMAs may be used as a primary airway management devices in the operative
setting in pre-selected, fasted patients. In the emergency setting, LMAs are used
as a temporary bridge to intubation by pre-hospital providers, in cardiac arrest
situations, as a rescue device in “can’t intubate, can’t oxygenate” situations, as a
means to attempt ventilation in a failed airway situation followed by either
intubation through the device or while a surgical airway is performed.[4][5][6]
LMAs are excellent alternatives to the use of bag masks to reduce the risk
of gastric inflation thus decreasing the risk of aspiration. While it may decrease the
risk of aspiration, it is far less protective than an endotracheal tube. LMAs are
an effective method of ventilation and should be utilized unless it is ineffective in
patients requiring prolonged mask ventilation.
LMAs have been used successfully with pediatric patients, adults, and obese
individuals.

Contraindications
The LMA offers a great alternative to endotracheal intubation in pre-fasted,
selected patients and may be associated with fewer complications as compared to
intubation in selected patients. Despite this, significant complications may result
from the utilization of an LMA including laryngospasm, nausea, vomiting,
aspiration, and coughing. They may stimulate the gag reflex, and, therefore, should
not be used in a conscious or awake patient. Contraindications to elective use
include poor pulmonary compliance, high airway resistance, pharyngeal pathology,
risk for aspiration, and/or airway obstruction below the larynx.

Equipment
LMAs come in many forms and configurations. They consist of a tube attached to
an inflatable, elliptical cuff designed to cover the supraglottic area, facilitating an
open airway passage and allowing for either spontaneous or positive pressure
ventilation. While the original LMA was a multi-use device, cleaning requirements
and high cost have steered providers towards less costly, single-use LMAs. Several
configurations are available from multiple vendors. The original LMA design has
crossbars over the aperture designed to prevent passive herniation of the epiglottis
into the opening. However, that design makes intubation through that device much
more challenging. Those first-generation devices are still commonly used for
29
routine cases due to the low cost, and they have low complication rates. Newer
second-generation LMAs are now available and provide for higher seal pressures
due to improved seal material or design, have no aperture bars, allowing for easier
intubation using regular endotracheal tubes and providing a gastric access port to
vent or aspirate gastric contents. Some even incorporate a bite block.
The LMA Fastrach, also called the ILMA is specifically designed to facilitate blind
intubation. It is available in both reusable and disposable forms and has a handle
designed to allow for optimal positioning and a bar designed to elevate the
epiglottis out of the way to facilitate intubation. This device is designed for use
with specialized endotracheal proprietory tubes made and packaged with the
ILMA.
The I-Gel devices are unique in that they have a pre-shaped non-inflatable cuff.
They are made from a gel-like-substance, which may be easier to insert because
there is no cuff to inflate. The i-Gel also allows for the passage of standard
endotracheal tubes. It may be used in patients of all ages from small infants to
adults.

Personnel
While initially used by anesthesia providers, success in placing LMAs has been
demonstrated by novice incubators, EMS providers, nurses, advanced practice
providers, and physicians of multiple specialties.

Preparation
Prior to the insertion of an LMA, the patient should ideally be fasted and assessed
for markers of difficulty or contraindications. This may not be possible in
emergency situations where it is used as a rescue device. The LMA comes in
various sizes, and recommendations are generally weight-based and printed on the
package and the devices. For adults, the following is a simple size guide: size three
for adults 30 to 50 kg, size four for adults 50 to 70 kg, and size five for adults over
70 kg. In general, the larger size should be chosen for patients between sizes
because it will seal more effectively.[7]

Technique
Prior to insertion, the device should be placed on a flat surface. The cuff should be
inflated and then completely deflated to ensure the cuff is not folded, pressing
firmly on the flat surface. Lubricate both sides of the device with a water-soluble
lubricant. When there is no risk of neck damage, the neck is extended in a sniffing
position. Otherwise, a jaw thrust may be performed to facilitate passage. The LMA
30
is introduced behind the tongue with backward pressure using the index finger,
pressing the device against the hard palate until it is completely inserted. Then use
the other hand to push the LMA until some resistance is felt and it can go no
further. The collar should then be inflated with approximately 20 mL for number
three, 30 mL for number four and 40 mL for number five. This volume may need
to be adjusted to optimize the seal and minimize the air leak. Once the cuff is
inflated with the designated amount of air and placement is checked by attaching a
bag mask and delivering breaths, assessing breath sounds and/or using continuous
waveform capnography or at a minimum a CO2 detector device.
Endotracheal intubation can be achieved by inserting the endotracheal tube (ETT)
through most second generation LMAs. Those devices do not have aperture bars at
the cuff end and usually have higher seal pressures than the original LMAs that are
still frequently used. The LMA Fastrach has a higher rate of intubation success
compared to the standard 1 generation and is designed for blind intubation using
the company’s proprietary endotracheal tube. However, failure rates can be as high
as 40%, and endotracheal intubation is best facilitated under direct visualization
using a flexible bronchoscope. Regular endotracheal tubes are usually not long
enough to go past the vocal cords when inserted through an LMA. Using either a
tube exchanger that slides over a flexible bronchoscope or using a nasal RAE tube,
which is longer will overcome that problem.

