BACKGROUND: In patients after total laryngectomies, the trachea and the lung can be easily infected by SARS-CoV-2 because the respiration happens through the tracheostoma.
OBJECTIVE: The aim of our study was to examine whether patients with LaryTube™ can distribute aerosols to a greater extent than without LaryTube™, and to observe whether the surface of different protective instruments can be examined using the thermal camera in total laryngectomees. An important objective was also to confirm the assumption that the use of HME (heat and moisture exchanger) alone does not provide protection during COVID-19 pandemic. Finally, during our tests, we tried to get an answer to our assumption that the sample taken from the inner surface of the HME can be tested for SARS-CoV-2.
METHODS: A total of 23 patients who underwent total laryngectomies were analyzed by velocity measurements and thermal imaging with and without HMEs and laryngeal tubes, using different types of PPEs. COVID-19 PCR testing was performed on patient tracheas and the inner surfaces of the HMEs.
RESULTS: Male patients with laryngeal tubes without HMEs demonstrated an increase in exhaled airflow velocity of more than 43% compared to male patients without laryngeal tubes; in female patients, the same value was more than 39%. Thermal imaging results confirmed that the lowest surface temperature was measured on FFP2 masks. The sent samples can be tested for SARS-CoV-2 using PCR, the presence of the virus was not detected.
CONCLUSIONS: Laryngectomized patients without laryngeal tubes pose a lower risk for spreading viral aerosols due to the reduced velocity of the exhaled airflow caused by the absence of the tube as the narrowing factor. Patients with laryngeal tubes who undergo total laryngectomies during the COVID-19 pandemic should use HMEs with viral filter, if possible, also changing the laryngeal tubes to dermal adhesives for fitting their HMEs seems to be the best option. The surface of the used protective equipment can also be examined with thermal camera in the case of total laryngectomees. COVID-19 PCR testing of the tracheal secretion from the inner HME surfaces should become a routine in clinical practice if deemed necessary. Orv Hetil. 2023; 164(34): 1327-1336.
Bevezetés: A teljes gégeeltávolításon átesett betegeknél a légcső és a tüdő a SARS-CoV-2 közvetlen fertőzésének további helyeként szolgálhat, mivel a légúti áramlás a tracheostomán keresztül történik. Célkitűzés: Tanulmányunk célja volt, hogy megvizsgáljuk, LaryTube™ mellett a betegek képesek-e nagyobb mértékben aeroszolok terjesztésére, mint LaryTube™ nélkül, továbbá az, hogy megfigyeljük, vizsgálható-e különböző védőeszközök felszíne a hőkamera segítségével ebben a betegcsoportban. Fontos célkitűzésként szerepelt az is, hogy megerősítsük a feltételezést, miszerint a HME (heat and moisture exchanger – hő- és nedvességcserélő) használata önmagában nem nyújt védelmet COVID–19-pandémia esetén. Végül vizsgálataink során próbáltunk választ kapni arra a feltételezésünkre, hogy a HME belfelszínéről vett minta tesztelhető-e SARS-CoV-2 irányában. Módszer: Teljes gégeeltávolításon átesett 23 beteg kilélegzett levegőjének sebességét mértük HME-vel és HME nélkül, LaryTube™ használatával, illetve anélkül. Az általunk kiválasztott védőeszközök felszínén hőkamerás vizsgálatot végeztünk, melyeket minden esetben a beteg stomája elé helyeztünk. A HME belfelszínéről és a trachea hátsó faláról vett váladékot az esetleges SARS-CoV-2-pozitivitás miatt PCR-vizsgálatnak vetettük alá. Eredmények: LaryTube™-bal ellátott férfi betegeink HME nélkül 43%-kal gyorsabban fújták ki levegőjüket, mint a LaryTube™ nélküliek. Nők esetében ez az érték 39% fölött volt. A legalacsonyabb felszíni hőmérsékletet az FFP2-es maszk esetében regisztráltuk. A küldött minták PCR segítségével SARS-CoV-2-re tesztelhetők, vírus jelenlétét nem mutatták ki. Következtetés: A teljes gégeeltávolításon átesett betegek LaryTube™ nélkül kisebb eséllyel képesek az aeroszolok terjesztésére, mivel hiányzik a tubus mint a stoma szűkítő tényezője. Ezen betegeknek ajánlott COVID–19-pandémia idején a vírusszűrővel ellátott HME használata, sőt a legracionálisabb megoldás a tubus elhagyása és tapaszra cserélése a HME rögzítése miatt. A használt védőeszközök felszíne hőkamerával vizsgálható laryngectomián átesett betegek esetében is. Szükség esetén bevezethető a klinikai gyakorlatba a HME belfelszínéről vett minta PCR-tesztelése SARS-CoV-2 irányában, mely sokkal biztonságosabb módszernek bizonyult. Orv Hetil. 2023; 164(34): 1327–1336.

