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Descriptive study of ultrasound images of the upper airway obtained after insertion of laryngeal mask
Imágenes ultrasonográficas de vía aérea superior tras la inserción de mascarilla laríngea: estudio descriptivo y utilidad clínica
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Intercost: external intercostal muscles; M. Serr: serratus anterior muscle. <span class="elsevierStyleSup">*</span>Radiopaque contrast deposited between the fascia of the serratus anterior muscle and the fascia of the external intercostal muscle. The arrows indicate the direction of the needle.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O. Varela, A. Melone, R. López-Menchaca, R. Sevilla, D. Callejo, S. López-Álvarez, A. Román Fernández, S. García, I. Mantilla, M. Zaballos" "autores" => array:10 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Varela" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Melone" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "López-Menchaca" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Sevilla" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Callejo" ] 5 => array:2 [ "nombre" => "S." "apellidos" => "López-Álvarez" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Román Fernández" ] 7 => array:2 [ "nombre" => "S." 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Flores, J. Sánchez-Ruano, M. Otero, F. Buisán" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M.A." "apellidos" => "Pérez-Herrero" "email" => array:1 [ 0 => "mapeherrero@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "O." "apellidos" => "de la Varga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Flores" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Sánchez-Ruano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Otero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "F." "apellidos" => "Buisán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Imágenes ultrasonográficas de vía aérea superior tras la inserción de mascarilla laríngea: estudio descriptivo y utilidad clínica" ] ] "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" => 1010 "Ancho" => 2000 "Tamanyo" => 166609 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Placement of the transducer in the right lateral transverse (or axial) plane at the suprasternal level (TSE) with the laryngeal airway correctly inserted. (A) The oesophagus (ESO) is correctly located behind the trachea (TRA). (B) Rotation of the transducer in the cranial direction. The anechoic shadow of the cuff of the laryngeal airway compresses the oesophagus and prevents visualisation. CA, internal carotid artery; ESO, oesophagus; TC, thyroid cartilage; TG, thyroid gland; TRA, trachea; YI, internal jugular vein.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Airway management is one of the most important skills that an anaesthesiologist must master, since close to 64% of anaesthesia-related deaths are due to difficulties in securing an airway.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,2</span></a> Supraglottic airway devices (SADs) or laryngeal mask airways (LMAs) can effectively maintain oxygenation and have several advantages over tracheal intubation (cost-effective, no need for muscle relaxation, and no laryngoscopy-related complications). This is why they are becoming increasingly popular, to the point that they are now considered the technique of choice in most interventions performed under general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The type and size of the SAD should be chosen on the basis of several factors, such as weight, sex, ease of insertion, seal, whether it impinges on the operating field, and airway morbidity.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> In routine clinical practice, correct positioning of the SAD is usually confirmed by clinical signs<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5,6</span></a>; in recent years, it has been done using fibrobronchoscopy<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7,8</span></a> and upper-airway ultrasound.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ultrasound is a portable, non-invasive, easy to use, highly sensitive, and dynamic instrument that can be used when ionising radiation is contraindicated. Airway management guidelines recommend using ultrasound to confirm the correct position of the tracheal tube whenever capnography is unavailable.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11,12</span></a> It has also been used to predict difficult intubation, to guide the choice of the orotracheal tube size on the basis of objective measurements, to locate the cricothyroid membrane, to select the optimal moment for extubation, etc.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13,14</span></a> Visualisation of the SAD was hitherto thought to be impossible, unless the cuff was filled with liquid.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> However, recent studies have shown the feasibility of ultrasound visualisation, and this could be of great help in objectively verifying the correct placement of the SAD<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10,15</span></a> without the need to mobilise it, thus avoiding complications secondary to this “blind” manoeuvre.