Complications
The distal tip of the collar on the LMA may occasionally roll-upwards on insertion,
which may hinder optimal placement. Some experts recommend partial inflation of
the cuff before insertion or inserting the LMA upside-down and rotating it into
position to prevent this complication, but there is insufficient evidence to
recommend this practice. Forceful insertion may cause abrasion of the pharyngeal
tissues or bleeding. Insufflation of the stomach may occur. It is not known to what
degree an LMA will prevent aspiration of gastric contents and it should be
considered a temporary or rescue measure in patients at risk for vomiting and
aspiration and not considered a replacement for endotracheal intubation. It may be
difficult to maintain an effective seal in patients with high airways pressures. The
device may become easily malpositioned during CPR or if the patient is moved
during transport and must be maintained in the midline.[8]
LMAs are not a good primary airway device in morbidly obese patients as those
patients do require higher positive airway pressures that may produce leaks around
the LMA cuff. In addition, having morbidly obese patients breathe spontaneously

31
through an LMA during anesthesia may lead to significant hypoventilation due to
the position of the patient and the weight of the abdomen.[9]
The complication rates with LMAs are low and less than those associated with
both endotracheal intubation and use of bag valve masks.

Clinical Significance
LMAs have been shown to be as effective as other airway management strategies
in patients receiving CPR.
LMAs may be used appropriately and successfully in pediatric patients.
Success rates for blind intubation through an LMA range from 60% to 99%,
depending on the device and skill of the operator. Blind intubation rates are highest
for the Fastrach LMA (ILMA) as compared to other supraglottic devices but
should best be facilitated by flexible fiberoptic guidance whenever possible.
LMAs should not be the final secured airway solution in a failed airway rescue.
They can become displaced when changing from a temporarily stable situation to
another airway emergency and should be used as a conduit to a secure airway with
an endotracheal tube.

Enhancing Healthcare Team Outcomes

LMAs have an important role in the management of a patient with respiratory
distress. While most healthcare workers are familiar with the endotracheal tube, the
use of the LMA does require experience. Healthcare workers include nurse
practitioners who have never used an LMA should first consult with an
anesthesiologist before attempting intubation. The LMA is only a temporary
solution to the airway and can be easily dislodged with patient movements; hence,
it is generally only used in the operating theater.

LMA-Fastrach
The LMA-Fastrach (intubating LMA, ILMA, ILM, intubating laryngeal
mask airway) was designed to overcome some of the limitations of the
LMA-Classic during tracheal intubation. The LMA-Classic was too
floppy to optimize alignment with the glottis, and the long narrow tube
could not accommodate a standard tracheal tube. Another objective was
to eliminate the need to distort the anterior pharyngeal anatomy in
order to visualize the laryngeal inlet, making the device applicable to

32
patients with a history of difficult intubation and a “high” or “anterior”
larynx.
Description
The LMA-Fastrach (Fig. 17.9 ) has a short, curved stainless steel shaft
with a standard 15-mm connector. The tube is of sufficient diameter
that a cuffed 9-mm tracheal tube can be inserted and short enough to
allow a standard tracheal tube cuff to pass beyond the vocal cords. The
metal handle is securely bonded to the shaft near the connector end to
facilitate one-handed insertion, position adjustment, and maintain the
device in a steady position during tracheal tube insertion and removal.
There is a single, movable epiglottic elevator bar in place of the two
vertical bars (Fig. 17.10A ). A V-shaped guiding ramp is built into the
floor of the mask aperture to direct the tracheal tube toward the glottis.
The tip is slightly curved to permit atraumatic insertion. Figure 17.10B
shows tracheal tube protruding through the LMA tube and into the
bowl.
The LMA-Fastrach does not contain latex. It is available in sizes 3, 4,
and 5. These fit the same size patients as the LMA-Classic. Both
reusable and disposable versions are available.
Insertion
The LMA-Fastrach was designed for use with the patient in the neutral
position. This includes using a head support, such as a pillow, but no
head extension. The insertion technique consists of one-hand
movements in the sagittal plane. It does not require placing fingers into
the patient's mouth, thus minimizing the risk of injury or infection
transmission as well as allowing insertion from almost any position.

Figure 17.9 LMA-Fastrach with tracheal tube. The

tube on the LMA is shorter and wider than on the
LMA-Classic and has a metal handle. Note that the
tracheal tube connector has been removed.
(Courtesy of LMA North America.)

33
 View Figure

The LMA-Fastrach should be deflated and lubricated in a manner

similar to the LMA-Classic. It is held by the handle, which should be
approximately parallel to the patient's chest. The mask tip is positioned
flat against the hard palate immediately posterior to the upper incisors,
then slid back and forth over the palate to distribute the lubricant.
After the mask is flattened against the hard palate, it is inserted with a
rotational movement along the hard palate and the posterior pharyngeal
wall. The mouth opening may need to be increased momentarily to
permit the widest part of the mask to enter the oral cavity. The handle
should not be used as a lever to force the mouth open. As the mask
moves toward the pharynx, it should be firmly pressed to the soft
palate and posterior pharyngeal wall to keep the tip from folding. The
curved part of the metal tube should be advanced without rotation until
it contacts the patient's chin, then kept in contact with the chin as the
device is rotated inward. The handle should not be used to lever
upward during insertion, because this will cause the mask to press into
the tongue.

