Airway AN0514 WM

PRINTER-FRIENDLY VERSION AVAILABLE AT ANESTHESIOLOGYNEWS.
COM
Current Concepts
In the Management
Of the Difficult Airway
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Volume 11, Number 1

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CARIN A. HAGBERG, MD
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Joseph C. Gabel Professor and Chair

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Department of Anesthesiology
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The University of Texas Medical School at Houston

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Director of Advanced Airway Management

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Memorial Hermann HospitalTexas Medical Center

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Houston, Texas
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Executive Director 2009-Present, Society for Airway Management

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Dr. Hagberg has received grant support from Ambu, Cadence Pharmaceuticals,
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and Karl Storz Endoscopy, and is also an unpaid consultant for Ambu.
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anagement of the difficult airway remains one of the most
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relevant and challenging tasks for anesthesia care providers. This

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review focuses on several of the alternative airway management

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devices/techniques and their clinical applications, with particular emphasis

on the difficult or failed airway. It includes descriptions of many new
airway devices, several of which have been included in the American
Society of Anesthesiologists (ASA) Difficult Airway Algorithm (Figure).
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G A N E S T H E S I O L O G Y N E W S M AY 2 0 1 4 1
place an ET through intubating supraglottic ventilatory
devices for visualization of ET placement through the
SGA (Table 2A).
RIGID/VIDEO LARYNGOSCOPES
Video-assisted techniques have become pervasive
in various surgical disciplines, as well as in anesthesi-
ology. As more video laryngoscopes are introduced
into clinical practice, and as airway managers become
more skillful with the technique of video-assisted laryn-
goscopy, it could well become standard procedure
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for patients with known or suspected difficult airways.

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It also may become the standard for routine intuba-

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tions as the equipment and users skills improve and

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the cost of the devices decreases, with the potential for

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important savings in time and decreased morbidity in

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patients. It is beyond the scope of this review to discuss

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all of the laryngoscopes that have been manufactured;

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thus, only some of the most recently developed blades

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Figure. The ASA Difficult Airway Algorithm. will be described (Table 3).
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(Anesthesiology 2013;118[2]:251-270) INDIRECT RIGID FIBER-OPTIC LARYNGOSCOPES

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The algorithm can be viewed at:

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www.asahq.org/publicationsAndServices/practiceparam.htm These laryngoscopes were designed to facilitate tra-

cheal intubation in the same population that would be
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considered for flexible fiber-optic bronchoscopy, such

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as patients with limited mouth opening or neck move-

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Alternative Airway Devices

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ment. Relative to the flexible fiber-optic bronchoscopes

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A common factor preventing successful tracheal (FOBs), they are more rugged in design, control soft tis-
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intubation is the inability to visualize the vocal cords sue better, allow for better management of secretions,
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during the performance of direct laryngoscopy. Many are more portable (with the exception of the new por-
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devices and techniques are now available to circumvent table FOBs), and are not as costly. Intubation can be
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the problems typically encountered with a difficult air- performed via the nasal or oral route and can be accom-
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way using conventional direct laryngoscopy. plished in awake or anesthetized patients (Table 4).
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ENDOTRACHEAL TUBE GUIDES SUPRAGLOTTIC VENTILATORY DEVICES

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Several endotracheal tube (ET) guides have been The Laryngeal Mask Airway (LMA, LMA North Amer-
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used to aid in intubation or extubation, including both ica, a Teleflex Company) is the single most important
reusable/disposable and solid/hollow introducers, sty- development in airway devices in the past 25 years. Since
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lets, and tube exchangers (Table 1). its introduction into clinical practice, it has been used
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in more than 200 million patients worldwide with no

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LIGHTED STYLETS reported deaths. Other supraglottic ventilatory devices

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In the past decade, many lighted stylets have been are available for routine or rescue situations. The most
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developed, including light wands, which rely on trans- recently developed supraglottic ventilatory devices have
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illumination of the tissues of the anterior neck to demon- a gastric channel or are intended to be used as a conduit
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strate the location of the tip of the ETa blind technique, for fiber-optic guided intubation (Table 5).
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unless combined with direct laryngoscopy, and visual

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scopes, which use fiber-optic imagery and allow indirect Special Airway Techniques
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visualization of the airway. They also can be used alone

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or in conjunction with direct laryngoscopy (Table 2).

AWAKE INTUBATION
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For managing patients in whom a difficult airway is

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VIEWING STYLETS suspected or anticipated, securing the airway before

Viewing stylets provide a view from the tip of the induction of general anesthesia adds to the safety of
endotracheal tube. Whereas the view from a video anesthesia and helps minimize the possibility of major
laryngoscope is at the end of the laryngoscope, view- complications, including hypoxic brain damage and
ing stylets provide a view from the tip of the ET for death. To perform awake intubation, the patient must
steering the ET through the cords. The stylet size for be adequately prepared for the procedure. Good topi-
this device allows it to be placed within an ET as an cal anesthesia is essential to obtund airway reflexes and
independent instrument, or as an adjunct to video or can be provided by various topical agents and admin-
direct laryngoscopy. In addition, some can be used to istrative devices (Table 6). Other relatively new devices
2 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
can be used to best position patients and maintain an Conditional 3.0 Tesla manual jet ventilator (Anesthesia
open airway during awake intubation (Table 7). Associates, Inc., AincA) is also now available to enable
Atomizing devices currently available for delivering TTJV in the MRI suite for both planned and emergency
topical anesthesia to nasal, oral, pharyngeal, laryngeal, procedures (Table 6).
and tracheal tissues include the DeVilbiss Model 15 Med-
ical Atomizer (DeVilbiss Healthcare), the Enk Fiberop- CRICOTHYROTOMY
tic Atomizer Set (Cook Medical), and the LMA MADgic Cricothyrotomy (Table 8), a lifesaving procedure, is
Laryngo-Tracheal Atomizer (LMA North America, a the final option for cannot-intubate, cannot-ventilate
Teleflex Company). Although any technique of tracheal patients according to all airway algorithms, whether
intubation can be performed under topical anesthesia, they concern prehospital, emergency department,
flexible fiber-optic intubation is most commonly used. intensive care unit, or operating room patients.
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In adults, needle cricothyrotomy should be per-

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FLEXIBLE FIBER-OPTIC INTUBATION formed with catheters at least 4 cm and up to 14 cm in

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Flexible fiber-optic intubation is a very reliable length. A 6 Fr reinforced fluorinated ethylene propyl-
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approach to difficult airway management and assess- ene Emergency Transtracheal Airway Catheter (Cook
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ment. It has a more universal application than any other Medical) has been designed as a kink-resistant cathe-
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technique. It can be used orally or nasally for both ter for this purpose.
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upper and lower airway problems and when access to Percutaneous cricothyrotomy involves using the
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the airway is limited, as well as in patients of any age Seldinger technique to gain access to the cricothyroid
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and in any position. Technological advancesincluding membrane. Subsequent dilation of the tract permits
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improved optics, battery-powered light sources, better passage of the emergency airway catheter. Surgical cri-
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aspiration capabilities, increased angulation capabili- cothyrotomy is performed by making incisions through
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ties, and improved reprocessing procedures have been the cricothyroid membrane using a scalpel, followed by
developed. The Airway Mobilescope (MAF; Olympus)
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the insertion of an ET. This is the most rapid technique

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is a portable, flexible endoscope with expanded view- and should be used when equipment for the less inva-
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ing and recording capability, incorporating a monitor, sive techniques is unavailable and speed is particularly
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LED light source, battery and recording device in a sin- important.

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gle unit. A completely disposable system, the aScope

TRACHEOSTOMY
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(Ambu) also is available. Rescue techniques, such as

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direct laryngoscopy and placing a retrograde guide- Tracheostomy (Table 9) establishes transcutane-
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wire through the suction channel, may be used if the ous access to the trachea below the level of the cricoid
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glottic opening cannot be located with the scope, or if cartilage. Emergency tracheostomy may be neces-
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blood or secretions are present. Insufflation of oxygen sary when acute airway loss occurs in children under
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or jet ventilation through the suction channel may pro- 10 years of age or children whose cricothyroid space is
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vide oxygen throughout the procedure, and allow addi- considered too small for cannulation, as well as in indi-
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tional time when difficulty arises in passing the ET into viduals whose laryngeal anatomy has been distorted by
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the trachea. the presence of pathologic lesions or infection.

Percutaneous dilatational tracheostomy is the most
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RETROGRADE INTUBATION commonly performed tracheostomy technique, yet it is

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Retrograde intubation (Table 6) is an excellent tech- still considered invasive and can cause trauma to the
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nique for securing a difficult airway either alone or in tracheal wall. Translaryngeal tracheostomy, a newer tra-
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conjunction with other airway techniques. Every anes- cheostomy technique, is considered to be safe and cost-
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thesia care provider should be skilled in employing this effective, and it can be performed at the bedside. It may
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simple, straightforward technique. It is especially use- be beneficial in patients who are coagulopathic. Surgi-
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ful in patients with limited neck mobility (that is associ- cal tracheostomy is more invasive, and should be per-
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ated with cervical spine pathology, or in those who have formed on an elective basis and in a sterile environment.
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suffered airway trauma). Cook Medical has 2 retrograde

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intubation sets: a 6.0 Fr for placing tubes of 2.5 mm or Conclusion

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greater ID, and a 14.0 Fr for placing tubes of 5.0 mm or Most airway problems can be solved with relatively
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greater ID. simple devices and techniques, but clinical judgment

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born of experience is crucial to their application. As

TRANSTRACHEAL JET VENTILATION with any intubation technique, practice and routine use
Transtracheal jet ventilation (TTJV) is a well-accepted will improve performance and may reduce the likeli-
method for securing ventilation in rigid and interven- hood of complications. Each airway device has unique
tional bronchoscopy, and there are several commer- properties that may be advantageous in certain situ-
cial manual jet ventilation devices available (Table 6). ations, yet limiting in others. Specific airway manage-
The Enk Oxygen Flow Modulator (Cook Medical) is a ment techniques are greatly influenced by individual
device recommended for use when jet ventilation is disease and anatomy, and successful management may
appropriate but a jet ventilator is not available. A MRI require combinations of devices and techniques.
A N E S T H E S I O L O G Y N E W S M AY 2 0 1 4 3
Table 1. Endotracheal Tube Guides
Name (Manufacturer) Description Length, cm
Aintree Intubation Catheter Polyethylene 19 Fr AEC allows passage of an FOB through its 56
(Cook Medical) lumen. Has 2 distal side holes and is packaged with Rapi-Fit
adapters. Color: light blue.
Arndt Airway Exchange Polyethylene 8 and 14 Fr AEC with a tapered end, multiple 50, 65, 78
Catheter Set side ports, packaged with a stiff wire guide, bronchoscope
(Cook Medical) port, and Rapi-Fit adapters. Color: yellow.
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Cook Airway Exchange 8, 11, 14, and 19 F Polyethylene designs facilitate exchange of 43, 83, 100
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Catheters SLT or DLT of 4.0 mm ID. The DLT versions are extra firm
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(Cook Medical) with soft-tips. Colors: Yellow, green; soft-tip is purple.

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Cook Staged Extubation Set Soft-tipped marked extubation wire to maintain continuous This set can facilitate
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(Cook Medical) airway access, wire holder and Tegaderm for securement, reintroduction of ETs
(Available outside of USA soft-tipped Reintubation Catheter, Rapi-Fit adapters to assist with ID >5 mm.
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only) in oxygen delivery, if necessary.

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CoPilot VL Single-Use 14 Fr polyethylene single-use ET introducer with coud tip. 60 cm length. For use
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Bougie (Magaw Medical) with ETs 6.0 mm ID.

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CoPilot VL Rigid Stylet Reusable CoPilot VL intubation stylet. For use with ET 6.0
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(Magaw Medical) mm ID.

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Frova Intubating Introducer Polyethylene 8 and 14 Fr AEC with angled distal tip with 2 35, 65
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(Cook Medical) side ports. Has hollow lumen and is packaged with a stiff-
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ening cannula and removable Rapi-Fit adapters. 14 Fr also

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packaged in box of 10. Colors: 8 Fr, yellow; 14 Fr, blue.

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GlideRite Rigid Stylet Reusable, sterilizable, semirigid stylet that conforms to Stylet rod length is 26.6
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(Verathon) GlideScope unique blade angulation; provides improved cm. Accommodates ETs
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maneuverability in ET placement. 6.0 mm ID.

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Introes Pocket Bougie Single-use 14 Fr (4.7 mm) malleable ET introducer made from 60 accommodates
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(BOMImed) special blend of Teflon. Packaged in box of 10. ETs 5.0 mm ID.
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Muallem ET Tube Stylet Single-use 8, 12, 14 Fr stylet; malleable, but with soft and 40, 65
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(VBM Medizintechnik GmbH) atraumatic coud tip. Color: green.

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OptiShape Stylet Reusable, sterilizable, semirigid stylet with optimal shape 4 sizes. Accommodates
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(Truphatek International Ltd) memory for indirect intubation procedures. ETs 2.5-3.5, 4.0-5.5, 5.0-
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6.5, and 7.0-9.0 mm ID.

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Pocket Introducer Single-use 15 Fr Introducer with coud tip. Color: blue. 65

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(VBM Medizintechnik GmbH)

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Portex Venn Tracheal Tube 15 Fr ET introducer made from a woven polyester base, with 60
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Introducer a coud tip (angled 35 degrees at its distal end). Also known
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(Smiths Medical) as the gum elastic bougie. Color: golden brown.

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Single-Use Bougie 15 Fr, PVC ET introducer with coud tip. Has a hollow lumen 70
(Smiths Medical) that discourages reuse and is provided sterile. Color: ivory.
Truflex Flexible Stylet Reusable, stainless steel stylet. Has flexible tip with upward Suitable for use with
(Truphatek International Ltd) lift action of 30-60 degrees, depending on size of ET. ETs 6.5-8.5 mm ID.
Abbreviation key for all tables is on page 28.
Clinical Applications Special Features
Exchange of SGAs for ETs 7.0 mm using an FOB. Its hollow Large lumen (4.7 mm) allows passage of FOB. Rapi-Fit
lumen allows insertion of an FOB directly through the cathe- adapters allow both jet ventilation and ventilation with
ter so that the airway can be indirectly visualized. 15-mm adapter (anesthesia circuit or Ambu bag).
Single use.
Exchange of LMAs and ETs using an FOB. Tapered end and multiple side ports. Rapi-Fit adapters
allow both jet ventilation and ventilation with 15-mm
adapter (anesthesia circuit or Ambu bag). Single use.
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The Cook airway exchange catheter is intended for uncom- EF with 2 distal side holes. The soft-tip version offers a
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plicated, atraumatic, ET exchange for both single- and more flexible tip to help minimize tracheal trauma.
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double-lumen tubes. Rapi-Fit adapters as above, but should be used primar-

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ily for jet ventilation because of length. Single use.

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Provides a tool for a more complete extubation strategy, Utilizes an atraumatic wire to maintain continuous air-
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which should be in place for every patient. way access and a soft-tipped reintubation catheter to
facilitate a successful reintubation if required and deliv-
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ery of oxygen when desired.

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Facilitate endotracheal intubation.

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Designed to shape the ET and facilitate intubation with VL.

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Facilitates endotracheal intubation and allows simple ET Can be used in pediatric population for ETs as small as
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exchange. Can also be used by placing it first in the ET, with 3.0 mm. Hollow lumen allows oxygenation/ventilation
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its tip protruding, or placing it directly into the glottis and in all sizes. Single use.
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then placing the ET over it.

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Designed to work with GlideScope AVL, GVL, Cobalt, and Reusable, durable stainless steel; easy to clean and
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Ranger video laryngoscopes to facilitate intubations in OR, sterilize in an autoclave.

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ED, and emergency settings.

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Designed to facilitate endotracheal Intubation for both Self-lubricated bougie, Tactiglide technology for tactile
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direct and video laryngoscopy. Unique curvature designed sensation, optimal curve with shape memory, balanced
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to follow natural path of the airway. Flexibility allows for rigidity with soft tissue protection, non-removable
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manipulation of distal tip for anterior airways. Customizable depth markings, packaged sterile.
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coud tip angles.

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Difficult intubation. Malleable stylet with soft coud tip and graduation
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marks for insertion depth.

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Facilitates smooth passage of ET in both routine and diffi- Easily adjustable to a variety of ET sizes. Suitable for
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cult intubations. Especially useful in combination with the use in combination with a variety of video laryngo-
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variety of video laryngoscopes that employ >42-degree scopes that employ >42-degree angle of vision.
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angles. Designed with the ideal curve to closely follow the

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blade shape and ensure successful passage of ET through

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vocal cords.
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Facilitates endotracheal intubation. Folded to only 20 cm, unfolds to 65 cm within seconds,

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ideal space solution for emergency bags.

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Proven useful in patients with an anterior larynx (grades Non-disposable and reusable. Size 5 Fr is single use. Has
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2b, 3, and 4) and those with limited mouth opening. Can memory properties. Coud tip effectively detects tra-
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be used by slightly protruding through the ET, or placing it cheal clicks to confirm correct placement. Part of a
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directly into the glottis and then placing an ET over it. range of introducers, stylets, and guides for adults and
pediatrics. Can be reused after cold-water disinfection.
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Single-use product reduces the risk for cross-contamination. Similar to Portex Venn Tracheal Tube Introducer, but hol-
Otherwise, same as Portex Venn Tracheal Tube Introducer. low lumen allows oxygenation/ventilation. Single use.
Eases clinical coordination difficulties associated with use of Adjustable stopper allows use with e-tubes of differing
video laryngoscopes by providing greater control of ET tip lengths.
direction.
table continues on next page
Table 1. Endotracheal Tube Guides (continued)
Name (Manufacturer) Description Length, cm

VBM Introducer Single-use 15 Fr introducer with coud tip and hollow for 65
(VBM Medizintechnik GmbH) oxygenation. Color: orange.
VBM Tube Exchanger Single-use 11, 14, and 19 Fr tube exchanger that is hollow to 80
(VBM Medizintechnik GmbH) allow oxygenation. Color: blue.
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Table 2. Lighted Stylets

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Name (Manufacturer) Description Size

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Aaron Surch-Lite 10-in sterile, single-use, flexible stylet. Adult.

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(Bovie Medical Industries,

Inc.)
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AincA Lighted Stylet Easily malleable, lighted stylet with adjustable ET Adult and children
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(Anesthesia Associates, Inc.) holder. Shapes and guides ET while forwardly illumi- (ETs 5 mm).
nating the passage. Completely reusable device con- Infant (ETs 3 mm).
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sisting of removable handle with xenon bulb.

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Rsch Trachlight Stylet & Consists of 3 parts: a reusable handle, a flexible Available in 3 sizes: adult, child,
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Tracheal Light Wand wand, and a stiff retractable stylet. and infant. Accommodates ETs
(Teleflex Medical) 3.0-10.0 mm ID.
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Tube-Stat Lighted Intubation Similar to AincA lighted stylet. Nasotracheal: 33 cm shaft.

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Stylet (Medtronic) Orotracheal: 25 cm shaft.

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Vital Signs Light Wand Similar to AincA lighted stylet. Adult.

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Illuminating Stylet
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Table 2A. Viewing Stylets

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AincA VideoStylet Easily malleable, video imaging stylet with built-in ET holder. Adult and children
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(Anesthesia Associates, Inc.) Shapes and guides ET while forwardly illuminating the passage (ETs 6 mm).
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and providing color image. Completely reusable device consist-

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ing of removable VideoStylet and attached rechargeable LCD

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monitor.
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air-Vu Plus Fiber-optic Stylet High-resolution, stainless steel, rigid stylet. Incorporates an Adult (ETs 5.5
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(Cookgas LLC; distributed adjustable tube stop and optional oxygen port for oxygen mm).
by Mercury Medical) insufflation.
Bonfils Retromolar High-resolution rigid fiber-optic stylet with a fixed 40-degree 3.5 and 5.0 mm OD.
Intubation Endoscope curved shape at the distal end. Available with a standard eye- ET must be 0.5
(KARL STORZ Endoscopy) piece or with a DCI to endoscopic camera system. Can be used mm larger to fit.
within the C-MAC system while using the portable monitor of the
C-MAC VL with C-CAM camera head.
Difficult intubation with oxygenation possibility. Supplied with unique removable connector to allow
oxygenation with 15-mm connector or jet. Graduation
marks for insertion depth.
Exchange of tracheal tubes. Similar to Muallem ET Tube Introducer.
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Although usable for routine blind intubations or additional illumi- Can be used alone or with other techniques.
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nation during laryngoscopy, it is especially useful when the FOB is System is completely disposable. Intended for

unavailable (eg, outside locations or ambulances), or when bron- single use. Individually packaged in boxes of 3.
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choscopy is difficult to perform (eg, obscured airway or limited

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head motion allowed).

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Same as Aaron Surch-Lite. Can be used alone or with other techniques.

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Handle-mounted xenon light source is always on

and keeps stylet tip cold. Uses 2 AA batteries.
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System is completely reusable and sterilizable.

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Although it can be used for routine intubations, it is especially use- Blind technique that can be used alone or with
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ful in situations in which the FOB is unavailable (eg, in ambulances other techniques.
or outside locations), or in which bronchoscopy is difficult to per-
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form (eg, when an airway is obscured by blood or secretions or

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when a patients head cannot be flexed or extended).

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Ideal for difficult intubations, teaching. Minimizes neck flexion and head hyperexten-
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sion in trauma cases.

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Although usable for routine intubations or video imag- Provides rapid learning curve due to similarity to standard
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ing during laryngoscopy, it is especially useful when ET advancement techniques, but with the added benefit of
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the FOB is unavailable (eg, outside locations or ambu- an attached, clear video image of all landmarks forward of
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lances), or when bronchoscopy is difficult to perform the ET tip. Allows for one-handed use with imaging or used
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(eg, obscured airway or limited head motion allowed). in conjunction with a laryngoscope, as desired for physical
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Low price allows for multiple units in all critical loca- alignment.
tions and reusable nature ensures economy of use.
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Allows for visualization during intubation through an A portable, durable rigid stylet that allows for a fiber-optic
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air-Q laryngeal mask. view during intubation through the air-Q. Light source
options include GreenLine laryngoscope handle or fiber-
optic light source (4 AA batteries).
Able to elevate a large, floppy epiglottis and navigate Fixed-shape shaft with an adjustable eyepiece that allows
through the oropharynx of patients with excessive pha- ergonomic movement during intubation, in addition to an
ryngeal soft tissue, midline obstruction, limited mouth adapter for fixation of ETs and oxygen insufflation. Porta-
opening, or fragile veneers on incisors. ble, rugged, and better maneuverability than the flexible
FOB. Used with a battery-powered or portable light source.
Table 2A. Viewing Stylets (continued)

Brambrink Intubation High-resolution semi-rigid fiber-optic stylet with a 40-degree 2.0 mm OD. ET
Endoscope curved shape at the distal end, 40 magnification, a fixed eye- must be 0.5 mm
(KARL STORZ Endoscopy) piece, a movable ET holder, and an insufflation port. larger to fit.
Clarus Video System Malleable (shapeable) rigid stylet scope with attached LCD 5 mm OD. ETs 5.5
30000V (Clarus Medical) screen and adjustable curve shape provides view from end of sty- mm.
let; USB for recharging lithium ion battery and option to connect
to notebook or monitor; red LED for transillumination. Assist with
DL/VL or used as independent device. Also malleable to be used
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through intubating supraglottic ventilatory devices.

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Levitan GLS Portable high-resolution optics from end of stylet, malleable Adult (ETs 5.5 mm
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(Clarus Medical) (shapeable) rigid stainless steel stylet that protects the illumi- ID).
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nation optic fibers. Comes in a preformed hockey-stick shape

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that can be changed, if necessary. Built-in tube stop to hold ET

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in place with integral oxygen port for oxygen insufflation during

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intubation. Assist with DL/VL like regular stylet or used as inde-

pendent device. Also malleable to be used through intubating

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supraglottic ventilatory devices. Optional adapter uses

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smartphones to transform optics to video.

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PocketScope Conveniently sized, easy to clean, and cost-effective (reusable) Adult (ETs 4.0 mm
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(Clarus Medical) flexible stylet that has a patented, deflected, non-directable tip. ID).
Optional adapter uses smartphones to transform optics to video.
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Often used to confirm placement and patency of airways.

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SensaScope Hybrid S-shaped, semi-rigid fiber-optic intubation video 6.0 mm OD. ET

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(Acutronic Medical stylet. Has a 3 cm steerable tip with video chip that can must be >0.5 mm
Systems AG) be flexed in sagittal plane 75 degrees in both directions with larger to fit.
bl
lever at proximal end of device. Has no working channel.

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ho
hi
ng
le
Shikani Optical Stylet Viewing stylet: High-resolution, stainless steel, malleable (shape- Adult (ETs 5.5 mm
or
(SOS; Clarus Medical) able) fiber-optic stylet that comes in a preformed hockey-stick ID). Pediatric (ETs
G
shape. Has an adjustable tube stop and integral oxygen port for 2.5-5.0 mm ID).
ro
in
oxygen insufflation. Use to assist with DL/VL like regular stylet or

up
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used as independent device. Also malleable to be used through

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intubating supraglottic ventilatory devices. Optional adapter uses

smartphones to transform optics to video.
w
le
ith
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tp
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Table 3. Rigid/Video Laryngoscopes

er
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m
e
is

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Airtraq Avant Disposable video laryngoscope that provides a magnified Regular adult for ET 7.0-8.5 mm
te
(Prodol Meditec SA; dis- angular view of the glottis without alignment of oral, pha- ID. Small adult for ET 6.0-7.5 mm
d.
is
tributed by Airtraq LLC) ryngeal, and tracheal axes. Includes a guiding channel to ID.
pr
both hold and direct ET toward the vocal cords. Reusable

oh
optic piece (up to 50 intubations) and anti-fog heater resists

lens clouding. Disposable blade and eyecup.
ib
ite
Airtraq SP The SP model is single-use with all the features of the 6 color-coded sizes available: reg-
(Prodol Meditec SA; dis- Avant but fully disposable. Both Airtraq models have ular adult for ET 7.0-8.5 mm ID;
d.
tributed by Airtraq LLC) an optional snap-on camera, with integrated 2.8 Touch small adult for ET 6.0-7.5 mm ID;
Screen that flips and rotates on 2 axes and can be attached pediatric for ET 4.0-5.5 mm ID;
to all Airtraq models. It records and can Wi-Fi connect to infant for ET 2.5-3.5 mm ID; non-
iPad/iPhone/PC. channeled blade; and double-
lumen endobronchial tubes.
Similar to Bonfils Retromolar Intubation Fiberscope. Available for DCI video cameras.
ET intubation, confirmation, extubation (with video); Red LED provides better illumination than the white LED,
LMA placement, positioning, and intubation with cer- and better transillumination when used like a light wand in
tain LMAs. Provides access with limited mouth open- cases when use of the scope is contraindicated because of
ing; malleable stylet provides shaping to reduce cervical blood or vomit.
movement.
A
ll
rig
Co
Originally designed as an adjunct to direct laryngos- GreenLine laryngoscope handle or a Turbo LED can be used
ht
py
copy. Many use it as a stand-alone device similar to the for light sources. Very similar to the SOS, but requires the
s
Shikani for intubation, cric/trach tubes, LMAs, and intu- user to cut the ET because it does not have a movable tube
rig ed.
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bation through LMAs or just positioning or checking stop.

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placement of the same.

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20
14
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Allows for visualization during intubation through ILMA This device has been modified with a patented deflected
cM
od
or quick confirmation of SGA, DLTs, or ET placement/ tip that allows it to be used for viewing while performing
positioning patency. May also be used for extubation. nasal intubation.
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Similar to Brambrink Intubation Endoscope. Offers an improved view of glottis, simultaneous direct
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Pu
and endoscopic views, full visual control over passage of

ET, and confirmation of final position. No need for extreme
bl
head extension or forced traction of laryngoscope. Can be

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rapidly assembled for immediate use.

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le
Similar to flexible FOB. Can be used alone or as an Has the simple form of a standard stylet, plus the advan-
or
adjunct to laryngoscopy and is especially useful for tage of a fiber-optic view and maneuverability of its tip.
G
those unable to maintain skills with a bronchoscope. Portable, rugged, and able to lift tissue. Light source
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in
options are light cable, Turbo LED or GreenLine laryngo-

up
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scope handle with adapter.

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is
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is

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Intended to facilitate intubation in both routine and dif- Optics fully isolated from patient, preventing cross-con-
te
ficult airway situations. Useful in all cases where ET tamination. Advanced airway device with built-in anti-fog
d.
is
intubation is desired. Also appropriate for emergency system, and low-temperature light source. Can be used
pr
settings, cervical spine immobilization, fiberscope guid- with standard ETs. Integral tracking channel allows ET to
oh
ance, tube exchange, and foreign body removal. be directed without a stylet or bougie. May be used in MRI
suite as MRI-compatible.
ib
ite
Same as Airtraq Avant. Same as Airtraq Avant but totally disposable and
self-contained. 3-year shelf-life.
d.
Table 3. Rigid/Video Laryngoscopes (continued)
(continued)

Berci-Kaplan DCI Video Video laryngoscope system with interchangeable laryngo- MAC 2-4, Miller 0, 1, 4,
Laryngoscope System scope blades. Platform system enables a DCI camera head Drges universal blade and
(KARL STORZ to snap onto any standard eyepiece fiberscopes (flexible or D-Blade for difficult very anterior
Endoscopy) semi-rigid). Required components include a camera control airways.
unit, xenon light source, and monitor. Telepack portable
combination video/light source/monitor unit is also avail-
able for use with this system.
A
C-MAC Video Laryngo- Instant on, battery-powered video laryngoscope with stan- MAC 2-4, Miller 0 and 1,
ll
scope (KARL STORZ dard shaped interchangeable Macintosh and Miller blades MAC 3 and 4 with channel for
rig
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Endoscopy) for obese adults through neonates as well as a difficult suction, D-Blade, and S-Blade
ht
py
airway blade (D-Blade) for very anterior airways. Blades (single-use).

s
house high-resolution CMOS distal chip and LED tech-

rig ed.
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nology. Real-time viewing on 7-inch LCD monitor. Drges

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se
D-Blade has angle of view that is approximately 80 degrees

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acute curvature design.

20
C-MAC Pocket Monitor Highly portable rescue device, 2.4-in monitor fits directly Same as C-MAC.
14
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(KARL STORZ on all C-MAC blades. LCD 4.3 ratio high-resolution screen
Endoscopy) works in direct sunlight; rechargeable battery lasts one
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pr
hour; ergonomic screen can be moved in several directions

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od
and folded away for transportation; fully immersible.

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CoPilot VL Next-generation portable VL with an acutely angled blade Adult sizes 3 and 4.
tio
on
(Magaw Medical) and C-shaped channel for a bougie. Rechargeable lithium

polymer internal battery provides over 2 hours of continu-
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ous use. Built-in anti-fog mechanism.

bl
GlideScope Titanium GlideScope Titanium systems are available in reusable or 4 blade designs available in reus-
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Video Laryngoscope single-use options and feature streamlined, low-profile able or disposable format: LoPro 3
ho
hi
(Verathon) blade designs and durable, lightweight titanium construc- & 4 angled blades, and Mac-style
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tion. Built-in anti-fog mechanism. 3 & 4 blades. Compatible with full

or
line of GlideScope AVL pediatric

G
ro
blades.
in
up
GlideScope AVL Portable advanced VL features a digital color monitor and 6 disposable blades, sizes 0-4.
pa
(Advanced Video Laryn- digital camera for DVD clarity. Also includes integrated Reusable blades in 4 sizes: GVL
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goscope; Verathon) real-time recording and onboard video tutorial. Anti-fog 2-5.
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feature to resist lens fogging. Reusable and single-use

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options available.
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GlideScope Ranger and Portable video laryngoscope designed for EMS and military Reusable Ranger offers 2 blade
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Ranger Single Use Video paramedics. Compact and rugged. Operational in seconds. sizes, 3 and 4. Ranger Single Use
is
Laryngoscopes is offered with 6 disposable Stats

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(Verathon) sizes 0-4.

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King Vision Durable, fully portable digital video laryngoscope with a One size, 2 versions, correlat-
d.
Video Laryngoscope high-quality reusable display and disposable blades. Dis- ing to size 3 laryngoscope. Chan-
is
(Ambu Inc.) play aligned with blade, ergonomic handle integrated into neled blade allows use of 6.0 to
pr
blade, the disposable blades incorporate the camera and 8.0 mm ET and minimum mouth
oh
light source, anti-fog coating on distal lens. Channel is soft, opening of 18 mm. Standard blade
ib
allowing for easy ET detachment. requires minimum mouth opening

ite
of 13 mm.
d.
McGrath MAC Portable VL designed for everyday use in the OR, ICU, and Blade sizes 2, 3, and 4 and X3.
(Aircraft Medical Ltd; ED. Uses disposable Macintosh shaped blades as well as
distributed by Covidien) acutely curved X3 Blade. Durable (drop tested up to 2 m).
Screen displays minute-by-minute battery life countdown.
Useful for anterior airways, obese patients, and patients The wide-angle camera allows improved visualization and
with limited mouth opening or neck extension. Vari- video documentation of laryngoscopy and intubation.
ety of blade sizes and designs accommodates patients Extreme positioning of the head is unnecessary. Blades
ranging from morbidly obese to neonate (500 g). Addi- provide 80-degree field of view.
tionally useful for teaching purposes, verification of ET
position, aiding application of external laryngeal manip-
ulation, or passage of an intubating introducer. May also
be used for nasal intubation and ET exchange.
A
Same as DCI. Highly portable system for use in all Unique platform design is compatible with multiple intuba-
ll
hospital settings. tion devices, including video laryngoscopes, the F.I.V.E. dis-
rig
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tal chip flexible video scopes, and standard eyepiece scopes

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(fiber-optic and semi-rigid) via C-CAM camera head. Built-in

s
still and video image capture on memory card, with real-time

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playback on monitor. Angled distal lens provides 80-degree

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field of view. Inherent anti-fog design. Unit can be pole-

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mounted or inserted into waterproof field bag. No special

ETs or stylets needed. Can be used while battery is charging.

20
Ideal for ICU, crash carts, ED and all prehospital envi- Lightweight, handheld, and battery-operated device well
14
Re
ronments including EMS, ambulatory services, air trans- suited for areas outside the OR. Waterproof.
port, and military. Has familiar blade design and
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80-degree field of view.

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Same as DCI. Patent-pending Bougie Port is designed to enhance glottic

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on
entry. A 14 Fr suction catheter, FOB, reusable rigid stylets,

or regular malleable stylets may also be used via this port.
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Pu
A built-in heating mechanism helps prevent fogging.

bl
More VL options for routine and difficult airways Reusable blades and video cable, as well as the single-
is
including new Mac-style bladesprovide clinicians with use Smart Cable, can be completely immersed in the rec-
ho
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a choice of airway tools for a wide range of patients, ommended cleaning solution (IPX8 compliant). Includes
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clinical settings, and teaching purposes. anti-fog capability, plus real-time recording, display, and
or
playback features on 6.4-in digital, color GlideScope Video

G
ro
Monitor.
in
up
DVD-quality airway view enables intubation in a wide Real-time recording, onboard video tutorial, anti-fog fea-
pa
range of adult and pediatric patients, including pre- ture to resist lens fogging, advanced resolution output to
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term/small child and morbidly obese, bloody or anterior an external monitor, intuitive user controls and status icons,
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airways, and patients with limited neck mobility. Opti- lightweight and easily transportable, impact-resistant, dura-
ith
ss
mized for demanding applications in the OR, ED, ICU, ble polycarbonate-coated video screen. Disposable blades
and NICU. Can be used for teaching. allow quick turnaround and help limit the possibility of
ot
cross-contamination.
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tp
Ideal for EMS (ground and air), military, ED, ICU, and Ranger models are compact, rugged, portable, and built to
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crash cart settings. Offers same benefits as AVL, GVL. military and EMS specifications. Powered by rechargeable
is
lithium polymer battery; 1.5 lb. Awarded US Army

m
Airworthiness and US Air Force Safe-to-Fly certifications.

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Reusable and disposable.

