NONINVASIVE POSITIVE

PRESSURE VENTILATION
DR AMRITHA GEORGE
WHAT IS NIV?

• Delivery of positive pressure

ventilation through a
noninvasive interface rather
than an invasive interface
• Via sealed mask
• Ventilatory support for patients
with acute or chronic
respiratory failure.
 Physiology of Positive- Pressure Breathing

• Respiratory cycle in spontaneously

breathing patients - negative
intrathoracic pressure
• lateral ribs bucket- handle fashion
• Increases the intrathoracic volume
pressure gradient between intra-
and extra- thoracic airspaces net
airflow into the lungs
• Relaxation of the diaphragm and recoil
of the chest wall passive exhalation
• Force required to generate adequate
inspiration work of breathing.
• When the work of breathing increases
-unable to generate enough negative
force
• NIV - Delivery of humidified air with
positive pressure.
• The amount of positive pressure
required for adequate ventilation -
dependent on the patient’s respiratory
effort
• Inhalation occurs by driving air into
the lungs under positive pressure
• Air is passively exhaled when the chest
wall recoils.
CLINICAL CONSEQUENCES

• Pressure changes in the thoracic cavity  pressures in the chambers of the

heart.
• Spontaneous inspiration  augments venous return and preload.
• Cardiac output is increased  increased pressure gradient between the
left ventricle and aorta.
• Positive- pressure ventilation (PPV)  venous return is diminished, cardiac
output falls.
• Hypotension can occur after ventilatory support has been initiated
• Exaggerated in patients with clinical hypovolemia or vasodilatory states.
ADVANTAGES

• Noninvasive
• Avoid complications related to ETT
• Reduces need for sedation
• Preserved oral patency
• Decreased hospital stay, morbidity & mortality
• Prevents expiratory collapse of airways & alveoli
• Increases tidal volume
• Recruits more & more alveoli
• Decreases work of breathing
• decreases preload
TIMING, SITE, ANCILLARY STAFF
• Initiated as soon as possible.
• Delays in NIV implementation deterioration and increase the likelihood of NIV
failure
• Site - Emergency department (ED), the intensive care unit, or a specialized
respiratory or high/intermediate-care dependency unit. NIV may also be
successfully used in the general ward setting
• Appropriate staff knowledgeable and experienced in NIV use - critical to its
success.
• Ensure the provision of a comfortable snug-fitting interface with minimal air
leaks, appropriate initial settings, and patient reassurance with follow-up that
comprises frequent check-ins and altered settings.
 COMPONENTS
• Standard ventilator /bedside portable ventilator/NIV
machines
• Ventilator choice - institutional resources, practices,
and policies
-the location of the service
-chosen mode of ventilation
-required fraction of inspired
oxygen
• Precise FiO2 - standard ICU ventilator
• Many portable ventilators are limited in the flow rate
of oxygen that can be delivered
• Dual-limb tubing  minimizes the rebreathing of CO2.
• ICU ventilators  better monitoring and alarm features
-tidal volume, major air leaks, and/or patient disconnection - more
readily detected.
Interface (mask)

• Straps hold the interface in place

• Adjust to avoid excess pressure on the nose or face.
• Straps - loose enough to allow one or two fingers to pass between the face
and the strap.
• TYPES – 1) Oronasal mask
2) Nasal mask
3) Nasal pillows
4) Full face mask
Oronasal mask

• Includes the nose and mouth, but not the

eyes
• Face mask or orofacial mask.
• Most commonly used in patients with
acute respiratory failure for the delivery
of NIV
• Well tolerated and eliminate CO2
effectively.
Nasal mask

• Covers just the nose

• Alternative in those who do not
tolerate an oronasal mask
• large air leak through the mouth 
interfere with effective ventilation.
• Air leak interfering with ventilation
alleviated by chin strap
Nasal prongs

• Inserted into the nares

• Option in patients who are intolerant of an oronasal or nasal mask.
• A chin strap is also often needed to minimize oral air leak.
Full face mask

• Eyes, nose, and mouth.

• Superior in terms of maximizing the NIV delivered and minimizing air
leaks,
• Poorly tolerated.
Mouth piece

• Devices that can be inserted into the mouth .