Figure 17.10 LMA-Fastrach. A: Note the single,

movable epiglottic elevator bar and the V-shaped
guiding ramp built into the floor of the mask
aperture to direct the tracheal tube toward the
View Figure glottis. B: Tracheal tube emerging from the LMA.

When properly inserted, the tube should emerge from the mouth
directed somewhat caudally. Aligning the internal LMA-Fastrach
aperture and the glottic opening by finding the position that produces
optimal ventilation and then applying a slight anterior lift with the

34
LMA-Fastrach handle facilitates correct positioning and blind
intubation
The LMA-Fastrach can be inserted with a 180° rotation technique
Use
Although the LMA-Fastrach has been designed to facilitate tracheal
intubation, it can also be used as a primary airway device. It is
especially useful for the anticipated or unexpected difficult airway
Studies indicate that most insertion attempts with the LMA-Fastrach
are successful, and a patent airway is secured in nearly all patients. It
has been used successfully in children, morbidly obese patients, and
acromegalic patients.
The LMA-Fastrach can be inserted with the same or better success than
the LMA-Classic. It is easier to place than the LMA-Classic when
manual in-line stabilization is used However, in patients with limited
neck movement, intubation may be less likely to be successful and take
longer than if a lighted intubation stylet is used
The LMA-Fastrach has been used successfully in the emergency
department and prehospital care). It can be used with the patient in the
lateral position
Tracheal Intubation
Muscle relaxants are not necessary for intubation through the LMA-
Fastrach but may increase the success rate). Cricoid pressure will
decrease the likelihood of success and may need to be released to allow
intubation
The tracheal tube recommended by the manufacturer for use with the
LMA-Fastrach is a silicone, wire-reinforced, cuffed tube with a tapered
patient end and a blunt tip This tube is flexible, which allows
negotiation around the anatomical curves of the airway. It has a high-
pressure, low-volume cuff that reduces resistance during intubation and
makes cuff perforation as the tube passes through the LMA less likely.
There is a stabiliizer that allows the LMA to be removed without
extubating the patient.
When using the LMA-Fastrach, standard curved plastic tracheal tubes
are associated with a greater likelihood of laryngeal trauma. Warming
35
a plastic tube will result in success and complication rates similar to
that of the tube from the LMA-Fastrach manufacturer A spiral-
embedded tube should not be used. If a curved plastic tracheal tube is
used, it may be helpful to orient the curve opposite the LMA curve
Whatever tracheal tube is used, it is essential that it is possible to
remove the connector. It is important to lubricate the tracheal tube well
and pass it through the LMA several times before use.
Blind Intubation
The patient's head is maintained in the neutral position. The tracheal
tube connector should be loosely fitted for easy removal. The tracheal
tube should be lubricated with a water-soluble lubricant and passed
into the metal shaft of the LMA-Fastrach until the tube tip is about to
enter the mask aperture. With the silicone tracheal tube specially
designed for the LMA-Fastrach, the longitudinal line should face the
handle of the LMA, and the tracheal tube should not be passed beyond
the point where the transverse line on the tube is level with the outer
rim of the LMA-Fastrach airway tube.
The LMA-Fastrach handle is grasped with one hand to steady it while
the tracheal tube is being inserted, then lifted like a laryngoscope (not
levered) to draw the larynx forward a few millimeters. This increases
the seal pressure and helps to align the axes of the trachea and the
tracheal tube. It also corrects the tendency for the mask to flex.
As it is advanced into the LMA-Fastrach, the tube should be rotated
and moved up and down to distribute the lubricant. Ventilation and
carbon dioxide monitoring can be performed during tracheal tube
insertion by connecting the tracheal tube to the anesthesia breathing
system.
The tracheal tube should be advanced gently. The LMA-Fastrach
handle should not be pressed downward. If no resistance if felt, it is
likely that the epiglottic elevating bar is lifting the epiglottis upward,
allowing the tracheal tube to pass into the trachea. When the tracheal
tube is thought to be in the trachea, the cuff should be inflated and its
position in the trachea confirmed.
If the tracheal tube fails to enter the trachea, a number of problems
may have contributed to the lack of success. The epiglottis may have

