Zusammenfassung
Effektives und sicheres Atemwegsmanagement ist eine der Kernaufgaben für Anästhesisten und akutmedizinisches Personal. Trotzdem stellen Fehler im Atemwegsmanagement bei der Analyse der Gerichtsverfahren immer noch den häufigsten Grund mit der höchsten Auswirkung auf die Patientenmorbidität und –mortalität dar.
Der Anästhesist muss den Atemweg mit der größtmöglichen Sicherheit für den Patienten bei gleichzeitig geringer Beeinträchtigung des respiratorischen und kardiozirkulatorischen Systems sichern. Die klinische Kompetenz umfasst dabei das Management sowohl des erwartet als auch des unerwartet schwierigen Atemweges in unterschiedlichen Umgebungen. Weiterhin ist es die Aufgabe des Anästhesisten, nicht nur die Weiterbildungsassistenten zur unterrichten, sondern sämtliches medizinisches Personal, das mit der Atemwegssicherung befasst ist, wie beispielsweise Notärzte, Intensivmediziner oder Rettungskräfte.
Moderne Instrumente, Strategien und Ausbildungskonzepte zur Atemwegssicherung müssen diese teilweise diametralen und weit gefächerten Anforderungen erfüllen. Die Anwendung von supraglottischen Atemwegen in der Routineversorgung wird zunehmen, nicht nur aufgrund der vielen Vorteile im Vergleich zu einem Endotrachealtubus, sondern auch wegen der Eigenschaft einiger Instrumente, die den gastralen vom Atemwegstrakt separieren und Informationen zur pharyngealen Lage geben. Neue alternative Methoden zur schwierigen Atemwegssicherung sollten trainiert und in der täglichen Praxis angewendet werden.
Abstract
Effective and safe airway management is one of the core skills among anaesthesiologists and all physicians involved in acute care medicine. However, failure in airway management is still the most frequent single incidence with the highest impact on patientŽs morbidity and mortality known from closed claims analyses.
The anaesthesiologist has to manage the airway in elective patients providing a high level of safety with as little airway injury and interference with the cardio–vascular system as possible. Clinical competence also includes the management of the expected and unexpected difficult airway in different clinical environments. Therefore, it is the anaesthesiologist's responsibility not only to educate and train younger residents, but also all kinds of medical personnel involved in airway management, e.g. emergency physicians, intensive care therapists or paramedics.
Modern airway devices, strategies and educational considerations must fulfill these sometimes diverse and large range requirements. Supraglottic airway devices will be used more often in the daily clinical routine. This is not only due the multiple advantages of these devices compared to the tracheal tube, but also because of the new features of some supraglottic airways, which separate the airway from the gastric track and give information of the pharyngeal position. For the event of a difficult airway, new airway devices and concepts should be trained and applied in daily practice.
Schlüsselwörter:
Atemwegsmanagement - Algorithmus - Konzept - Larynxmaske - Endotrachealtubus
Key words:
Airway Management - Algorithm - Concept - Laryngeal mask - Endotracheal tube
Kernaussagen
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Die respiratorisch bedingten Zwischenfälle haben die höchste Inzidenz mit den Folgen Tod oder permanenter Hirnschaden.
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Supraglottische Atemwege haben in der Routineversorgung vielfältige Vorteile gegenüber der Verwendung eines endotrachealen Tubus.
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Moderne supraglottische Atemwege verfügen über einen separaten gastrischen Kanal, der zusätzlich wichtige Informationen über die korrekte Lage liefern kann.
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Die Untersuchung der Patienten hinsichtlich der Prädiktoren des schwierigen Atemwegs gehört zur obligaten Untersuchung vor jeder geplanten Atemwegssicherung.
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Bei Verdacht auf eine schwierige Atemwegssicherung ist ein Verfahren unter Erhalt der Spontanatmung und Schutzreflexe anzustreben.
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Die Präoxygenierung ist ein wichtiges Verfahren zur Erhöhung der Apnoetoleranz und muss daher vor jeder Atemwegssicherung korrekt durchgeführt werden.
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Die Beherrschung der Basismaßnahmen zur Sicherung der Atemwege ist die Grundvoraussetzung für das erfolgreiche Management des schwierigen Atemwegs.
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Die Verwendung von optischen Verfahren wird zukünftig einen höheren Stellenwert sowohl in der Ausbildung als auch in der Sicherung des schwierigen Atemwegs erhalten.