• Air leak through the nose can occur unless nasal
pledgets are used.
• Commonly used in some patients with chronic
respiratory failure due to neuromuscular
disorders,
• Less practical for patients with acute respiratory
failure.
Helmet Device
• Allows patients to talk, read, and drink through a straw
• Minimize complications such as skin necrosis, gastric distension, and eye irritation .
• Reservoir between the ventilator and the patient.
• High flow and short inspiratory time are required to pressurize the helmet rapidly.
• Able to deliver higher levels of positive end-expiratory pressure (PEEP) to improve oxygenation
• Suitable in those who are PEEP-responsive.
• Drawbacks - accumulation of CO2 within the helmet
-a level of noise exposure sufficiently high to cause hearing damage
-more patient-ventilator asynchrony (due to delayed triggering and cycling)
-less relief of inspiratory effort .
-actual tidal volume delivered via helmet ventilation is unknown, owing to the
distensibility of the device.
Ventilator circuit
• Positive pressure and oxygen are delivered via tubing attached to the
interface.
• If a standard mechanical ventilator is used, then high flows effectively
delivered.
• Many portable ventilators can only deliver lower flow
• Oxygen - heated and humidified to improve tolerance and prevent
mucosal dryness
• Standard ventilators  typical dual-limb circuitry is used
MODES OF NIV
• Bilevel NIV [BPAP] - most commonly used mode of NIV in patients with acute
respiratory failure. .
• In patients with acute hypercapnic respiratory failure.
-AECOPD
- disorders associated with acute hypoventilation
• Most commonly used mode in patients with nonhypercapnic hypoxemic acute
respiratory failure
-pneumonia
-early acute respiratory distress syndrome
- asthma.
• Continuous positive airway pressure (CPAP)
• Indicated in patients with acute cardiogenic pulmonary edema
INITIAL SETTINGS

• Key feature required for success  adjustment of

initial settings and mode.
• Achieved at the bedside when experienced staff
take the time to provide patient education and
reassurance during the initial trial
Copyrights apply
Follow-up
• Check for air leaks, readjust straps as
needed
• Add humidifier as indicated
• Consider mild sedation (eg, intravenously
administered lorazepam 0.5 mg) in
agitated patients
• Encouragement, reassurance, and frequent
checks and adjustments as needed
• Monitor occasional blood gases (within 1 to
2 hours) and then as needed
Uncommon modes
• Volume-limited modes and pressure support ventilation (PSV) may be
delivered noninvasively.
• Limited to patients with specific requirements or poor tolerance of BPAP or
CPAP.
• Switching to a standard ventilator may be necessary.
• Volume-limited ventilation in the assist controlled mode (ACVC) —
when patients need a "guaranteed" tidal volume or minimal minute
ventilation.
• Pressure support ventilation — when patient comfort and synchrony
need to be maximized .
Rarely used modes
 Controlled mechanical ventilation
 Intermittent mandatory ventilation (IMV)
 Synchronized IMV (SIMV)
 Pressure controlled ventilation
 Proportional assist ventilation
 Neurally adjusted ventilatory assist (NAVA)
HFNC

• Noninvasive oxygen supplementation can also by achieved with high- flow

nasal cannula (HFNC).
• Use high- pressure oxygen and air, a gas blender, humidifier, and large-
diameter tubing to deliver oxygen at flow rates often exceeding 60 L/ min.
BENEFITS OF HFNC
• high flow rates more closely match patients’ inspiratory flow and volume
demands, so more inspired gas comes from the device than ambient air
increasing the fraction of inspired oxygen (Fio2);
• the high flow washes out anatomic dead space and replaces it with oxygen;
• Fio2 and flow rate can be titrated independently
• many devices deliver a small amount of PEEP (1 to 3 cm H2O);
• gas is humidified and heated, which makes the high flow rate more tolerable;
• the large nasal prongs on the cannula devices often occlude the entire nares,
reducing entrainment of ambient air during closed- mouth breathing.
INDICATIONS & CONTRAINDICATIONS

• Acute hypoxemic respiratory failure without significant hypercarbia

• In whom supplementary intrathoracic pressure would not be necessary.
• HFNC cannot be used in patients without a patent upper airway.
• Other relative contraindications include
-depressed mental status
-facial injury
-inability to manage secretions
-respiratory arrest.
NIV TRIAL

