Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial | Revista Española de Anestesiología y Reanimación (English Edition)

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Portas, M.I. Canal, M. Barrio, M. Alonso, P. Cabrerizo, M. López-Gil, M. Zaballos" "autores" => array:7 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Portas" ] 1 => array:2 [ "nombre" => "M.I." "apellidos" => "Canal" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Barrio" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Alonso" ] 4 => array:2 [ "nombre" => "P." "apellidos" => "Cabrerizo" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "López-Gil" ] 6 => array:4 [ "nombre" => "M." "apellidos" => "Zaballos" "email" => array:1 [ 0 => "mati@plagaro.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y terapéutica del dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2951 "Ancho" => 2499 "Tamanyo" => 253433 ] ] "descripcion" => array:1 [ "en" => "Study flow chart." ] ] ] "textoCompleto" => "IntroductionDespite the technological progress made in recent decades in anaesthesiology, airway management continues to be one of the main causes of anaesthesia-related morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> Difficult airway management guidelines developed by prominent international anaesthesiology societies, such as the American Society of Anesthesiology (ASA) and the Difficult Airway Society of the United Kingdom (DAS), among others, recommend supraglottic airway devices (SAD), with or without flexible bronchoscopy, as an alternative to intubation.<a class="elsevierStyleCrossRefs" href="#bib0130">2,3</a> The Fastrach™ (ML-Fastrach™ reusable; Teleflex Medical Co., Westmeath, Ireland) laryngeal mask is a SAD designed to facilitate intubation in both anticipated and unanticipated difficult airway (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and maintains oxygenation during intubation attempts. The overall success rate for blind intubation with this device is 96.2–99.3%.<a class="elsevierStyleCrossRefs" href="#bib0140">4–6</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>The Air-Q® (Air-Q reusable laryngeal mask®, Cookgas®, St Louis, USA) is a SAD designed for ventilation and tracheal intubation. It can be used with any standard endotracheal tube, has no metal handle or wire-reinforced tube, and is available in paediatric sizes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Preliminary studies with the Air-Q® showed a blind intubation success rate of 57% at the first attempt, and of 74% after 3 attempts.<a class="elsevierStyleCrossRefs" href="#bib0155">7,8</a> Compared with the ML-Fastrach™ (99% success rate), blind tracheal intubation through the Air-Q® was only achieved in 77% of patients after 2 attempts. In contrast, when combined with flexible bronchoscopy, the success rate increased to 100% in the ML-Fastrach group™ versus 95% in the Air-Q group®.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>The combination of a SAD with a flexible bronchoscope is considered an effective method for difficult airway management. Nevertheless, this is the first study to compare the efficacy and ease of fibreoptic-guided tracheal intubation (FTI) through the Air-Q® and ML-Fastrach™. The aim of the study was to evaluate the efficacy and ease of use of both SADs for FTI carried out by anaesthesiology residents in mannequins.Material and methodAfter consulting the institutional review board, it was considered that, due to the nature of the study, their approval was not required. All anaesthesiology residents with no prior experience in FTI through the Air-Q® or the ML-Fastrach™ were invited to participate. Thirty-three residents out of a total of forty gave verbal consent to participate in the study. All intubations were performed on the same mannequin located in one of the hospital's operating rooms. After 15min of verbal instruction, intubation through each study SAD was demonstrated on the “Bill I” mannequin (VBM, Germany). Each participant practised the study procedure once with each SAD immediately before their test intubation. The order in which the SADs were used was determined by a computer-generated randomized sequence. The sequence was enclosed in sealed opaque envelopes that were opened immediately before the start of each intubation test. The researchers had previously tested different sizes of the study SADs, and found that the Air-Q®3.5 and the ML-Fastrach™ 4 provided the best glottic vision. In the case of the Air-Q®, a no. 7 wire-reinforced cuffed endotracheal tube with a 15mm detachable connector (“Safety-Soft”, Mallinckrodt Medical, Athlone, Ireland) were used. For the ML-Fastrach™, the device's own reusable no. 7 wire-reinforced silicone endotracheal tube was chosen ™ (LMA Fastrach™ ETT-Laryngeal Mask Company Ltd, Victoria, Mahé, Seychelles). Each participant performed the procedures without the presence of the other residents to avoid the potential for observation-induced bias. Prior to each procedure, the SADs (the cup and the inside of the airway tube), the endotracheal tubes and the pilot balloon tube, and the fibreoptic bronchoscope were lubricated with a water-soluble lubricant. The lubricant was spread inside the airway tube of the SAD by sliding the respective endotracheal tube up and down several times.The study procedure was divided into 3 stages:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Stage 1: Insert the SAD into the mannequin and check position with 2 ventilations. The ML-Fastrach™ was inserted following the standard technique with the cuff deflated. The Air-Q® was inserted with the inflation valve open, which improved the manoeuvrability of the cuff. Once inserted into the mouth, the left index finger was used to slide the tip of the cuff behind the base of the tongue while pressing downward on the airway tube with the right hand to advance the SAD to its position. The cuff of the Air-Q® was inflated with 4ml of air, and that of the ML-Fastrach™ with 10ml (the required volume of air was checked before the study). The chronometer was started as soon as the participant took hold of the SAD, and ended when correct pulmonary ventilation was observed with 2 manual ventilations with a reservoir bag (Ambu® Mark IV-Reusable Resuscitator).</li></ul>Before moving on to stage 2, correct insertion of the SAD was verified using validated a fibroscopic scale<a class="elsevierStyleCrossRef" href="#bib0170">10</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010">•Grade I: full view of vocal cords.</li><li class="elsevierStyleListItem" id="lsti0015">•Grade I: partial view of vocal cords including arytenoids.</li><li class="elsevierStyleListItem" id="lsti0020">•Grade III: only the epiglottis is seen.</li><li class="elsevierStyleListItem" id="lsti0025">•Grade IV: the pharynx and the cuff of the SAD are seen.</li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">•Stage 2: FTI with a 5.2mm outer diameter fibrescope (Karl Storz, Tuttlingen, Germany). The endotracheal tube was inserted into the air tube of the Air-Q® to a depth of 18cm. In case of the ML-Fastrach™, the endotracheal tube was introduced with the vertical line towards the participant and advanced until the tip was located under the epiglottic elevating bar (indicated by the horizontal marking on the endotracheal tube). The fibrescope was then inserted into the endotracheal tube as far as, but not beyond, the distal orifice. Both were then simultaneously advanced 1.5cm. Once the distal end of tube reached the larynx, the fibrescope was advanced to the trachea and the endotracheal tube was advanced over the fibrescope.<a class="elsevierStyleCrossRef" href="#bib0175">11</a> Stage 2 began when the participant took hold of the endotracheal tube and ended when correct pulmonary ventilation was observed with 2 manual ventilations through the tube.</li><li class="elsevierStyleListItem" id="lsti0035">•Stage 3: Air-Q®/ML Fastrach™ withdrawal over the endotracheal tube. The cuff of the Air-Q® and the endotracheal tube were fully deflated. The 15-mm connector was removed from the endotracheal tube. The cuff of the ML-Fastrach™ was fully deflated but not the cuff of the endotracheal tube. The 15mm connector was removed from the endotracheal tube. The adaptors of the Air-Q® (Air-Q® Removal Stylet, Cook Gas®) and the ML-Fastrach™ (LMA™ Stabilizer Rod, Laryngeal Mask Company Ltd) were inserted into the proximal end of the endotracheal tube. The devices were removed over the adaptor. Then the adaptor was removed and the 15mm connector was adjusted. Stage 2 began when the participant deflated the cuff and ended when correct pulmonary ventilation was observed with 2 manual ventilations.