TAKE NO AIRWAY FOR GRANTED Supraglottic airway devices are your first-line backup if you get caught off guard by a challenging intubation.

Supraglottic airways have become a mainstay of managing the difficult airway. Today you’d be hard-pressed to find an operating room where SGAs aren’t used extensively. Here are 10 tips and techniques to get the most out of these devices.

Keeping an SGA in the edentulous patient.
Edentulous means lacking teeth. A common struggle for anesthesia providers is placing an SGA in a patient with no teeth and watching as it slowly migrates out onto the patient’s chin. Taping it down doesn’t always work; the SGA tube slips from right to left with little or no seal. When tape doesn’t do the trick, try using the commercial tube holder that respiratory uses in the ICU to hold endotracheal tubes. This works in 2 ways. First, the device’s Velcro wraps around the head, so it’s secure. Second, the actual tube holder C-clamp will keep the SGA tube in the center of the patient’s mouth, encouraging correct seating and much less leaking.

Keeping the tongue out of the way during insertion.
I’ve watched many students and providers struggle to place an SGA in the patient with an uncooperative tongue. Either the tongue folds over itself or slips from one side or another, stopping the SGA from seating correctly. To solve this dilemma, I use a basic tongue depressor to hold the rebel tongue in place as I slip the SGA into position.

Stopping the tip of an SGA from flipping.
One of the most frustrating events for providers is when you cannot ‘seat’ an SGA because the tip of the SGA flips backwards during insertion, resulting in a non-existent seal. One of the best ways to avoid this from happening is to not deflate the SGA at all before insertion. Simply take it out of the package and insert it as is, using the tongue depressor. The amount of air in the SGA is enough to help stop the SGA tip from flipping back on you.

An SGA is just a bigger and better oral airway — just leave it there.
It’s common practice in anesthesia to pull an SGA while the patient’s still asleep and place an oral airway to help prevent patients from obstructing in the PACU. However, this just adds an unnecessary step. An SGA is nothing more than a bigger and better oral airway. Leave it there and let the PACU nurses (or the patient) pull it out when they’re ready. It’s no different than taking out an oral airway on a patient, but it works better than any oral airway you can place. It takes a little education with the PACU nurses, but afterward they’ll love it. In addition, you get out of the OR faster so the turnover team can get started.

Fixing the crowing patient.
A crowing patient gets everyone’s attention in the OR. Not only can it be loud and annoying, but also it’s a risk: Crowing patients are having partial laryngospasms or obstructions. There are many ways to skin this cat, but the one that works the best is a combination approach. I give these patients 5-10 mg of IV succinylcholine, suction the airway through the SGA with a soft suction catheter and squirt in a few cc’s of lidocaine from an LTA kit through the SGA. Since partial laryngospasms are often the result of secretions on the cords, I also usually give 0.2 mg of glycopyrrolate IV. To date this has not failed me.

Fixing the patient who chews down on the SGA, resulting in obstruction.
Everyone has made the mistake of letting a patient get “too light” with an SGA in. Usually it’s the young strapping lad who bends the normally straight SGA tube into a 90-degree angle with his teeth. While this may seem innocuous and he’ll let go eventually, the negative inspiratory pressure during his attempts at inspiration against an obstructed tube can result in negative-pressure pulmonary edema. Not something you want to have happen in the elective SGA case. I’ve seen everything from using multiple tongue blades placed on top of each other to “wedge” open the mouth to a rapid bolus of IV propofol or narcotic throwing the patient back into apnea. What works best in my opinion is 10 mg of IV succinylcholine. It works fast and only lasts long enough to push in a few breaths of your volatile anesthetic of choice to get the patient back to a safe anesthetic depth before pulling the SGA or continuing the surgery.

Lube where the tube meets the mask of the SGA.
To effectively place an SGA, you have to use some lube for placement. But don’t place gobs of lube on the back of the mask and tip of the SGA. Not only does this do little to help with placement, but it can be a risk for partial laryngospasm. The portion of the SGA that needs the most lube during placement is the portion of the tube just distal to the mask. This portion sees the most friction going in against the palate. Placing a small amount of lube where the tube meets the mask will ease insertion and avoid any unintentional partial laryngospasms.

Doing a bronchoscopy case? Use an SGA.
Bronchoscopy cases can be challenging. There have been 2 prevailing ways to do these cases: straight sedation and with an endotracheal tube. Straight sedation often results in obstruction requiring significant airway manipulation; the act of paralyzing and intubating patients comes with its own risks. One easy way to accomplish these cases is to place an SGA, attach the bronchoscope connector with the port to the back of the SGA and proceed. This way you have a spontaneously ventilating patient with a secure airway without the risk of constant obstruction or the risks association with intubation.

Your ETT’s pulled out in the prone or lateral position? Use an SGA.
Having an ETT pulled out in the prone or lateral position has happened to me on more than one occasion. Depending on the surgery, it isn’t always as simple as placing the patient supine and reintubating. Besides, few providers are skilled at lateral and prone intubations. The first thing you should do is place an SGA and continue to keep the patient anesthetized and ventilated. This gives you time until you have an optimal chance to reintubate.

You have a difficult mask ventilation or a difficult airway? Use an SGA.
We saved a common airway challenge for last. We’ve all come across the patient who, after inducing with propofol narcotic and paralytic, is apneic and all of a sudden hard to ventilate — but not paralyzed enough to intubate. For the hard-to-ventilate patient, placing an SGA gets all of the soft tissue out of the way and often results in an easier mask until you’re ready for an intubation attempt. Additionally, if you try and fail to intubate a patient, a quick SGA placement can keep your patient ventilated until someone brings the video laryngoscope to you. Or, if you have it available, you could use an intubating SGA and place the ETT through it.