• Observe closely for the first few minutes

• Once the patient is comfortable - vital signs, oxygenation, and mental
status are observed for the next one to two hours in a closely monitored
setting .
• Re-evaluate the patient clinically and obtain arterial blood gases.
• When the patient demonstrates improvement in clinical signs and
symptoms and gas exchange - persist with NIV .
• No improvement/signs of deterioration  prompt intubation.
HACOR SCORE
• Score >5 at 1 hour of NIV
- >80% risk of NIV failure
• Regardless of age,
diagnosis & disease
severity
• Bedside tool
Troubleshooting

• Ventilator dyssynchrony - the phases of ventilator breath do not match

that of the patient.
• due to - auto-positive end-expiratory pressure (auto-PEEP)
-reduced flow due to an interface leak
-discomfort and anxiety
• Auto-PEEP - reduction in respiratory rate and/or tidal volume
-raising the inspiratory flow rate
-treating the underlying airflow obstruction
-application of extrinsic PEEP.
• Reducing interface leak – Leak increase the time required for the ventilator
to achieve its pressure target  prolonging inspiration and causing
discomfort.
• Tightening the straps or changing the mask is typically the first maneuver
• Changing the mode of ventilation may be needed.
• Improving patient comfort and reducing anxiety –careful explanation
and reassurance help alleviate fears and anxieties associated with NIV.
• Ill-fitting masks / local discomfort associated with the interface 
switching to an alternate interface may improve comfort and tolerance.
• When these simple adjustments fail, lowering the settings or changing the
mode or may help improve tolerance.
• Sedation is rarely needed
• When a change in mode is desired for comfort or dyssynchrony  pressure
support ventilation (PSV).
• PSV allows the patient to trigger each breath and independently regulate the
depth and pattern of breathing.
• Proportional assist ventilation (PAV) or neurally adjusted ventilatory assist
(NAVA) -helpful in patients who do not tolerate PSV or bilevel NIV.
• PAV has the advantage of having an inspiratory flow and delivered volume
that is proportional to the patient's effort.
• Cessation of inspiration is determined entirely by the patient, allowing the
patient to control the entire respiratory cycle.
Trial duration and reassessment

• Most initial trials of NIV should target one to two hours, unless the patient
acutely deteriorates
• Improvement of the pH and arterial carbon dioxide tension (PaCO2)
within 30 minutes to two hours predicts continued success.
• Trial success — A trial is considered successful when both clinical and gas
exchange criteria are improved.
• In such cases, persisting with NIV and monitoring for another two hours or
more for continued success is reasonable.
• Patients should also be monitored for complications such as aspiration
and pressure ulcers.
• Continued improvement should prompt weaning while deterioration at
any point should prompt intubation and mechanical ventilation
• Trial failure — If a patient does not improve or deteriorates following a one to
two hour trial of NIV  failed NIV.
• Clinical judgement is imperative
• Clinical criteria suggesting failure -worsening gas exchange
-increasing respiratory rate
-worsening encephalopathy or agitation
- inability to clear secretions
- inability to tolerate any of the interfaces
-hemodynamic instability
Weaning
• When gas exchange and clinical parameters of acute respiratory failure have
improved dramatically and the cause of respiratory failure has improved.
• A RR – 12- 22 breaths per minute.
• SpO2 ≥90% on ≤60% FiO2 or predicted needs can be met with oxygen delivered via
high flow nasal cannulae (HFNC) or low flow oxygen.
• Hemodynamic stability - off /on low dose vasopressors and HR 50-120/’
• The pH is preferably >7.25
• Afebrile, awake and alert, or easily arousable.
• Minimal NIV settings (eg, bilevel positive airway pressure 10 cm H2O/5 cm H2O or
continuous positive airway pressure ≤10 cm H2O).
• No universal protocol for weaning
• Dependent upon the patient’s response to decreased support.
• Progressively decreasing the amount of positive airway pressure
• By permitting the patient to be disconnected from the NIV for
progressively longer durations.
 COMPLICATIONS
• Local skin damage - pressure effects of the mask and straps .
-Cushioning the forehead and the bridge of the nose.
• Eye irritation, sinus pain, congestion, or epistaxis due to mucosal
dryness lower inspiratory pressure or an oronasal mask.
-Heated humidification may help prevent this complication.
• Mild gastric distention - rarely clinically significant at typical levels of
inspiratory pressure.
• Vomiting and aspiration - Routine use of a nasogastric tube is not typically
warranted.
• Anxiety, fear, and claustrophobia
• Delirium - increased risk of NIV failure
• Complications related to positive pressure ventilation (eg, barotrauma,
hemodynamic instability) are rare.
SUPPORTIVE CARE AND PROCEDURES
• Patient position —upright or semi-upright position.
• Sedation — Sedative and analgesic therapy that decreases respiratory
drive in small doses on an individualized basis.
• Feeding —not typically enterally fed due to the slight increased risk of aspiration.
-Nasogastric tubes also disrupt the seal in the interface and promote
air leaks.
-If malnutrition is a concern, parenteral feeding is an option.
• Bronchoscopy —not typically performed during NIV
- Theoretical risk of precipitating worsening respiratory failure or respiratory
arrest.
-technically feasible
-performed using a full face mask with a swivel adapter through which the
bronchoscope can pass
• Nebulizers —universal nebulizer or inhaler ports
• The optimal method of drug delivery to the lung
during NIV is unclear.
• Some experts reduce inspiratory flow during
nebulization to maximize drug deposition
• Some patients tolerate being off NIV for a short
period (a few minutes) while the drug is being
nebulized in the standard fashion.
• Suctioning — Suctioning is routine during NIV.
• Patients wearing nasal masks or prongs may be suctioned orally or
orotracheally.
• Oronasal or full-face masks - the interface can be temporarily removed for
a limited period.
• NIV - relatively contraindicated in patients who need frequent
suctioning to clear their own secretions /at increased risk of vomiting
into an orofacial mask.
• Circuit — Circuit maintenance is similar to that described for patients on
mechanical ventilation.
• Nursing care and travel — Routine nursing care such as turning and
mouth care can be delivered during NIV.
• For procedures that require travel ,a portable ventilator can be used
• Procedures that require travel should be minimized, performed only when
absolutely necessary, and trained staff should always accompany the
patients
SUPRAGLOTTIC AIRWAY
DEVICES
• Conduit between the mouth and laryngeal inlet at the vocal cords,
• bypasses tongue-induced airway obstruction in the sedated and paralyzed
patient during an operation.
• The classic laryngeal mask airway (cLMA) - original example of a SAD.
• Rescue airway device - back-up technique after unsuccessful ET tube
placement
• conduit for oxygenation and ventilation to buy some time.
• Temporary airway devices - must be removed or replaced with another
airway device within a few hours.
ANATOMY AND PATHOPHYSIOLOGY
• low resistance to gas flow
• provide a variable degree of protection to the trachea from gastric and
oropharyngeal secretions
• suitable to provide positive-pressure ventilation in the apneic patient
while limiting potential adverse events.
• not designed to pass through the vocal cords.
• rely on the close anatomic relationships between the laryngeal inlet and
the upper esophagus for proper device placement and facilitation of gas
movement
