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| COMMENTARY |
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| Year : 2019 | Volume
: 35
| Issue : 4 | Page : 546-547 |
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Supraglottic airway devices in airway management of obese patients
Manpreet Singh
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32B, Chandigarh, India
| Date of Web Publication | 13-Dec-2019 |
Correspondence Address:
Manpreet Singh
Government Medical College and Hospital, Sector 32B, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/joacp.JOACP_271_19
How to cite this article:
Singh M. Supraglottic airway devices in airway management of obese patients. J Anaesthesiol Clin Pharmacol 2019;35:546-7 |
Supraglottic airway devices (SADs) have been used for routine airway management and maintenance during anesthesia in patients without increased risks for aspiration of gastric contents.[1] SADs offer an alternative airway to traditional tracheal intubation with potential benefits, including ease of fitness and less airway disturbance.[1] Airway of an obese individual is a major concern for an anesthesiologist while providing general anesthesia or securing the airway in the intensive care unit. The incidence of obesity is 11% of the global population according to world health organization and anesthesiologist will encounter obese patients quite often.[2] Endotracheal intubation is usually done in most surgeries but incidence of difficult intubation in an obese patient is much higher than normal weight patients.[3],[4] National Audit Project 4 also stated that SADs were associated with lowering the major airway complications than all other devices in UK.[5]
SADs are used in difficult airway management, where they can be used for oxygenation and also as conduits for insertion of tracheal tubes in the scenarios of difficult or failed intubation. These also act as a rescue device in the cases of difficult oxygenation with the facemask.[6] With new, improved versions of these devices, some borderline indications for their use, such as laparoscopies or insertion in the obese patients have also appeared.
In United States, 60%–70% of the adult population is overweight and >30% of them obese. Western Europe, including the United Kingdom, has a prevalence of adult obesity over 20% with an increasing trend. Morbidly obese patients are at risk of difficult mask ventilation as well as intubation, and airway management is a major factor underlying morbidity and mortality related to anaesthesia in such patients.[3]
SAD can be used alone to maintain the airway during short surgical procedures or it can act as a conduit for passage of endotracheal tube during major surgical procedures or in the intensive care. Studies have shown that there need not be any fear of airway-related complications while using SAD in obesity.[7] Obese have a limited neck movement due to restriction of atlanto-axial joint and cervical spine by upper thoracic and lower cervical fat pads. Obese individuals usually have short thick neck.[7] The excessive tissue fold in mouth may be missed during routine preanesthetic check-up. They also have suprasternal, presternal and posterior cervical fat and a very thick submental fat pad.[7] All these factors contribute to a difficulty in laryngoscopy and tracheal intubation. Many SADs can be used as valuable equipment for morbidly obese patients and it is now standard tool for airway management in clinical practices. Abdi et al. proved laryngeal mask airway (LMA) supreme as effective tool in obese patients.[8] Zoremba et al. concluded that using an LMA and avoidance of muscle relaxation reduced postoperative deterioration of lung function, compared with tracheal intubation. It is also important to note that LMA causes lesser incidence of laryngospasm, postoperative sore-throat and coughing.[9] SADs cause less atelectasis especially during induction of anaesthesia.[9]
