The use of the Ambu intubation SGA,Aura-i, in difficult airways
Anette Kristiansen, Clinical Research Specialist, Ambu A/S.

This document reports 3 cases in which the intubation SGA, Ambu Aura-i, was used in diffcult airways. The first case is a
7 years-old girl, weighing 30 kg, who had previous history of difficult airway. The 2 other cases are adult patients in whom
Aura-i was also used to intubate. This reports ilustrate the potential of intubating SGA to deal with predicted and unpredicteddifficut airways.

and good local anesthesia. When the optical scope was entering thepharynx, the anesthesiologist lost track of his landmarks and was notable to identify trachea or any other landmarks in the larynx.
Therefore he called for assistance and soon after 3 anesthesiologists
and 2 anesthetic nurses were attending the case. The 2nd and moreskilled anesthesiologist took over a scope but was not able toidentify any of the landmarks. The patient had to this point stopped
breathing because of the anesthesia and analgesia given. His
oxygenation was decreasing and one of the anesthesiologist
requested an Ambu Aura-i.

Infant with a predicted difficult airway
The patient was a 7 years-old girl, who suffered from a very seldom
disease which caused her to have extreme stiffness of the neck, little
mouth opening due to a stiffness in the jaw. She had been intubatedat Rigshospitalets ENT Department before but it had been very
difficult. The anaethesiologists knew that it was possible to ventilate
her. She was therefore inhaled to sleep with Sevoflurane (gas anesthesia)
and kept on spontaneous ventilation.
A size 3 Aura-i was successfully inserted and after placement of thelaryngeal mask there was a free airway with a sufficient CO2 curveand saturation was 100%.

Once the Ambu Aura-i was inserted into the patient a flexible opticalscope was railroaded via the airway tube of Aura-i. All anatomical
landmarks became visual and as soon as the epiglottic, vocal cords
and trachea were identified the patient was successfully intubated.

A wiretube size 5.0 was inserted through the Aura-i and placed justoutside the airway tube of Aura-i (in the hypopharynx). The cuff ofthe ET tube was inflated and the circle system was connected to thewiretube, still with a free airway. Sufficient CO2 curve and 100%
saturation were obtained.

59 years-old patient with a difficult airway scheduled
for cholecystoscopy
A 59 year old woman was scheduled for a cholecystoscopy. The plan
was to intubate her using direct laryngoscopy, she was a Mallampati I
or II and didn’t have any other signs of a difficult airway besides aBMI of 37,5 (weighing 104, height 167).

A fiber-optic scope was inserted through the wiretube and provided aclear that there was a view of the epiglottis. The doctor made a gentle
jaw lift (her jaw was very stiff). (A size 3 was probably a little too big
and the jaw lift might not have been necessary with a Aura-i size 2,5).
When going through the Aura-i there was a full optical view and thefiber-optic was inserted till just above the carina. The wire tube wasrailroaded over the fiber-optic and the child was successfully intubated.

After induction of anesthesia and analgesia direct laryngoscopy wasperformed but it was difficult to get a good view of epiglottis, and at
2nd attempt there was blood and other secretion plus edema in thehypopharynx and around the laryngeal inlet, which only madeeverything more difficult. The patient was then ventilated with afacemask and a oral airway and it was decided to try with an Aura-i
and the aScope. The Aura-i size 4 was easily inserted and the patient
could be ventilated via the device. An ET tube was railroaded over theaScope and the scope was inserted through the airway of Aura-i.
Once the aScope reached the navigation mark the scope was bended
upwards and a full view of the epiglottis and vocal cords appeared.

The cuff of Aura-i was deflated and Aura-i was removed by using
another ET tube size 5.0. After removal a second look with the fiber
optic was done to verify the correct positioning of the ET tube.
The procedure was documented in the patients journal.
The reasons why this procedure was chosen to this patient were:• an awake flexible optical intubation was not possible due to the ageof the child. It was evaluated that cooperation with the child during
an awake procedure would not be possible.
• the Aura-i could be inserted while the patient was asleep but stillbreathing spontaneously

The patient was easily intubated and the surgical procedure could begin.
During a cholecystoscopy it is important that a gastric tube is placedin the esophagus, because air is inflated into the abdominal cavity,
and this increases the pressure against the stomach which increases
the risk of aspiration. Therefore the surgeon will like to ensure thatthe stomach is empty, and if the pressure is too high the abdominal
content can escape via the gastric tube.

Male patient with a difficult airway
A male patient with a very difficult airway was, due to his anatomy,scheduled for an awake fiber optic intubation. The anesthesiologist incharge initiated the case with a low dose of anesthesia and analgesia
1More and more experts recommend a maximum of 2 intubation
attempts with direct laryngoscopy. If intubation is not successful after
2nd attempt the clinicians could place an intubation supraglottic
airway, such as Aura-i to ensure ventilation. Then, the supraglottic
airway could be used as an intubation conduit.

The anesthesiologist didn’t want to remove the Aura-i with a risk losing
the airway. He decided to place the gastric tube with Aura-i still inserted.
Therefore the cuff of Aura-i was deflated and the anesthesiologist
was able to pass a thick gastric tube behind the Aura-i easily.
After placement of the gastric tube an adrenal cortex was given to
decrease the edema of the pharynx. Once the procedure was over an
exchange catheter was inserted via the ET tube and the patient was
extubated from the trachea with the Aura-i still in place. Whensufficient respiration returned the Aura-i was removed and the patient
was transferred to the post operative recovery unit with the exchange
catheter in place. The next day the patient was withdrawn from thehospital feeling great:)

When following the ASA Airway Algorithm the recommendation is a
maximum of 3 intubation attempts, and if this does not succeed, toplace a supraglottic airway and use it as an intubation conduit. The
reason for not trying more times with a laryngoscope is because it
can damage the mucosa and provoke swelling. Mucosa swelling cancreate a difficult situation in which it will not be possible to place asupraglottic airway.

These cases describe 3 situations in which Aura-i (and aScope) wereused as intubation aids in predicted and unpredicted difficult airways.

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