</li></ul>Intubation failure was defined as failure to ventilate through the endotracheal tube after 5min or after 3 attempts. This included failure to insert the SAD or the endotracheal tube, or accidental extubation during removal of the SAD.The data collection sheet recorded the time taken to complete each of the 3 stages, the total time, operator-perceived ease of use at each stage (0 very difficult, 10 very easy), the fibroscopic scale score, the experience of the anaesthetist, and the number of prior intubations through the Air-Q® and/or the ML-Fastrach™.Statistical analysis was performed using SPSS 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables that followed a normal distribution were expressed as mean and standard deviation. Categorical variables were expressed as frequency and percentages. Continuous variables were compared using the Student's t test for paired data or the Wilcoxon test. The Chi-square test or Fisher's exact test was used for categorical variables. All p values were 2-tailed. Significance was set at p<0.05.ResultsThirty-three anaesthesiology residents with varying years of experience took part in the study. Seven of the 40 residents initially invited to participate in the study were eliminated: 5 because they had prior experience with FTI through the ML-Fastrach™ and 2 because they refused to give their consent (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). None of the 33 participants had prior experience in FTI through SADs. There were no differences among the participants in respect of prior experience in the use of both study SADS, p=0.21 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Both ventilation and intubation were successful on the first attempt in all (100%) cases. The mean time to SAD insertion and subsequent ventilation was 10±3 s for the Air-Q® and 11±3s for the ML-Fastrach™, p=0.07. Both SADs were inserted correctly in all cases (full view of the vocal cords with the fibreoptic bronchoscope). The time taken to achieve FTI through the Air-Q® was significantly shorter (38±15s) than intubation through the ML-Fastrach™ (47±19s), p=0.017 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The time taken to remove the SAD was similar in both devices, although the participants considered that the Air-Q® was easier to remove than the ML-Fastrach™, 7±1 versus 6±1s, p=0.005 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The total time (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) was significantly shorter with the Air-Q® (74±21s) that the ML-Fastrach™ (87±28s), p=1.002.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe main finding of our study has been that FTI performed by residents on a mannequin was faster using the Air-Q® than the ML-Fastrach™. Although none of the participants had prior experience in FTI through a SAD, the success rate was 100% with both devices. Our results with both devices are consistent with the findings of previous mannequin studies evaluating FTI through the Air-Q®<a class="elsevierStyleCrossRef" href="#bib0180">12</a> and the ML-Fastrach™,<a class="elsevierStyleCrossRefs" href="#bib0185">13,14</a> and showed a similar success rate (97%–100%) with both SADs. In patients, the success rate of FTI through the ML-Fastrach™ can be as high as 100%.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> As far as we are aware, no prospective clinical studies have yet been performed to evaluate FTI through the Air-Q® in adults. This study is the first to compare FTI through both SADs. Case studies describing FTI through the Air-Q® have reported a success rate of 77%–100%.<a class="elsevierStyleCrossRefs" href="#bib0165">9,15,16</a> In paediatric patients, the success rate was as high as 100% after 2 attempts.<a class="elsevierStyleCrossRef" href="#bib0205">17</a>The main difference between FTI through both SADs occurred in stage 2. FTI was faster through the Air-Q® than the ML-Fastrach™. This could be due to the absence of an epiglottis elevator bar in the Air-Q®. Raising the epiglottis using the elevator bar in the ML-Fastrach™ with a flexible fibrescope is simple,<a class="elsevierStyleCrossRef" href="#bib0175">11</a> but the operator must know how to do it and apply it, which inevitably prolongs intubation time. The difference in operator-perceived ease of use with each device in stage 2 (which was more favourable for the Air-Q®) was not statistically significant.In their mannequin study, Ueki et al. evaluated the use of the Aintree intubation catheter in FTI through 3 SADs: the single-use ML-Fastrach™, the Air-Q®, and the i-gel.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> They also observed longer intubation times with the single-use ML-Fastrach™ than with the other SADs, regardless of whether they used the Aintree catheter. Total intubation times were shorter, but they used a different methodology, insofar as the authors did not withdraw the SAD after tracheal intubation. We decided to include withdrawal of the SAD because it more closely resembles real clinical practice.Only 1 published mannequin study has included withdrawal in an evaluation of FTI through the Air-Q®.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> In this study, both residents and trained anaesthesiologists had previous experience with flexible fibrescope intubation. They performed the complete procedure 5 consecutive times. In all cases, intubation times were shortened with each repetition, irrespective of their previous study experience. The total intubation time decreased from 102±31s to 68±14s, with a relative reduction of 33% and an average difference of 34s. The most noticeable improvement in intubation times occurred during the first 3 repetitions, and was attributed to time saved in stages 2 and 3 (fibreoptic-guided tracheal tube insertion and withdrawal of the Air-Q®). In our study, the total intubation time for the Air-Q® in operators who had only practiced once with each SAD was 74±21s, less than the time recorded for the second attempt in the Galgon study, which was 85±19s. Taking into account the improved performance obtained with each repetition, our results would be comparable to the third (75±16s) or fourth (72±18s) repetition in the Galgon study.Our tracheal intubation time (the sum of stages 1 and 2) with the ML-Fastrach™ were slightly shorter (58s) than those reported by Hodzovic et al. (66s), even though no fully trained anaesthesiologist participated in our study.<a class="elsevierStyleCrossRef" href="#bib0190">14</a> This could be as much to the explanation and demonstration given to the residents as to the pre-study practice session. Previous studies have shown that consecutive repetitions improve intubation time.<a class="elsevierStyleCrossRefs" href="#bib0180">12,19</a>One previous mannequin study reported longer FTI times through the ML-Fastrach™ than those observed in our series. In the foregoing study, operators with previous experience in FTI through the ML-Fastrach™ took 86s to complete intubation, compared to 82s observed in inexperienced operators.<a class="elsevierStyleCrossRef" href="#bib0185">13</a> In our study, the total intubation time with the ML-Fastrach™ (stages 1 and 2) was 58s. Although in both studies the procedure was explained to participants before the test intubation, our residents were allowed to practice the procedure once before the test procedure.In our study, correct ventilation was achieved at the first attempt in 100% of cases. The time taken to insert the device and administer 2 ventilations was only 10±3s for the Air-Q® and 11±3s for the ML-Fastrach™. A previous mannequin study reported an intubation time of 10±3s on the third repetition with the Air-Q®and 10±2s on the fourth.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> A study comparing insertion times in patients using the Air-Q® versus the ML-Proseal showed shorter times with the Air-Q®, 20±14 versus 28±11s for the ML-Proseal, although this was inserted using a bougie, which increases the success rate and shortens the insertion time.<a class="elsevierStyleCrossRef" href="#bib0220">20</a> In their study in patients, Baskett et al.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> reported a median time of 14s and 10s for insertion and ventilation through the ML-Fastrach™, respectively, although they did not describe the number of ventilations administered. Pandit et al.