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to evaluate the clinical utility of upper-airway ultrasound in evaluating correct placement of the Ambu<span class="elsevierStyleSup">®</span> AuraGain™ LMA. Specifically, we describe the ultrasound images obtained after insertion of the LMA (comparing them with images obtained in the same ultrasound window before placement and after removal), checking for cuff-leaks, correct LMA placement, and the presence of anatomical changes or oedema after use of the LMA. Finally, we also determined the correlations between the different parameters used in the study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a prospective observational study approved by the Hospital Ethics Committee, document number PI 17-634. We analysed data from patients scheduled for open abdominal surgery under general anaesthesia between 27 February and 31 March 2017. Only patients who had previously accepted and signed the specific informed consent form for inclusion in the study were considered. Inclusion criteria were: age<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>18, BMI<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>25, scheduled abdominal surgery under general anaesthesia with an LMA, ASA physical status I–III, and signed informed consent form. Exclusion criteria were: history or clinical criteria of difficult airway (thyromental distance and Mallampati test), history of neck surgery, contraindication for SADs (laryngeal masses, gastroesophageal reflux), refusal to participate, or failure to meet inclusion criteria.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Considering a target population of 40 patients (abdominal surgery under general anaesthesia with LMA in the previous month), and for a confidence interval of 95% and an estimated optimal placement of the 80<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15%, we calculated that we would need a minimum sample of 27 patients. Estimating a loss rate of 10%, we included 30 valid patients in the study.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was initially placed in the supine position in order to scan the upper airway using a 6–15<span class="elsevierStyleHsp" style=""></span>MHz high-frequency linear transducer and a Siemens Acuson P300 ultrasound system. The same sequence was used in all ultrasound scans: first, the longitudinal axis of the transducer was placed perpendicular to the cervical spine (cross-section). Then, the transducer was turned in a craniocaudal direction to locate the pharyngolaryngeal structures and collect static images on four levels: suprahyoid, thyroid cartilage, cricoid cartilage, and first tracheal rings. Following this, the longitudinal axis of the transducer was placed on the anterior cervical midline, and finally on the sagittal planes, placing the transducer immediately anterior to the sternal fasciculus of the right and left sternocleidomastoid muscle. The ultrasound study was performed three times: once in the anaesthesia prep room, once in the operating room, after anaesthetic induction, and insertion of the LMA and before the surgical incision; and once in the postanaesthesia care unit (PACU) 15<span class="elsevierStyleHsp" style=""></span>min after the end of surgery, with the patient awake and after removal of the LMA.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The same anaesthesia procedure was used in all patients. A peripheral venous line was placed, and the patients were monitored in the standard manner with electrocardiogram, non-invasive blood pressure, axillary temperature, and peripheral oxygen saturation. Premedication was not used in any of the patients. Anaesthesia was induced with intravenous propofol (2–2.5<span class="elsevierStyleHsp" style=""></span>mg/kg). The desired level of hypnosis was achieved using a target controlled infusion (TCI) system with an effect site propofol concentration of 2–5<span class="elsevierStyleHsp" style=""></span>μg/ml delivered with a Braun Perfusor<span class="elsevierStyleSup">®</span> infusion pump following the Schnider model, to achieve a patient state index (PSI) of 30–40 on the Masimo<span class="elsevierStyleSup">®</span> Sedline<span class="elsevierStyleSup">®</span> monitor.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The airway was secured with an Ambu<span class="elsevierStyleSup">®</span> Auragain™ LMA. The size of the mask was adjusted to the weight and sex of the patient, using number 4 for female patients and 5 for male patients, except for those with a bodyweight below the 50th percentile. Before insertion, the LMA was prepared by deflating the cuff and lubricating the back with Sulki<span class="elsevierStyleSup">®</span> water-soluble lubricant, and the patient was placed in the supine position with the head in the sniffing position (head extension and cervical flexion). Once adequate depth of anaesthesia was achieved (PSI values of 30–40 [Masimo<span class="elsevierStyleSup">®</span> Sedline<span class="elsevierStyleSup">®</span>]), an expert anaesthesiologist (with more than 600 successful placements) inserted the LMA by holding the tube with the index and second fingers of the right hand in the cranial position and the thumb in the caudal position until the tip of the cuff was seated, visually checking its adaptation to the palate and following the palatopharyngeal curve until resistance is felt. Once placed, progressive boluses of 5 cc of air were used to inflate the cuff, until a negative cuff-test leak or cuff pressure of 40<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O or less was obtained. Once correct LMA placement was confirmed (bilateral expansion and symmetrical thoracic auscultation, square capnography wave form, and absence of gastric insufflation), volume-controlled mechanical ventilation was initiated at a tidal volume (Vt) of 6–8<span class="elsevierStyleHsp" style=""></span>ml/kg, 12–16 breaths per minute, and FiO<span class="elsevierStyleInf">2</span> of 0.6 to maintain end tidal carbon dioxide (EtCO<span class="elsevierStyleInf">2</span>) within normal ranges.</p><p id="par0050" class="elsevierStylePara elsevierViewall">If muscle relaxation was required to facilitate the surgical technique, 0.3–0.4<span class="elsevierStyleHsp" style=""></span>mg/kg/h rocuronium was administered and reversed with 2<span class="elsevierStyleHsp" style=""></span>mg/kg sugammadex at the end of surgery. Paracetamol (1<span class="elsevierStyleHsp" style=""></span>g) was administered for postoperative analgesia, and ondansetron (4<span class="elsevierStyleHsp" style=""></span>mg) was administered 30<span class="elsevierStyleHsp" style=""></span>min before the end for surgery to prevent postoperative nausea and vomiting. All drugs were administered intravenously. Once the surgical procedure was completed, and after removing the laryngeal mask, the patients were transferred to the PACU, where the ultrasound scan was repeated.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The data collected were: patient demographics (sex, age, weight, height), the size of the laryngeal mask used, the presence of a cuff leak when the Datex Aestiva 7100 ventilator (GE Healthcare, Cheshire, USA) was set at a pressure gradient of 20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, correct placement of the mask, and anterior and posterior measurements of upper-airway structures. The LMA cuff was checked for leaks<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> at the start of the intervention by closing the expiratory circuit valve with a constant fresh gas flow of 3<span class="elsevierStyleHsp" style=""></span>l/min, which increased the pressure of the circuit until a point of equilibrium was reached that corresponded to the sealing pressure of the airway. At this point, the pressure gradient in the circuit, which should not exceed 20<span class="elsevierStyleHsp" style=""></span>cm of H<span class="elsevierStyleInf">2</span>O, was noted.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The following ultrasound criteria were used to confirm correct LMA placement: visualisation of both shadows of the cuff symmetrical to the midline in the transverse plane at the thyrohyoid (TH) level after placing the transducer as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>; placing the transducer as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> in the transverse suprasternal plane (TSE), the oesophagus appears behind the trachea and is “displaced” and overshadowed by the cuff when placed in the pharyngolaryngeal parasagittal plane; and visualisation of the oesophagus and the tip of the cuff at the same level in the pharyngolaryngeal parasagittal plane as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. The quality of the image was rated according to whether one or more of the foregoing criteria were met, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">To evaluate the presence of anatomical changes or oedema after the use of the laryngeal mask, untrasound measurements of the anteroposterior internal laryngeal diameter were made in the transverse plane at the level of the vocal cords both before and after insertion of the device. The images were described as grade 1, if there were no changes in diameter; grade 2, if the diameter had changed by less than 1<span class="elsevierStyleHsp" style=""></span>mm; and grade 3, if the difference was greater than 1<span class="elsevierStyleHsp" style=""></span>mm.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The data obtained were divided into grades for the purpose of statistical analysis. The difficulty of insertion was graded from 1 to 3, depending on the number of attempts made to place the mask: grade 1, if the LMA was inserted in a single attempt; grade 2, if it was inserted in 2 attempts; and grade 3, if more than two attempts were necessary. Similarly, the results of the cuff-leak test were described as grade 1 if there was no leak, grade 2 if there was moderate leakage that did not prevent ventilation, and grade 3, if the leak was significant enough to prevent oxygenation.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The ultrasound evaluation of LMA placement was quantified according to the total score obtained in each of the three static images recorded after insertion of the device. Images that met the criteria for correct placement were awarded 0 points; those that did not were awarded 1 point. Therefore, the lowest possible score per patient was 0, and the highest was 3. Placement was described as grade 1, corresponding to a score of 0 points, grade 2 to a score of between 1 and 2 points, and grade 3 if 3 points were obtained (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The statistical analysis of the data was performed on SPSS vs 22 for Windows using descriptive techniques. Quantitative variables, which were shown by the Shapiro–Wilk test to be normally distributed, are shown as mean and standard deviation, and quantitative variables as frequencies. Qualitative variables were tested for correlations using Pearson's Chi-square test. If more than 20% of cells has expected values of less than 5, Fisher's exact test or the likelihood ratio test was used for variables with more than two categories. Correlation was determined between the degree of leakage and the total score obtained in the ultrasound evaluation of mask placement, and between the degree of leakage and the presence of laryngeal oedema. These parameters were tested using Fisher's exact test, after constructing various 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2 contingency tables.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">Data from 30 patients were analysed: 20 women and 10 men, age 61<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.3 years, weight 69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.6<span class="elsevierStyleHsp" style=""></span>kg, height 164.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.4<span class="elsevierStyleHsp" style=""></span>cm, and body mass index (BMI) 25.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.65. The patients underwent abdominal hysterectomy (15 patients), eventroplasty (6 patients), uterine myomectomy (3 patients), and umbilical (4) and inguinal (2) hernioplasty. The mask size usually used was number 4 (70% of cases), followed by 3 (8 patients), and 5 (2 patients). All the quantitative variables followed a normal distribution.</p><p id="par0090" class="elsevierStylePara elsevierViewall">“Blind” insertion of the mask was uneventful in 24 patients (80%), and classed as grade 2 (two attempts) in 6 patients (20%).