Obesidad y vía aérea / Obesity and airway

Junio 28, 2017. No. 2733

Índices predictores de vía aérea en pacientes obesos Dr. Javier A Ramírez-Acosta, Dra. Gabriela Griselda Torrico-Lara, Dra. Carla Mónica Encinas-Pórcel Rev Mex Anestesiología Vol. 36. No. 3 Julio-Septiembre 2013 pp 193-201 RESUMEN La tráquea de los pacientes obesos puede ser más difícil de intubar que la de aquellos pacientes con un peso normal. La incidencia de intubación difícil en personas obesas (índice de masa corporal >30 kg/m2) se incrementa hasta tres veces en comparación con pacientes no obesos. Sin embargo, la obesidad por sí sola no predice una intubación traqueal difícil, por lo que se considera un factor de riesgo independiente de la intubación difícil. En la actualidad, las pruebas de detección disponibles para intubación difícil tienen sólo poder de discriminación de pobre a moderado cuando se usan solas. La combinación de tests o maniobras predictivas podría ser más efi ciente al determinar anticipadamente una vía aérea difícil. Incluir el índice de masa corporal en índices de riesgo multifactoriales puede mejorar la predicción de intubación difícil. La gran cantidad de parámetros que predicen intubación difícil como Mallampati, Cormack y Lehane, índice de masa corporal, etc., no son específi cos en la predicción de la intubación traqueal difícil. Previamente, el paradigma de la intubación segura se ha basado en: 1) una valoración preoperatoria adecuada de la vía aérea de los pacientes, 2) habilidades adecuadas para la intubación y 3) herramientas adecuadas para la intubación. Palabras clave: Obesidad, vía aérea difícil. PDF Manejo de la vía aérea en pacientes llevados a cirugía bariátrica en el Hospital Universitario de San Ignacio, Bogotá, Colombia Fritz E. Gempelera,, Lorena Díazb y Lina Sarmient Rev Colomb Anestesiol. 2012;40(2):119-123 Resumen Introducción. La obesidad ha aumentado en los últimos años y aún más los obesos mórbidos, en quienes se han reconocido comorbilidades que dificultan el manejo perioperatorio anestésico, incluido el manejo de la vía aérea. En la valoración preanestésica existen parámetros del examen físico y de la historia clínica que son predictores de intubaciones difíciles o fallidas, y es en estos casos cuando el fibroscopio retromolar de Bonfils ha sido una herramienta útil. Objetivo: Observar los predictores de vía aérea difícil a partir del examen físico, la incidencia de intubación difícil y las herramientas utilizadas para el manejo de la vía aérea en pacientes obesos. Material y métodos: Estudio observacional descriptivo de 352 pacientes obesos llevados a cirugía bariátrica en el Hospital Universitario de San Ignacio, Bogotá, en quienes se evaluó índice de masa corporal, apertura oral, Mallampati, distancia tiromentoniana, circunferencia del cuello y uso de laringoscopio o fibroscopio retromolar de Bonfils y su dificultad en la utilización. Conclusiones: La intubación con fibroscopio retromolar de Bonfils es exitosa en el 100% de los casos observados en pacientes obesos y la dificultad de la intubación con dicho dispositivo no se correlaciona con los parámetros evaluados. PDF Rapidez y eficacia del signo ultrasonográfico de ¨pulmón deslizante¨ y auscultación en la confirmación de la intubación endotraqueal en pacientes con sobrepeso y obesidad. Rapidity and efficacy of ultrasonographic sliding lung sign and auscultation in confirming endotracheal intubation in overweight and obese patients. Rajan S1, Surendran J1, Paul J1, Kumar L1. Indian J Anaesth. 2017 Mar;61(3):230-234. doi: 10.4103/0019-5049.202164. Abstract BACKGROUND AND AIMS: Obese individuals are predisposed to difficult airway and intubation. They usually yield confusing or misleading auscultatory findings. We aimed to assess the rapidity and efficacy of ultrasonographic (USG) sliding lung sign for confirming endotracheal intubation in normal as well as overweight and obese surgical patients. METHODS: This prospective, observational study was performed in forty surgical patients. Twenty patients with body mass index (BMI) <25 were recruited to Group A, whereas twenty patients with BMI ≥25 constituted Group B. Following induction and intubation, appearance of end-tidal carbon dioxide waveform was used to confirm endotracheal intubation. Presence of breath sounds bilaterally was sought by auscultation, and time taken for auscultatory confirmation was noted. The USG confirmation of air entry to the lung field as indicated by lung sliding was sought, and the time taken was noted. Chi-square test, independent t-test and paired t-test were used as applicable. RESULTS: Auscultatory confirmation was more rapid in Group A as compared to Group B (9.34 ± 2.43 s vs. 14.35 ± 5.53 s, P = 0.001). However, there was no significant difference in USG confirmation time in both the groups (8.57 ± 2.05 s vs. 8.61 ± 1.66 s). Four patients in Group B had doubtful breath sounds against none in Group A. There was no doubtful lung slide with USG in both groups. One case of endobronchial intubation in Group B was diagnosed with USG which was doubtful by auscultation. CONCLUSION: Ultrasound directed confirmation of endotracheal tube placement in overweight and obese patients is superior in speed and accuracy in comparison to the standard auscultatory method. KEYWORDS: Auscultation; endotracheal intubation; obesity; sliding lung sign; ultrasonography PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información

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Vía aérea, posición lateral y ML / Airway; Lateral position; Proseal laryngeal mask

Abril 17, 2017. No. 2662

Efecto del neumoperitoneo y de la posición lateral sobre las presiones de sello orofaríngeo de LMA Proseal en procedimientos urológicos laparoscópicos. Effect of Pneumoperitoneum and Lateral Position on Oropharyngeal Seal Pressures of Proseal LMA in Laparoscopic Urological Procedures. Rustagi P1, Patkar GA2, Ourasang AK3, Tendolkar BA4. J Clin Diagn Res. 2017 Feb;11(2):UC05-UC09. doi: 10.7860/JCDR/2017/22168.9422. Epub 2017 Feb 1. Abstract INTRODUCTION: A sustained and effective oropharyngeal sealing with supraglottic airway is required to maintain the ventilation during laparoscopic surgery. Previous studies have observed the Oropharyngeal Seal Pressure (OSP) for Proseal Laryngeal Mask Airway (PLMA) after pneumoperitoneum in supine and trendelenburg position, where PLMA was found to be an effective airway device. This study was conducted with ProSeal LMA, for laparoscopic Urologic procedures done in lateral position. AIM: To measure OSP in supine and lateral position and to observe the effect of pneumoperitoneum in lateral position on OSP. Secondary objectives were to assess adequacy of ventilation and incidence of adverse events. MATERIALS AND METHODS: A total number of 25 patients of American Society of Anaesthesiologists (ASA) physical status II and I were enrolled. After induction of anaesthesia using a standardized protocol, PLMA was inserted. Ryle's tube was inserted through drain tube. The position of PLMA was confirmed with ease of insertion of Ryle's tube and fibreoptic grading of vocal cords. Patients were then put in lateral position. The OSP was measured in supine position. This value was baseline comparison for OSP in lateral position and that after pneumoperitoneum. We assessed the efficacy of PLMA for ventilation, after carboperitoneum in lateral position (peak airway pressure, End Tidal Carbon dioxide (EtCO2), SPO2). Incidence of adverse effects (displacement of device, gastric insufflation, regurgitation, coughing, sore throat, blood on device, trauma) was also noted. RESULTS: The OSP was above Peak Airway Pressure (PAP) in supine (22.1±5.4 and 15.4±4.49cm of H2O) and lateral position (22.6±5.3 and 16.1±4.6). After pneumoperitoneum, which was in lateral position, there was statistically significant (p-value <0.05) increase in both PAP (19.96±4.015) and OSP (24.32±4.98, p-value 0.03). There was no intraoperative displacement of PLMA. There was no event of suboptimal oxygenation. EtCO2 was always within normal limits. Gastric insufflation was present in one patient. One patient had coughing and blood was detected on device. Three patients had throat discomfort post-operatively. CONCLUSION: In this study, Oropharyngeal seal pressures with PLMA were found to increase after pneumoperitoneum in lateral position. PLMA forms an effective seal around airway and is an efficient and safe alternative for airway management in urological laparoscopic surgeries done in lateral position. KEYWORDS: Airway; Lateral position; Proseal laryngeal mask PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Más de SAOS y anestesia / More on OSA and anaesthesia