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Facilitates both routine and difficult intubations. Can be used alone or with other techniques. Powered by 3
d.
AAA batteries. OLED screen allows wide-angle viewing in

is
various lighting conditions. Video out available for connec-

pr
tion to external display or video capture device.

oh
ib
ite
d.
Its dual capability combines the benefits of a video-sup- Does not require additional training. Supports direct and
ported anterior view as well as a direct visualization to indirect visualization due to video support. Blade is very
support a wide range of airways from routine to more slimline for improved agility. Blade shape requires less tube
extreme cases. curvature than other video laryngoscopes for easier inser-
tion and a stylet is not always required. Highly portable and
lightweight. Does not require an electrical outlet and thus
is ideal for settings outside the OR. Uses disposable blades
for quick turnaround between uses and for limiting cross-
contamination. The monitor is located on the handle to
remain in a more natural line. Waterproof.
Table 3. Rigid/Video Laryngoscopes (continued)

McGrath Series 5 Portable VL with adjustable-length single-use disposable Adjusts to fit many adult and
Video Laryngoscope blade that can be disarticulated from the handle to fur- pediatric sizes.
(Aircraft Medical Ltd; ther assist with difficult airways. The flat screen monitor is
distributed by LMA located on the handle to remain in a more natural line of
North America, a Teleflex sight with the patient.
Company)
The McGrath Series 5 HLDi is the new High Level Disinfec-
tion Immersible system that is entirely waterproof.
A
ll
Truview PCD-R Optical Fully portable, lightweight and compact system with inter- Blade sizes 0, 1, 2, 3,
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Laryngoscope blades with changeable, low-profile, stainless steel 47-degree angled and 4.
recording capabilities narrow tip laryngoscope blades with built-in oxygen deliv-
ht
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(Truphatek International ery system. Can be used independently or magnetically

s
rig ed.
Ltd) linked to the camera and 5-in LCD color monitor with pic-
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ture and video recording capabilities.

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Venner AP Advance Fully portable VL with 3.5-in monitor that attaches to a MAC 3 and 4, and
Video Laryngoscope reusable handle. Self-contained LED light source. Built-in Difficult Airway Blade.
20
(Venner Capital S.A.) anti-fogging mechanism.

14
Re
VividTrac Video intubation device that works on many computer sys- ET 6.0-8.5 mm.
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pr
(Mercury Medical/ tems equipped with USB II port as a standard USB cam-
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FujiFilm/SonoSite) era, using available video camera applications on Windows,

Mac, and Linux systems. Alternatively, automated video
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display software (VividVision) can be downloaded.

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Table 4. Indirect Rigid Fiber-Optic Laryngoscopes

or
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in

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Drges Emergency Developed in Europe as a universal blade that combines fea- One size only for
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Laryngoscope Blade tures of both the MAC and Miller laryngoscope blades. patients >10 kg to adult.
w
(KARL STORZ Endoscopy)

le
ith
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Modified MAC Blades

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AincA Flex-Tip Fiber-Optic Flexible tip or levering fiber-optic MAC laryngoscope blades Adult sizes 3 and 4.
he
tp
Laryngoscope Blade are designed with a hinged tip controlled by a lever at the Pediatric size 2.
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(Anesthesia Associates, Inc.) proximal end. Designed to fit standard handles.

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Flipper Adult sizes only.

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is
(Teleflex Medical)
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Heine Flex Tip Fiber-Optic

Laryngoscope Blade
d.
is
(Heine USA, Ltd.)

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oh
AincA Macintosh Viewing An optically polished viewing prism for attachment to most Sizes 2, 3, and 4 for use
Prisms Macintosh laryngoscope blades (conventional OR fiber- on Macintosh laryngo-
ib
(Anesthesia Associates, Inc.) optic). Effectively repositions the practitioners viewpoint to scope blades of sizes 2,
ite
the forward portion of the MAC curve via a 30-degree refrac- 3, and 4.
d.
tion without inverting the image. Clips to the vertical flange

of the MAC to look around the curve of the blade.
Rsch Truview EVO Indirect rigid laryngoscope with specially designed 42-degree Adult, small adult, and
(Truphatek International Ltd; blade curvature; fits onto all standard endoscopic camera infant sizes.
distributed by heads. Provides clear, unmagnified view of the glottis. Oxygen
Teleflex Medical) channel for demisting, clearing secretions, and insufflation.
Useful in patients with limited mouth opening or head Highly portable and lightweight. Uses disposable blades
and neck movement, anterior airways; obese patients; for quick turnaround between uses and for limiting cross-
patients in whom an increased hemodynamic response contamination. An adjustable blade allows use of different
is a concern; and for teaching. blade lengths on the spot. Low-profile blade and disarticu-
lating handle can accommodate patients with very limited
mouth opening and severely limited movement of the head
and neck. The monitor is located on the handle to remain in
a more natural line of sight with the patient.
A
ll
Difficult intubation cases where mouth opening and Blades can be linked to STORZ HD or other endoscopic
rig
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neck extension are limited and stable oxygen saturation systems.

levels are critical.
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py
s
rig ed.
re
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se
rv
Similar to C-MAC VL. Can be used as traditional laryngoscope and converted to

video laryngoscope by attachment of monitor.
20
14
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Intended to facilitate intubation in both routine and VividTrac is inserted more like an oral airway device (or
M
pr
difficult airway situations. LMA) than a laryngoscope blade. The ET can be preloaded
cM
od
or inserted once visualization is achieved in the VividTrac

tube channel.
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or
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in

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Blade is inserted into the oropharynx to the appropriate Has 10-kg and 20-kg markings on the blade.
un ou
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depth, which correlates with the patients size.

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le
ith
ss
ot
Controlled manipulation of large or floppy epiglottis. A lever controls the tip angle through 70 degrees
he
tp
Also useful in patients with a recessed mandible and during intubation to lift the epiglottis, if necessary, to
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decreased mouth opening. improve laryngeal visualization.

is
m
Useful in patients with a recessed mandible and

e
is
decreased mouth opening.

no
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te
d.
is
pr
oh
Allows viewing of the vocal cords even in a patient with A built-in clip on each prism allows attachment to any
an anterior airway position. Also useful during nasal Macintosh-type laryngoscope blade that has a standard
ib
intubation (with impaired view) and for postoperative thickness vertical flange. Usable on both conventional and
ite
examination of the larynx. fiber-optic type MAC blades. Reusable and sterilizable.
d.
Useful for difficult adult and infant airways, includ- Rugged, portable, easy to maintain. Depth lines on the
ing patients with an anterior airway and limited neck blade to guide insertion. Can be used with all fiber-optic
extension. laryngoscope handles. Designed to provide indirect laryn-
goscopy with continuous oxygen insufflation. Infant size
features an LED light and rechargeable battery.
Table 5. Selected Supraglottic Ventilatory Devices
AES The Guardian CPV All-silicone laryngeal mask with a vented gastric tube Adult sizes 3, 4, 5.
(AES, Inc.) and CPV that constantly monitors cuff pressure.
AES Ultra All-silicone laryngeal mask with standard cuff valve. Adult sizes 3, 4, 5, 6.
(AES, Inc.)
AES Ultra Clear Silicone cuff and PVC tube, laryngeal mask with stan- Adult sizes 3, 4, 5, 6.
A
(AES, Inc.) dard cuff valve.

ll
rig
AES Ultra Clear CPV Silicone cuff and PVC tube, laryngeal mask with Pediatric to adult sizes 1, 1, 2,
Co
(AES, Inc.) cuff pilot valve (CPV) that constantly monitors cuff 2, 3, 4, 5, 6.
ht
py
pressures.
s
rig ed.
re
AES Ultra CPV All-silicone laryngeal mask with CPV that constantly Pediatric to adult sizes 1, 1, 2,
ht
se
(AES, Inc.) monitors cuff pressures. 2, 3, 4, 5, 6.

rv

20
AES Ultra EX All-silicone, multiple-use laryngeal mask (40 uses). Pediatric to adult sizes 1, 1, 2,
14
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(AES, Inc.; distributed by 2, 3, 4, 5, 6.

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pr
Anesthesia Associates, Inc.)

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od
AES Ultra Flex CPV Wire-reinforced, silicone cuff and tube with CPV that Pediatric to adult sizes 1, 1, 2,
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ah in w
(AES, Inc.) constantly monitors pressure changes in the cuff. 2, 3, 4, 5, 6.

tio
on
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Pu
AES Ultra Flex EX All-silicone, wire-reinforced, multiple-use laryngeal Pediatric to adult sizes 1, 1, 2,
bl
(AES, Inc.; distributed by mask (40 uses). 2, 3, 4, 5, 6.

is
Anesthesia Associates, Inc.)

ho
hi
air-Q Blocker Combines the features of air-Q Disposable Laryn- Sizes (2.5, 3.5, and 4.5) that
ng
le
Disposable Laryngeal Mask geal Mask, with an additional soft flexible guide tube can accommodate standard ETs
or
(Cookgas LLC; located to the right of the breathing tube. This chan- up to 8.5 mm. Also available in
ro
in
distributed by nel provides access to the esophagus with a nasogas- kits with syringe and lubricant
up
Mercury Medical) tric tube or Blocker tube that allows clinicians to vent, packet.
pa
suction and further block the esophagus.

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air-Q Disposable Laryngeal Same features as air-Q Reusable Laryngeal Mask, Sizes (1.0, 1.5, 2.0, 2.5, 3.5, and
tp
Mask (Cookgas LLC; except disposable. 4.5) that can accommodate

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distributed by standard ETs up to 8.5 mm.

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Mercury Medical)
e
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air-Q Reusable Laryngeal Hypercurved intubating laryngeal airway that resists Sizes (2.0, 2.5, 3.5, and 4.5)
on
Mask (Cookgas LLC; kinking, and removable airway connector. Anterior that can accommodate stan-
te
distributed by portion of mask is recessed; a larger mask cavity dard ETs 5.5-8.5 mm.
d.
is
Mercury Medical) allows intubation using standard ETs. Air-Q removal

pr
after intubation is accomplished by using air-Q

oh
reusable removal stylet.

ib
air-Q SP Combines the features of the air-Q disposable and Sizes (1.0, 1.5, 2.0, 2.5, 3.5, 4.5)
ite
(Cookgas LLC; reusable laryngeal masks with the added advantage that can accommodate stan-
d.
distributed by of a self-pressurizing mask. No inflation line or pilot dard ET tubes up to 8.5 mm.
Mercury Medical) balloon is needed.
Ambu AuraFlex Disposable wire-reinforced flexible LMA. Adult and pediatric sizes 2-6.
(Ambu Inc.)
Similar to LMA Supreme, but with built-in CPV to min- The CPV detects changes caused by temperature, nitrous
imize postoperative sore throat. Color indicator bands oxide levels, and movement within the airway, enabling
provide instant feedback regarding pressure changes. clinician to maintain a recommended cuff pressure of
60 cm H2O. Single use.
Standard all-silicone SGA. All silicone. Single use.
Combines all-silicone cuff with PVC tube for cost All-silicone cuff with PVC tube. Single use.
A
savings.
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Similar to AES Ultra CPV. Similar to AES Ultra CPV.

Co
ht
py
s
rig ed.
re
Similar to LMA Classic, but with built-in CPV to minimize The CPV detects changes caused by temperature, nitrous
ht
se
postoperative sore throat. Color indicator bands provide oxide levels, and movement within the airway, enabling
rv
instant feedback regarding pressure changes. clinician to maintain a recommended cuff pressure of

60 cm H2O. Single use.

20
Reusable, standard SGA. 40 uses.

14
Re
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pr
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od
Wire-reinforced SGA that accommodates reposition- Single use. The cuff pressure indicator detects changes
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ing of the head and neck. Color indicator bands provide caused by temperature, nitrous oxide levels, and movement
instant feedback regarding pressure changes. within the airway. The CPV enables the clinician to maintain
tio
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a recommended cuff pressure of 60 cm H2O.

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Reusable, wire-reinforced SGA, designed to accommo- 40 uses.

bl
date repositioning of the head and neck during surgery.

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Enhanced version of the standard air-Q. It is indicated The soft guide tube allows access to the posterior pharynx
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as a primary airway device when an oral endotracheal and esophagus by supporting and directing medical instru-
or
tube is not necessary or as an aid to intubation in diffi- ments beneath the air-Q mask and into the pharynx and
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in
cult situations. esophagus. Medical instruments especially suited are suc-

up
tion catheters, nasogastric tubes up to size 18.0 Fr, and the

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newly designed air-Q Blocker tubes. The Blocker tubes are

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designed to suction the pharynx, or suction, vent and block

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the upper esophagus during use of the air-Q Blocker airway.

ith
ss
Removable color-coded connector allows intubation with

standard ETs up to 8.5 mm.
ot
he
Same as air-Q Reusable Laryngeal Mask. Removable color-coded connector allows intubation with
tp
standard ETs up to 8.5 mm.