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Cuff leakage was detected in eight patients (26.7%), which was classified as moderate (7 cases) or serious (1 case). In the case of a serious leak, the device had to be removed to reposition it and facilitate ventilation.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The description of the ultrasound findings of the airway, as defined in the methodology, confirmed correct placement of the mask in 22 patients (73.3%), since they met all the criteria listed above.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The ultrasound findings correlated with the degree of leakage, with a significance of 0.154.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Anatomical changes or oedema in the airway were observed after removal of the LMA (differences in anteroposterior measurements at the level of vocal cords before and after mask insertion) in three patients (12%), although none were classed above grade 2 (less than 1<span class="elsevierStyleHsp" style=""></span>mm difference is diameter). The degree of cuff leakage correlated with the anteroposterior laryngeal diameter at the level of the thyroid cartilage assessed by ultrasound, with a significance of 1.00.</p><p id="par0115" class="elsevierStylePara elsevierViewall">A statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.05) correlation was found between the degree of difficulty in inserting the LMA and the degree of cuff leakage. Likewise, the degrees of cuff leakage corresponded with grades 1 and 2 ultrasound mask placement; the greater the degree of cuff leakage, the higher the percentage of airway oedema.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">The ultrasound parameters analysed allowed us to evaluate LMA placement as correct, taking into account all study parameters, in 73.3% of the patients. However, when only clinical criteria (negative leak test) were considered, which are the ones generally used in clinical practice, the mask was corrected inserted in 96.67% of cases. The Ambu<span class="elsevierStyleSup">®</span> AuraGain™ laryngeal mask used in our study is suitable for ultrasound evaluation due to its inflatable cuff and adaptation to the hypopharynx and prelaryngeal structures.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Our results are consistent with those reported in earlier studies that evaluated the benefits of ultrasound in determining the correct placement of LMAs in Asian patients, including women undergoing gynaecological surgery<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> and surgical patients of both sexes<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> and also in western populations.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Zhou et al.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> found that clinical placement was correct in 89.1% of patients, but only in 67.2% when evaluated using ultrasound criteria. Our results should be interpreted considering that our population was western, of greater age<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> and weight,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> and included men, all of which are factors that increase the incidence of difficult ventilation with SADs.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The importance of complementing the usual clinical seal tests with imaging tests to confirm correct SAD placement is indisputable.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Even when good SAD management practices are followed (individualised choice of size and type taking into account sex, height, weight, body mass index and anatomical characteristics of the oropharynx, correct and careful insertion technique, minimum cuff inflation volume, stable position, identification and early correction of possible incorrect placement) malpositions are still detected in up to 43.4% of the cases when SAD location is verified by fibroscopy or other imaging techniques.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Fibroscopy is still the gold standard confirmation technique, but ultrasound should be considered as an alternative diagnostic tool<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> due to its safety (no radiation), effectiveness<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> (particularly is detecting LMA rotation), and availability.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The use of SADs has increased steadily since they were first described by Brain in the early 1980s. They are now used in around 50% of all procedures performed under general anaesthesia, given the lower incidence and severity of complications compared with intubation.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> Although most of the side effects described are mild (sore throat, soft tissue abrasion, dysphonia, and dysphagia), more serious nerve injuries have also been reported, such as dysfunction due to recurrent laryngeal nerve injury.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> The main causes of pharyngeal mucosa hypoperfusion are inflating the cuff beyond the maximum recommended pressure of 60<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O or 44<span class="elsevierStyleHsp" style=""></span>mmHg,<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">26,27</span></a> or malpositioning of the mask (even after successful insertion).</p><p id="par0140" class="elsevierStylePara elsevierViewall">Recognising the anatomical structures of the larynx on ultrasound imaging is a skill that requires in-depth knowledge of the anatomy of that region.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> However, sonoanatomical analysis of the airway is relatively simple once the operator is familiar with the basic planes. One of the main problems with ultrasound evaluation is interobserver variability in interpreting the images. In an attempt to overcome this, we designed the “standard views” and the scoring system based on specific criteria.