European Journal of Cardiovascular Medicine

The management of airways requires the use of supraglottic airway devices, or SADs.(1) In any situation where intubation cannot be done, the use of SADs in order to facilitate tracheal intubation is advised by several guidelines.(2, 3)

The FastrachTM-laryngeal mask airway (FT-LMA, Laryngeal Mask Company, Jersey, United kingdom) was designed to allow for both ventilating and the blind insertion of a tracheal tube into the trachea.(4,5)

Several successful intubations have been performed for both expected and unexpectedly difficult airways, and blind tracheal intubation is generally successful. Nonetheless,    Fastrach-LMA has certain drawbacks, such as hardness of airway tube, which restricts its long-term usage. Also, the tracheal tube needed is a different and exorbitant. Furthermore, it is not present for pediatric age group.(6,7)

The Aura-i, a single-use intubating SAD from Ambu USA, is meant to be used for tracheal intubation as well as ventilation.(8,9) If a fiberscope is to be inserted during intubation, it features navigation markings, a biting block, and a 90° prepared curve. Eight distinct sizes are offered for the Aura-i to accommodate all age groups. There are reports of successful intubations with it, despite difficult airway clearance.(9–15)

The Ambu aura-I and FastrachTM Intubating Laryngeal Mask Airway (ILMA) represent innovative advancements in airway management, offering a reliable and efficient alternative for tracheal intubation. The AMBU Aura-I features a unique anatomically curved design and integrated suction capabilities, enhancing both ease of insertion and patient safety during airway management procedures. On the other hand, the FastrachTM

Lacuna in Knowledge

ILMA combines the benefits of a laryngeal mask airway with a guiding mechanism for tracheal tube placement, facilitating swift and accurate intubation even in challenging situations. These devices are particularly crucial in emergency scenarios or difficult airway situations where traditional intubation methods may be impractical or unsuccessful. Their significance lies in their ability to provide a secure airway and ensure optimal patient outcomes while minimizing the risk of complications associated with conventional intubation techniques.(16)

After extensive research on the literature, it is discovered that there is insufficient information available regarding the Ambu Aura-i tracheal intubation assessment. Thus, the objective of the present study is to compare adult Fastrach- LMA with Aura-i for tracheal intubation procedures

Objectives:

Primary- To evaluate the effectiveness of intubation with FastrachTM LMA and Ambu aura-i in Anticipated Difficult Airway Management

Secondary- To evaluate the time taken and number of attempts for intubation with FastrachTM and Ambu Aura-i in Anticipated Difficult Airway Management

Adult patients with an anticipated difficult intubation undergoing scheduled surgery who required tracheal intubation with general anaesthesia were prospectively included in the study after informed consent taken Study Design: A Randomized interventional two group comparative prospective clinical study Sample Size: 50 (25 in each group) 50 (25 in each group) Formula Sample size estimation with two means N = ( r+1) (Z α/2 + Z 1-β)2σ2 rd2 Where, Zα is normal deviate at a level of significance (Zα is 1.96 for 5% level of significance and 2.58 for 1% level of significance) Z 1-ẞ is the normal deviate at 1-8% power with ẞ5 of Type II error (0.84 at 80% power and 1.28 at 90% statistical power) R=n1n2 is the ratio of sample size required for 2 groups, generally it is one for keeping equal sample size for 2 groups. d and σ are pooled standard deviation and difference of mean of two groups. Duration of study: 18 months Study Participants: This study was conducted on patients posted for procedures under General Anaesthesia with Anticipated Difficult Airway Management at R L Jalappa Hospital and Research Centre, Tamaka, Kolar. Sampling Method: Computer generated random sequence of numbers and concealed by closed envelope technique. Inclusion Criteria • Age 18 to 60 years • ASA 1 and 2 Exclusion Criteria • Younger than 18 years old • American Society of Anaesthesiologists physical status IV or V • Diagnosed with respiratory tract pathology or coagulation disorders requiring a nasal route for tracheal intubation • Those at risk of regurgitation–aspiration (previous upper gastrointestinal tract surgery, known hiatus hernia, oesophageal reflux, peptic ulceration, or not fasted). SAMPLING PROCEDURE: 1. Detailed history of the patient 2. Complete physical examination was done. 3. Routine investigations were checked. 4. Intravenous line was secured and IV fluids will be connected. 5. Patients were divided into two groups randomly. Group A: Pre-emptive multimodal group with anticipated difficult intubation were intubated with FastrachTM Laryngeal Mask Airway. Group B: Pre-emptive multimodal group with anticipated difficult intubation were intubated with Ambu Aura-i Laryngeal Mask Airway. Using a data collection form, concerned anesthesiologist and an assistant recorded the following information: the number of total attempts, the time taken for the successful attempt (the time interval between the insertion of the device and the confirmation of end-tidal carbon dioxide), the technique's success or failure, and the anaesthetic doses used. Measurements of hemodynamics were made all along the process. Unfavorable incidents that occurred during tracheal intubation were noted. These included bronchospasm, soft tissue damage with hemorrhage, and oxygen desaturation (saturation of 90%). Parameters to be observed • Heart rate • Mean arterial pressure • Oxygen Saturation • Time taken for intubation • Number of attempts for intubation STATISTICAL ANALYSIS Excel sheets with data were filled in, and SPSS v23.0 running on Windows 10 was used for analysis. The mean, standard deviation, frequency, and percentage of the data were summarised. Tables, figures, and bar diagrams were used to illustrate the summarised data. The average difference between follow-up data using a paired t-test and continuous data compared using an unpaired t-test. The chi-square test was used to compare the category data. A p-value of less than 0.05 was considered statistically significant for all purposes of statistics

In present study total of 50 patients fulfilling inclusion criteria are included with mean age of 40.31±12.1yrs. They were divided into two groups according to the study procedure as

Group A:  Pre-emptive multimodal group with anticipated difficult intubation were intubated with Fastrach^TM Laryngeal Mask Airway.

Group B: Pre-emptive multimodal group with anticipated difficult intubation were intubated with Ambu Aura-i Laryngeal Mask Airway.

TAble 1: Comparison of mean age between the groups

There is no significant difference in mean age of the patients between the groups.

Table 2: Distribution of gender and ASA grade between the groups

Among included patients, there is no significant difference in the gender distribution between the groups, however there is overall female preponderance in the present study. The ASA grade was also comparable between the groups.

Table 3: Comparison of mean weight, height and BMI between the groups

Among the patients, the physical characters such as weight, height and BMI were comparable between the groups.

Table 4: Comparison of the mean heart rate between the groups

The heart rate was comparable between the groups at the preintubation period. Post intubation there is significant lower mean heart rate in group A patients at 3min. however other period of time it was comparable with no significant difference noted.

Table 5: Comparison of mean systolic blood pressure between the groups

On assessment of the systolic blood pressure, there is no significant difference in the mean SBP between the groups.

Table 6: Comparison of mean diastolic blood pressure between the groups

On assessment of diastolic blood pressure at pre and post intubation period, there is no significant difference in DBP between the groups.

Table 7: Comparison of the mean arterial pressure between the groups

On assessment of the mean arterial pressure at pre and post intubation period, there is no significant difference in MAP between the groups.

Table 8: Comparison of the oxygen saturation between the groups

On assessment of the oxygen saturation between the groups, there is no significant difference noted between them.

Table 9: Comparison of the SAD insertion time and tracheal tube insertion time between the groups

On assessment of the SAD insertion time between the groups, the mean time required is comparable with no significant difference noted.

Similarly, on assessment of the tracheal tube insertion time, there is significant short time required in group A (16.1±2.0sec) patients compared to group B (19.1±1.9sec). (p<0.05)

Table 10: Comparison of number of attempts for SAD insertion and tracheal tube insertion between the groups

On comparison of the number of attempts required for SAD insertion and tracheal tube insertion between the groups, the results were statistically comparable. However, there is higher incidence of 2^nd attempt to insert the SAD and Tracheal tube in group B (16%) compared to group A (8%).(p>0.05)

Table 11: Comparison of the blood on SAD and sore throat between the groups

On assessment of the complications, there is no significant difference in the presence of blood on SAD and sore throat reported between the groups. However, there is higher incidence of blood on SAD and sore throat among the patients of group B (12% & 12% respectively) compared to patients in group A (4% & 8% respectively).

When conventional intubation techniques are impractical or ineffective, use of supraglottic airway devices (SADs) has become a crucial part of managing difficult airways. The Ambu Aura-i and the FastrachTM Intubating Laryngeal Mask Airway (ILMA) are two of the most widely used of these devices because of their ability to operate as both ventilation and tracheal intubation conduits. With its prepared curvature and inbuilt navigation markers, the Ambu Aura-i is a single-use gadget that may be used by patients of various ages. Conversely, the Fastrach™ ILMA, designed for both ventilation and blind intubation, is noted for its guiding mechanism that facilitates accurate tracheal tube placement. Despite the advancements each device offers, comparative data on their performance in anticipated difficult airway scenarios remain sparse. The objective of this conversation is to assess the Ambu Aura-i and FastrachTM ILMA critically in terms of efficacy, efficiency, and safety. Specific topics of discussion include success rates for intubations, ease of insertion, time efficiency, and related issues. Through this comparative analysis, we aim to provide insights that can guide the selection of the most appropriate SAD for managing challenging airway conditions. The findings from this study, which compared the effectiveness of the Ambu Aura-i and Fastrach™ Intubating Laryngeal Mask Airways (LMA in tracheal intubation among 25 patients, offer valuable insights into their clinical performance. Both devices were evaluated in patients with anticipated difficult airways, split up into two groups: Group A, intubated using Fastrach™ LMA, and Group B, intubated using Ambu Aura-i LMA. The mean age of the patients in the groups was similar in the current study. Marginal female preponderance is noted in study by Mishra et al. also the physical character between the group were comparable.(16) Except for a lower mean heart rate in Group A three minutes after intubation, hemodynamic parameters such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) did not significantly differ between the groups during the pre- and post-intubation periods. Throughout the process, there was no significant difference in the groups' oxygen saturation levels. In similar to present study Salahu D et al., found hemodynamic responses did not differ significantly between ILMA and DL during endotracheal intubation with propofol, fentanyl, and suxamethonium. However, the ILMA group experienced significantly longer intubation times compared to the DL group. (15) In similar to present study Mishra et al., also revealed similar blood pressure, MAP, oxygen saturation, and mean heart rate among the groups. (16) In another study by Anand L et al., also found female preponderance in both group and mean age of patients comparable between both the groups. Also, the ASA grade and physical attributes like height, weight, and BMI were similar between the groups.(1) Hemodynamically both the Aura-I airway and FT-LMA were comparable between the group during pre and post intubation in study done by Anand L et al.(1) The study found that while the time required for supraglottic airway device (SAD) insertion was similar in both groups, Group A had a significantly shorter tracheal tube insertion time (16.1±2.0 seconds) compared to Group B (19.1±1.9 seconds) (p<0.05). Additionally, Group B required more second attempts for both SAD and tracheal tube insertion (16%) compared to Group A (8%). Despite this, the difference was not statistically significant. Complication rates, including presence of blood on SAD and reports of sore throat, were slightly higher in Group B. However, these variations fell short of statistical significance. According to the current research Anand L et al., documented higher number of attempts for SAD and tracheal tube insertion in Aura I airway tube group 2 compared to the patients in FT-LMA group 1 group. Also there is higher incidence of the sorethroat among group 2 patients compared to group 1. But in their study, it was not statistically significant.(1) According to the research conducted by Solarajan S et al., the majority of patients from groups B (95%) and F (82.5%) reported that inserting LMA was easy. In comparing the performance of the Fastrach™ LMA (Group F) and the Blockbuster LMA (Group B), significant differences were observed in several key areas. For LMA insertion, 7 patients in Group F (17.5%) required two attempts, whereas only 1 patient in Group B (2.5%) needed a second attempt. This suggests a higher initial success rate with the Blockbuster LMA. Both groups exhibited similar ease in endotracheal tube (ETT) intubation overall; however, Group F had a slightly higher incidence of requiring two attempts for ETT placement, affecting 8 patients (20%) compared to just 2 patients (5%) in Group B. Post-operatively, Group F also demonstrated a higher occurrence of complications, specifically sore throats and blood stains, when compared to Group B. In conclusion, the Blockbuster LMA showed superior performance in terms of initial success rates for both LMA insertion and ETT intubation, along with fewer post-operative complications, while both devices achieved a 100% success rate for overall intubation.(18) In study by Zhi J et al., the time needed for Ambu Aura-I to be inserted was not significantly different from that of other groups. They documented lower blood staining in Ambu Aura I group compared to the SaCoVLM group. (17) In study by Mishra N et al., the number of attempts to intubate using ILMA/Ambu Aura-i did not significantly differ from one another. In their study Ambu Aura-i demonstrated superior performance over ILMA, less time is needed for a successful insertion, making it a potentially better independent ventilatory device.(16) In line with findings, Karim YM et al., recorded that the LMA Fastrach group had a 100% success rate for successful intubation after three tries, whereas the Air-Q group had a 95% success rate. These findings imply that when it comes to facilitating blind tracheal intubation, the single-use LMA Fastrach outperforms the Air-Q.(11) Study found that the Fastrach™ Intubating Laryngeal Mask Airway (LMA) outperformed the Ambu Aura-i LMA, particularly with shorter tracheal tube insertion times and fewer insertion attempts. Although both devices effectively managed difficult airways, the Fastrach™ LMA provided advantages in ease and efficiency, making it a potentially better choice for situations requiring quick and reliable tracheal intubation.

In conclusion, the Fastrach™ LMA demonstrated a marginally superior performance over the Ambu Aura-i LMA, particularly in terms of shorter tracheal tube insertion times and fewer attempts required for successful insertion. Both devices are effective for managing difficult airways, but there could be some benefits to using FastrachTM LMA in terms of usability and effectiveness. This study supports the use of Fastrach™ LMA as a potentially more effective option in scenarios where rapid and reliable tracheal intubation is critical.

1. Anand L, Singh M, Kapoor D, Singh A. Comparative evaluation of Ambu Aura-i           and FastrachTM intubating laryngeal mask airway for tracheal intubation: A                     randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2019;35(1):70–5.

2.             Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL,                et al. Obstetric Anaesthetists’ Association and Difficult Airway Society                       guidelines for the management of difficult and failed tracheal intubation in                 obstetrics. Anaesthesia. 2015;70(11):1286–306.

3.             Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al.         Difficult Airway Society 2015 guidelines for management of unanticipated         difficult intubation in adults. BJA Br J Anaesth. 2015;115(6):827–48.

4.             Gerstein NS, Braude DA, Hung O, Sanders JC, Murphy MF. The Fastrach             intubating laryngeal mask airway. an Overv Updat. 2010;2010:57.

5.             Brain AI, Verghese C, Addy E V, Kapila A. The intubating laryngeal mask. I:      Development of a new device for intubation of the trachea. Br J Anaesth. 1997;79(6):699–703.

6.             Lu P-P, Yang C-H, Ho ACY, Shyr M-H. The intubating LMA: a comparison of   insertion techniques with conventional tracheal tubes. Can J Anaesth.         2000;47:849–53.