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m
e
is
no
si
Similar to both LMA Classic and LMA Fastrach. Allows Designed to minimize folding of the cuff tip on insertion.
on
easy access for flexible fiber-optic devices. Use as rou- Same use and benefits as LMA Classic and LMA Fastrach.
te
tine masked laryngeal airway. Removable connector Integrated bite block reinforces the tube while diminishing
d.
is
allows intubation with standard ETs up to 8.5 mm. the need for a separate bite block. Color-coded removable
pr
connectors are tethered to the airway tube, avoiding epi-

oh
sodes of misplaced connectors.

ib
Same as regular air-Q but eliminates the need for mask PPV self-pressurizes the mask cuff. On exhalation, mask cuff
ite
inflation. decompresses to the level of PEEP. Removable connector

d.
allows intubation with standard ETs.
Designed for use in ENT, ophthalmic, dental, and torso Integrated pilot tube, and high flexibility enables position-
surgeries. ing away from the surgical field, without a loss of seal. Sin-
gle use. EasyGlide texture and extra-soft cuff ease insertion
and removal. Convenient depth marks for monitoring cor-
rect position of the mask.
Table 5. Selected Supraglottic Ventilatory Devices (continued)
(continued)

Ambu Aura-i Laryngeal mask with built-in curve and bite blocker Adult and pediatric sizes 1-6.
(Ambu Inc.) designed as a conduit for optical endotracheal
intubation.
Ambu AuraOnce A laryngeal mask with a special built-in curve that Adult and pediatric sizes 1-6.
(Ambu Inc.) replicates natural human anatomy. It is molded in
1 piece with an integrated inflation line and no epi-
glottic bars on the anterior surface of the cuff.
A
ll
rig
Co
Ambu AuraStraight Similar to the LMA Unique but without epiglottic bars Adult and pediatric sizes 1-6.
ht
(Ambu Inc.) on the anterior surface of the cuff.

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rig ed.
re
Ambu Aura40 (Ambu Inc.) Same design as the Ambu AuraOnce, but reusable. Adult and pediatric sizes 1-6.
ht
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Ambu Aura40 Straight Similar to the LMA Classic. No epiglottic bars on the Adult and pediatric sizes 1-6.
rv
(Ambu Inc.) anterior surface of the cuff.

20
CobraPLA Large ID laryngeal tube, which is soft and flexible Adult and pediatric sizes -6.
14
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(Pulmodyne) with a tapered, striated tip. Now has an improved dis-

M
pr
tal curve, softer tube, and softer head. It has a high-

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volume, low-pressure oropharyngeal cuff.

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uc
CobraPLUS Similar to the CobraPLA. Includes temperature moni- Adult and pediatric sizes -6.
ah in w
(Pulmodyne) tor and distal gas sampling in all sizes.

tio
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is
ho
hi
Esophageal Tracheal A disposable DLT that combines the features of a Two adult sizes.
ng
le
Combitube conventional ET with those of an esophageal obtura- 41 Fr: height >5 ft.
(Covidien) tor airway. Has a large proximal latex oropharyngeal 37 Fr: height 4-6 ft.
or
balloon and a distal esophageal low-pressure cuff

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in
with 8 ventilatory holes in between.

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i-gel SGA with a noninflating cuff, designed to mirror the Adult sizes 3-5 and pediatric
ith
ss
(Intersurgical Inc.) anatomy over the laryngeal inlet, with an integral bite sizes 1-2.5.
block, buccal cavity stabilizer and a gastric channel. Adult sizes accommodate ET
ot
It also incorporates a wide-bore airway channel that sizes 6.0-8.0 mm.

he
tp
can be used as a conduit for intubation with fiber-

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optic guidance (sizes 3, 4, and 5).

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i-gel O2 Resus Pack SGA with a supplementary oxygen port, an integral Adult sizes 3-5.
on
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(Intersurgical Inc.) color-coded hook ring for securing of the airway sup- Adult sizes accommodate ET
d.
port strap and identification of size and is designed sizes 6.08.0 mm.
is
to facilitate ventilation. It also includes a non-inflating

pr
cuff to mirror the anatomy, with an integral bite block,

oh
buccal cavity stabilizer and a gastric channel. The

ib
pack contains an i-gel O2 second-generation SGA, a

ite
sachet of lubricant and an airway support strap.

d.
KING LT Multiuse, latex-free, single-lumen silicone tube with Sizes 0-5.

(Ambu Inc.) oropharyngeal and esophageal low-pressure cuffs, 2
ventilation outlets, insertion marks, and a blind dis-
tal tip (almost like a single-lumen, shortened Combi-
tube). Color-coded connectors for each size.
Combines everyday routine use of SGA with direct intu- Anatomically correct curve designed as Ambu AuraOnce
bation capability in case of difficult airway situations. and Ambu Aura40 but specially designed as a conduit for
intubation. Compatible with standard ETs.
Allows easy access for flexible fiber-optic devices. For Anatomically correct curve facilitates placement. One-piece
use in both anesthesia and emergency medicine. mold. EasyGlide texture for ease of insertion. Convenient
depth marks for monitoring correct position of the mask.
MRI safe. Extra-soft cuff. If intubation becomes necessary
or desired, recommend intubation over Aintree AEC. -Sin-
A
gle use.
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For use in both anesthesia and emergency medicine. Single-use, one-piece mold. EasyGlide texture for ease of
ht
insertion. Convenient depth marks for monitoring correct

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position of the mask. MRI safe. Extra-soft cuff.

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rig ed.
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Same as LMA Classic. Same as LMA Classic, but reusable.

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Same as LMA Classic. Reusable. Available only in the United States.

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20
Same as LMA Classic. Disposable. If intubation becomes necessary or desired, will

14
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accommodate ET up to 8.0 mm. Single use.

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od
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Same as LMA Classic. An added benefit is the ability to Similar to CobraPLA, but CobraPLUS allows monitoring of
ah in w
measure core temperature. In addition, distal CO2 can be the patients core temperature. In neonatal and infant
tio
on
monitored in pediatric patients. patients, CobraPLUS has the ability to increase the accu-
n
racy of end-tidal CO2 and volatile gas analysis. If intubation

Pu
becomes necessary or desired, will accommodate ET up to

bl
8.0 mm. Single use.

is
ho
hi
Same as LMA Classic but not contraindicated in non- Ventilation is possible with either tracheal or esophageal
ng
le
fasting patients. Appropriate for prehospital, intraopera- intubation. Distal cuff seals off the esophagus to prevent
tive, and emergency use. Especially useful for patients in aspiration of gastric contents. Allows passage of an oro-
or
whom direct visualization of the vocal cords is not possi- gastric tube when placed in the esophagus. Single use.
ro
in
ble, patients with massive airway bleeding or regurgita-

up
pa
tion, limited access to the airway, and patients in whom

neck movement is contraindicated.
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w
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Indicated for use in routine and emergency anesthe- The non-inflating cuff allows easy and rapid insertion, pro-
ith
ss
sia and resuscitation in adult patients. i-gel is not indi- vides high seal pressures and minimizes the risk for tissue
cated for use in resuscitation in children. Can be used as compression. Gastric channel provides an early warning of
ot
a conduit for intubation with fiber-optic guidance (sizes regurgitation. Buccal cavity stabilizer reduces the risk for
he
tp
3, 4, and 5). Gastric channel provides an early warning rotation or displacement and the integral bite block pre-
rw
of regurgitation, allows for the passing of a nasogastric vents occlusion of the airway channel. The wide-bore air-
er
tube to empty the stomach contents and can facilitate way channel also allows for use as a conduit for intubation
is
m
venting of gas from the stomach (except size 1). with fiber-optic guidance (sizes 3, 4, and 5).
is
no
si
Indicated for use in routine and emergency anesthe- The non-inflating cuff allows easy and rapid insertion, pro-
on
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sia and resuscitation in adult patients. Can be used as a vides high seal pressure and minimizes the risk for tissue
d.
compression. The supplementary oxygen port allows for

is
conduit for intubation with fiber-optic guidance. i-gel O2

can also be used for providing supplementary oxygen the administration of passive oxygenation as a component
pr
during postoperative care or patient transfer. of cardio-cerebral resuscitation. Gastric channel provides
oh
Gastric channel provides an early warning of regurgi- an early warning of regurgitation. Buccal cavity stabilizer
ib
tation, allows for the passing of a nasogastric tube to reduces the risk for rotation or displacement and the inte-
ite
empty the stomach contents and can facilitate venting gral bite block prevents occlusion of the airway channel.
of gas from the stomach. The wide-bore airway channel also allows for use as a con-
d.
duit for intubation with fiber-optic guidance.

Same as LMA Classic, but with ventilatory seal charac- Easily inserted, possible aspiration protection, and allows
teristics like those of LMA ProSeal. both PPV and spontaneous breathing. Reusable
(up to 50 times).
(continued)

KING LT-D Same design as the KING LT, except disposable. Adult sizes 3-5 and pediatric
(Ambu Inc.) sizes 2, 2.5.
KING LTS Double-lumen laryngeal tube that incorporates a sec- Adult sizes 3-5 and pediatric
(Ambu Inc.) ond (esophageal) lumen posterior to the ventilation sizes 0, 1, 2, 2.5.
lumen.
KING LTS-D Same as KING LTS, except disposable. Adult sizes 3-5.
(Ambu Inc.)
A
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LMA Classic Supraglottic ventilatory device that consists of an Adult and pediatric sizes 1-6,
rig
(LMA North America, oval inflatable silicone cuff in continuity with a wide- accommodating ET 3.5-7.0 mm.
Co
a Teleflex Company) bore tube that can be connected to an Ambu bag

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py
or anesthesia circuit. Designed to fit the pharynx of

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rig ed.
patients of various weights.

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20
LMA Classic Excel The Classic Excel has the benefits of LMA Classic and Adult and pediatric sizes 3-5.
14
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(LMA North America, an improved design to facilitate intubation.

a Teleflex Company)
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cM
od
LMA Fastrach Consists of a mask attached to a rigid stainless steel Adult sizes 3-5 that can
(LMA North America, tube curved to align the barrel aperture to the glot- accommodate special
uc
ah in w
a Teleflex Company) tic vestibule. The set includes an LMA with a stainless ETs 6.0-8.0 mm.
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steel shaft covered with silicone (reusable version)

n
and a single movable epiglottic elevating bar, ET sta-

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bilizer, and silicone wire-reinforced ET. The single-use

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Fastrach is made of PVC and includes a disposable

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wire-reinforced ET.
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LMA Flexible Original LMA cuff design attached to smaller diame- Adult and pediatric sizes 2-6.
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(LMA North America, ter, flexible armored tube that allows repositioning of
or
a Teleflex Company) the tube without cuff displacement. New single-use

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in
version is easier to insert.

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LMA ProSeal Designed with a modified cuff and dual tubes to sep- Adult and pediatric sizes 1-5.
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(LMA North America, arate the respiratory and alimentary tracts. Has a
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a Teleflex Company) built-in bite block.

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ith
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LMA Supreme Has a gastric drain tube designed to suction the Adult and pediatric sizes 1-5.
(LMA North America, stomach, channel gases and fluids away from the air-
ot
a Teleflex Company) way, and confirm placement of the tip of mask at

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tp
upper esophageal sphincter. The airway tube has a

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gentle curve and oblong shape to allow easier inser-

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tion and more stable placement.