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The three standard scanning planes devised for our study, two transverse and one sagittal, were based on observations from earlier studies in the literature<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6,7,17</span></a> and on the spatial structures of the pharynx and larynx.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> The LMA cuff is visualised as an anechoic structure bordered by three parallel lines. The best window for locating the tip of the mask is obtained with the transducer placed in a longitudinal position parallel to the midline, under the cricoid cartilage, where the trachea and oesophagus are visualised (as indicated in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><p id="par0150" class="elsevierStylePara elsevierViewall">LMA placement was satisfactory in most of our patients, with no change in anatomical structures after it was removed. This is consistent with other studies evaluating the complications associated with the use of SADs,<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">24,26,27</span></a> in general, and with second-generation laryngeal masks, in particular,<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">29,30</span></a> and specifically in the case of the study LMA.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">This study has some limitations. The small sample size prevented us from establishing a greater number of significant correlations between variables; larger series will be needed to increase the statistical power. Another limitation is the absence of another reliable diagnostic method with which to compare our ultrasound findings. In this respect, fibre-optic bronchoscopy, which has been used in similar studies, would have allowed us to correlate and confirm the correct placement of the LMA by direct visualisation; however, recent studies recommend using ultrasound for this purpose.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,23</span></a> The study was performed in a single hospital, which has prevented us from evaluating the external validity of ultrasound evaluation of the airway. In addition, the recent description of upper-airway parameters for ultrasound scanning and their use in confirming correct SAD placement provide limited scientific evidence. Further comparative studies and randomised clinical trials are required, ideally performed in various different centres and in a larger number of patients are required.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Based on our results, we can conclude that ultrasound is a useful diagnostic method in the perioperative assessment of the upper airway. The ultrasound scan is a quick, non-invasive, dynamic tool for evaluating correct LMA placement and can guide attempts to correctly reposition the device, thus avoiding the need for blind manoeuvres. The Ambu<span class="elsevierStyleSup">®</span> AuraGain™ LMA was correctly placed in our patients, and no anatomical changes were observed after removal of the device.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Authorship</span><p id="par0165" class="elsevierStylePara elsevierViewall">All the authors have participated in the design, data collection, and final writing of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1092831" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1035692" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1092832" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1035691" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authorship" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-02-28" "fechaAceptado" => "2018-05-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035692" "palabras" => array:3 [ 0 => "Extraglottic devices" 1 => "Ultrasound" 2 => "Upper-airway management" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1035691" "palabras" => array:3 [ 0 => "Dispositivos supraglóticos" 1 => "Ecografía" 2 => "Manejo de vía aérea superior" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate clinical usefulness of ultrasound images of the upper airway in order to check correct laryngeal mask placement.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was conducted on patients scheduled for abdominal surgery under general anaesthesia, in whom the patency of the upper airway was ensured using an Ambu<span class="elsevierStyleSup">®</span>AuraGain™ laryngeal mask. An ultrasound scan was performed of the upper-airway in the cranio-caudal direction and with longitudinal scans in the anterior midline and parasagittal axis, in three moments: before, after inserting and after removing the mask. All recorded images were evaluated for a second time by an expert radiologist in upper-airway ultrasound. Subsequently, the ultrasound data were related to the clinical difficulty of the insertion and presence of air leaks.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data were collected from 30 patients (20 females and 10 males) being operated on for abdominal hysterectomy (15), eventroplasty (6), uterine myomectomy (3), and umbilical (4) and inguinal herniorrhaphy (2). The blind insertion of the masks did not present difficulties in 24 (80%) patients. Air leakage was detected in eight (26.7%) patients, which was moderate in seven cases and severe in one. The ultrasound findings confirmed good mask placement in 22 (73.3%) patients. Anatomical airway changes after laryngeal mask extraction were only observed in three (12%) patients, all of them minor. There was a statistically significant association (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) between difficulty in inserting the device and the level of air leakage.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Upper-airway ultrasound is a useful diagnostic method to evaluate laryngeal mask placement. Laryngeal oedema was not observed after removal of the device.