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Die Verwendung einer Larynxmaske im Falle einer „canŽt intubate, canŽt ventilate”–Situation wird von vielen Fachgesellschaften empfohlen.
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Maßnahmen im Falle einer schwierigen Atemsicherung müssen innerhalb der Klinik festgelegt, kommuniziert und trainiert werden.
Literatur
-
1
Tanaka A, Isono S, Ishikawa T, Sato J, Nishino T..
Laryngeal resistance before and after minor surgery: endotracheal tube versus Laryngeal Mask Airway.
Anesthesiology.
2003;
99
252-258
-
2
Mort TC..
Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts.
Anesth Analg.
2004;
99
-
3
Domino KB, Posner KL, Caplan RA, Cheney FW..
Awareness during anesthesia: a closed claims analysis.
Anesthesiology.
1999;
90
1053-1061
-
4
Maltby JR, Beriault MT, Watson NC..
Use of the laryngeal mask is not contraindicated for laparoscopic cholecystectomy.
Anaesthesia.
2001;
56
800-802
-
5 Brimacombe J.. Airway Morbidity. In: Brimacombe J, ed. Laryngeal Mask Anesthesia. Philadelphia: WB Saunders 2005: 552-561
-
6 Russo SG, Goetze B, Troche S, Barwing J, Quintel M, Timmermann A.. The ProSeal™–Laryngeal Mask Airway for elective postoperative care on the intensive care unit – a prospective, randomized trail. Anesthesiology 2009 (im Druck)
-
7 Brimacombe J.. Emergence Phase. In: Brimacombe J, ed. Laryngeal Mask Anesthesia. Philadelphia: WB Saunders 2005: 265-280
-
8 Brimacombe J.. Placement Phase. In: Brimacombe J, ed. Laryngeal Mask Anesthesia. Philadelphia: WB Saunders 2005: 191-234
-
9
Cook TM, Lee G, Nolan JP..
The ProSeal laryngeal mask airway: a review of the literature.
Can J Anaesth.
2005;
52
739-760
-
10
Hohlrieder M, Brimacombe J, Eschertzhuber S, Ulmer H, Keller C..
A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postoperative analgesia requirements following gynaecological laparoscopic surgery.
Anaesthesia.
2007;
62
913-918
-
11 Brimacombe J.. Educational considerations. In: Brimacombe J, ed. Laryngeal Mask Anesthesia. Philadelphia: WB Saunders 2005: 539-549
-
12
Junger A, Klasen J, Hartmann B. et al. .
Shorter discharge time after regional or intravenous anaesthesia in combination with laryngeal mask airway compared with balanced anaesthesia with endotracheal intubation.
Eur J Anaesthesiol.
2002;
19
119-124
-
13
Macario A, Chang PC, Stempel DB, Brock–Utne JG..
A cost analysis of the laryngeal mask airway for elective surgery in adult outpatients.
Anesthesiology.
1995;
83
250-257
-
14
Todd DW..
A comparison of endotracheal intubation and use of the laryngeal mask airway for ambulatory oral surgery patients.
J Oral Maxillofac Surg.
2002;
60
4-5
-
15 Schleppers A.. Vergleichende Prozesskostenanalyse zwischen Larynxmaske und Endotrachealtubus. Hauptstadtkongress, Berlin 2005
-
16
Ahmad NS, Yentis SM..
Laryngeal mask airway and lingual nerve injury.
Anaesthesia.
1996;
51
707-708
-
17
Laxton CH, Kipling R..
Lingual nerve paralysis following the use of the laryngeal mask airway.
Anaesthesia.
1996;
51
869-870
-
18
Majumder S, Hopkins PM..
Bilateral lingual nerve injury following the use of the laryngeal mask airway.
Anaesthesia.
1998;
53
184-186
-
19 Brimacombe J.. Pathophysiology. In: Brimacombe J, ed. Laryngeal Mask Anesthesia. Philadelphia: WB Saunders 2005: 105-136
-
20
Warner MA, Warner ME, Weber JG..
Clinical significance of pulmonary aspiration during the perioperative period.
Anesthesiology.
1993;
78
56-62
-
21 Brimacombe J.. ProSeal LMA for ventilation and airway protection. In: Brimacombe J, ed. Laryngeal Mask Anesthesia. Philadelphia: Saunders 2005: 505-537
-
22
Wenzel V, Idris AH, Banner MJ. et al. .
Respiratory system compliance decreases after cardiopulmonary resuscitation and stomach inflation: impact of large and small tidal volumes on calculated peak airway pressure.
Resuscitation.
1998;
38
113-118
-
23
Brimacombe J, Keller C..
Prime the ProSeal drain tube with lube from a tube!.
Can J Anaesth.
2005;
52
338-339
-
24
Brimacombe J, Keller C..
The ProSeal laryngeal mask airway: A randomized, crossover study with the standard laryngeal mask airway in paralyzed, anesthetized patients.
Anesthesiology.
2000;
93
104-109
-
25
Braun U, Zerbst M, Fullekrug B. et al. .
Ein Vergleich der Larynxmaske (LMA) vom Typ Proseal gegen die Standard–LMA bei anasthesierten, nicht relaxierten Patienten. Ergebnisse einer deutschen Multizenterstudie.
Anasthesiol Intensivmed Notfallmed Schmerzther.
2002;
37
727-733
-
26
Brimacombe J, Keller C, Fullekrug B. et al. .
A multicenter study comparing the ProSeal and Classic laryngeal mask airway in anesthetized, nonparalyzed patients.
Anesthesiology.
2002;
96
289-295
-
27
Maltby JR, Beriault MT, Watson NC, Liepert DJ, Fick GH..
LMA–Classic and LMA–ProSeal are effective alternatives to endotracheal intubation for gynecologic laparoscopy.
Can J Anaesth.
2003;
50
71-77
-
28
Timmermann A, Cremer S, Eich C, Kazmaier S, Bräuer A, Graf BM, Russo SG..
Prospective clinical and fiberoptic evaluation of the Supreme laryngeal mask airway.
Anesthesiology.
2009;
110
262-5
-
29
Timmermann A, Cremer S, Heuer J, Braun U, Graf BM, Russo SG..
Larynxmaske LMA Supreme. Anwendung durch im Airwaymanagement unerfahrenes medizinisches Personal.
Anaesthesist.
2008;
57
970-975
-
30
Verghese C, Ramaswamy B..
LMA–Supreme – a new single–use LMA with gastric access: a report on its clinical efficacy.
Br J Anaesth.
2008;
101
405-410
-
31
Brain AI, Verghese C, Strube PJ..
The LMA 'ProSeal' – a laryngeal mask with an oesophageal vent.
Br J Anaesth.
2000;
84
650-654
-
32
Borkowski A, Perl T, Heuer J, Timmermann A, Braun U..
The Applicability of the ProSeal Laryngeal Mask Airway for Laparotomies.
Anasthesiol Intensivmed Notfallmed Schmerzther.
2005;
40
477-486
-
33
Piper SN, Triem JG, Rohm KD, Maleck WH, Schollhorn TA, Boldt J..
Ein Vergleich der ProSeal(R)–Larynxmaske mit der konventionellen endotrachealen Intubation bei Laparoskopien in der Gynakologie.
Anasthesiol Intensivmed Notfallmed Schmerzther.
2004;
39
132-137
-
34
Verghese C, Brimacombe JR..
Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage.
Anesth Analg.
1996;
82
129-133
-
35
Lu PP, Brimacombe J, Yang C, Shyr M..
ProSeal versus the Classic laryngeal mask airway for positive pressure ventilation during laparoscopic cholecystectomy.
Br J Anaesth.
2002;
88
824-827
-
36
Maltby JR, Beriault MT, Watson NC, Liepert D, Fick GH..
The LMA–ProSeal is an effective alternative to tracheal intubation for laparoscopic cholecystectomy.
Can J Anaesth.
2002;
49
857-862
-
37
Stevens RA, Mikat–Stevens M, Flanigan R. et al. .
Does the choice of anesthetic technique affect the recovery of bowel function after radical prostatectomy?.
Urology.
1998;
52
213-218
-
38
Iwama H, Nakane M, Ohmori S, Kato M, Kaneko T, Iseki K..
Propofol dosage achieving spontaneous breathing during balanced regional anesthesia with the laryngeal mask airway.
J Clin Anesth.
2000;
12
189-195
-
39
Brimacombe JR, Wenzel V, Keller C..
The proseal laryngeal mask airway in prone patients: a retrospective audit of 245 patients.
Anaesth Intensive Care.
2007;
35
222-225
-
40
Kette F, Reffo I, Giordani G. et al. .
The use of laryngeal tube by nurses in out–of–hospital emergencies: preliminary experience.
Resuscitation.
2005;
66
21-25
-
41
Klaver NS, Kuizenga K, Ballast A, Fidler V..
A comparison of the clinical use of the Laryngeal Tube S and the ProSeal Laryngeal Mask Airway by first–month anaesthesia residents in anaesthetised patients.
Anaesthesia.
2007;
62
723-727
-
42
Kikuchi T, Kamiya Y, Ohtsuka T, Miki T, Goto T..
Randomized prospective study comparing the laryngeal tube suction II with the ProSeal laryngeal mask airway in anesthetized and paralyzed patients.
Anesthesiology.
2008;
109
54-60
-
43
Kurola J, Pere P, Niemi–Murola L. et al. .
Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA by paramedical students in anaesthetized patients.
Acta Anaesthesiol Scand.
2006;
50
40-44
-
44
Caplan RA, Posner KL, Ward RJ, Cheney FW..
Adverse respiratory events in anesthesia: a closed claims analysis.
Anesthesiology.
1990;
72
828-833
-
45
Tiret L, Desmonts JM, Hatton F, Vourc'h G..
Complications associated with anaesthesia – a prospective survey in France.
Can Anaesth Soc J.
1986;
33
336-344
-
46
Braun U, Goldmann K, Hempel V, Krier C..
Airway Management. Leitlinie der Deutschen Gesellschaft für Anästhesiologie.
Anaesth Intensivmed.
2004;
45
302-306
-
47
Heidegger T, Gerig HJ, Henderson JJ..
Strategies and algorithms for management of the difficult airway.
Best Pract Res Clin Anaesthesiol.
2005;
19
661-674
-
48
Heidegger T, Starzyk L, Villiger CR. et al. .
Fiberoptic intubation and laryngeal morbidity: a randomized controlled trial.
Anesthesiology.
2007;
107
585-590
-
49
Cook TM, Silsby J, Simpson TP..
Airway rescue in acute upper airway obstruction using a ProSeal Laryngeal mask airway and an Aintree catheter: a review of the ProSeal Laryngeal mask airway in the management of the difficult airway.
Anaesthesia.
2005;
60
1129-1136
-
50
Ferson D, Chi TL..
Developments in general airway management.
Thorac Surg Clin.
2005;
15
39-53
-
51
Dimitriou V, Voyagis GS..
Light–guided intubation via the intubating laryngeal mask using a prototype illuminated flexible catheter. Clinical experience in 400 patients.
Acta Anaesthesiol Scand.
2000;
44
1002-1006
-
52
Timmermann A, Russo S, Graf BM..
Evaluation of the CTrach – an intubating LMA with integrated fibreoptic system.
Br J Anaesth.
2006;
96
516-521
-
53
Timmermann A, Russo S, Natge U, Heuer J, Graf BM..
LMA CTrach: Erste Erfahrungen bei Patienten mit schwieriger Atemwegssicherung.
Anaesthesist.
2006;
55
528-534
-
54
Nickel EA, Timmermann A, Roessler M, Cremer S, Russo SG..
Out–of–hospital airway management with the LMA CTrach – A prospective evaluation.
Resuscitation.
2008;
79
212-218
-
55
Braun U..
Gazette Synopsis of the Practice Guidelines for Airway Management of the German Society of Anaesthesiology and Intensive Care Medicine.
The Airway Gazette.
2006;
10
9-12
-
56
Langeron O, Masso E, Huraux C. et al. .
Prediction of difficult mask ventilation.
Anesthesiology.
2000;
92
1229-1236
-
57
Asai T, Koga K, Vaughan RS..
Respiratory complications associated with tracheal intubation and extubation.
Br J Anaesth.
1998;
80
767-775
-
58
el–Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD..
Preoperative airway assessment: predictive value of a multivariate risk index.
Anesth Analg.
1996;
82
1197-1204
-
59
Rose DK, Cohen MM..
The airway: problems and predictions in 18,500 patients.
Can J Anaesth.
1994;
41
372-383
-
60
von Goedecke A, Voelckel WG, Wenzel V. et al. .
Mechanical versus manual ventilation via a face mask during the induction of anesthesia: a prospective, randomized, crossover study.
Anesth Analg.
2004;
98
-
61
Wenzel V, Idris AH, Banner MJ, Kubilis PS, Williams Jr. JL.
Influence of tidal volume on the distribution of gas between the lungs and stomach in the nonintubated patient receiving positive–pressure ventilation.
Crit Care Med.
1998;
26
364-368
-
62
Pearce A..
Evaluation of the airway and preparation for difficulty.
Best Pract Res Clin Anaesthesiol.
2005;
19
559-579
-
63
Baraka AS, Taha SK, El–Khatib MF, Massouh FM, Jabbour DG, Alameddine MM..
