Dr Narasimhan Jagannathan´s articles

Correspondence

The air-QÒ intubating laryngeal airway for endotracheal intubation in children with difficult airway: our experience

SIR—We read with interest and true appreciation both the article by Jagannathan N et al. (1) and the com- ment by Parotto M et al. (2) as well as the recent arti- cle by Jagannathan N et al. (3) where they reported their experience with air-QÒ intubating laryngeal air- way (ILA) (CookgasÒ, LLC St Louis, MO, Mercury MedicalÒ, Clearwater, FL, USA) as a conduit for lar- yngeal mask-assisted tracheal intubation in patients with difficult airway.
It is a novel supraglottic airway device recently introduced into the anesthesia’s market, designed to perform a guidance for tracheal intubation with a cuffed tracheal tube and to facilitate its removal by a custom stylet.
At once, we were intrigued by the described easy use of this novel device to perform a fiberoptic intubation in pediatric patients with difficult laringoscopy.
Therefore, we also begun to employ it from March 2009 to September 2011 in infants and children with documented or predictable difficult direct laryngoscopy scheduled for surgery where it was indispensable to perform an endotracheal intubation, especially for cra- niomaxillo-facial reconstructive surgery of congenital malformations.
We are describing our experience in anesthesia care of 12 patients with difficult airways.
The median age was 78.7 (1–160) months and the median weight was 23.8 (2.5–50) kilograms.
All patients (ASA I-II) were premedicated by oral midazolam 0.2 mgÆkg)1 4500 prior to their admittance into the operating room and received 0.01 mgÆkg)1 of IV atropine sulfate to minimize secretions as soon as a vascular access was established after performing gene- ral anesthesia by volatile agents such as sevoflurane 3–5% in 40% oxygen/60% nitrous oxide gas mixture via face mask, while patients breathe spontaneously.
References
1 Jagannathan N, Roth AG, Sohn LE et al. The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series. Pediatr Anesth 2009; 19: 618–622.
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The air-QÒ ILA, without deflating cuff, was easily inserted with the index finger of the right hand, while the anesthetist performed jaw’s lift with left hand, without a rotational technique. A flexible fiberoptic bronchoscope (FOB), preloaded with a well lubricated by KYÒ Jelly (Johnson & Johnson Medical, New Brunswick, NJ, USA) cuffed oral endotracheal tube (ETT), was inserted into the lumen of the air-QÒ ILA after removing the circuit connector. The larynx was always easily visualized as the bronchoscope traveled outside the air-QÒ ILA. Before going beyond vocal cords, an IV bolus of propofol 2 mgÆkg)1 was injected prior to advance FOB to carina. Then, ETT was slid over the scope through the air-QÒ ILA into trachea. Positioning of ETT was confirmed by FOB visualiza- tion, end-tidal C02 and lung sounds.
In case of craniomaxillo-facial surgery, we easily removed air-QÒ ILA using a specially designed removal stylet to prevent dislodging the ETT during this maneuvre. Otherwise the laryngeal mask was left in the mouth.
In summary, we fully agree with Authors that air- QÒ ILA may be a well-suited alternative to the classic laryngeal mask in children with difficult airway, espe- cially when an ETT is required.
Conflict of interest
No conflicts of interest declared.
Fabio Ferrari & Raoul Laviani
Department of Anesthesiology and Intensive care, Children’s Hospital ‘Bambino Gesu`’ of Rome, Italy Email: fabio.ferrari@opbg.net
doi:10.1111/j.1460-9592.2011.03792.x
Jagannathan N, Kho MF, Kozlowski RJ et al. Retrospective audit of the air-Q intubating laryngeal mask as a conduit for tracheal intu- bation in pediatric patients with a difficult air- way. Pediatr Anesth 2011; 21: 422–427.
a 2012 Blackwell Publishing Ltd Pediatric Anesthesia 22 (2012) 490–507

ORIGINAL ARTICLE
A randomized trial comparing the Ambu® Aura-iTM with the air-QTM intubating laryngeal airway as conduits for tracheal intubation in children
Narasimhan Jagannathan, Lisa E. Sohn, Amod Sawardekar, Jason Gordon, Ravi D. Shah,
Isabella I. Mukherji, Andrew G. Roth & Santhanam Suresh
Department of Pediatric Anesthesia, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA

Keywords
airway devices; clinical trials; laryngeal mask airway; air-Q
Correspondence
Narasimhan Jagannathan, Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children’s Hospital of Chicago, Assistant Professor of Anesthesiology, Northwestern University’s Feinberg School of Medicine, 225 E. Chicago Avenue, Chicago, IL 60611, USA
Email: simjag2000@yahoo.com Section Editor: Jerrold Lerman Accepted 7 August 2012 doi:10.1111/pan.12024

Summary
Objectives: To assess the clinical performance of the Ambu Aura-i (Aura-i) in children.
Aim: To compare the Aura-i with the air-Q intubating laryngeal airway (air- Q) for the purposes of fiberoptic-guided tracheal intubation.
Background: The Aura-i is a new supraglottic airway designed for tracheal intubation.
Materials/Methods: One hundred twenty children, ages 1 month to 6 years, were randomized to receive either the Aura-i or air-Q, and divided into three equal subgroups (Group 1, 2, 3) based on weight. The time for successful tra- cheal intubation was primarily assessed. The ease, time, and number of attempts for successful device insertion, leak pressures, fiberoptic grade of lar- yngeal view, number of attempts time for removal of the device after tracheal intubation, and complications were secondarily assessed.
Results: Device placement, tracheal intubation, and removal after tracheal intubation were successful in all patients. There were no differences in the time to successful tracheal intubation through the Aura-i (32.9 ± 13.3 s), and the air-Q (33.9 ± 13 s; P = 0.68), or fiberoptic grade of view between devices. There was not a statistically significant correlation between the time to intubation and the fiberoptic grade of laryngeal view in any of the groups. There were no statistically significant differences in the overall leak pressures, air-Q (18.3 ± 6.1 cm H2O) vs Aura-i (16 ± 5.1 cm H2O; P = 0.05). In Group 1 (5–10 kg), leak pressures were higher with the air-Q (23.4 ± 7.2 cm H2O) than the Aura-i (16.1 ± 5.2 cm H2O; P = 0.001). There were no statistically significant differences in the time for removal between the two devices (P = 0.11). However, with the size 1.5 Aura-i, the pilot balloon of the tra- cheal tube was removed in order to facilitate the removal of the device after tracheal intubation.
Conclusions: Both devices served as effective conduits for fiberoptic-guided tracheal intubation. The limitation of the narrower proximal airway tube of the size 1.5 Aura-i should be considered if cuffed tracheal tubes are to be utilized.

Introduction
As newer supraglottic airway devices become available, it is important to compare them with established devices

to evaluate their safety and efficacy (1). These compari- sons are particularly important in children as fewer number of studies on pediatric airway devices have been performed. The air-QTM intubating laryngeal airway
© 2012 Blackwell Publishing Ltd
Pediatric Anesthesia 22 (2012) 1197–1204

Pediatric Anesthesia 2009 19: 618–622 doi:10.1111/j.1460-9592.2009.02990.x

Case report
The new air-QTM intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series
NARASIMHAN JAGANNATHAN MD, ANDREW G. ROTH
MD, LISA E. SOHN MD, THOMAS Y. PAK DO, SAPAN AMIN
MD AND SANTHANAM SURESH MD FAAP
Department of Pediatric Anesthesiology, Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA