Unintetional tracheal extubation during prone position: what is the best rescue airway device?

Germano De Cosmo

Risultato della ricerca: Contributo in rivistaArticolo in rivistapeer review

6 Citazioni (Scopus)


Unintentional tracheal extubation during surgery is a dramatic situation and may be a life-threatening event if it is not followed by a rapid reintubation. This is particularly true in patients with difficult airways or in patients whose airways are difficult to access such as patients undergoing facial surgery or in prone position. The patient prone is a problem for the anesthesiologist because accidental tracheal extubation in this setting could be a catastrophic event often treated by turning the patient supine for ventilation and tracheal re intubation. However, patient's rotation in supine position is not always achievable and requires time, the support of personnel not necessarily immediately available, and it may contaminate the sterile surgical field with serious postoperative complications.[1] In the last years, several reports have been published to describe the anesthesiological management after unexpected intraoperative tracheal extubation particularly focusing on devices more often used.[2,3] The laryngeal mask airway (LMA) has become the most used device in the catastrophic situation “cannot intubate, cannot ventilate” and in literature, it has been described its insertion as rescue airway management in patients with unintentional tracheal extubation during general anesthesia in prone position.[4] In 1993, McCaughey and Bhanumurthy have inserted for the 1st time a supraglottic airway device (SAD) following the induction in prone position and from that time several studies have been performed to valuate the facility and the security of insertion in this position. In fact, it has been shown that prone insertion may be easy as in the supine because the tongue falls anteriorly and creates an open space for the placement of LMA device (LMAD), whose seal is improved by the cephalic displacement of the larynx. Moreover, the risk of aspiration is reduced because regurgitant fluid for the gravity will be drained from the airway.[5] In the issue of “Journal of Emergencies, Trauma, and Shock” Gupta et al. describe an observational study that they conducted to test the feasibility of SAD insertion for ensure airway ventilation in prone position and fixed head as in neurosurgical patients during accidental extubation.[6] Forty partecipanting anesthesia residents were asked to place to airway trainer (Laerdal) manikin in the prone position three SADs; i-gel, LMA Proseal™ (PLMA), and LMA Classic™ (CLMA). The authors found that despite all three SADs were successful as rescue devices during accidental extubation in prone position, however, the ease of insertion was maximum with i-gel followed by CLMA and PLMA, in fact, i-gel was characterized by fewer time taken for insertion, least resistance in insertion, no maneuvers required for optimal positioning and bronchoscopic view and insertion score was significantly higher with i-gel as compared to CLMA and PLMA. Therefore, the authors compared three different SADs of which CLMA belongs to the first generation of LMA, whereas PLMA and i-gel to second generation of LMA. Second generation LMA was born to reduce the problems associated to the first generation LMA such as the difficult in positioning, the relatively low airway pressures with the risk of aspiration, and dislodgment. The second generation LMADs like proseal have a gastric channel allowing the passage of a tube for gastric decompression. i-gel is a more recent SAD with a non-inflatable cuff made of a thermoplastic elastomer, able to provide a seal by conforming to differently shaped throats. Several studies have compared the i-gel with various types of LMADs regarding to efficacy and ease of insertion. In a systematic review and meta-analysis performed by de Montblanc et al., i-gel was superior regarding first generation LMAD in terms of time of insertion and leak pressure despite this superiority was not for i-gel compared to the second generation LMADs. The main clinical
Lingua originaleEnglish
pagine (da-a)2-3
Numero di pagine2
RivistaJournal of Emergencies, Trauma and Shock
Stato di pubblicazionePubblicato - 2017


  • accidental tracheal extubation


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