A large variety of airway devices, techniques, and cognitive tools have been developed during the last 100 years to improve airway management safety and became a topic of major research interest. This article reviews the main developments in this period, starting with modern day laryngoscopy in the 1940s, fiberoptic laryngoscopy in the 1960s, supraglottic airway devices in the 1980s, algorithms for difficult airway in the 1990s, and finally modern video-laryngoscopy in the 2000s.

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.
Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.
The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.
Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.
HINTERGRUND: Das Atemwegsmanagement mit supraglottischen Atemwegshilfen (SGA) bei lebensbedrohlichen Kindernotfällen stellt eine der Hauptsäulen des Notfallatemwegsmanagements dar. Hierbei kommen unterschiedliche Arten von Larynxmasken (LM) und Larynxtuben (LT) zum Einsatz. Auf der Basis einer aktualisierten, umfassenden Literaturauswertung wird ein Update der 2015 erstmalig publizierten, interdisziplinären Stellungnahme zum Einsatz von SGA bei Kindernotfällen präsentiert.
Literaturrecherche über die Datenbank „PubMed“ und Einordnung der Studien analog den Kriterien des Oxford Centre for Evidence-based Medicine – Levels of Evidence (bis 31.12.2020) sowie anschließende Konsensusfindung innerhalb der Autor*Innen-Gruppe.
Die Evidenz zum erfolgreichen Einsatz der LM im Kindesalter wird zunehmend größer, und LM werden mittlerweile auch für die Neugeborenenversorgung empfohlen. Erfolgreiche Anwendungen des LT beschränken sich weiterhin auf wenige Arbeitsgruppen und Zentren sowie eine insgesamt geringe Anzahl von Anwendungen. Vor allem für Kinder unter 10 kgKG erscheint eine Anwendung des LT weiterhin nicht sicher und kann daher nicht empfohlen werden. Ein für die Notfallbeatmung verwendeter SGA sollte über die Möglichkeit eines gastralen Kanals (2. Generations-SGA) verfügen.
Unter Berücksichtigung der wissenschaftlichen Datenlage und der großen klinischen Erfahrung mit der LM in der Elektiv- und Notfallanwendung bei Neugeborenen und Kindern kann derzeit zum notfallmäßigen Atemwegsmanagement im Kindesalter von den supraglottischen Atemwegshilfen nur die Larynxmaske empfohlen werden. Die Larynxmaske sollte sowohl prähospital als auch innerklinisch in allen für Kinder verfügbaren Größen (1, 1½, 2, 2½, 3) vorgehalten und in der Anwendung regelmäßig geschult werden.

Supraglottic airway devices are increasingly used during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients in the United States and worldwide. In this study, we aimed to compare the neurologic outcomes of OHCA patients managed with the King Laryngeal Tube (King LT) to the neurologic outcomes of patients managed with the iGel.
We used the Cardiac Arrest Registry to Enhance Survival (CARES) public use research dataset for our analysis. Non-traumatic OHCA cases with attempted EMS resuscitation enrolled from 2013-2021 were included. We used two-level mixed effects multivariable logistic regression analyses with treating EMS agency as the random effect to determine the association between supraglottic airway device and outcome. The primary outcome was survival with a Cerebral Performance Category (CPC) score of 1 or 2 at discharge. Secondary outcomes included survival to hospital admission and survival to hospital discharge. Age, sex, calendar year of OHCA, initial ECG rhythm, witnessed status (unwitnessed, bystander witnessed, 9-1-1 responder witnessed), bystander CPR, response interval, and OHCA location (private/home, public, institutional) were used as covariables.
In comparison to use of the King LT, use of the iGel was associated with greater neurologically favorable survival (aOR: 1.45 [1.33, 1.58]). In addition, use of the iGel was associated with greater survival to hospital admission (1.07 [1.02, 1.12]) and survival to hospital discharge (1.35 [1.26, 1.46]).
This study adds to the body of literature suggesting that use of the iGel during OHCA resuscitation is associated with better outcomes than use of the King LT.

