LETTER TO EDITOR

Year : 2022  |  Volume : 42  |  Issue : 3  |  Page : 151-152

A modified device for airway management in procedural sedation and analgesia

Chun-Chang Yeh¹, Wei-Lee Lin², Tai-Hsiang Chiu³, Wei-Cheng Tseng^1
1 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
² Department of Anesthesiology, Tri-Service General Hospital, Songshan Branch, Taipei, Taiwan
³ Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center; Department of Anesthesiology, Tri-Service General Hospital, Songshan Branch, Taipei, Taiwan

Correspondence Address:
Dr. Wei-Cheng Tseng
Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei
Taiwan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmedsci.jmedsci_242_20

[1],[2],[3] In addition, anesthetic agents such as propofol and ketamine are associated with increased salivation,^[4],[5] which may result in choking and aspiration during prolonged procedures. Accordingly, advanced airway care is one key to ensure patient safety during PSA.

Patients undergoing PSA are usually oxygenated with a nasal cannula or simple mask, which may be insufficient in those having risks of airway problems and receiving prolonged procedures. Nasopharyngeal airway (NPA) plays an essential role in airway rescue during PSA.^[2] It has better patient tolerance and unique utilization in procedures with a shared airway such as upper gastrointestinal endoscopy.^[6] Herein, we intend to introduce a modified device to enhance procedural safety in patients with predicted difficult airway or under long-lasting PSA.

The modified device is composed of a classic NPA (PAHSCO, Pacific Hospital Supply Co., Ltd., Taipei, Taiwan) and easily available accessories [Figure 1]. Initially, we lubricate a proper sized NPA and insert into the nostril with an optimal depth.^[7] After confirming airway patency, a connector of an endotracheal tube covered by a suction adapter is inserted into the flange of the NPA. Then, we fix a tracheal suction tube in the NPA through the adapter and keep their tips approaching. Finally, the proximal end of the tracheal suction tube is cut and connected to the oxygenating tube, capnography monitoring, and surgical connecting tube via the three-way stopcocks [Figure 2] and [Figure 3]. In our clinical practice, the oxygen flow usually ranges between 1 and 3 L/min, up to 6 L/min, and the concentration between 50% and 100% depending on patient statuses. Moreover, concerning about the interference with oxygenation and capnography detection, intermittent rather than continuous suction is used in the modified device.

Figure 1: View of components of modified oxygenating device as following: 1) nasopharyngeal airway, 2) connector of endotracheal tube, 3) suction adapter, 4) three-way stopcock, 5) oxygenating tube, 6) tracheal suction tube, 7) breathing circuit, and 8) surgical connecting tube Click here to view

Figure 2: View of modified nasopharyngeal oxygenating device connected with the capnography monitoring and suction system Click here to view

Figure 3: View of clinical practice in a woman with moderate obesity undergoing close reduction and pin fixation of calcaneus Click here to view

The modified design remains inherent advantages of NPA on maintaining airway patency and preventing hypoxemia. It also provides an easier access to eliminate accumulated secretions even if the patient's head is away from the anesthesia provider or covered by surgical drapes. Although high-flow nasal cannula (HFNC), a new oxygenating device in anesthetic practice, similarly supplies sufficient oxygenation and generates positive airway pressure,^[3] there are some limitations in clinical practice of HFNC during PSA. First, capnography monitoring seems to unable to detect patients' ventilation status with the use of HFNC due to rapid CO₂ washout. Second, the main part of the HFNC system is contraindicated in some locations such as magnetic resonance imaging room. Third, additional suction devices are necessary while using the HFNC system. Finally, the cost of HFNC utilization is relatively higher than other oxygenating devices in nonintubated patients.

In conclusion, we suggest that the modified oxygenating device is easily instituted and can provide several clinical benefits during PSA, especially in patients having expected airway promise and undergoing prolonged procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Hinkelbein J, Lamperti M, Akeson J, Santos J, Costa J, De Robertis E, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol 2018;35:6-24.
2.	Thackeray EM, Johnson KB. Airway rescue during sedation: A proposed airway rescue pathway for nonanesthesiologists. Curr Opin Anaesthesiol 2019;32:464-71.
3.	Kuzhively J, Pandit JJ. Anesthesia and airway management for gastrointestinal endoscopic procedures outside the operating room. Curr Opin Anaesthesiol 2019;32:517-22.
4.	Lai HC, Chang YH, Huang RC, Hung NK, Lu CH, Chen JH, et al. Efficacy of sevoflurane as an adjuvant to propofol-based total intravenous anesthesia for attenuating secretions in ocular surgery. Medicine (Baltimore) 2017;96:e6729.
5.	Kye YC, Rhee JE, Kim K, Kim T, Jo YH, Jeong JH, et al. Clinical effects of adjunctive atropine during ketamine sedation in pediatric emergency patients. Am J Emerg Med 2012;30:1981-5.
6.	Müller M, Wehrmann T, Eckardt AJ. Prospective evaluation of the routine use of a nasopharyngeal airway (Wendl Tube) during endoscopic propofol-based sedation. Digestion 2014;89:247-52.
7.	Tseng WC, Lin WL, Cherng CH. Estimation of nares-to-epiglottis distance for selecting an appropriate nasopharyngeal airway. Medicine (Baltimore) 2019;98:e14832.

Figures

  [Figure 1], [Figure 2], [Figure 3]