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> reported longer intubation times with the ML-Fastrach™, 24±7s, but administered 4 ventilations instead of 2.Our anaesthesiology residents found it easier to withdraw the Air-Q® than the ML-Fastrach™ (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). This would explain the shorter times recorded in stage 3 with the Air-Q®, although the difference was not statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There were no significant differences in insertion or intubation. Withdrawal of the SAD is a critical step due to the greater risk of accidental extubation. Galgon et al.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> obtained a global success rate of 97%, despite a 100% success rate in FTI. This was due to 3 instances of accidental extubation during SAD withdrawal.LimitationsThe main limitation of this study is the use of mannequins. This would explain why a grade I view was obtained in all cases, and why the total time for FTI was less than 2min with both SADs. Different Air-Q® and ML-Fastrach™ sizes were tested before carrying out the study. The Air-Q® 3.5 and the ML-Fastrach™ 4 were chosen because they provided a better glottic view. This selection process is infeasible in real clinical practice. However, as Cook argued in an editorial, new airway devices should be evaluated before being released on the market by testing their performance and safety on specially designed mannequins Phase II would involve a clinical study in patients, and finally, if both these studies find that the device is safe and effective in both mannequins and patients, it should be compared to the gold-standard device for certain procedures, such as the ML-Fastrach™ for FTI.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> Another drawback is our use of different endotracheal tubes. Intubation through the Air-Q® was performed using a wire-reinforced tube, while with the ML-Fastrach™ a specific tube recommended by the manufacturer was used. The blind intubation success rate with the ML-Fastrach™ is higher using the specially designed tube compared to a conventional polyvinyl chloride tube.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> The conical tip of the distal segment of this offers a smaller surface compared to conventional tubes with a bevelled distal end. This reduces the risk of collision with the arytenoids or vocal cords. This, however, should have shortened intubation time with the ML-Fastrach™, but the opposite was observed in our series.Unlike patients with a difficult airway, the manikin used in our study had a normal airway. In addition, patients may suffer desaturation during intubation. Although tracheal intubation time was less than 1min, in patients with decreased functional residual capacity it is advisable to administered assisted ventilation during intubation attempts. In the case of the ML-Fastrach™, after inserting the tube, the cuff is inflated and a Swivel connector is placed between the endotracheal tube and the ventilation system. A flexible bronchoscope can be inserted through the Swivel connector without causing leakage. The bronchoscope is advanced as far as the carina, and the tracheal tube with the cuff deflated is advanced over the bronchoscope to prevent leaks.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> Using this technique, Wong et al. reported a case in which they successfully performed awake FTI through the Air-Q® with the application of BIPAP ventilation.<a class="elsevierStyleCrossRef" href="#bib0195">15</a> They introduced a 6.5mm tracheal tube to a depth of 14cm in a size 4.5 Air-Q®. They inflated the tube and connected it to the BIPAP via a flexible connector with a bronchoscope port. Once the bronchoscope reached the carina, they deflated the endotracheal tube and advanced it over the bronchoscope into the trachea. Finally, although the difference in total intubation time between the 2 devices was not significant, 13.77s (CI: 5.24–22.3s), we cannot be sure that it would not be greater in clinical practice.In conclusion, FTI through the Air-Q® was faster than through the ML-Fastrach™. Anaesthesiology residents found withdrawal of the Air-Q® to be easier than the ML-Fastrach™, with no significant differences in terms of insertion and intubation. The inexperienced residents were able to perform FTI through the Air-Q® and the ML-Fastrach™ in a clinically acceptable time with a high success rate.Conflict of interestsM. Zaballos and M. López Gil have occasionally received honoraria from the Laryngeal Mask Company for attending conferences." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1008329" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec968006" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1008330" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec968005" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-07" "fechaAceptado" => "2017-09-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec968006" "palabras" => array:3 [ 0 => "Fibreoptic-guided intubation" 1 => "Air-Q®" 2 => "LMA Fastrach™" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec968005" "palabras" => array:3 [ 0 => "Intubación guiada por fibrobroncoscopia" 1 => "Air-Q®" 2 => "Mascarilla laríngea Fastrach™" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionAirway management is still a major cause of anaesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q® and the LMA Fastrach™ for fibreoptic guided tracheal intubation. MethodsThirty-three anaesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fibreoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q®/LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anaesthesia trainees were measured. ResultsThere was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10±3s for the Air-Q® and 11±3s for the LMA Fastrach™, p=0.07. Time taken to intubate the trachea was shorter with the Air-Q®, 38±15s, than with the LMA Fastrach™, 47±19s, p=0.017. Overall procedure time was significantly shorter with the Air-Q® as compared with the LMA Fastrach™, with a mean time of 74±21s and 87±28s respectively, p=0.002. Air-Q® removal was considered easier than LMA Fastrach™ removal, p=0.005. There were no tube dislodgements during the removal of the dedicated airways. ConclusionsInexperienced anaesthesia residents can perform fibreoptic-guided intubation through Air-Q® and LMA Fastrach™ in a clinically acceptable time with high success." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLos dispositivos supraglóticos forman parte esencial en el manejo de la vía aérea difícil. El objetivo del presente estudio fue comparar las características de la intubación con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ (ML-Fastrach™) por residentes de anestesia en maniquís. MétodosEstudio aleatorizado y cruzado en el que participaron 33 residentes de anestesia. Se midió el tiempo de inserción (inserción del dispositivo en el maniquí y administración de 2 insuflaciones), el tiempo hasta la intubación traqueal (intubación guiada con el fibrobroncoscopio) y el tiempo para retirar los dispositivos (retirada de la Air-Q®/ML Fastrach™ sobre el tubo endotraqueal). Se evaluó la opinión de la facilidad de utilización. ResultadosHubo una tasa de éxito del 100% para la intubación traqueal con ambos dispositivos al primer intento. El tiempo de inserción y administración de 2 ventilaciones fue de 10±3s para Air-Q® y de 11±3s para la ML-Fastrach™, p=0,07. El tiempo de intubación traqueal fue más corto con Air-Q®, 38±15s, que con la ML-Fastrach™, 47±19s, p=0,017. El tiempo total fue significativamente más corto con Air-Q® en comparación con la ML-Fastrach™, con un tiempo medio de 74±21 y 87±28s respectivamente, p=0,002. La retirada de la Air-Q® se consideró más fácil que la de la ML-Fastrach™, p=0,005. No se registraron desplazamientos del tubo endotraqueal durante la extracción de los dispositivos. ConclusionesLos residentes de anestesia pueden realizar la intubación con fibrobroncoscopio a través de la Air-Q® y de la ML-Fastrach™ de forma exitosa y con tiempos clínicamente aceptables." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Portas M, Canal MI, Barrio M, Alonso M, Cabrerizo P, López-Gil M, et al. Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís. Rev Esp Anestesiol Reanim. 2018;65:135–142." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1430 "Ancho" => 1250 "Tamanyo" => 265062 ] ] "descripcion" => array:1 [ "en" => "Laryngeal mask airway and Air-Q®with the tip of the fibreoptic bronchoscope protruding from the distal end of the corresponding endotracheal tube." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2951 "Ancho" => 2499 "Tamanyo" => 253433 ] ] "descripcion" => array:1 [ "en" => "Study flow chart." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are shown as numbers (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">None \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><5 times \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5–10 times \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">10–20 times \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Experience in ML-Fastrach™ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Experience in Air-Q® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1707581.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Previous experience of residents." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values are represented as mean±standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the Air-Q® \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the ML-Fastrach™ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 1 (time to insertion of the SAD; s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10±3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11±3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 2 (time to tracheal intubation; s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47±19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.017 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 3 (time to withdrawal of the SAD; s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total time for the procedure; s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74±21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1707580.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Time needed for tracheal intubation." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Higher values denote greater ease of use. Values are shown as mean±standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the Air-Q® \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the ML-Fastrach™ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 1 (insert the SAD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Step 2 (fibreoptic-guided tracheal intubation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7±2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 3 (withdraw the SAD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1707582.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Operator-perceived ease of fibreoptic-guided tracheal intubation of the Air-Q®and the Ml-Fastrach™ in." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. 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Original article

Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial

Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís

M. Portas, M.I. Canal, M. Barrio, M. Alonso, P. Cabrerizo, M. López-Gil, M. Zaballos

Corresponding author

mati@plagaro.net

Corresponding author.

Servicio de Anestesiología, Reanimación y terapéutica del dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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    "titulo" => "Air-Q<span class="elsevierStyleSup">&#174;</span> versus LMA Fastrach&#8482; for fiberoptic-guided intubation&#58; A randomized cross-over manikin trial"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Despite the technological progress made in recent decades in anaesthesiology&#44; airway management continues to be one of the main causes of anaesthesia-related morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Difficult airway management guidelines developed by prominent international anaesthesiology societies&#44; such as the American Society of Anesthesiology &#40;ASA&#41; and the Difficult Airway Society of the United Kingdom &#40;DAS&#41;&#44; among others&#44; recommend supraglottic airway devices &#40;SAD&#41;&#44; with or without flexible bronchoscopy&#44; as an alternative to intubation&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;3</span></a> The Fastrach&#8482; &#40;ML-Fastrach&#8482; reusable&#59; Teleflex Medical Co&#46;&#44; Westmeath&#44; Ireland&#41; laryngeal mask is a SAD designed to facilitate intubation in both anticipated and unanticipated difficult airway &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and maintains oxygenation during intubation attempts&#46; The overall success rate for blind intubation with this device is 96&#46;2&#8211;99&#46;3&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#8211;6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The Air-Q<span class="elsevierStyleSup">&#174;</span> &#40;Air-Q reusable laryngeal mask<span class="elsevierStyleSup">&#174;</span>&#44; Cookgas<span class="elsevierStyleSup">&#174;</span>&#44; St Louis&#44; USA&#41; is a SAD designed for ventilation and tracheal intubation&#46; It can be used with any standard endotracheal tube&#44; has no metal handle or wire-reinforced tube&#44; and is available in paediatric sizes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Preliminary studies with the Air-Q<span class="elsevierStyleSup">&#174;</span> showed a blind intubation success rate of 57&#37; at the first attempt&#44; and of 74&#37; after 3 attempts&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#44;8</span></a> Compared with the ML-Fastrach&#8482; &#40;99&#37; success rate&#41;&#44; blind tracheal intubation through the Air-Q<span class="elsevierStyleSup">&#174;</span> was only achieved in 77&#37; of patients after 2 attempts&#46; In contrast&#44; when combined with flexible bronchoscopy&#44; the success rate increased to 100&#37; in the ML-Fastrach group&#8482; versus 95&#37; in the Air-Q group<span class="elsevierStyleSup">&#174;</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The combination of a SAD with a flexible bronchoscope is considered an effective method for difficult airway management&#46; Nevertheless&#44; this is the first study to compare the efficacy and ease of fibreoptic-guided tracheal intubation &#40;FTI&#41; through the Air-Q<span class="elsevierStyleSup">&#174;</span> and ML-Fastrach&#8482;&#46; The aim of the study was to evaluate the efficacy and ease of use of both SADs for FTI carried out by anaesthesiology residents in mannequins&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">After consulting the institutional review board&#44; it was considered that&#44; due to the nature of the study&#44; their approval was not required&#46; All anaesthesiology residents with no prior experience in FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> or the ML-Fastrach&#8482; were invited to participate&#46; Thirty-three residents out of a total of forty gave verbal consent to participate in the study&#46; All intubations were performed on the same mannequin located in one of the hospital&#39;s operating rooms&#46; After 15<span class="elsevierStyleHsp" style=""></span>min of verbal instruction&#44; intubation through each study SAD was demonstrated on the &#8220;Bill <span class="elsevierStyleSmallCaps">I&#8221;</span> mannequin &#40;VBM&#44; Germany&#41;&#46; Each participant practised the study procedure once with each SAD immediately before their test intubation&#46; The order in which the SADs were used was determined by a computer-generated randomized sequence&#46; The sequence was enclosed in sealed opaque envelopes that were opened immediately before the start of each intubation test&#46; The researchers had previously tested different sizes of the study SADs&#44; and found that the Air-Q<span class="elsevierStyleSup">&#174;</span>3&#46;5 and the ML-Fastrach&#8482; 4 provided the best glottic vision&#46; In the case of the Air-Q<span class="elsevierStyleSup">&#174;</span>&#44; a no&#46; 7 wire-reinforced cuffed endotracheal tube with a 15<span class="elsevierStyleHsp" style=""></span>mm detachable connector &#40;&#8220;Safety-Soft&#8221;&#44; Mallinckrodt Medical&#44; Athlone&#44; Ireland&#41; were used&#46; For the ML-Fastrach&#8482;&#44; the device&#39;s own reusable no&#46; 7 wire-reinforced silicone endotracheal tube was chosen &#8482; &#40;LMA Fastrach&#8482; ETT-Laryngeal Mask Company Ltd&#44; Victoria&#44; Mah&#233;&#44; Seychelles&#41;&#46; Each participant performed the procedures without the presence of the other residents to avoid the potential for observation-induced bias&#46; Prior to each procedure&#44; the SADs &#40;the cup and the inside of the airway tube&#41;&#44; the endotracheal tubes and the pilot balloon tube&#44; and the fibreoptic bronchoscope were lubricated with a water-soluble lubricant&#46; The lubricant was spread inside the airway tube of the SAD by sliding the respective endotracheal tube up and down several times&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study