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LMA Unique Original, disposable LMA design. Sterile, latex-free, Adult and pediatric sizes 1-5.
no
si
(LMA North America, available with or without syringe and lubricant. Soft
on
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a Teleflex Company) cuff and airway tube allow for conformity to patients
d.
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natural anatomy.
pr
Rsch Easy Tube Disposable LT that combines the features of a con- Small 28 Fr; large 41 Fr.
oh
(Teleflex Medical) ventional ET with those of an esophageal obturator

airway similar in design to the Combitube.
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ite
d.
Soft-Seal Laryngeal Mask Similar in shape to the LMA Unique, but differs in its Adult and pediatric sizes 1-5.
(Smiths Medical) 1-piece design, in which the cuff is softer and there
is no step between the tube and the cuff, an inte-
grated inflation line, no epiglottic bars on the anterior
surface of the cuff, and a wider ventilation orifice.
Same as KING LT. Also available in a kit. Single use.
Same as KING LT, except that it has a second lumen for Allows easy passage of a gastric tube to evacuate stomach
gastric access, similar to LMA ProSeal. contents. Distal tip reduced in size to facilitate insertion.
Reusable.
Same as KING LTS. Allows passage of 18 Fr gastric tube. Also available in a kit.
A
ll
Although originally developed for airway management Reusable.

rig
of routine cases with spontaneous ventilation, it is now

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listed in the ASA Difficult Airway Algorithm as an airway

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ventilatory device or a conduit for endotracheal intuba-

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rig ed.
tion. Can be used in both pediatric and adult patients in

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whom ventilation with a face mask or intubation is diffi-

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cult or impossible. Can also be used as a bridge to extu-

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bation and with pressure support or PPV.

20
Same as LMA Classic. Removable connector and epiglottic elevating bar to facil-
14
Re
itate intubation. Works with ET up to 7.5 mm. Reusable up

to 60 times.
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od
Useful for ventilation and intubation. Designed for blind Both reusable and disposable versions now available. Can
orotracheal intubation but can be used with lighted sty- be utilized as a blind or visually guided technique. Benefits
uc
ah in w
lets, FOB, or Flexible Airway Scope Tool. FOB recom- include ability to intubate with larger ET and remove the
tio
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mended when using PVC ET. device easily over the ET.
n
Pu
bl
is
ho
hi
Particularly useful in ENT/head and neck procedures. Both reusable and disposable versions now available. Air-
ng
le
way tube resists kinking and cuff dislodgment, and thus

or
may be positioned away from the surgical field without loss

ro
in
of seal.
up
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Same as LMA Classic except drain tube also allows for Second cuff allows tighter seal for PPV. Reusable.
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evacuation of stomach contents.

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w
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ith
ss
Same as LMA ProSeal. A single-use LMA with a redesigned mask that achieves a
50% higher seal pressure than the Classic or Unique. Similar
ot
to all LMAs, the Supreme is designed to protect the airway

he
tp
from epiglottic obstructionin this model with molded fins

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er
in the bowl of the mask.

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m
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is
Same as LMA Classic. Included in AHA 2000 Guidelines Single use.

no
si
for CPR and Emergency Medicine Cardiovascular Care.

on
te
d.
is
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Same as Esophageal Tracheal Combitube. Similar to Combitube with following differences: single
oh
lumen at distal tip, soft latex-free cuff, open proximal sec-

ond lumen allows use of fiber-optic device or passage of a
ib
suction catheter or tube exchanger. Single use.

ite
d.
Same as LMA Classic. Allows easy access for flexible If intubation becomes necessary or desired, will accommo-
fiber-optic devices. date ET up to 7.5 mm. Single use.

Solus Satin Laryngeal Mask A range of single-use, latex-free laryngeal mask air- Adult sizes 3-5.
Airway ways with a softer airway tube to provide more
(Intersurgical Inc.) flexibility.
A
Solus Standard Laryngeal

ll
A range of single-use, latex-free laryngeal mask Adult sizes 3-5 and pediatric
rig
Mask Airway airways. sizes 1-2.5.

Co
(Intersurgical Inc.)
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20
14
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Table 6. Devices for Special Airway Techniques

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Awake Intubation
n
Pu
DeVilbiss Model 15 Metal atomizer; includes glass receptacle (for liquid), Length: 10.5 in.
bl
Medical Atomizer pair of metal outlet tubes extending from metal atom-
is
(DeVilbiss Healthcare) izing nozzle, and adjustable tip for directing spray to
ho
hi
inaccessible areas of the throat. Can be used with or

ng
le
without RhinoGuard tip cover.

or
Enk Fiberoptic Atomizer Set Device for atomizing small doses of local anesthetics.
ro
in
(Cook Medical) Atomizer set consists of a pressure-resistant oxygen

up
pa
tube and a connecting tube attached by a 3-way side-

arm fitting with a small flow control opening. The set
un ou
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also contains an introducer catheter and 2 syringes

w
le
(1-mL).
ith
ss
EZ-Spray Disposable atomizer device which comprises a plastic

ot
(Alcove Medical) receptacle, atomizer nozzle, and gas inlet tube. Tubing
he
tp
is connected from an air or oxygen flowmeter nipple to

rw
the gas inlet tube on the device.

er
is
m
LMA MADdy Pediatric Pediatric Mucosal Atomization Device delivers Typical particle size:
e
is
Mucosal Atomization Device intranasal/intraoral medications in a fine mist that 30 microns.

no
si
(LMA North America, enhances absorption and improves bioavailability for System dead space: 0.12 mL
on
te
a Teleflex Company) fast and effective drug delivery. (with syringe), 0.07 mL (device
d.
only). Tip diameter: 0.19 in

is
(4.8 mm). Applicator length:

pr
4.5 in (11.4 cm).

oh
LMA MADgicWand Mucosal Combines atomized topical anesthesia and oxygen Typical particle size:
ib
Atomization Device delivery in a fiber-optic oral airway. Packaged in a box 30-100 microns.
ite
(LMA North America, of 20. System dead space: 0.25 mL.

d.
a Teleflex Company)
Indicated for use in anesthesia and emergency medicine. Classic cuff shape for optimum anatomic conformance with
Single-use laryngeal mask airway, provided sterile and a firm, smooth-surfaced back plate to aid ease of inser-
ready for use. tion. The Satin Solus has a softer airway tube to provide
more flexibility. Clear, pliable airway tube allows for early
detection of rising fluids. Cuff size indicators are accurately
aligned and prominently displayed at top of tube and on
pilot balloon. Essential user information on exposed section
of airway tube for quick visual reference.
A
ll
Indicated for use in anesthesia and emergency medicine. Classic cuff shape for optimum anatomic conformance with
rig
Single-use laryngeal mask airway, provided sterile and a firm, smooth-surfaced back plate to aid ease of insertion.
Co
ready for use. Clear, pliable airway tube allows for early detection of rising
ht
py
fluids. Cuff size indicators are accurately aligned and prom-

s
rig ed.
inently displayed at top of tube and on pilot balloon. Essen-

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tial user information on exposed section of airway tube for

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quick visual reference.

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20
14
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tio
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n
Pu
Intended for the application of topical anesthetics to Includes glass receptacle for dispensing the liquid; adjust-
bl
the nose, oropharynx, and upper airway of patients, at able swivel top and vented nasal guard attached to a hand
is
the direction/discretion of a clinician. bulb. Can be used with all types of oil or water solutions
ho
hi
that are compatible with rhodium metal plating. The all-

ng
le
metal top can be autoclaved. Reusable.

or
To apply topical anesthetics to laryngotracheal area Device is an accessory to a bronchoscope. Delivery form
ro
in
through the working channel of a bronchoscope using is a fine spray mist using oxygen flow through the working
up
pa
oxygen flow. Designed and intended to be used by channel bronchoscope. Sterile. Single use.
those trained and experienced in techniques of flexible
un ou
rt
fiber-optic intubation.
w
le
ith
ss
Application of topical anesthetic to the nose, Trigger-valve system provides controlled release of com-
ot
oropharynx, and upper airway of patients, at the pressed gas to an atomizing nozzle, creating a liquid spray.
he
tp
direction/discretion of a clinician. Gas flow is adjusted to the desired setting. Use with either
rw
oil- or water-based solutions. Nonsterile. Single use.

er
is
m
Application of topical anesthetics to oropharynx and Child-friendly and no sharps (bright colors in a toy-like
e
is
upper airway region. Fits through vocal cords, down presentation make the procedure less scary for young
no
si
LMA, or into nasal cavity. patients). Flexible (internal stylet provides support, malle-
on
te
ability and memory). Disposable (single patient use, elimi-

d.
nates risk for cross-contamination). Practitioner-controlled

is
(patient needs targeted specially by medication, concentra-

pr
tion, position, and location).

oh
Allows retraction of soft tissue while applying topical Device blade positioned along floor of the mouth can be
ib
anesthesia in a fine, gentle mist. Used to apply topical directed immediately in front of laryngeal inlet to generate
ite
anesthetic to the airway before awake intubation. a fine mist by a piston syringe. Nonsterile. Single use.
d.
Table 6. Devices for Special Airway Techniques (continued)
(continued)

LMA MADgic Mucosal atomization device that incorporates a small Typical particle size: 30-100
Laryngo-Tracheal Atomizer flexible, malleable tube with an internal stiffening sty- microns. System dead space:
(LMA North America, let that connects to a 3-mL syringe. 0.25 and 0.13 mL. Tip diame-
a Teleflex Company) ter: 0.18 in (4.6 mm). Applica-
tor length: 8.5 in (21.6 cm) and
4.5 in (11.4 cm).
LMA MAD Nasal-Intranasal Disposable, compact atomizer for delivery of medica- Typical particle size:
Mucosal Atomization Device tions to the nose and throat in a fine, gentle mist. 30-100 microns.
A
(LMA North America, System dead space:

ll
rig
a Teleflex Company) 0.13 and 0.07 mL.

Co
Tip diameter: 0.17 in (4.3 mm).

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py
Applicator length: 1.65 in

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rig ed.
(4.2 cm).
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Retrograde
20
Cook Retrograde Available as a complete set in 6.0, 11.0, or 14.0 F. 14 F 6.0 F=50 cm; 14.0 F=60 cm,
14
Re
Intubation Set version includes Airway Exchange Catheter with Rapi- extra stiff floppy tipped guide
M
pr
(Cook Medical) Fit adapters to allow for delivery of oxygen. wire = 110 cm.
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Face Mask Ventilation

on
n
Boussignac CPAP System Open CPAP with an integral pressure-relief system. Small, small adult, medium
Pu
(LMA North America, The CPAP device has 2 ports: a green one with integral adult, and large adult.
bl
a Teleflex Company) oxygen connecting tube, and a colorless port for con-
is
trolling pressure, monitoring CO2, and adding oxygen.

ho
hi
ng
Endoscopy Mask Face mask with diaphragm to allow simultaneous ven- Newborn, infant, child, and
le
(VBM Medizintechnik GmbH) tilation and endoscopy. adult.

or
G
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in
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Transtracheal Jet Ventilation

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AincA Manual Jet Ventilator Portable jet ventilation device with thumb depression Jet ventilation catheters of
w
le
(Anesthesia Associates, Inc.) mechanism that initiates a controlled burst of oxygen malleable copper with Luer fit-
ith
ss
flow. Customizable assembly includes DISS inlet con- tings accommodate adults,
ot
nection, 5 ft of inlet tubing, flow control knob, on/off children, and infants. Adapt-
he
thumb control, internal filter, back pressure gauge, ers allow direct connection to
tp
and 2 ft of outlet hose ending in a Luer-Lok male fit- bronchoscope or ET.

rw
er
ting. Connects to any tool or port that has a Luer-

is
m
Lok female connection (ie, malleable stylets, various

e
is
adapters, etc).
no
si
on
AincA MRI Conditional 3.0 Similar to AincA Manual Jet Ventilator but certified Jet ventilation catheters of
te
Tesla Manual Jet Ventilator MRI Conditionalcompatible for use in units up to 3.0 malleable copper with Luer fit-
d.
is
(Anesthesia Associates, Inc.) Tesla strength. tings accommodate adults,

pr
children, and infants. MRI Con-

oh
ditional 3.0 Tesla.

ib
Enk Oxygen Flow Complete set including 15-gauge needle with rein- 7.5 cm (2.0 mm ID).
ite
Modulator Set forced fluorinated ethylene propylene catheter,

(Cook Medical) syringe (5 cc), connecting tubing, and Enk oxygen
d.
flow modulator with tracheal catheter connector.