Oxygenation using tidal volume breathing after maximal exhalation.
Anesth Analg.
2003;
97
1533-1535
-
64
McGowan P, Skinner A..
Preoxygenation – the importance of a good face mask seal.
Br J Anaesth.
1995;
75
777-778
-
65
Mertzlufft F, Zander R..
Optimale O2–Applikation uber den nas–oralen Weg.
Anasthesiol Intensivmed Notfallmed Schmerzther.
1996;
31
381-385
-
66
Heck Z, Stegmann JU, Lorenz C, Heck M, Schlack W..
Akzeptanz der Praoxygenierung in der klinischen Routine.
Anasthesiol Intensivmed Notfallmed Schmerzther.
2001;
36
471-475
-
67
Kasper SM, Lucke S..
(The unexpectedly difficult airway – a plea for the oxford–non–kinking–tube. Anasthesiol Intensivmed Notfallmed Schmerzther. 2004; 39:610–5).
Anasthesiol Intensivmed Notfallmed Schmerzther.
2005;
40
124
-
68
Combes X, Le Roux B, Suen P. et al. .
Unanticipated difficult airway in anesthetized patients: prospective validation of a management algorithm.
Anesthesiology.
2004;
100
1146-1150
-
69
Bein B, Wortmann F, Meybohm P, Steinfath M, Scholz J, Dorges V..
Evaluation of the pediatric Bonfils fiberscope for elective endotracheal intubation.
Paediatr Anaesth.
2008;
18
1040-1044
-
70
Bein B, Yan M, Tonner PH, Scholz J, Steinfath M, Dorges V..
Tracheal intubation using the Bonfils intubation fibrescope after failed direct laryngoscopy.
Anaesthesia.
2004;
59
1207-1209
-
71
Matsumoto S, Asai T, Shingu K..
TruViewEVO2 videolaryngoscope.
Masui.
2007;
56
213-217
-
72
Shippey B, Ray D, McKeown D..
Use of the McGrath videolaryngoscope in the management of difficult and failed tracheal intubation.
Br J Anaesth.
2008;
100
116-119
-
73
O'Leary AM, Sandison MR, Myneni N, Cirilla DJ, Roberts KW, Deane GD..
Preliminary evaluation of a novel videolaryngoscope, the McGrath series 5, in the management of difficult and challenging endotracheal intubation.
J Clin Anesth.
2008;
20
320-321
-
74 Hofstetter C, Scheller B, Flondor M. et al. .Videolaryngoskopie versus direkte Laryngoskopie zur elektiven endotrachealen Intubation. Anaesthesist 2006
-
75
Cooper RM..
Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway.
Can J Anaesth.
2003;
50
611-613
-
76
Cooper RM..
The GlideScope videolaryngoscope.
Anaesthesia.
2005;
60
1042
-
77
Weiss M, Schwarz U, Dillier CM, Gerber AC..
Teaching and supervising tracheal intubation in paediatric patients using videolaryngoscopy.
Paediatr Anaesth.
2001;
11
343-348
-
78
Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology.
2003;
98
1269-1277
-
79
Baraka AS..
Tension pneumothorax complicating jet ventilation via a cook airway exchange catheter.
Anesthesiology.
1999;
91
557-558
-
80
Gold MI, Buechel DR..
Translaryngeal anesthesia: a review.
Anesthesiology.
1959;
20
181-185
-
81
Timmermann A, Eich C, Nickel E. et al. .
Simulation und Atemwegsmanagement.
Anaesthesist.
2005;
54
582-587
-
82
Timmermann A, Russo SG, Crozier TA. et al. .
Laryngoscopic versus intubating LMA guided tracheal intubation by novice users – A manikin study.
Resuscitation.
2007;
73
412-416
-
83
Timmermann A, Russo SG, Crozier TA. et al. .
Novices Ventilate and Intubate Quicker and Safer via Intubating Laryngeal Mask Than by Conventional Bag–Mask Ventilation and Laryngoscopy.
Anesthesiology.
2007;
107
570-576
-
84
Keller C, Brimacombe J..
Bronchial mucus transport velocity in paralyzed anesthetized patients: a comparison of the laryngeal mask airway and cuffed tracheal tube.
Anesth Analg.
1998;
86
1280-1282
-
85 Steinmann D, Priebe HJ.. Krikoiddruck. Anaesthesist 2009
PD Dr. med. Arnd Timmermann
eMail: atimmer@med.uni-goettingen.de