7.             Jagannathan N, Sohn LE, Sawardekar A, Gordon J, Shah RD, Mukherji II, et al.                 A randomized trial comparing the Ambu® Aura‐iTM with the air‐QTM              intubating laryngeal airway as conduits for tracheal intubation in children. Pediatr                 Anesth. 2012;22(12):1197–204.

8.             Kundra P, Sujata N, Ravishankar M. Conventional tracheal tubes for intubation                through the intubating laryngeal mask airway. Anesth Analg. 2005;101(4):1245.

9.             Altamirano A, Artime C, Normand K, Ferrario L, Maheshwari P, Aijazi H, et al.   Flexible optical intubation via the Ambu aura-i versus blind intubation via the          single use intubating LMA-a prospective randomized clinical trial. Anesthesiol A.                2013;3252.

10.          Fukutome T, Amaha K, Nakazawa K, Kawamura T, Noguchi H. Tracheal           intubation through the intubating laryngeal mask airway (LMA-FastrachTM) in          patients with difficult airways. Anaesth Intensive Care. 1998;26(4):387–91.

11.          Karim YM, Swanson DE. Comparison of blind tracheal intubation through the   intubating laryngeal mask airway (LMA FastrachTM) and the Air‐QTM.       Anaesthesia. 2011;66(3):185–90.

12.          Neoh EU, Choy YC. Comparison of the air-Q ILATM and the LMA-FastrachTM               in airway management during general anaesthesia. South African J Anaesth             Analg. 2012;18(3):150–5.

13.          De Lloyd LJ, Subash F, Wilkes AR, Hodzovic I. A comparison of                            fibreoptic‐guided tracheal intubation through the Ambu® Aura‐iTM, the       intubating laryngeal mask airway and the i‐gelTM: a manikin study.     Anaesthesia. 2015;70(5):591–7.

14.          Kavitha J, Tripathy DK, Mishra SK, Mishra G, Chandrasekhar LJ, Ezhilarasu P. Intubating condition, hemodynamic parameters and upper airway morbidity: A        comparison of intubating laryngeal mask airway with standard direct    laryngoscopy. Anesth Essays Res. 2011;5(1):48–56.

15.          Salahu D, Usman N, Mamuda A. Haemodynamic Changes Associated with        Tracheal Intubation Using Direct Laryngoscopyand Intubating Laryngeal Mask            Airway: A Comparative Analysis. J Med Basic Sci Res. 2022;3(2):141–7.

16.          Mishra N, Bharadwaj A. Comparison of Fiberoptic-guided tracheal intubation     through intubating laryngeal mask airway (ILMA) FastrachTM and Ambu®   Aura-iTM: a randomized clinical study. Cureus. 2020;12(9).

17.          Zhi J, Yan F-X, Wei L-X, Yang D, Deng X-M. Intubation using video laryngeal    mask airway SaCoVLM and laryngeal mask airway Ambu® Aura-i in   anesthetized children with microtia: a randomized controlled study. J Clin Monit                Comput. 2023;37(3):857–65.

18.          Solarajan S, Murukan MS, Monica G, Nanthaprabu M, Thalaiappan M. A study               to compare the intubating laryngeal mask airway blockbuster and the laryngeal mask airway fastrach as an airway tool in general anaesthesia. Int J Acad Med Pharm. 2023;5(2):236–9.

1. Anand L, Singh M, Kapoor D, Singh A. Comparative evaluation of Ambu Aura-i           and FastrachTM intubating laryngeal mask airway for tracheal intubation: A                     randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2019;35(1):70–5.

2.             Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL,                et al. Obstetric Anaesthetists’ Association and Difficult Airway Society                       guidelines for the management of difficult and failed tracheal intubation in                 obstetrics. Anaesthesia. 2015;70(11):1286–306.

3.             Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al.         Difficult Airway Society 2015 guidelines for management of unanticipated         difficult intubation in adults. BJA Br J Anaesth. 2015;115(6):827–48.