36
folded downward, or the tube may have impacted on the periglottic
structures. The LMA-Fastrach may be too small or too large for the
patient. The larynx may have been pushed downward during insertion.
There may have been inadequate anesthesia or muscle relaxation so
that the vocal cords were closed.
During blind tracheal intubation, the operator relies on tactile
perceptions, especially a feeling of resistance, while advancing the
tracheal tube. If the mask is not aligned with the glottic opening or the
size of the LMA-Fastrach is inappropriate, resistance will be
encountered as the tracheal tube tip pushes against glottic or periglottic
structures, such as the downfolded epiglottis, valleculae, arytenoids, or
aryepiglottic folds.
If resistance is felt after the tracheal tube leaves the LMA-Fastrach,
there are a number of maneuvers that can be taken to relieve the
situation. If resistance is felt at 2 cm beyond the 15-cm mark on the
tracheal tube, it is likely that the tube has impacted on the vestibular
wall. Rotating the tracheal bevel may overcome the impaction. Another
problem at this level may be a downfolded epiglottis. Without deflating
the cuff, the device should be swung outward for 6 cm and reinserted.
If resistance is encountered 3 cm beyond 15 cm, the epiglottis may be
out of the reach of the elevating bar, and a larger LMA should be used.
If resistance occurs immediately after the tracheal tube leaves the
LMA-Fastrach, the LMA may be too large and should be replaced with
a smaller one. If resistance is felt at 15 plus 4 cm, the LMA may be too
large, and a smaller size should be used.
Other maneuvers that can be tried include slightly rotating the LMA-
Fastrach in the sagittal plane by using the metal handle until the least
resistance to manual ventilation is achieved, removing the head
support, pulling the metal handle toward the user (extension), or
pushing it away from the user (flexion).
The LMA-Fastrach can be used to place an airway exchange catheter,
which can then be used to direct a tracheal tube into the trachea.
Blind intubation using the LMA-Fastrach is faster than fiberoptic-
guided intubation or intubation using direct laryngoscopy. It can be
performed awake. When compared with awake fiberoptic intubation for
patients with known difficult airways, patient satisfaction was greater
with the LMA-Fastrach
37
The success rate of blind intubation varies from 40% to 100%
depending on the number of attempts and the experience of the
operator.
The blind technique can be time consuming and may result in trauma or
esophageal intubation). If difficulty is encountered, the use of an
LMA-CTrach should be considered.
Removing the LMA-Fastrach after Intubation
After the trachea has been intubated, the decision needs to be made
whether to remove the LMA-Fastrach or to leave it in place. It is
usually recommended that the LMA-Fastrach be removed. Alternately,
the cuff can be deflated to 20 to 30 cm H 2 O and the LMA-Fastrach left
in situ. The LMA-Fastrach may exert mucosal pressures in excess of
capillary perfusion pressure. Patients in whom the LMA-Fastrach is
retained have a higher incidence of hoarseness, sore throat, and
dysphagia.
Removing the LMA is associated with a hemodynamic response.
Delaying removal for a few minutes may slightly decrease the
associated pressor response (
The tracheal tube needs to be stabilized to prevent extubation during
LMA-Fastrach removal. The tube connector needs to be removed. A
stabilizer rod (extender) that is placed in the end of the tracheal tube is
available from the manufacturer. Inserting the tip of a smaller tracheal
tube into the end of the inserted tracheal tube will allow ventilation
while the LMA-Fastrach is being removed
The LMA-Fastrach cuff is deflated, and the LMA-Fastrach is swung
out of the pharynx into the oral cavity while applying counterpressure
to the tracheal tube. The stabilizing rod is removed when the LMA-
Fastrach cuff is clear of the mouth. The tracheal tube is then firmly
grasped while unthreading the inflation tube and pilot balloon from the
LMA-Fastrach. Finally, the tracheal tube connector is replaced.
Problems with Intubation
Pharyngeal pathology may make intubation through the LMA-Fastrach
impossible.

38
Currently, the smallest size available of the LMA-Fastrach is the
number 3. This has been found to work well for intubation of patients
over 30 kg, but for patients under this weight, successful intubation
through this device is less certain.
The LMA-Fastrach tracheal tube is expensive and should not remain in
place for long periods of time because it has a high-pressure cuff.
The LMA-Fastrach requires more time for intubation and results in
more esophageal intubations and mucosal trauma than rigid
laryngoscopy. Blind intubation through the LMA-Fastrach generates
cardiovascular responses similar to tracheal intubation using direct
laryngoscopy
When the LMA-Fastrach is removed, the tracheal tube may be
displaced downward or dislodged

Fiberoptic Intubation:
Fiberoptic Technology

The technology of fiberoptics is based on the opticalcharacteristics

of very thin (diameter of 8–25 _m) flexibleglass fibers that are
capable of transmitting light over theirlength. Insulation of these
fibers by a glass layer with adifferent optical density enables
transmission by internalreflection of light. An image is transmitted
through thelength of the scope by an organized coherent bundle
offibers that have the exact orientation at both ends of thescope. A
separate fiberoptic bundle is attached to a lightsource to provide
illumination, and lenses at the tip of thescope and eyepiece provide
an image that can be focusedby the user. In brief, the fiberoptic
bronchoscope consistsof an eyepiece atop a control handle with a
focusing ringthat is attached to a thin flexible fiberscope. A
thumbcontrol lever allows the distal tip of the scope to be flexedor
extended. A separate port that travels the distance of thescope can
be utilized for suction, injection of saline orlocal anesthetic, oxygen
insufflation, or passage of brushesor forceps for diagnostic
purposes.A more recent evolution to the bronchoscope is theaddition
39
of a charge-coupled device camera, whereby acaptured digital image
is then transmitted electronically toan external monitor screen. More
recent hybrid technologyretains fiberoptic bundles from the distal
end of the scopeto the handle, where the charge-coupled device
camera islocated. This configuration allows smaller external
diametersof bronchoscopes with larger working channels
andenhanced flexibility.The components of the flexible fiberoptic
bronchoscopehave been detailed well in prior reviews. Figures 1 and

highlight
basic components of a flexible bronchoscope.We refer the reader to
one such comprehensive book chapterto explore these components in
more detail.8 Rigid orsemirigid fiberscopes such as the Bonfils and
UpsherScopehave also been described in successful management of
thedifficult airway9,10 but are not discussed in this review.