This study aimed to investigate the overall success of tracheal intubation using the intubating Laryngeal Tube Suction-Disposable (iLTS-D™, VBM, Sulz a. N., Germany) compared to the Laryngeal Mask Airway (LMA) Fastrach™ (Teleflex, Athlone, Ireland). We hypothesised that the iLTS-D™ would be non-inferior to the LMA Fastrach™ for tracheal intubation and ventilation.
Multicentric, non-inferiority, randomised controlled study.
Operating rooms from two tertiary and one secondary centre in Switzerland from January 2017 to July 2019. The investigators were trained anaesthetists with extensive experience with laryngeal masks but limited to laryngeal tubes. The study was discontinued after the planned interim analysis.
Ninety-nine adult patients were included after randomisation. The inclusion criteria were American Society of Anesthesiologists physical status 1 to 3 in patients scheduled for elective surgery requiring tracheal intubation. Patients with a history of difficult intubation were excluded.
After anaesthesia induction and once neuromuscular blockade was obtained, ventilation was initiated, and tracheal intubation was performed through the randomised device with the flexible endoscope tip placed proximally to the tip of the tracheal tube (visualised blind intubation).
The primary outcome was the intubation success rate after two attempts. The secondary outcomes were time to intubation, successful ventilation rate, time to achieve ventilation, and gastric access success rate.
The overall intubation success rate was significantly higher in the Fastrach™ group than in the iLTS-D™ group (91.8% vs 70.0%, p = 0.006). No difference was found in the ventilation success rate (94% for iLTS-D™ and 100% for LMA Fastrach™ [p = 0.829]). The time to achieve ventilation and intubation were similar between the groups. No major airway complications were noted.
Although both supraglottic devices provided the same effective ventilation rate, the LMA Fastrach™ was superior to the iLTS-D™ as a conduit for intubation in 99 adult patients without a known difficult intubation. These preliminary results need to be confirmed in studies that include a larger population.
Clinicaltrials.gov, 21.09.2016, Identification Number NCT02922595.

Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty, number of attempts before successful insertion and overall success rate of insertion.
All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful insertion, by either same or different ambulance personnel, and the difficulty of insertion graded by easy, medium or hard. Secondary outcomes were reported complications with inserting the SAD\'s.
Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86%) compared to LTS-D (75%, p = 0.043). The rates of successful placements were higher when using I-gel compared to LTS-D, and there was a significant increased risk that the insertion of the LTS-D was unsuccessful compared to the I-gel (risk ratio 1.8, p = 0.04). I-gel was assessed to be easy to insert in 80% of the patients, as opposed to LTS-D which was easy to insert in 51% of the patients.
Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.

BACKGROUND: It is unclear which advanced airway device has better placement success and fewer adverse events in out-of-hospital cardiac arrests (OHCAs). This study aimed to evaluate the efficacy of the VBM laryngeal tube (LT) against the laryngeal mask airway (LMA) in OHCAs managed by emergency ambulances in Singapore.
METHODS: This was a real-world, prospective, cluster-randomised crossover study. All OHCA patients above 13 years old who were suitable for resuscitation were randomised to receive either LT or LMA. The primary outcome was placement success. Per-protocol analysis was performed and association between outcomes and airway device group was compared using multivariate binomial logistic regression analysis.
RESULTS: Of 965 patients with OHCAs from March 2016 to January 2018, 905 met the inclusion criteria, of which 502 (55.5%) were randomised to receive LT while 403 (44.5%) were randomised to receive LMA. Only 174 patients in the LT group actually received the device due to noncompliance. Placement success for LT was lower than for LMA (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.90). Complications were more likely when using LT (OR 2.82,0 95% CI 1.64-4.86). Adjusted OR for prehospital return of spontaneous circulation (ROSC) was similar in both groups. A modified intention-to-treat analysis showed similar outcomes to the per-protocol analysis between the groups.
CONCLUSIONS: LT was associated with poorer placement success and higher complication rates than LMA. The likelihood of prehospital ROSC was similar between the two groups. Familiarity bias and a low compliance rate to the LT were the main limitations of this study.