Obese persons are also prone to several cardiovascular complications. SADs are better option as they help in reduction of pressor response and provide better hemodynamic stability compared to laryngoscopy and intubation.[10],[11] Many intubating SAD devices like Ambu Aura gain, Intubating Laryngeal tube Suction device, Block buster airway, etc., are the advanced airways that usually care for all the issues that are raised in other SADs. Role of SADs have not been observed in different surgeries in detail. In ophthalmic surgeries, there is increased intraocular and intracranial tension caused due to SAD is lesser than in endotracheal tube (ETT). Thus, it remains ideal for eye surgeries.[12] SAD can be used in Emergency surgeries as rescue device mostly and in obese patients' elective surgeries. Time spent is also lesser and securing the airway with SADs is an art and skill. Since the advent of SAD, there has been the fear of aspiration associated with its use. A meta-analysis involving 12,901 patients with LMA usage showed that clinical evidence of pulmonary aspiration using the LMA was comparable to anesthesia administered with an endotracheal tube (ETT) (2.3 per 10,000).[13] The 2011, NAP4 project done in United Kingdom shows only a 4% chance of aspiration associated with second-generation airway devices, compared with 35% chance seen with tracheal tube. Rati et al. in 2018 compared i-gel in obese and nonobese patients and they concluded that i-gel is as effective in obese patients as in nonobese patients when used for securing the airway for surgical procedures.[14] This makes SAD a superior choice.[5]
Difficult laryngoscopy and difficulty in intubation are the common problems that an anesthesiologist will face when an obese patient comes to the emergency department, ICU or for surgery.[15] In such situations, supraglottic airway device should be made available. These devices gained importance with concept of oropharyngeal leak pressures (OLP). More the OLP better is the SAD. With maintenance of OLP and the intracuff pressures throughout procedure, longer duration surgeries can be performed under SADs. Obese patients gained advantages over the years with the concept of OLP. SADs are now key to successful airway management. Practicing different SADs on normal or obese patients is a skill and this has been a revolution in the field of airway management in modern anesthesia practice. SADs also gained a firm place in obese and nonobese patients, probably because of its ease of placement and efficacy, and are being used in patients undergoing diagnostic and therapeutic procedures where tracheal intubation is not necessary.
| References | |  |
| 1. | Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev 2013:CD010105.  |
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| 3. | Voyagis GS, Kyriakis KP, Dimitriou V, Vrettou I. Value of oropharyngeal mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol 1998;15:330-34. |
| 4. | Benumof JL. Obstructive sleep apnea in the adult obese patient: Implications for airway management. J Clin Anesth 2001;3:144-56. |
| 5. | NAP4 Report and findings of the 4 th National Audit Project of The Royal College of Anaesthetists 2011:91-2. |
| 6. | Gupta B, Gupta S, Hijam B, Shende P, Rewari V. Comparison of three supraglottic airway devices for airway rescue in the prone position. A manikin-based study. J Emerg Trauma Shock 2015;8:188-92. [ PUBMED] [Full text] |
| 7. | Kurien BB, Padmanabha S, Mathias V. Morbid obesity and supraglottic airway devices. Int J Rehabil Res 2014;3:44-8. |
| 8. | Abdi W, Dhonneur G, Amathieu R, Adhoum A, Kamoun W, Slavov V, et al. LMA supreme versus facemask ventilation performed by novices: A comparative study in morbidly obese patients showing difficult ventilation predictors. Obes Surg 2009;19:1624-30. |
| 9. | Larsson A. LMA: A big choice. Acta Anaesthesiol Scand 2009;53:436-42. |
| 10. | Wilson IG, Fell D, Robinson SL, Smith G. Cardiovascular responses to insertion of the laryngeal mask. Anaesthesia 1992;47:300-02. |
| 11. | Siddiqui NT, Khan FH. Haemodynamic response to tracheal intubation via intubating laryngeal mask airway versus direct laryngoscopic tracheal intubation. J Pak Med Assoc 2007;57:11-4. |
| 12. | Natalini G, Franceschetti ME, Pantelidi MT, Rosano A, Lanza G, Bernardini A. Comparison of the standard laryngeal mask airway and the ProSeal laryngeal mask airway in obese patients. Br J Anaesth 2003;90:323-6. |
| 13. | Brimacombe JR, Berry A. The incidence of aspiration associated with laryngeal mask airway; A meta-analysis of published literature. J Clin Anesth 1995;7:297-305. |
| 14. | Prabha R, Raman R, Khan MP, Kaushal D, Siddiqui AK, Abbas H. Comparison of I-gel for general anesthesia in obese and nonobese patients. Saudi J Anaesth 2018;12:535-9. |
| 15. | Nicholson A, Cooke TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev 2013;CD010105. doi: 10.1002/14651858.CD010105.pub2. |
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