IndicationsFiberoptic bronchoscopes are currently used to

facilitateendotracheal intubation via either the nasal or oral route,

40
inthe positioning of endotracheal and endobronchial tubesand
bronchial blocking devices, and in airway examinationor evaluation.
In clinical scenarios in which tracheal intubationis deemed
necessary and mask or supraglottic ventilation(eg, via a laryngeal
mask airway [LMA]) is unlikelyto be successful or poses an
aspiration risk, awakeFOI is a standard approach. FOI remains the
acceptedstandard in elective airway management of the awake
spontaneouslybreathing patient with an anticipated
difficultairway.11 FOI is ideally suited in such patients
becauseintubation can be performed prior to the induction of
generalanesthesia with its attendant risks of inadequate
ventilationand oxygenation, loss of upper airway patency,and failed
intubation. This FOI technique also safeguardsagainst the risk of the
cannot intubate/cannot ventilate scenario.Success of the technique,
however, presupposes adequatetime for preparation in a cooperative
patient, arequirement for safe and successful. Theneed for FOI may
be anticipated based on a history ofdifficult intubation and various
anatomic and anthropometricfeatures that may predict difficult
laryngoscopy.These include limited mouth opening, limited
thyromentaldistance, reduced neck mobility, inability to prognath,
oropharyngealclassification, and obesity.12 FOI may also
beindicated for known or suspected cervical spine
instability,anatomic malformations of the mandible or larynx,
congenital deformities of the head and neck, and history ofhead,
neck, and spine trauma. If a difficult airway is suspected,the ability
to mask ventilate and the need for trachealintubation should be
assessed. Awake intubation isrecommended for patients who are at
high risk for difficultmask ventilation, particularly those who may
be at anelevated risk for aspiration during the airway
managementprocess. While difficult airway guidelines are
availablefrom a number of specialty societies, these are derived
byexperts with analysis of limited randomized controlled trials;few
recommendations have been validated rigorously.Familiarity,
experience, and skill with different approaches,as well as equipment
availability, must be considered whenapplying such guidelines to
41
clinical practice.During preoperative assessment, a detailed
anesthetichistory may elicit a history of difficult or
unsuccessfulattempts by direct laryngoscopy. Prior anesthetic
recordsshould be obtained whenever possible. Multiple studies
haveattempted to identify exam features or to define
characteristicsthat predict difficult intubation. However, the
reportedusefulness of such predictive tests has been questioned
giventheir low positive predictive value. To complicate matters,the
term “difficult intubation” has been variously defined inthe
literature as limited view on direct laryngoscopy theneed for more
than one attempt or use of different airwayaids,15,16 and a
quantitative score termed the Intubation DifficultyScale.17 These
approaches limit the means of definingand assessing difficult
intubation.Nonetheless, a recent meta-analysis found that the
overallincidence of difficult intubation in subjects
withoutpathologic airway anatomy was 5.8%.18 The incidence
ofdifficult intubation in select groups such as those withabnormal
anatomic features of the head, neck, or airway isdifficult to establish
given that direct laryngoscopy is lesslikely to be performed in these
patients. However, it islikely to be higher than in those subjects
without airwayanatomic abnormalities. In an observational study,
independentpredictors of difficult/impossible mask ventilationand
difficult intubation included limited mandibular protrusion,abnormal
neck anatomy, sleep apnea or snoring,and body mass index of 30
kg/m2 or greater.19 In a follow-up study, this same group reviewed
over 50,000 anestheticrecords over a 4-year period and
demonstratedimpossible mask ventilation as an infrequent event
(0.15%);of this patient subset, 25% were difficult to
intubate.20Patients for whom FOI was planned were excluded
fromdata collection and analysis.FOI is often performed in patients
with cervical spineinjury or instability. Although there are no
outcome data tosupport a recommendation of FOI over other
techniques insuch airway management scenarios, surveys of North
Americananesthesiologists indicate that they prefer to use FOI
inpatients with cervical spine injury. Interestingly, many alsoadmit
42
limited skills with use of the fiberoptic bronchoscope.In one study
of nearly 500 responses from 1,000 active membersof the ASA who
were surveyed, 78% reported a preferencefor an awake intubation
and use of a bronchoscope inpatients with cervical spine injury.21 A
similar survey showedthat most respondents favored awake FOI in
patients withcervical spine disease (ankylosing spondylitis or
rheumatoidarthritis) presenting for elective surgery.22It is important
to note that FOI has not been provensuperior to other intubation
techniques with regard to intubationsuccess rates or clinical
outcomes in patients withcervical spine injury, although studies on
this subject tendto be limited by their retrospective nature and small
samplesize.23 In one retrospective case control study examining454
subjects with critical cervical spine injuries overan 8 y period, a
case group of 165 subjects required intubationwithin 2 months of
injury due to the need for airwayprotection, respiratory failure, or
provision of general anesthesia.24 Of this subset, all subjects were
intubated by anawake technique without the aid of general
anesthesia ormuscle relaxants: 46% by fiberoptic laryngoscope, 32%
byblind nasal intubation, and 22% by direct laryngoscopy.Despite a
higher injury severity score in this case group of165 subjects, there
was no difference in neurologic deteriorationbetween this subset and
those who were not intubated.Despite the lack of unequivocal
evidence demonstratingimproved neurologic outcomes in cervical
spine injury patientsmanaged with an awake FOI technique, there
arepurported advantages. All airway interventions, from
maskventilation to direct or indirect laryngoscopy, result in
somedegree of neck movement. This movement is typicallysmall,
within physiologic ranges, and of unknown clinicalimportance. If
performed, cervical in-line mobilization canprotect the cervical
spine by diminishing such small movementsregardless of airway
technique. However, awakeFOI techniques in patients with injured
cervical spinesmay have several benefits. First, the head and neck
can bemaintained in a neutral position during airway
management,and neck flexion and extension can be easily limited.