4.             Gerstein NS, Braude DA, Hung O, Sanders JC, Murphy MF. The Fastrach             intubating laryngeal mask airway. an Overv Updat. 2010;2010:57.

5.             Brain AI, Verghese C, Addy E V, Kapila A. The intubating laryngeal mask. I:      Development of a new device for intubation of the trachea. Br J Anaesth. 1997;79(6):699–703.

6.             Lu P-P, Yang C-H, Ho ACY, Shyr M-H. The intubating LMA: a comparison of   insertion techniques with conventional tracheal tubes. Can J Anaesth.         2000;47:849–53.

7.             Jagannathan N, Sohn LE, Sawardekar A, Gordon J, Shah RD, Mukherji II, et al.                 A randomized trial comparing the Ambu® Aura‐iTM with the air‐QTM              intubating laryngeal airway as conduits for tracheal intubation in children. Pediatr                 Anesth. 2012;22(12):1197–204.

8.             Kundra P, Sujata N, Ravishankar M. Conventional tracheal tubes for intubation                through the intubating laryngeal mask airway. Anesth Analg. 2005;101(4):1245.

9.             Altamirano A, Artime C, Normand K, Ferrario L, Maheshwari P, Aijazi H, et al.   Flexible optical intubation via the Ambu aura-i versus blind intubation via the          single use intubating LMA-a prospective randomized clinical trial. Anesthesiol A.                2013;3252.

10.          Fukutome T, Amaha K, Nakazawa K, Kawamura T, Noguchi H. Tracheal           intubation through the intubating laryngeal mask airway (LMA-FastrachTM) in          patients with difficult airways. Anaesth Intensive Care. 1998;26(4):387–91.

11.          Karim YM, Swanson DE. Comparison of blind tracheal intubation through the   intubating laryngeal mask airway (LMA FastrachTM) and the Air‐QTM.       Anaesthesia. 2011;66(3):185–90.

12.          Neoh EU, Choy YC. Comparison of the air-Q ILATM and the LMA-FastrachTM               in airway management during general anaesthesia. South African J Anaesth             Analg. 2012;18(3):150–5.

13.          De Lloyd LJ, Subash F, Wilkes AR, Hodzovic I. A comparison of                            fibreoptic‐guided tracheal intubation through the Ambu® Aura‐iTM, the       intubating laryngeal mask airway and the i‐gelTM: a manikin study.     Anaesthesia. 2015;70(5):591–7.

14.          Kavitha J, Tripathy DK, Mishra SK, Mishra G, Chandrasekhar LJ, Ezhilarasu P. Intubating condition, hemodynamic parameters and upper airway morbidity: A        comparison of intubating laryngeal mask airway with standard direct    laryngoscopy. Anesth Essays Res. 2011;5(1):48–56.

15.          Salahu D, Usman N, Mamuda A. Haemodynamic Changes Associated with        Tracheal Intubation Using Direct Laryngoscopyand Intubating Laryngeal Mask            Airway: A Comparative Analysis. J Med Basic Sci Res. 2022;3(2):141–7.

16.          Mishra N, Bharadwaj A. Comparison of Fiberoptic-guided tracheal intubation     through intubating laryngeal mask airway (ILMA) FastrachTM and Ambu®   Aura-iTM: a randomized clinical study. Cureus. 2020;12(9).

17.          Zhi J, Yan F-X, Wei L-X, Yang D, Deng X-M. Intubation using video laryngeal    mask airway SaCoVLM and laryngeal mask airway Ambu® Aura-i in   anesthetized children with microtia: a randomized controlled study. J Clin Monit                Comput. 2023;37(3):857–65.

18.          Solarajan S, Murukan MS, Monica G, Nanthaprabu M, Thalaiappan M. A study               to compare the intubating laryngeal mask airway blockbuster and the laryngeal mask airway fastrach as an airway tool in general anaesthesia. Int J Acad Med Pharm. 2023;5(2):236–9.