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la utilidad clínica de la ecografía de vía aérea superior en la visualización de la mascarilla laríngea correctamente insertada.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo en pacientes programados para cirugía abdominal bajo anestesia general, a quienes se aseguraba la permeabilidad de la vía aérea mediante mascarilla Ambu<span class="elsevierStyleSup">®</span>AuraGain™. Se llevó a cabo un escaneo ecográfico de la vía aérea superior, mediante cortes trasversales en sentido cráneo-caudal y cortes longitudinales en línea media cervical anterior y parasagital, en tres momentos: antes, tras insertar y tras retirar la mascarilla. Las imágenes registradas eran evaluadas en un segundo tiempo por un radiólogo experto en ecografía de la vía aérea. Posteriormente, se relacionaban los datos ecográficos con los clínicos de dificultad de inserción y presencia de fuga aérea.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Recogimos datos de 30 pacientes (20 mujeres y 10 varones) intervenidos de histerectomía abdominal (15), eventroplastia (6), miomectomía uterina (3) y hernioplastia umbilical (4) e inguinal (2). La inserción a ciegas del dispositivo no presentó dificultades en 24 pacientes (80%). Detectamos fuga aérea en 8 pacientes (26.7%): moderada en 7 casos y grave en uno. Los hallazgos ecográficos confirmaban buena colocación de la mascarilla en 22 pacientes (73,3%). Se objetivaron cambios anatómicos en la vía aérea tras extraer la mascarilla laríngea en 3 pacientes (12%), todos leves. Hubo asociación estadísticamente significativa (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05) entre el grado de dificultad de inserción del dispositivo y el grado de fuga aérea detectado.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La ultrasonografía de la vía aérea superior podría confirmar la colocación correcta de la mascarilla laríngea. No se objetivó oedema laríngeo tras la extracción del dispositivo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez-Herrero MA, de la Varga O, Flores M, Sánchez-Ruano J, Otero M, Buisán F. Imágenes ultrasonográficas de vía aérea superior tras la inserción de mascarilla laríngea: estudio descriptivo y utilidad clínica. Rev Esp Anestesiol Reanim. 2018;65:434–440.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0180" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1324 "Ancho" => 1583 "Tamanyo" => 167068 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Placement of the ultrasound transducer and images obtained in the transverse plane at the thyrohyoid (TH) level. The shadows of the cuff are symmetrical to the middle line once the laryngeal airway is in place.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1010 "Ancho" => 2000 "Tamanyo" => 166609 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Placement of the transducer in the right lateral transverse (or axial) plane at the suprasternal level (TSE) with the laryngeal airway correctly inserted. (A) The oesophagus (ESO) is correctly located behind the trachea (TRA). (B) Rotation of the transducer in the cranial direction. The anechoic shadow of the cuff of the laryngeal airway compresses the oesophagus and prevents visualisation. CA, internal carotid artery; ESO, oesophagus; TC, thyroid cartilage; TG, thyroid gland; TRA, trachea; YI, internal jugular vein.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1497 "Ancho" => 1583 "Tamanyo" => 140020 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Placement of the transducer in the parasagittal pharyngolaryngeal plane. Both the tip of the cuff and the oesophagus (ESO) are visualised in the same plane.</p>" ] ] 3 => 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" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">PPL, parasagittal pharyngolaryngeal plane; TH, transverse plane at the thyrohyoid level; TSE, transverse suprasternal plane.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Plane \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">Ultrasound image \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">Score \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">TH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The two shadows of the cuff are not symmetrical to the midline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">TSE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The shadow of the cuff does not displace the oesophagus posterior \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">PPL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tip of the cuff and oesophagus are not visualised in the same plane \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1868909.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Ultrasound criteria for incorrect positioning of the laryngeal mask.</p>" ] ] 4 => 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:1 [ "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 " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound images of correct placement</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">Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score 0 \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">Grade 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score from 1 to 2 \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">Grade 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score 3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1868908.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Grading of ultrasound images based on their fulfilment of the ultrasound criteria defined in Table 1.</p>" ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 195117 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practice guidelines for management of the difficult airway. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 5 | 2 | 7 |
| 2019 April | 1 | 0 | 1 |
| 2018 December | 2 | 2 | 4 |
| 2018 October | 1 | 0 | 1 |