43
Table 1. Common Indications for Awake Fiberoptic Intubation

Known difficult intubation

Suspected difficult intubation by direct laryngoscopy (eg, history

ofdifficult intubation, limited mouth opening, decreased
thyromentaldistance)

Unstable cervical spine

Abnormal anatomy

Congenital airway deformities (eg, Pierre Robin syndrome)

Head and neck cancers (eg, supraglottic tumors)

TraumaFace/neckUpper airway

A second benefit to awake FOI is that protectivereflexes can be

maintained, thereby reducing the risk ofaspiration. Additionally,
neurologic assessment can bemade after intubation and patient
positioning and prior toinduction of a general anesthetic.Fiberoptic
bronchoscopy can also be used diagnosticallyduring and/or after FOI
to facilitate inspection of theairway for the identification and
diagnosis of airway traumathat may co-present in patients with head,
neck, and cervicalspine injuries. The use of techniques that do
notpermit visualization of the lower airway in such cases
maypredispose to incorrect endotracheal tube (ETT) placementvia a
false lumen or through injured tissue, for example.Such
conventional techniques may then lead to severe orcatastrophic
complications, including massive subcutaneousemphysema and
airway loss. Sengupta et al27 reporteda patient with complete
tracheal disruption after blunttrauma in which the injury was
identified during an awakeFOI, facilitating precise ETT placement
and positioning.Other reports have described soft tissue swelling
and hematomacausing airway obstruction in patients with
cervicalspine injuries.28,29 Fiberoptic techniques permit
preciseevaluation of such pre-existing injury and can be usedto

44
facilitate ETT placement beyond the level of injury. Forthese
reasons, FOI in the spontaneously breathing patienthas been
previously referred to as the method of choice forairway
management in patients with airway trauma.30Airway management
challenges also exist in patientswith head and neck pathologies, a
large category includingcongenital craniofacial defects such as
micrognathia, headand neck cancers that may distort airway
anatomy, surgicalscarring, and radiation fibrosis. Early studies have
shownthat the difficult airway resulting from head and neck
pathologyis a significant cause of deaths during
generalanesthesia.31 Altered algorithms have been developed foruse
in this population.32 Radiographic studies such as
computedtomography and magnetic resonance imaging maybe
particularly useful in airway evaluation of these patients.During
preoperative assessment, a history of hoarsenessmay indicate the
location of a mass or progression ofdisease. Upper airway
obstructive symptoms and signsshould be elicited. Positional
dyspnea, specifically orthopnea,is particularly worrisome.
Furthermore, even with successfulchemotherapy and radiation
treatment in head andneck cancer patients, post-treatment changes
can distortthe submandibular space and limit neck mobility,
renderinglaryngoscopy difficult or impossible. In one recentstudy of
152 difficult airway cases due to head and neckpathology, several
factors that predicted airway difficultywere identified.33 These
included cancer diagnosis, historyof radiation therapy, and
supraglottic/glottic sites. Thosesubjects with glottic or subglottic
lesions required the mostintubation attempts. Fiberoptic techniques
may be ideallysuited for use in this patient subset. In this study,
awakeFOI was performed successfully in 68 (44.7%) cases.33The
other most common airway techniques were inductionwith mask
ventilation, followed by direct laryngoscopy(25%) and a dilator
cricothyroidotomy technique (28.9%).Awake tracheostomy was
performed in 1.3% of subjects.

Fiberoptic Techniques

45
FOI can be performed nasally or orally in awake patientswith topical
or regional anesthesia alone, or in sedatedor anesthetized patients.
The technique is most easilyperformed with the patient supine or in
the seatedposition. Standard airway and emergency equipment
shouldbe available. In circumstances in which mask ventilationmay
be difficult and risk of airway loss is high, an awaketechnique is
preferred. A nasal approach is particularlyuseful in patients with a
large tongue, limited mouth opening,receding lower jaw, or tracheal
deviation or in cases inwhich an unobstructed surgical field is
beneficial (eg, dentalsurgery). This approach is also anatomically
favorablein that the laryngeal opening is more easily seen with
thefiberscope as it courses past the nasopharynx with lessobstruction
by the tongue.34If performed orally, FOI may be facilitated by
variousintubating airways or supraglottic devices. Such airwaysor
devices allow the user to protect the bronchoscope,maintain a
midline position, and displace the tongue moreeasily. Combination
approaches utilizing supraglottic devicesare discussed below. There
are a variety of oral biteblocks and intubating airways available as
well to facilitateoral FOI. Unlike standard oral airways, these
devicesutilize channels along their sides or top that permit
themidline introduction and passage of a bronchoscope andETT.
Proper placement prevents the base of the tongue orthe phalange of
the airway from protruding into the posteriororopharynx and
facilitates easy scope and tube passageto the hypopharynx. One such
common airway device,the Ovassapian airway, is illustrated in
Figure 3.Other techniques to facilitate FOI include the jaw
thrust,tongue protrusion, positioning the scope in the midline ofthe
pharynx during advancement, and rotating the ETT90°
counterclockwise if resistance is encountered duringadvancement to
facilitate passage through the vocal cords.A laryngoscope blade can
be used as an adjuvant to displacethe tongue in order to promote
bronchoscope andETT passage. Additionally, specialized face masks
areavailable that can deliver oxygen and permit mask
ventilationduring FOI attempts (Fig. 4)