Manual Jet Ventilator Complete set includes an on/off valve, 6 ft of high- Jet ventilation catheter size
(Instrumentation Industries) pressure tubing, and 4 ft of small-bore tubing. 13G can accommodate adults,
and 14G children.
Manujet III Complete set including 13 ft high-pressure hose Jet ventilation catheters can
(VBM Medizintechnik GmbH) assembly with oxygen DISS fittings, 40-degree small accommodate adults, children,
bore tube assembly (with luer lock fitting) and and infants.
3 jet ventilation catheters (13G, 14G, and 16G).
Application of topical anesthetics to oropharynx and Malleable applicator retains memory to adapt to individual
upper airway region. Fits through vocal cords, down patients anatomy. Delivery of a fine spray mist is generated
LMA, or into nasal cavity. by a piston syringe. Luer connection adapts to any luer lock
syringe. Nonsterile. Single use.
Intranasal medication delivery offers a rapidly effec- Rapidly effective (atomized nasal medications absorb
tive method to deliver selected medications to a patient directly into blood stream, avoiding first-pass metabolism;
A
without the need for a painful shot and without the atomized nasal medications absorb directly into the brain
ll
rig
delays in onset seen with oral medications. and cerebrospinal fluid via olfactory mucosa to nosebrain
Co
pathway, achieves medication levels comparable to injec-

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py
tions). Controlled administration (exact dosing, exact vol-

s
rig ed.
ume, titratable to effect [repeat if needed], atomizes in any

re
position, atomized particles are optimal size for deposition

ht
se
across broad area of mucosa).

rv

20
Technique used for securing a difficult airway, either Packaged as a complete kit with everything needed to per-
14
Re
alone or with other alternative airway techniques. Espe- form a retrograde intubation. The recently added Arndt
M
pr
cially useful in patients with limited neck mobility or Airway Exchange Catheter allows for patient oxygenation
cM
od
patients who have suffered airway trauma. 6.0 Fr places and facilitates placement of an ET. Disposable.
tubes 2.5 mm ID; 14.0 Fr places tubes 5.0 mm ID.
uc
ah in w
tio
on
n
Provides respiratory assistance to patients breath- Compatible with all face masks, ETs, and tracheostomy
Pu
ing spontaneously. Effective postoperatively in obese tubes. Mask head harness is designed for patient comfort.
bl
patients with sleep apnea.

is
ho
hi
ng
Fiber-optic intubation Available in different sizes and with different sizes of dia-
le
Airway endoscopy phragms for a perfect seal during endoscopy. Special Bron-
or
Gastroenterology choscope Airway available to protect equipment and aid

ro
in
Transesophageal echocardiography endoscopy.

up
pa
un ou
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Manual Jet Ventilation for oxygen saturation mainte- Easy factory customization available for hose lengths and
w
le
nance and usable for emergency direct TTJV and for oxygen source connection type (DISS vs various quick-
ith
ss
laser throat surgery (elimination of plastic ET in laser disconnect types) as well as optional pressure regulator
ot
path). (with gauge) and standard or custom regulator-to-source

he
connection hoses. Adapters, fittings, and connectors avail-

tp
able. Completely reusable and sterilizable.

rw
er
is
m
e
is
no
si
on
Similar to the AincA Manual Jet Ventilator, but fully Easy factory customization available for hose lengths and
te
certified for use in MRI suites with coil strength to 3.0 oxygen source connection type (DISS vs various quick-
d.
is
Tesla. Allows emergency oxygen saturation maintenance disconnect types). Adapters, fittings, and connectors avail-
pr
while determining how to solve airway issues. able. Completely reusable and sterilizable.
oh
ib
Similar to the AincA Manual Jet Ventilator. Recom- Packaged as a complete set with everything needed to per-
ite
mended for use when jet ventilation is appropriate but a form TTJV. Disposable.
jet ventilator is unavailable.
d.
Same as Manujet III. Can also be used in unobstructed Offered with and without an adjustable pressure regulator.
difficult airway management. Partially reusable outlet tube is disposable.
NOTE: Outlet tube is single-use.
Well-accepted method for securing ventilation in rigid Packaged as a complete kit with jet ventilation catheters to
and interventional bronchoscopy. Because airflow is perform TTJV. Includes gauge and regulator.
generally unidirectional, it is important that air has a
route to escape (unobstructed airway).
Table 7. Positioning Devices
Name (Manufacturer) Description
Chin-UP Hands-free airway support device used to lift up the patients
(Dupaco Inc.; distributed by Mercury Medical) chin and hold it in position to keep the airway open.
Face-Cradle (Mercury Medical) Fully adjustable cushion set accommodates most adult head sizes.
JED Jaw Elevation Device Hands-free, noninvasive device that helps clinicians maintain an
(Hypnoz Therapeutic Devices; distributed by open airway during any procedure in which a patient is sedated
LMA North America, Inc., a Teleflex Company) and the airway may be compromised.
A
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RAMP Rapid Airway Management Positioner Air-assisted medical device that can be inflated to transfer and
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(Airpal Patient Transfer Systems, Inc.) position patients for various procedures.
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Troop Elevation Pillow Foam positioning device that quickly achieves the head-
20
(Mercury Medical) elevated laryngoscopy position (HELP). Includes many

14
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accessories (head cradle, arm board pads, additional pillow).

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Table 8. Cricothyrotomy Devices

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Needle Cricothyrotomy
or
Emergency Transtracheal Air- 6 Fr reinforced fluorinated ethylene propylene 5.0 and 7.5 cm.
ro
way Catheter (Cook Medical) catheter.

in
up
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Percutaneous Cricothyrotomy
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Melker Emergency Complete set including syringe (10 cc), 2- to 18-gauge Standard kit: 3.8 cm (3.5 mm
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Cricothyrotomy Catheter Set introducer needles with TFE catheter (short and long), ID), 4.2 cm (4.0 mm ID), and
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(Cook Medical) 0.038-in diameter Amplatz extra-stiff guidewire with 7.5 cm (6.0 mm ID). Special kit:
flexible tip, scalpel, curved dilator with radiopaque 4.2 and 7.5 cm.
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stripe, and PVC airway catheter. Also available in a

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Special Operations kit, which includes all of the above

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in a slip peel-pouch and 2 airway catheters.

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Pertrach Emergency Contents include 2 splitting needles, cuffed or Adult: 6.8 cm (5.6 mm ID).
e
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Cricothyrotomy Kit uncuffed Trach tube, dilator with flexible leader, twill Child: 3.9 cm (3.0 mm ID),
no
si
(Pulmodyne) tape, syringe, extension tube, and scalpel (optional). 4.0 cm (3.5 mm ID), 4.1 cm
on
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(4.0 mm ID), and 4.4 cm

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(5.0 mm ID).
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Quicktrach Emergency Complete kit includes airway catheter, stopper, needle, Adult (4.0 mm ID) and
Cricothyrotomy Device and syringes that come preassembled. child (2.0 mm ID).
ib

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d.
Aids during monitored anesthesia care and total Disposable polyurethane foam cushions.
intravenous anesthesia sedation procedures.
For use in prone-position surgeries.
OR procedures, MRI, recovery, FOB intubation, and Assists provider in maintaining an open airway in sedated
interventional radiology, oral surgery, and endoscopy or anesthetized patients without the need for additional
procedures. instrumentation. Frees medical personnel from the need
to hold the jaw manually in sedated patients. When left
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in place after a procedure, reduces postoperative airway

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complications. Noninvasive and easy to use. Reusable

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device with disposable pads.

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Allows for the positioning of a patient for direct laryngos- Base of the RAMP is integrated with an Airpal plat-
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copy, extubation, and central venous access. Enhances form (air-assisted lateral patient transfer and position-
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the safe apnea period, bag valve mask ventilation, and ing device). Inflates and deflates, thus can remain in place
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chest wall excursion. during surgery and reinflate for extubation. Reusable.
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Aids airway management for obese patients by align- Available in disposable and reusable formats. Troop
20
ing upper airway axes, and facilitating mask ventilation, Elevation Pillow may be added for super morbidly obese
14
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laryngoscopy, direct laryngoscopy, and central venous patients.

access. Allows patients to breathe more comfortably
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during preoxygenation and regional anesthesia.

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or
A lifesaving procedure that is the final option for cannot- Designed to be kink-resistant specifically for the purpose
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ventilate, cannot-intubate patients in all airway algorithms. of needle cricothyrotomy.

in
up
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Same as Emergency Transtracheal Airway Catheter. Packaged as a complete kit with everything needed to
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Intended to be used with the Seldinger technique via the perform a percutaneous cricothyrotomy. The Special
ith
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cricothyroid membrane; however, it has the capability to be Operations kit comes in a slip peel-pouch for easy trans-
used as a surgical cricothyrotomy. port to offsite locations. Also can be used in the OR. It
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comes with 2 differently sized airway catheters to reduce

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tp
the number of kits needed in the field. Disposable.

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Use in failed orotracheal or nasotracheal intubation and/ Serves as an emergency cricothyrotomy or tracheostomy
e
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or fiber-optic bronchoscopy. Immediate airway control in device that uses a patented splitting needle and dilator to
no
si
patients with maxillofacial, cervical spine, head, neck, and perform a rapid and simple procedure.
on
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multiple trauma. Also used when endotracheal intubation

d.
is impossible and/or contraindicated. Immediate relief of

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upper airway block.

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Same as Melker Emergency Cricothyrotomy Catheter Set. Packaged as a complete kit with everything needed to
perform a percutaneous cricothyrotomyeven the neck
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tape and connecting tube. The removable stopper is used

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to prevent a too-deep insertion and avoid the possi-

d.
bility of perforating the rear tracheal wall. The conical

needle tip allows for the smallest necessary stoma and
reduces the risk for bleeding. Easily transported to offsite
locations. Disposable.
Table 8. Cricothyrotomy Devices (continued)
Surgical Cricothyrotomy
Melker Surgical Cricothyrot- Cuffed cricothyrotomy tube, scalpel, tracheal hook 9.0 cm (5 mm ID).
omy Set (Cook Medical) Trousseau dilator, and blunt curved dilator in compact
package for convenient storage.
Melker Universal Emergency Same as Melker Cuffed Emergency Cricothyrot- 9.0 cm (5.0 mm ID).
Cricothyrotomy Catheter Set omy Catheter Set for percutaneous technique. Also
(Cook Medical) includes for surgical technique: tracheal hook, safety
A
scalpel, Trousseau dilator, and blunt curved dilator.

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Surgicric 1 Surgical cricothyrotomy. 7.0 mm ID.

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Table 9. Tracheostomy Devices

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Percutaneous Dilatational Tracheostomy

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Ciaglia Blue Dolphin Balloon Complete kit with size-specific Blue Dolphin balloon dilator. 21, 24, 26, 27, 28, 30 Fr
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Percutaneous Tracheostomy Available with or without Shiley 6 or 8 PERC tracheostomy introducers.

Introducer tubes. A tray version is available that includes lidocaine/epi-
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(Cook Medical) nephrine, 15-mm swivel connector, chlorhexidine skin prep,

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drape, and suture.

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Ciaglia Blue Rhino Complete kit includes 24.0, 26.0, and 28.0 Fr loading dila- 74 mm (6.4 mm ID);
or
Percutaneous Introducer Set tors and Shiley 6 or 8 PERC disposable dual-cannula tracheos- 79 mm (7.6 mm ID).
G
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(Cook Medical) tomy tube. A tray version is available that includes lidocaine/
in
epinephrine, connector, chlorhexidine skin prep, drape, needle

up
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driver, and suture.

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Portex Ultraperc Complete set with or without a tracheostomy tube. 70.0 mm (7.0 mm ID);
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Percutaneous Dilatational 5.5 mm (8.0 mm ID);

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Tracheostomy Kit 81.0 mm (9.0 mm ID).

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(Smiths Medical)
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Weinmann Tracheostomy Includes Cook Airway Exchange Catheter, Tracheostomy For use with tracheos-
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Exchange Set loading dilators, and a Blue Rhino dilator for re-dilation if tomy tubes as follows:
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(Cook Medical) necessary. 74 mm (6.4 mm ID);

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79 mm (7.6 mm ID).
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Shiley TracheoSoft XLT Available in 4 ISO sizes (5.0, 6.0, 7.0, and 8.0 mm ID). Each 90 mm (5.0 mm ID);
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Extended-Length Tracheos- size offers the choice of cuffed or uncuffed stylets, and prox- 95 mm (6.0 mm ID);
d.
tomy Tubes (Covidien) imal or distal extensions. Disposable inner cannula; replace- 100 mm (7.0 mm ID);
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ments sold in packages of 10. 105 mm (8.0 mm ID).