BACKGROUND: Supraglottic airways, which are easily inserted and minimize interruptions in cardiopulmonary resuscitation manoeuvres, are now widely used in pre- and in-hospital emergencies. However, most studies in these devices do not specify whether they ensure good ventilation during CPR. This systematic review aims to determine whether there is evidence that supraglotic airways enable effective ventilation during resuscitation.
METHODS: The MEDLINE and COCHRANE databases were searched for studies published in English up to 30 November 2018. Eligible studies were all those that objectively evaluated tidal volume during resuscitation maneuvers in patients over 18 years of age using various supraglottic airways.
RESULTS: A total of 3734 articles were identified, of which 252 were duplicates. Only 1 objectively evaluated ventilation during resuscitation maneuvers and presented data relevant to this review. The study included 470 patients, 51 of which underwent spirometry. Only 4.48% of patients survived to hospital discharge; however, the correlation with ventilation effectiveness was not assessed.
CONCLUSIONS: There is no scientific evidence that supraglottic airways provide effective ventilation during resuscitation maneuvers. Evaluation by spirometry, chest impedance and ultrasound may help to determine the ventilatory efficacy of supraglottic airways during CPR, and clarify whether this factor contributes to the difficulties experienced in reversing cardiorespiratory arrest.

A 26-year-old female patient presented in cardiac arrest from presumed opioid overdose. An Ambu King LTS-D laryngeal device was placed by EMS providers for airway management during the resuscitation. There was no documented difficulty with placement and breath sounds and waveform capnography were consistent with appropriate placement. The resuscitation was terminated on scene after extensive resuscitative efforts by the EMS crew. Upon autopsy of the patient, it was discovered that the laryngeal tube device had caused a deep 5 cm perforation to the left piriform recess. The laryngeal tube had bent and was pushed into the perforation in the piriform recess; had the patient had regain of spontaneous circulation this could have caused significant morbidity. Laryngeal tube airway devices have shown increased usage in healthcare settings, in particular in the prehospital arena. Studies of these airway devices have shown they have quick insertion times, high success rates, and low complications. Tongue swelling and minor trauma are common complications of laryngeal tube airway devices. The case report describes a rare, yet potentially life-threatening, complication of laryngeal tube airway device placement- hypopharyngeal injury. If unrecognized, this injury could lead to serious complications. Providers should be aware of the common and uncommon injuries that are associated with prehospital laryngeal tube airway device placement.

UNASSIGNED: Newly developed supraglottic airway devices (SGAs) are designed to be used both for ventilation and as conduits for endotracheal intubation with standard endotracheal tubes (ETTs). We compared the efficacy of the Ambu AuraGain (AAG) and the newly developed intubating laryngeal tube suction disposable (ILTS-D) as conduits for blind and fiber-optically guided endotracheal intubation in an airway mannequin.
UNASSIGNED: This is a prospective, randomized, crossover study in an airway mannequin, with two arms: blind ETT insertion by medical students and fiber-optically guided ETT insertion by anesthesiologists. The primary outcome variable was the time to achieve an effective airway through an ETT using AAG and ILTS-D as conduits. Secondary outcome variables were the time to achieve effective supraglottic ventilation and successful exchange with an ETT, and the success rates for blind endotracheal intubation and fiber-optically guided intubation techniques for both SGAs.
UNASSIGNED: Forty participants were recruited to each group. All participants were able to insert both devices successfully on the first attempt. For blind intubation, the success rate for establishing a definitive airway with an ETT using the SGA as a conduit was significantly higher with ILTS-D (82.5%) compared with AAG (20.0%) (P < 0.001). None of the participants were able to successfully complete the exchange of the SGA for the ETT with the AAG. In the fiber optic guided intubation group, the rate of successful exchange was significantly higher with ILTS-D (84.6%) compared with AAG (61.5%) (P = 0.041).
UNASSIGNED: The ILTS-D successfully performs in an airway mannequin with higher success rate and shorter time for blindly establishing an airway with an ETT using the SGA as a conduit, compared with AAG. Further clinical trials are warranted.