Supraglottic devices for airway management in awake craniotomy

Abstract

Awake craniotomy is a unique technique utilized for mapping neuro and motor function during neurosurgical procedures close to eloquent brain tissue. Since active communication is required only during surgical manipulation of eloquent brain tissue and the patient is “sedated” during other parts of the procedure, different methods for anesthesia management have been explored. Furthermore, airway management ranges from spontaneous breathing to oro or nasotracheal intubation. Case reports have described the use of laryngeal masks (LMs) previously; however, its safety compared to tracheal intubation has not been assessed.We conducted a retrospective analysis of 30 patients that underwent awake craniotomy for tumor surgery to compare the feasibility and safety of different airway management strategies. Nasal fiberoptic intubation (FOI) was performed in 21 patients while 9 patients received LM for airway management. Ventilation, critical events, and perioperative complications were evaluated.Cannot intubate situation occurred in 4 cases reinserting the tube after awake phase, while no difficulties were described reinserting the LM (P < .0001). Furthermore, duration of mechanical ventilation after tumor removal was significantly lower in the LM group compared to FOI group (62 ± 24 vs. 339 ± 82 [min] mean ± sem, P < .0001). Postoperatively, 2 patients in each group were diagnosed with and treated for respiratory complications including pneumonia, without statistical significance between groups.In summary, LM is a feasible airway management method for patients undergoing awake craniotomy, resulting in reduced ventilation duration compared to FOI procedure.

Emergency Airway Management During Awake Craniotomy: Comparison of 5 Techniques in a Cadaveric Model

“…Unsuccessful intubation attempts (especially in the presence of posterior airway obstruction) can result in significant oropharyngeal trauma and bleeding, reducing intubation success rate. 12 Although the use of FOB and video laryngoscopy might be preferred to secure a difficult airway in both elective and emergency settings, this approach might not be best for patients during AC. Alternatively, the presence of an LMA, even 1 that is not sealed appropriately to deliver positive pressure ventilation, can significantly displace the tissue in the posterior pharynx and improve the likelihood of successful FOB-assisted intubation when performed through the LMA.…”

“…Displacement of the posterior pharyngeal tissue is difficult with either approach individually, as our simulation demonstrated. Unsuccessful intubation attempts (especially in the presence of posterior airway obstruction) can result in significant oropharyngeal trauma and bleeding, reducing intubation success rate 12…”

An Update of Neuroanesthesia for Intraoperative Brain Mapping Craniotomy

“…47 Using the fiberoptic bronchoscope, or LMA, as a conduit has been shown to be useful in awake intubation for difficult airways or when the head is fixated on a Mayfield (Integra LifeSciences) during craniotomy. 18 , 48…”

“…Airway management during the asleep phase is commonly accomplished with supraglottic airways, such as laryngeal mask airway (LMA), but endotracheal tube or other airway devices have been used. 18 The main challenge of this technique occurs at the emergence from GA and extubation. The key to success is to promote a smooth transition from asleep to awake state.…”

Severe gastric insufflation and consequent atelectasis caused by gas leakage using AIR-Q laryngeal mask airway: A case report

“…The use of supraglottic airway devices (SADs) has been proven to be a feasible airway management method for awake craniotomy (AC) to lower the risk of coughing or gagging during the transition to the awake state[ 1 ]. Recently, a retrospective analysis of 30 cases of AC reported that patients receiving laryngeal mask airway (LMA) had fewer complications and a shorter ventilation duration than patients who underwent fiberoptic intubation[ 2 ]. Considering the requirements of craniotomy and scalp blocks, head rotation and neck flexion may influence the performance of SADs including oropharyngeal leak pressure, ventilation, and fiberoptic view[ 3 , 4 ].…”