46
.Patient Position and General Techniques

Awake FOI can be performed with the patient in theseated or supine

position. When introducing the scope intothe patient’s mouth (oral
approach), the tip of the scopeshould be tilted _45° (upward if
intubating from the headof the bed or downward if intubating from
the side of thebed or with the patient in a seated position) as shown
inFigures 5 and 6. The tip of the scope is then advanced untilit is
beyond the base of the tongue. A jaw thrust providedby an assistant
can aid in bronchoscope passage throughthe oropharynx. The tip can
then be directed to the glotticopening. Fine adjustments with slight
motion of the wristand elevation or depression of the tip using the
angulation(thumb) control lever aid in steering the scope toward
thevocal cords. Once the scope enters the trachea, it is advancedto
the level of the mid-trachea, where a previouslyloaded ETT is then
guided into the trachea. The ETTshould be turned gently
counterclockwise with retractionand then re-advanced if resistance
is encountered duringplacement. This can decrease the likelihood of
laryngealtrauma. Adequate size matching of the ETT on the
scopepermits less play between the scope and tube and mayavoid the
tube becoming caught at the level of the epiglottisor on the
arytenoid cartilages (Fig. 7). In addition, thegreater the gap between
the ETT and the bronchoscope,the higher the likelihood of failure of
threading the tube.35Once the ETT is passed, a bronchoscopic view
can verifyplacement, with optimal tube positioning 2–3 cm abovethe
carina in an adult patient. The scope is then withdrawnas the tube is
held in place by hand. Finally, tube placementis checked by end-
tidal carbon dioxide and auscultationand subsequently secured and
connected to a circuitfor ventilation. For a nasal approach (see
below), a vasoconstrictorcan be applied to the preferred naris to
limit orprevent bleeding during intubation. After slow dilation ofthe
naris with increasingly sized nasopharyngeal airways,a well-
lubricated ETT (usually 7.0mmor smaller) is placedand gently
pushed medially and posteriorly _6–8 cm withthe goal of advancing
the tube into the posterior oropharynx.If resistance is encountered,

47
caution should be exercised.If this problem occurs with both nares,
the bronchoscopeshould be introduced first to assess for
alteredanatomy (eg, nasal polyps) and also to direct passage
aroundthe turbinates. With a firm jaw thrust by an assistant
(alternatively,the tongue can be grasped and pulled forward),the
bronchoscope is advanced and directed to the glotticopening for a
view of the cords in similar fashion as withthe oral approach. Once
past the cords, the ETT is advancedto the level of the mid-trachea,
and placement isconfirmed and finally secured.

Patient Preparation

In preparation for an awake FOI, the patient should bemade aware of

the steps involved and reassured that patientsafety and comfort will
be optimized. An antisialagogueis often used to decrease mucus and
salivary secretions.Glycopyrrolate is frequently chosen (0.1– 0.2
mgintravenously) because of a rapid onset and lack of
sedation;however, atropine and scopolamine can also be used.For
the nasal approach, the nasal mucosa (V1 and V2divisions of the
trigeminal nerve) must be anesthetizedwith local anesthetic.
Lidocaine is commonly used and istypically applied as a 2% gel or a
5% ointment. Solutionsof lidocaine can also be applied on pledgets
or soakedcotton swabs and are usually combined with a
vasoconstrictor(premixed solution of 0.25% phenylephrine and3%
lidocaine) to limit bleeding by shrinking the nasalmucosal
vasculature.The selected nasal passage is then gently dilated
withlubricated nasopharyngeal airways of increasing diameterprior
to passing an ETT. For the tongue, oropharynx, andlarynx (V3
division of the trigeminal nerve and glossopharyngealand vagus
nerves), topicalization can beachieved by aerosolized, gargled, or
nebulized lidocaine.Topical application of lidocaine during awake
FOI approachesreportedly results in plasma concentrations
wellbelow toxic levels.36 Other common topical anestheticssuch as
benzocaine have been shown to cause methemoglobinemiaeven in
therapeutic doses, and Cetacaine (amixture of benzocaine and
tetracaine) has a narrow therapeuticwindow.These techniques and
48
considerations for airway topicalizationhave been described in detail
in other reviews.37The spray-as-you-go technique utilizes the
fiberscope workingchannel to directly administer local anesthetic to
supraglotticand glottic structures during advancement of
theinstrument. This technique may minimize aspiration riskbecause
airway reflexes are maintained until just beforepassage of an ETT.
Supplemental oxygen can be deliveredby nasal cannula to reduce the
risk of hypoxia duringsedation and intubation.