Abril 14, 2017. No. 2659

Detección por ultrasonido de obstrucción de la vía aérea en un modelo de de apnea obstructiva del sueño Ultrasonographic Detection of Airway Obstruction in a Model of Obstructive Sleep Apnea. Isaiah A1, Mezrich R2, Wolf J3. Ultrasound Int Open. 2017 Feb;3(1):E34-E42. doi: 10.1055/s-0042-124503. Abstract Purpose Obstructive sleep apnea (OSA) is a common clinical disorder characterized by repetitive airway obstruction during sleep. The gold standard for diagnosis of OSA, polysomnogram (PSG), cannot anatomically localize obstruction. Precise identification of obstruction has potential to improve outcomes following surgery. Current diagnostic modalities that provide this information require anesthesia, involve ionizing radiation or disrupt sleep. To mitigate these problems, we conceived that ultrasound (US) technology may be adapted (i) to detect, quantify and localize airway obstruction and (ii) for translational application to home-based testing for OSA. Materials and Methods Segmental airway collapse was induced in 4 fresh cadavers by application of negative pressure. Following visualization of airway obstruction, a rotary US probe was used to acquire transcervical images of the airway before and after induction of obstruction. These images (n=800) were analyzed offline using image processing algorithms. Results Our results show that the non-obstructed airway consistently demonstrated the presence of a US air-tissue interface. Importantly, automated detection of the air-tissue interface strongly correlated with manual measurements. The algorithm correctly detected an air-tissue interface in 90% of the US images while incorrectly detecting it in 20% (area under the curve=0.91). Conclusion The non-invasive detection of airway obstruction using US represents a major step in expanding OSA diagnostics beyond PSG. The preliminary data obtained from our model could spur further research in non-invasive localization of obstruction. US offers the benefit of precise localization of the site of obstruction, with potential for improving outcomes in surgical management. KEYWORDS: head/neck; segmentation; technical aspects; ultrasound PDF Monitoreo postoperatorio con el Capnostream en pacientes con síntomas de apnea obstructiva del sueño - Serie de casos. Post operative capnostream monitoring in patients with obstructive sleep apnoea symptoms - Case series. Rao Kadam V1, Danesh M2. Sleep Sci. 2016 Jul-Sep;9(3):142-146. doi: 10.1016/j.slsci.2016.12.004. Epub 2016 Dec 13. Abstract Obstructive sleep apnoea (OSA) patients on opioid analgesic have an increased incidence of postoperative respiratory complications; prevention of these may be possible with appropriate post-operative monitoring. We recruited 4 OSA patients who had general anaesthesia for orthopaedic and septoplasty surgery. They required Patient Controlled Analgesia (PCA) or oral opioids in the post-operative period, hence continuous Saturation of Oxygen (Spo2), End Tidal Carbon dioxide (EtCo2) monitoring on Capnostream monitor with Integrated Pulmonary Index (IPI) was organized in high dependency unit. Overnight data was collected every 30 s which included pulse rate, respiratory rate, EtCo2, Spo2, and IPI. The nursing staff was also asked to document if any intervention was carried out due to altered IPI. For first two patient events occurred during various hours but there were no significant events in early night even though increased opioid use at that time. During the period of desaturation nurse intervention required to increase the O2 flow in the first patient but corrected spontaneously in the second patient. IPI index improved over a period of 2 min in most of the events. The duration of desaturation did not correspond with the IPI in only once, remaining period the clinical symptoms were consistent with fall in O2 saturation. The microstream capnography with IPI may provide complete respiratory status of the patient because of its comprehensive parameters on one screen. Main limitation was duration of monitoring was limited to overnight. Capnostream monitoring with IPI may have a role in patients monitoring with OSA on PCA in the postoperative ward but more trials are necessary. KEYWORDS: Capnostream monitor; Integrated pulmonary index; Obstructive sleep apnoea; Opioid analgesia; Post operative analgesia; Respiratory complications PDF Apnea obstructiva del sueño. Un factor de riesgo perioperatorio Obstructive Sleep Apnea-a Perioperative Risk Factor. Fassbender P1, Herbstreit F, Eikermann M, Teschler H, Peters J. Dtsch Arztebl Int. 2016 Jul 11;113(27-28):463-9. doi: 10.3238/arztebl.2016.0463. Abstract BACKGROUND: Obstructive sleep apnea (OSA) is a common disorder of breathing but is probably underappreciated as a perioperative risk factor. METHODS: This review is based on pertinent articles, published up to 15 August 2015, that were retrieved by a selective search in PubMed based on the terms "sleep apnea AND anesthesia" OR "sleep apnea AND pathophysiology." The guidelines of multiple specialty societies were considered as well. RESULTS: OSA is characterized by phases of upper airway obstruction accompanied by apnea/hypoventilation, with hypoxemia, hypercapnia, and recurrent overactivation of the sympathetic nervous system. It has been reported that 22% to 82% of all adults who are about to undergo surgery have OSA. The causes of OSA are multifactorial and include, among others, an anatomical predisposition and /or a reduced inspiratory activation of the bronchodilator muscles, particularly when the patient is sleeping or has taken a sedative drug, anesthetic agent, or muscle relaxant. OSA is associated with arterial hypertension, coronary heart disease, and congestive heart failure. It can be assessed before the planned intervention with polysomnography and structured questionnaires (STOP/STOP-BANG), with sensitivities of 62% and 88%. The utility of miniaturized screening devices is debated. Patients with OSA are at risk for perioperative problems including difficult or ineffective mask ventilation and/or intubation, postoperative airway obstruction, and complications arising from other comorbid conditions. They should be appropriately monitored postoperatively depending on the type of intervention they have undergone, and depending on individually varying, patient-related factors; postoperative management in an intensive care unit may be indicated, although no validated data on this topic are yet available. CONCLUSION: OSA patients need care by specialists from multiple disciplines, including anesthesiologists with experience in recognizing OSA, securing the airway of OSA patients, and managing them postoperatively. No randomized trials have yet compared the modalities of general anesthesia for OSA patients with respect to postoperative complications or phases of apnea or hypopnea. PDF SAOS implicaciones anestésicas Dra. Miriam del Carmen Miranda Mendoza Rev Mex Anestesiol Vol. 38. Supl. 1 Abril-Junio 2015 pp S255-S256 El síndrome de apnea obstructiva del sueño (SAOS) es un padecimiento más común de lo que podemos apreciar, se caracteriza por episodios de obstrucción de la vía aérea parcial o total, principalmente durante la noche que pueden durar entre 10 y 20 segundos por minuto; su prevalencia es de más del 10% de la población asociándose principalmente a la obesidad, diabetes, enfermedades cardíacas y edad avanzada, se estima que no todos los pacientes están diagnosticados adecuadamente. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org