procedure was divided into 3 stages&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Stage 1&#58; Insert the SAD into the mannequin and check position with 2 ventilations&#46; The ML-Fastrach&#8482; was inserted following the standard technique with the cuff deflated&#46; The Air-Q<span class="elsevierStyleSup">&#174;</span> was inserted with the inflation valve open&#44; which improved the manoeuvrability of the cuff&#46; Once inserted into the mouth&#44; the left index finger was used to slide the tip of the cuff behind the base of the tongue while pressing downward on the airway tube with the right hand to advance the SAD to its position&#46; The cuff of the Air-Q<span class="elsevierStyleSup">&#174;</span> was inflated with 4<span class="elsevierStyleHsp" style=""></span>ml of air&#44; and that of the ML-Fastrach&#8482; with 10<span class="elsevierStyleHsp" style=""></span>ml &#40;the required volume of air was checked before the study&#41;&#46; The chronometer was started as soon as the participant took hold of the SAD&#44; and ended when correct pulmonary ventilation was observed with 2 manual ventilations with a reservoir bag &#40;Ambu<span class="elsevierStyleSup">&#174;</span> Mark <span class="elsevierStyleSmallCaps">IV</span>-Reusable Resuscitator&#41;&#46;</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">Before moving on to stage 2&#44; correct insertion of the SAD was verified using validated a fibroscopic scale<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Grade <span class="elsevierStyleSmallCaps">I</span>&#58; full view of vocal cords&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Grade <span class="elsevierStyleSmallCaps">I</span>&#58; partial view of vocal cords including arytenoids&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Grade <span class="elsevierStyleSmallCaps">III</span>&#58; only the epiglottis is seen&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Grade <span class="elsevierStyleSmallCaps">IV</span>&#58; the pharynx and the cuff of the SAD are seen&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Stage 2&#58; FTI with a 5&#46;2<span class="elsevierStyleHsp" style=""></span>mm outer diameter fibrescope &#40;Karl Storz&#44; Tuttlingen&#44; Germany&#41;&#46; The endotracheal tube was inserted into the air tube of the Air-Q<span class="elsevierStyleSup">&#174;</span> to a depth of 18<span class="elsevierStyleHsp" style=""></span>cm&#46; In case of the ML-Fastrach&#8482;&#44; the endotracheal tube was introduced with the vertical line towards the participant and advanced until the tip was located under the epiglottic elevating bar &#40;indicated by the horizontal marking on the endotracheal tube&#41;&#46; The fibrescope was then inserted into the endotracheal tube as far as&#44; but not beyond&#44; the distal orifice&#46; Both were then simultaneously advanced 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; Once the distal end of tube reached the larynx&#44; the fibrescope was advanced to the trachea and the endotracheal tube was advanced over the fibrescope&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> Stage 2 began when the participant took hold of the endotracheal tube and ended when correct pulmonary ventilation was observed with 2 manual ventilations through the tube&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Stage 3&#58; Air-Q<span class="elsevierStyleSup">&#174;</span>&#47;ML Fastrach&#8482; withdrawal over the endotracheal tube&#46; The cuff of the Air-Q<span class="elsevierStyleSup">&#174;</span> and the endotracheal tube were fully deflated&#46; The 15-mm connector was removed from the endotracheal tube&#46; The cuff of the ML-Fastrach&#8482; was fully deflated but not the cuff of the endotracheal tube&#46; The 15<span class="elsevierStyleHsp" style=""></span>mm connector was removed from the endotracheal tube&#46; The adaptors of the Air-Q<span class="elsevierStyleSup">&#174;</span> &#40;Air-Q<span class="elsevierStyleSup">&#174;</span> Removal Stylet&#44; Cook Gas<span class="elsevierStyleSup">&#174;</span>&#41; and the ML-Fastrach&#8482; &#40;LMA&#8482; Stabilizer Rod&#44; Laryngeal Mask Company Ltd&#41; were inserted into the proximal end of the endotracheal tube&#46; The devices were removed over the adaptor&#46; Then the adaptor was removed and the 15<span class="elsevierStyleHsp" style=""></span>mm connector was adjusted&#46; Stage 2 began when the participant deflated the cuff and ended when correct pulmonary ventilation was observed with 2 manual ventilations&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Intubation failure was defined as failure to ventilate through the endotracheal tube after 5<span class="elsevierStyleHsp" style=""></span>min or after 3 attempts&#46; This included failure to insert the SAD or the endotracheal tube&#44; or accidental extubation during removal of the SAD&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The data collection sheet recorded the time taken to complete each of the 3 stages&#44; the total time&#44; operator-perceived ease of use at each stage &#40;0 very difficult&#44; 10 very easy&#41;&#44; the fibroscopic scale score&#44; the experience of the anaesthetist&#44; and the number of prior intubations through the Air-Q<span class="elsevierStyleSup">&#174;</span> and&#47;or the ML-Fastrach&#8482;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS 20&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; Illinois&#44; USA&#41;&#46; Continuous variables that followed a normal distribution were expressed as mean and standard deviation&#46; Categorical variables were expressed as frequency and percentages&#46; Continuous variables were compared using the Student&#39;s <span class="elsevierStyleItalic">t</span> test for paired data or the Wilcoxon test&#46; The Chi-square test or Fisher&#39;s exact test was used for categorical variables&#46; All <span class="elsevierStyleItalic">p</span> values were 2-tailed&#46; Significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">Thirty-three anaesthesiology residents with varying years of experience took part in the study&#46; Seven of the 40 residents initially invited to participate in the study were eliminated&#58; 5 because they had prior experience with FTI through the ML-Fastrach&#8482; and 2 because they refused to give their consent &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; None of the 33 participants had prior experience in FTI through SADs&#46; There were no differences among the participants in respect of prior experience in the use of both study SADS&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;21 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Both ventilation and intubation were successful on the first attempt in all &#40;100&#37;&#41; cases&#46; The mean time to SAD insertion and subsequent ventilation was 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 s for the Air-Q<span class="elsevierStyleSup">&#174;</span> and 11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s for the ML-Fastrach&#8482;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#46; Both SADs were inserted correctly in all cases &#40;full view of the vocal cords with the fibreoptic bronchoscope&#41;&#46; The time taken to achieve FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> was significantly shorter &#40;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>s&#41; than intubation through the ML-Fastrach&#8482; &#40;47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The time taken to remove the SAD was similar in both devices&#44; although the participants considered that the Air-Q<span class="elsevierStyleSup">&#174;</span> was easier to remove than the ML-Fastrach&#8482;&#44; 7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1 versus 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>s&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The total time &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; was significantly shorter with the Air-Q<span class="elsevierStyleSup">&#174;</span> &#40;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>s&#41; that the ML-Fastrach&#8482; &#40;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;002&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main finding of our study has been that FTI performed by residents on a mannequin was faster using the Air-Q<span class="elsevierStyleSup">&#174;</span> than the ML-Fastrach&#8482;&#46; Although none of the participants had prior experience in FTI through a SAD&#44; the success rate was 100&#37; with both devices&#46; Our results with both devices