Regional Anesthesia

Regional airway blocks can be performed in preparationfor FOI in

lieu of topical anesthetic approaches by theaforementioned methods.
These include the glossopharyngealnerve block, superior laryngeal
nerve block, and transtracheal(transcricoid) block. The
glossopharyngealnerve supplies sensory innervation to the posterior
third ofthe tongue, the vallecula, the anterior surface of the
epiglottis,the walls of the pharynx, and the tonsils. Blockadeof this
nerve can be performed using local anestheticsoakedpledgets held at
the base of the tonsillar pillars orby injecting local anesthetic using
the mandible and mastoidprocess as landmarks. The superior
laryngeal nerve(branch of the vagus nerve) provides sensory
innervationfrom the base of tongue and posterior surface of the
epiglottisto the arytenoids. It can be blocked by injectinglocal
anesthetic using landmarks at the cornu of the hyoidbone. The
transtracheal block is performed at the level ofthe cricothyroid
membrane in order to anesthetize the vagusnerve branches that
supply sensory innervation to theunderside of the epiglottis and
trachea.Details of these blocks are provided in other reviews.37They
are typically performed based on clinician familiarityand experience
as well as patient preference. A distinctadvantage of such blocks is a
more rapid onset of localanesthetic action and a longer duration of
action that mayfacilitate airway anesthesia with extubation. For
instance,the duration of action of plain 1% lidocaine solution

49
usedfor such specific nerve blocks is _75 min; it increases to400
min when 1/200,000 epinephrine is added to the solution.36
However, complications of airway blocks are notinsignificant and
include intra-arterial injection, hematomaformation, and tracheal
injury. Moreover, Sitzman et al38have shown that glossopharyngeal
nerve blocks are nomore effective than topical application of
lidocaine as aroute of local anesthetic administration for awake
directlaryngoscopy.

Sedation Versus General Anesthesia

Sedative medications and supplemental oxygen are

oftenadministered in patients undergoing awake FOI. Goalsare to
ensure patient comfort and to provide adequate anxiolysiswhile
maintaining a patent airway and ensuring adequateventilation. In
addition, patient responses to fiberopticscope advancement and
tracheal intubation can beblunted. Hypoxemia and aspiration are the
most commoncomplications associated with awake FOI.39 During
thistechnique, benzodiazepines are often combined with opioidsto
achieve adequate patient comfort and sedation.Midazolam is
commonly used because of its rapid onset,short half-life, and ability
to provide anterograde amnesia.Opioids such as fentanyl or
morphine provide analgesiaand can depress laryngeal reflexes.
However, they are associatedwith respiratory depression. In an older
studyusing volunteers, the combination of midazolam and
fentanylfor sedation produced apnea in half of the subjects,with
nearly all experiencing hypoxemia (oxyhemoglobinsaturation _
90%).40More recent case reports,41,42 case series,43,44 and
randomizedstudies45 have reported on dexmedetomidine
forconscious sedation during awake FOI and its superior
characteristicsin this setting. Dexmedetomidine is a selective_2
adrenergic agonist with sympatholytic, analgesic, andsedative
properties that does not cause respiratory depressionwithin
recommended dosing ranges (0.2– 0.7 _g/kg/h). Although studies are
small and limited, it is an alternateand perhaps superior alternative
for sedation of patientswith difficult airways during FOI attempts.
50
Other studieshave reported similar results regarding patient
comfort,sedation, and intubating conditions using a combination
ofmidazolam and remifentanil for awake fiberoptic
nasotrachealintubation.46 Still another study of 60 patients
undergoingfiberoptic nasotracheal intubation found thatremifentanil
facilitated better cooperation than propofol inpatients and may be
safer when spontaneous ventilation iscritical.47FOI can also be
performed under general anesthesia,often in the spontaneously
ventilating patient. There arefew studies investigating FOI in
spontaneously ventilatinganesthetized patients. Propofol and
sevoflurane have beencompared in this setting with little group
differences exceptthat patients receiving propofol had more
frequentepisodes of hypoxemia.48 Easy and titratable anesthesiawas
provided in both groups. Similar findings have beenreported in
patients with anticipated difficult airways usingsevoflurane49 and
propofol50 with the aid of pressuresupport ventilation. Another
recent randomized study comparingsevoflurane and propofol in
patients scheduled formaxillofacial surgery who were difficult to
intubate basedon predictive criteria reported a high intubation
successrate with both.51 In this study, apnea was limited in
bothgroups by the avoidance of opioids.One might question whether
awake FOI with topicalanesthesia solely might be a superior
alternative in aneffort to reduce the risks of aspiration, airway
compromise,inadequate ventilation, hypoxemia, and apnea
associatedwith sedation or general anesthesia. However, therehave
been some reports of upper airway obstruction usingtopical
anesthesia approaches.52,53 One study has reportedthat awake FOI
may be uncomfortable in 20% of patientseven with premedication
and incremental sedation duringthe procedure with a
benzodiazepine.54 Moreover, eventhe use of topical anesthesia
combined with heavy sedationmay be limited or may not prove
adequate for somepatients, as seen in at least one case series.55 In
selectpatient groups with difficult airways (children, uncooper-ative
adults, and patients with mental disabilities), generalanesthesia (via
mask induction or intravenous titration)may be required.
51
Complications

There is a paucity of data on the specific incidence andscope of

complications attributable to FOI. Potential complicationsassociated
with fiberoptic techniques include epistaxis(nasal approach),
laryngotracheal trauma, laryngospasm,and aspiration of saliva,
blood, or gastric contents.

52