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Surgical Tracheostomy
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Surgical tracheostomies are performed by making a curvilinear skin incision along relaxed skin tension lines between
ite
sternal notch and cricoid cartilage. A midline vertical incision is then made dividing strap muscles, and division of thy-
d.
roid isthmus between ligatures is performed. Next, a cricoid hook is used to elevate the cricoid. An inferior-based
flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the infe-
rior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal
wall. Finally, the tracheostomy tube is inserted, the cuff is inflated, and it is secured with tape around the neck or stay
sutures.
This set provides the tools that clinicians can use if they Complete and convenient packaging.
prefer a surgical approach to performing emergency
cricothyrotomy.
Same as Melker Emergency Cricothyrotomy Catheter Set. One-half of the tray is the same as Melker Cuffed Emer-
gency Cricothyrotomy Catheter Set for the percutaneous
technique. The other half of the tray includes all items
A
needed to perform a surgical emergency cricothyrotomy.

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Surgical cricothyrotomy according to the Rapid Four-Step Complete kit including scalpel, tracheal hook, dilator,
Co
Technique. A lifesaving procedure that is the final option for cuffed tracheal tube, fixation and extension tubing.
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cannot-ventilate, cannot-intubate situations.

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One-step dilation and tracheal tube insertion. Estab- Unique balloon-tipped design dilatation and tracheal tube
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lishes transcutaneous access to the trachea below the insertion in one step. Packaged as a complete kit with
level of the cricoid cartilage by Seldinger technique. everything needed to perform a percutaneous dilatational
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tracheostomy.
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Same as Portex Ultraperc Percutaneous Dilatational Packaged as a complete kit with everything needed to per-
or
Tracheostomy Kit. form a percutaneous dilatational tracheostomy. The single

G
ro
dilator with a hydrophilic coating and flexible tip results in a

in
simpler, less traumatic insertion. The wire guide has a Safe-

up
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T-J tip to reduce trauma. Disposable.

un ou
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Establishes transcutaneous access to the trachea below Packaged as a complete kit with everything needed to per-
w
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the level of cricoid cartilage. Allows for smooth inser- form a percutaneous dilatational tracheostomy. The dilator
ith
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tion of the tracheostomy tube over a Seldinger wire. is single-staged and prelubricated with an ergonomic han-
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dle to facilitate insertion. Disposable.

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This set is used to facilitate exchange of adult tracheos- This is the only device available that provides an airway
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tomy tubes allowing for stomal redilation if required. exchange catheter to maintain stomal access and that also
er
allows redilation of stoma if resistance is met.

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Flexible dual cannula tube for patients with unusual The only fixed-flange extended-length tube with disposable
on
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anatomy. Proximal length extension for thick necks; inner cannula. Flexible inner cannula conforms to the shape
d.
distal length extension for long necks, tracheal stenosis, of the outer cannula. Sixteen configurations to fit a wide
is
or malacia. variety of patients. Disposable.

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Recommended Reading
1. American Society of Anesthesiologists Task Force on Manage- mask airway: a randomised, crossover study of anesthetized adult
ment of the Difficult Airway. Practice guidelines for management of patients. Anesthesiology. 2000;92(6):1621-1623.
the difficult airway: an updated report by the American Society of 15. Drges V, Ocker H, Wenzel V, Schmucker P. The laryngeal tube: a
Anesthesiologists Task Force on Management of the Difficult Airway. new simple airway device. Anesth Analg. 2000;90(5):1220-1222.
Anesthesiology. 2003;98(5):1269-1277.
16. Gaitini LA, Vaida SJ, Somri M, Tome R, Yanovski B. A comparison
2. Miller CG. Management of the difficult intubation in closed malprac- of the Cobra, Perilaryngeal Airway, and Laryngeal Mask Airway
tice claims. ASA Newsletter. 2000;64(6):13-19. Unique in spontaneously breathing adult patients. Anesthesiology.
3. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intu- 2004;101:A518.
bation: a review. Anesth Analg. 2000;90(3):745-756. 17. Gupta B, McDonald JS, Brooks JH, Mendenhall J. Oral fiber-
4. Frass M, Kofler J, Thalhammer F, et al. Clinical evaluation of optic intubation over a retrograde guidewire. Anesth Analg.
a new visualized endotracheal tube (VETT). Anesthesiology. 1989;68(4):517-519.
1997;87(5):1262-1263. 18. Sivarajan M, Stoler E, Kil HK, Bishop MJ. Jet ventilation using fiber-
A
optic bronchoscopes. Anesth Analg. 1995;80(2):384-387.

ll
5. Tuckey JP, Cook TM, Render CA. Forum. An evaluation of the lever-
ing laryngoscope. Anaesthesia. 1996;51(1):71-73. 19. Audenaert SM, Montgomery CL, Stone B, Akins RE, Lock RL. Ret-
rig
Co
rograde-assisted fiberoptic tracheal intubation in children with

6. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the
ht
difficult airways. Anesth Analg. 1991;73(5):660-664.

py
management of a difficult airway. Can J Anesth. 2003;50(6):611-613.

s
20. Klain M, Smith RB. High-frequency percutaneous transtracheal jet

rig ed.
7. Agro F, Barzoi G, Montecchia F. Tracheal intubation using a Macin-

re
ventilation. Crit Care Med. 1977;5(6):280-287.

tosh laryngoscope or a GlideScope in 15 patients with cervical spine
ht
se
21. Enk D, Busse H, Meissner A, Van Aken H. A new device for oxy-
immobilization (letter). Br J Anaesth. 2003;90(5):705-706.
genation and drug administration by transtracheal jet ventilation.
rv
8. Gorback MS. Management of the challenging airway with the Bull- Anesth Analg. 1998;86:S203.
20
ard laryngoscope. J Clin Anesth. 1991;3(6):473-477.

22. Safar P, Penninckx J. Cricothyroid membrane puncture with special
14
9. Bjoraker DG. The Bullard intubating laryngoscopes. Anesthesiol Rev. cannula. Anesthesiology. 1967;28(5):943-948.
Re
1990;17(5):64-70. 23. Safar P, Bircher NG. Cardiopulmonary Cerebral Resuscitation. 3rd ed.
M
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10. Wu TL, Chou HC. A new laryngoscope: the combination intubating London, England: WB Saunders; 1988.
cM
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device. Anesthesiology. 1994;81(4):1085-1087. 24. Wong EK, Bradrick JP. Surgical approaches to airway management
for anesthesia practitioners. In: Hagberg CA, ed. Handbook of Dif-
uc
ah in w
11. Verghese C. Airway management. Curr Opin Anaesthesiol.

1999;12(6):667-674. ficult Airway Management. Philadelphia, PA: Churchill Livingstone;
tio
on
2000:209-210.
12. Benumof JL. Laryngeal mask airway and the ASA difficult airway
n
25. Gibbs M, Walls R. Surgical airway. In: Hagberg CA, ed. Benumofs
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algorithm. Anesthesiology. 1996;84(3):686-699.

Airway Management. 2nd ed. Philadelphia, PA: Mosby Elsevier;
13. Patel P, Verghese C. Delayed extubation facilitated with the use
bl
2007:678-696.
of a laryngeal mask airway in the intensive care unit. Anaesthesia.
is
26. Sarpellon M, Marson F, Nani R, Chiarini L, Bradariolo S, Fonzari C.

ho
2000;55(4):396.
hi
Translaryngeal tracheostomy (TLT): a variant technique for use in

ng
14. Brimacombe J, Keller C, Hrmann C. Pressure support ventila- hypoxemic conditions and in the difficult airway [in Italian]. Minerva
le
tion versus continuous positive airway pressure with the laryngeal Anestesiol. 1998;64(9):393-397.
or
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Abbreviation Key
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AEC airway exchange catheter ISO International Organization for Standardization

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AHA American Heart Association LCD liquid crystal display

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ASA American Society of Anesthesiologists LED light-emitting diode

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CCD charge-coupled device LMA laryngeal mask airway

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CMOS complementary metal oxide semiconductor LT laryngeal tube

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CPAP continuous positive airway pressure LTA laryngeal tracheal anesthesia

si
on
CPR cardiopulmonary resuscitation MAC Macintosh

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DCI direct coupled interface NICU neonatal intensive care unit

d.
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DISS diameter index safety system NTSC National Television System Committee
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DL direct laryngoscopy OD outer diameter

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DLT double-lumen tube OR operating room

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ED emergency department PEEP positive end-expiratory pressure

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EF extra firm PPV positive pressure ventilation

d.
EMS emergency medical services PVC polyvinyl chloride

ENT ear nose and throat PVP polyvinylpyrrolidone
ET endotracheal tube SGA supraglottic airway
FOB fiber-optic bronchoscope Stat sterile single-use blade
Fr French TFE tetrafluoroethylene
ICU intensive care unit TTJV transtracheal jet ventilation
ID internal diameter USB universal serial bus
ILMA intubating laryngeal mask airway VL video laryngoscopy

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PRINTER-FRIENDLY VERSION AVAILABLE AT ANESTHESIOLOGYNEWS.

Volume 11, Number 1

Joseph C. Gabel Professor and Chair

The University of Texas Medical School at Houston

Director of Advanced Airway Management

Memorial Hermann HospitalTexas Medical Center

Executive Director 2009-Present, Society for Airway Management

relevant and challenging tasks for anesthesia care providers. This

review focuses on several of the alternative airway management

devices/techniques and their clinical applications, with particular emphasis

for patients with known or suspected difficult airways.

It also may become the standard for routine intuba-

tions as the equipment and users skills improve and

the cost of the devices decreases, with the potential for

important savings in time and decreased morbidity in

patients. It is beyond the scope of this review to discuss

all of the laryngoscopes that have been manufactured;

thus, only some of the most recently developed blades

(Anesthesiology 2013;118[2]:251-270) INDIRECT RIGID FIBER-OPTIC LARYNGOSCOPES

The algorithm can be viewed at:

www.asahq.org/publicationsAndServices/practiceparam.htm These laryngoscopes were designed to facilitate tra-

considered for flexible fiber-optic bronchoscopy, such

as patients with limited mouth opening or neck move-

Alternative Airway Devices

ment. Relative to the flexible fiber-optic bronchoscopes

ENDOTRACHEAL TUBE GUIDES SUPRAGLOTTIC VENTILATORY DEVICES

in more than 200 million patients worldwide with no

LIGHTED STYLETS reported deaths. Other supraglottic ventilatory devices

unless combined with direct laryngoscopy, and visual

visualization of the airway. They also can be used alone

or in conjunction with direct laryngoscopy (Table 2).

For managing patients in whom a difficult airway is

VIEWING STYLETS suspected or anticipated, securing the airway before

In adults, needle cricothyrotomy should be per-

FLEXIBLE FIBER-OPTIC INTUBATION formed with catheters at least 4 cm and up to 14 cm in

the insertion of an ET. This is the most rapid technique

LED light source, battery and recording device in a sin- important.

gle unit. A completely disposable system, the aScope

(Ambu) also is available. Rescue techniques, such as

the trachea. the presence of pathologic lesions or infection.

RETROGRADE INTUBATION commonly performed tracheostomy technique, yet it is

suffered airway trauma). Cook Medical has 2 retrograde

intubation sets: a 6.0 Fr for placing tubes of 2.5 mm or Conclusion

greater ID. simple devices and techniques, but clinical judgment

born of experience is crucial to their application. As

(Cook Medical) with soft-tips. Colors: Yellow, green; soft-tip is purple.

only) in oxygen delivery, if necessary.

Bougie (Magaw Medical) with ETs 6.0 mm ID.

(Magaw Medical) mm ID.

ening cannula and removable Rapi-Fit adapters. 14 Fr also

packaged in box of 10. Colors: 8 Fr, yellow; 14 Fr, blue.

maneuverability in ET placement. 6.0 mm ID.

(VBM Medizintechnik GmbH) atraumatic coud tip. Color: green.

6.5, and 7.0-9.0 mm ID.

Pocket Introducer Single-use 15 Fr Introducer with coud tip. Color: blue. 65

(VBM Medizintechnik GmbH)

(Smiths Medical) as the gum elastic bougie. Color: golden brown.

Abbreviation key for all tables is on page 28.

double-lumen tubes. Rapi-Fit adapters as above, but should be used primar-

ily for jet ventilation because of length. Single use.