are consistent with the findings of previous mannequin studies evaluating FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> and the ML-Fastrach&#8482;&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">13&#44;14</span></a> and showed a similar success rate &#40;97&#37;&#8211;100&#37;&#41; with both SADs&#46; In patients&#44; the success rate of FTI through the ML-Fastrach&#8482; can be as high as 100&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> As far as we are aware&#44; no prospective clinical studies have yet been performed to evaluate FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> in adults&#46; This study is the first to compare FTI through both SADs&#46; Case studies describing FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> have reported a success rate of 77&#37;&#8211;100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#44;15&#44;16</span></a> In paediatric patients&#44; the success rate was as high as 100&#37; after 2 attempts&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The main difference between FTI through both SADs occurred in stage 2&#46; FTI was faster through the Air-Q<span class="elsevierStyleSup">&#174;</span> than the ML-Fastrach&#8482;&#46; This could be due to the absence of an epiglottis elevator bar in the Air-Q<span class="elsevierStyleSup">&#174;</span>&#46; Raising the epiglottis using the elevator bar in the ML-Fastrach&#8482; with a flexible fibrescope is simple&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> but the operator must know how to do it and apply it&#44; which inevitably prolongs intubation time&#46; The difference in operator-perceived ease of use with each device in stage 2 &#40;which was more favourable for the Air-Q<span class="elsevierStyleSup">&#174;</span>&#41; was not statistically significant&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In their mannequin study&#44; Ueki et al&#46; evaluated the use of the Aintree intubation catheter in FTI through 3 SADs&#58; the single-use ML-Fastrach&#8482;&#44; the Air-Q<span class="elsevierStyleSup">&#174;</span>&#44; and the i-gel&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> They also observed longer intubation times with the single-use ML-Fastrach&#8482; than with the other SADs&#44; regardless of whether they used the Aintree catheter&#46; Total intubation times were shorter&#44; but they used a different methodology&#44; insofar as the authors did not withdraw the SAD after tracheal intubation&#46; We decided to include withdrawal of the SAD because it more closely resembles real clinical practice&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Only 1 published mannequin study has included withdrawal in an evaluation of FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> In this study&#44; both residents and trained anaesthesiologists had previous experience with flexible fibrescope intubation&#46; They performed the complete procedure 5 consecutive times&#46; In all cases&#44; intubation times were shortened with each repetition&#44; irrespective of their previous study experience&#46; The total intubation time decreased from 102<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31<span class="elsevierStyleHsp" style=""></span>s to 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>s&#44; with a relative reduction of 33&#37; and an average difference of 34<span class="elsevierStyleHsp" style=""></span>s&#46; The most noticeable improvement in intubation times occurred during the first 3 repetitions&#44; and was attributed to time saved in stages 2 and 3 &#40;fibreoptic-guided tracheal tube insertion and withdrawal of the Air-Q<span class="elsevierStyleSup">&#174;</span>&#41;&#46; In our study&#44; the total intubation time for the Air-Q<span class="elsevierStyleSup">&#174;</span> in operators who had only practiced once with each SAD was 74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>s&#44; less than the time recorded for the second attempt in the Galgon study&#44; which was 85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>s&#46; Taking into account the improved performance obtained with each repetition&#44; our results would be comparable to the third &#40;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>s&#41; or fourth &#40;72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>s&#41; repetition in the Galgon study&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Our tracheal intubation time &#40;the sum of stages 1 and 2&#41; with the ML-Fastrach&#8482; were slightly shorter &#40;58<span class="elsevierStyleHsp" style=""></span>s&#41; than those reported by Hodzovic et al&#46; &#40;66<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; even though no fully trained anaesthesiologist participated in our study&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> This could be as much to the explanation and demonstration given to the residents as to the pre-study practice session&#46; Previous studies have shown that consecutive repetitions improve intubation time&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12&#44;19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">One previous mannequin study reported longer FTI times through the ML-Fastrach&#8482; than those observed in our series&#46; In the foregoing study&#44; operators with previous experience in FTI through the ML-Fastrach&#8482; took 86<span class="elsevierStyleHsp" style=""></span>s to complete intubation&#44; compared to 82<span class="elsevierStyleHsp" style=""></span>s observed in inexperienced operators&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> In our study&#44; the total intubation time with the ML-Fastrach&#8482; &#40;stages 1 and 2&#41; was 58<span class="elsevierStyleHsp" style=""></span>s&#46; Although in both studies the procedure was explained to participants before the test intubation&#44; our residents were allowed to practice the procedure once before the test procedure&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In our study&#44; correct ventilation was achieved at the first attempt in 100&#37; of cases&#46; The time taken to insert the device and administer 2 ventilations was only 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s for the Air-Q<span class="elsevierStyleSup">&#174;</span> and 11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s for the ML-Fastrach&#8482;&#46; A previous mannequin study reported an intubation time of 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s on the third repetition with the Air-Q<span class="elsevierStyleSup">&#174;</span>and 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>s on the fourth&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> A study comparing insertion times in patients using the Air-Q<span class="elsevierStyleSup">&#174;</span> versus the ML-Proseal showed shorter times with the Air-Q<span class="elsevierStyleSup">&#174;</span>&#44; 20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 versus 28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>s for the ML-Proseal&#44; although this was inserted using a bougie&#44; which increases the success rate and shortens the insertion time&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> In their study in patients&#44; Baskett et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> reported a median time of 14<span class="elsevierStyleHsp" style=""></span>s and 10<span class="elsevierStyleHsp" style=""></span>s for insertion and ventilation through the ML-Fastrach&#8482;&#44; respectively&#44; although they did not describe the number of ventilations administered&#46; Pandit et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> reported longer intubation times with the ML-Fastrach&#8482;&#44; 24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>s&#44; but administered 4 ventilations instead of 2&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Our anaesthesiology residents found it easier to withdraw the Air-Q<span class="elsevierStyleSup">&#174;</span> than the ML-Fastrach&#8482; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; This would explain the shorter times recorded in stage 3 with the Air-Q<span class="elsevierStyleSup">&#174;</span>&#44; although the difference was not statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were no significant differences in insertion or intubation&#46; Withdrawal of the SAD is a critical step due to the greater risk of accidental extubation&#46; Galgon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> obtained a global success rate of 97&#37;&#44; despite a 100&#37; success rate in FTI&#46; This was due to 3 instances of accidental extubation during SAD withdrawal&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Limitations</span><p id="par0130" class="elsevierStylePara elsevierViewall">The main limitation of this study is the use of mannequins&#46; This would explain why a grade I view was obtained in all cases&#44; and why the total time for FTI was less than 2<span class="elsevierStyleHsp" style=""></span>min with both SADs&#46; Different Air-Q<span class="elsevierStyleSup">&#174;</span> and ML-Fastrach&#8482; sizes were tested before carrying out the study&#46; The Air-Q<span class="elsevierStyleSup">&#174;</span> 3&#46;5 and the ML-Fastrach&#8482; 4 were chosen because they provided a better glottic view&#46; This selection process is infeasible in real clinical practice&#46; However&#44; as Cook argued in an editorial&#44; new airway devices should be evaluated before being released on the market by testing their performance and safety on specially designed mannequins Phase II would involve a clinical study in patients&#44; and finally&#44; if both these studies find that the device is safe and effective in both mannequins and patients&#44; it should be compared to the gold-standard device for certain procedures&#44; such as the ML-Fastrach&#8482; for FTI&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> Another drawback is our use of different endotracheal tubes&#46; Intubation through the Air-Q<span class="elsevierStyleSup">&#174;</span> was performed using a wire-reinforced tube&#44; while with the ML-Fastrach&#8482; a specific tube recommended by the manufacturer was used&#46; The blind intubation success rate with the ML-Fastrach&#8482; is higher using the specially designed tube compared to a conventional polyvinyl chloride tube&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> The conical tip of the distal segment of this offers a smaller surface compared to conventional tubes with a bevelled distal end&#46; This reduces the risk of collision with the arytenoids or vocal cords&#46; This&#44; however&#44; should have shortened intubation time with the ML-Fastrach&#8482;&#44; but the opposite was observed in our series&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Unlike patients with a difficult airway&#44; the manikin used in our study had a normal airway&#46; In addition&#44; patients may suffer desaturation during intubation&#46; Although tracheal intubation time was less than 1<span class="elsevierStyleHsp" style=""></span>min&#44; in patients with decreased functional residual capacity it is advisable to administered assisted ventilation during intubation attempts&#46; In the case of the ML-Fastrach&#8482;&#44; after inserting the tube&#44; the cuff is inflated and a Swivel connector is placed between the endotracheal tube and the ventilation system&#46; A flexible bronchoscope can be inserted through the Swivel connector without causing leakage&#46; The bronchoscope is advanced as far as the carina&#44; and the tracheal tube with the cuff deflated is advanced over the bronchoscope to prevent leaks&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> Using this technique&#44; Wong et al&#46; reported a case in which they successfully performed awake FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> with the application of BIPAP ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> They introduced a 6&#46;5<span class="elsevierStyleHsp" style=""></span>mm tracheal tube to a depth of 14<span class="elsevierStyleHsp" style=""></span>cm in a size 4&#46;5 Air-Q<span class="elsevierStyleSup">&#174;</span>&#46; They inflated the tube and connected it to the BIPAP via a flexible connector with a bronchoscope port&#46; Once the bronchoscope reached the carina&#44; they deflated the endotracheal tube and advanced it over the bronchoscope into the trachea&#46; Finally&#44; although the difference in total intubation time between the 2 devices was not significant&#44; 13&#46;77<span class="elsevierStyleHsp" style=""></span>s &#40;CI&#58; 5&#46;24&#8211;22&#46;3<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; we cannot be sure that it would not be greater in clinical practice&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion&#44; FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> was faster than through the ML-Fastrach&#8482;&#46; Anaesthesiology residents found withdrawal of the Air-Q<span class="elsevierStyleSup">&#174;</span> to be easier than the ML-Fastrach&#8482;&#44; with no significant differences in terms of insertion and intubation&#46; The inexperienced residents were able to perform FTI through the Air-Q<span class="elsevierStyleSup">&#174;</span> and the ML-Fastrach&#8482; in a clinically acceptable time with a high success rate&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0145" class="elsevierStylePara elsevierViewall">M&#46; Zaballos and M&#46; L&#243;pez Gil have occasionally received honoraria from the Laryngeal Mask Company for attending conferences&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Airway management is still a major cause of anaesthesia-associated morbidity and mortality&#46; Supraglottic devices are recommended in difficult airway management guidelines&#46; The aim of this study was to compare the performance of the Air-Q<span class="elsevierStyleSup">&#174;</span> and the LMA Fastrach&#8482; for fibreoptic guided tracheal intubation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thirty-three anaesthesia trainees participated in this randomized crossover study&#46; Time to insert the dedicated airways &#40;insertion of the airway into the manikin and delivery of two breaths&#41;&#44; time to tracheal intubation &#40;fibreoptic-guided tracheal intubation&#41;&#44; time to remove the dedicated airway &#40;removal of the Air-Q<span class="elsevierStyleSup">&#174;</span>&#47;LMA Fastrach&#8482; over the tracheal tube&#41; and the opinion of the ease of use of the anaesthesia trainees were measured&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There was 100&#37; success rate for tracheal intubation with both devices on the first attempt&#46; Time to insert the dedicated device and deliver two breaths was 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s for the Air-Q<span class="elsevierStyleSup">&#174;</span> and 11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s for the LMA Fastrach&#8482;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#46; Time taken to intubate the trachea was shorter with the Air-Q<span class="elsevierStyleSup">&#174;</span>&#44; 38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>s&#44; than with the LMA Fastrach&#8482;&#44; 47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>s&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#46; Overall procedure time was significantly shorter with the Air-Q<span class="elsevierStyleSup">&#174;</span> as compared with the LMA Fastrach&#8482;&#44; with a mean time of 74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>s and 87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28<span class="elsevierStyleHsp" style=""></span>s respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#46; Air-Q<span class="elsevierStyleSup">&#174;</span> removal was considered easier than LMA Fastrach&#8482; removal&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#46; There were no tube dislodgements during the removal of the dedicated airways&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Inexperienced anaesthesia residents can perform fibreoptic-guided intubation through Air-Q<span class="elsevierStyleSup">&#174;</span> and LMA Fastrach&#8482; in a clinically acceptable time with high success&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los dispositivos supragl&#243;ticos forman parte esencial en el manejo de la v&#237;a a&#233;rea dif&#237;cil&#46; El objetivo del presente estudio fue comparar las caracter&#237;sticas de la intubaci&#243;n con fibrobroncoscopio a trav&#233;s del dispositivo Air-Q<span class="elsevierStyleSup">&#174;</span> versus la mascarilla lar&#237;ngea Fastrach&#8482; &#40;ML-Fastrach&#8482;&#41; por residentes de anestesia en maniqu&#237;s&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio aleatorizado y cruzado en el que participaron 33 residentes de anestesia&#46; Se midi&#243; el tiempo de inserci&#243;n &#40;inserci&#243;n del dispositivo en el maniqu&#237; y administraci&#243;n de 2 insuflaciones&#41;&#44; el tiempo hasta la intubaci&#243;n traqueal &#40;intubaci&#243;n guiada con el fibrobroncoscopio&#41; y el tiempo para retirar los dispositivos &#40;retirada de la Air-Q<span class="elsevierStyleSup">&#174;</span>&#47;ML Fastrach&#8482; sobre el tubo endotraqueal&#41;&#46; Se evalu&#243; la opini&#243;n de la facilidad de utilizaci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Hubo una tasa de &#233;xito del 100&#37; para la intubaci&#243;n traqueal con ambos dispositivos al primer intento&#46; El tiempo de inserci&#243;n y administraci&#243;n de 2 ventilaciones fue de 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s para Air-Q<span class="elsevierStyleSup">&#174;</span> y de 11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>s para la ML-Fastrach&#8482;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#46; El tiempo de intubaci&#243;n traqueal fue m&#225;s corto con Air-Q<span class="elsevierStyleSup">&#174;</span>&#44; 38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>s&#44; que con la ML-Fastrach&#8482;&#44; 47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>s&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;017&#46; El tiempo total fue significativamente m&#225;s corto con Air-Q<span class="elsevierStyleSup">&#174;</span> en comparaci&#243;n con la ML-Fastrach&#8482;&#44; con un tiempo medio de 74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21 y 87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28<span class="elsevierStyleHsp" style=""></span>s respectivamente&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#46; La retirada de la Air-Q<span class="elsevierStyleSup">&#174;</span> se consider&#243; m&#225;s f&#225;cil que la de la ML-Fastrach&#8482;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#46; No se registraron desplazamientos del tubo endotraqueal durante la extracci&#243;n de los dispositivos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los residentes de anestesia pueden realizar la intubaci&#243;n con fibrobroncoscopio a trav&#233;s de la Air-Q<span class="elsevierStyleSup">&#174;</span> y de la ML-Fastrach&#8482; de forma exitosa y con tiempos cl&#237;nicamente aceptables&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Portas M&#44; Canal MI&#44; Barrio M&#44; Alonso M&#44; Cabrerizo P&#44; L&#243;pez-Gil M&#44; et al&#46; Estudio aleatorizado cruzado para evaluar la intubaci&#243;n guiada con fibrobroncoscopio a trav&#233;s del dispositivo Air-Q<span class="elsevierStyleSup">&#174;</span> versus la mascarilla lar&#237;ngea Fastrach&#8482; en maniqu&#237;s&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;135&#8211;142&#46;</p>"
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    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Laryngeal mask airway and Air-Q<span class="elsevierStyleSup">&#174;</span>with the tip of the fibreoptic bronchoscope protruding from the distal end of the corresponding endotracheal tube&#46;</p>"
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      1 => array:7 [
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Study flow chart&#46;</p>"
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        "etiqueta" => "Table 1"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;5 times&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&#8211;10 times&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">10&#8211;20 times&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Experience in ML-Fastrach&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Experience in Air-Q<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Previous experience of residents&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Values are represented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the Air-Q<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the ML-Fastrach&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 1 &#40;time to insertion of the SAD&#59; s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 2 &#40;time to tracheal intubation&#59; s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 3 &#40;time to withdrawal of the SAD&#59; s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total time for the procedure&#59; s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1707580.png"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Time needed for tracheal intubation&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Higher values denote greater ease of use&#46; Values are shown as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the Air-Q<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fibreoptic intubation through the ML-Fastrach&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 1 &#40;insert the SAD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Step 2 &#40;fibreoptic-guided tracheal intubation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 3 &#40;withdraw the SAD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1707582.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Operator-perceived ease of fibreoptic-guided tracheal intubation of the Air-Q<span class="elsevierStyleSup">&#174;</span>and the Ml-Fastrach&#8482; in&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Major complications of airway management in the UK&#58; results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society&#46; Part 1&#58; Anaesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46;M&#46; Cook"
                            1 => "N&#46; Woodall"
                            2 => "C&#46; Frerk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aer058"
                      "Revista" => array:7 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2011"
                        "volumen" => "106"
                        "paginaInicial" => "617"
                        "paginaFinal" => "631"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21447488"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673602115224"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practice guidelines for management of the difficult airway&#46; An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "American Society of Anesthesiologists Task Force on Management of the Difficult Airway"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;L&#46; Apfelbaum"
                            1 => "C&#46;A&#46; Hagberg"
                            2 => "R&#46;A&#46; Caplan"
                            3 => "C&#46;D&#46; Blitt"
                            4 => "R&#46;T&#46; Connis"
                            5 => "D&#46;G&#46; Nickinovich"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ALN.0b013e31827773b2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2013"
                        "volumen" => "118"
                        "paginaInicial" => "251"
                        "paginaFinal" => "270"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23364566"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Difficult Airway Society Intubation Guidelines Working Group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Frerk"
                            1 => "V&#46;S&#46; Mitchell"
                            2 => "A&#46;F&#46; McNarry"
                            3 => "C&#46; Mendonca"
                            4 => "R&#46; Bhagrath"
                            5 => "A&#46; Patel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aev371"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2015"
                        "volumen" => "115"
                        "paginaInicial" => "827"
                        "paginaFinal" => "848"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26556848"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The intubating laryngeal mask&#46; II&#58; A preliminary clinical report of a new means of intubating the trachea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;I&#46; Brain"
                            1 => "C&#46; Verghese"
                            2 => "E&#46;V&#46; Addy"
                            3 => "A&#46; Kapila"
                            4 => "J&#46; Brimacombe"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "1997"
                        "volumen" => "79"
                        "paginaInicial" => "704"
                        "paginaFinal" => "709"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9496199"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The intubating laryngeal mask&#46; Results of a multicentre trial with experience of 500 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;J&#46; Baskett"
                            1 => "M&#46;J&#46; Parr"
                            2 => "J&#46;P&#46; Nolan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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