• close anatomic relationships between laryngeal inlet and esophageal orifice help
explain some observed complications with SADs.
• The tip of the SAD was designed to go posterior to the glottis opening at the root of
the esophagus.
• The SAD may impinge into the laryngeal orifice and obstruct airflow to some degree.
• The device may still “buy some time” but will not function as a definitive airway.
• The epiglottis may become folded over upon SAD insertion, may fold into the
aperture meant to sit just outside the vocal cords.
• This results in varying degrees of airflow obstruction and requires the removal of the
SAD
INDICATIONS
• Reserved for the unconscious patient without an intact gag reflex.
• Use SADs in the unconscious patient who is difficult to ventilate with a
face mask while preparations are being made for ET intubation.
• Consider a SAD in the “can’t ventilate, can’t intubate” patient when time
is of the essence.
• The patient’s mouth must be able to open at least 1.5 to 2 cm to allow for
the insertion of the SAD
• As primary airway device or as a rescue airway device after unsuccessful ET
tube insertion
• In sudden cardiac arrest victim in the Emergency Department - quick to
insert and allow for progression to uninterrupted cardiac compressions.
• The primary advantage over ET intubation in a mass toxicology event -
time and ease of insertion while wearing a protective garment.
CONTRAINDICATIONS
• The presence of an intact gag reflex - absolute contraindication to the use of SADs.
• The inability to open the patient’s mouth 1.5 to 2 cm will prevent the insertion of
most SADs.
• Trauma to the upper airway - relative contraindication to placement of these
devices.
• Patient with a caustic ingestion or airway burns.
• Certain height and/or weight to be used. Refer to the specific manufacturer
recommendations.
• Dual lumen devices meant to be placed into the esophageal lumen had
esophageal disease as a contraindication
EQUIPMENT
• SADS, various sizes and brands
• Water-soluble lubricant
• Device-appropriate syringe, sized to inflate the cuff
• Oxygen source, tubing, and regulator
• Face mask
• Bag-valve-mask device
• Suction source, tubing, and Yankauer catheter
• Cardiac monitor
• Noninvasive blood pressure cuff
• Pulse oximeter
• End-tidal capnography
• ALS medications
• Advanced airway equipment
• Surgical airway equipment
CLASSIFICATION
• based on the primary separation between
the respiratory and gastrointestinal tracts.
• These include - cuffless preshaped
sealers
• cuffed perilaryngeal sealers
• cuffed pharyngeal sealers
cuffless anatomic preshaped sealers
• flexible molded devices whose shape is based on spiral computed
tomography (CT) scan investigations of normal subjects of varying heights
and weights.
• when inserted blindly will accommodate the “normal” airway in most cases
• less flexibility in their design, fit, and use.
• less potential protection from aspiration of gastric and oropharyngeal
contents than other SADs
• some devices do have a gastric sump channel that allows for removal of
gastric fluids and air insufflation
• SLIPA is more commonly used in the Operating Room
• The i-Gel can often be found in the prehospital and Emergency
Department airway equipment
Cuffed perilaryngeal sealers
• LMA and its many variations, and other laryngeal mask devices.
• These balloon sealers impact the mucosa of the airway above the laryngeal
inlet itself.
• The narrowest part of the inflatable lumen is meant to wedge into the
upper esophagus, theoretically limiting passive gastric distension during
positive-pressure ventilation
• Some include a potential gastric channel in the tip of the laryngeal mask
that allows for placement of a narrow (typically 14 French or smaller)
gastric sump tube for gastric suction and decompression.
Cuffed pharyngeal sealers
• use a design in which a balloon seals the hypopharynx upstream at the base of the tongue,
preventing passive air escape through the mouth and nose.
• Downstream from the balloon occluding the hypopharynx are numerous ventilation apertures
that allow for gas to pass into the tracheal and esophageal lumens.
• This category of SADs can be further subdivided into those devices with and without a second
balloon for the esophagus.
• Those devices without distal esophageal balloons have a less specific and precise anatomic
placement site.
• This may require more device manipulation to allow for easy ventilation with a theoretical lower
aspiration protection.
• Devices in this category of airways include the Cuffed OroPharyngeal Airway or COPA (Covidien,
Mansfield, MA; Figure 25-3), PAexpress or PAX (Vital Signs Inc., Totowa, NJ), and the CobraPLA and
CobraPlus (Pulmodyne Inc., Indianapolis, IN; Figure 25-4).
• Cuffed pharyngeal sealers with esophageal
balloons
• Occlude the airway proximally at the base
of the tongue,
• Esophageal balloon theoretically isolates
the esophageal lumen from the respiratory
tract.
• Combitube ,the EasyTube ,King Laryngeal
Tubes
• King Laryngeal Tubes are made in a variety of sizes and styles.
• They require a single large syringe to fill the esophageal and
hypopharyngeal balloons with a preestablished amount of air.
• Newer models incorporated a gastric sump channel that allows
for gastric decompression
• Most of the airway devices are made from silicone and require
the liberal use of a water-soluble lubricant to help ease airway
placement without mucosal trauma and abrasion.
• Size-appropriate airway adjuncts must be chosen for the
individual patient’s anatomy.
PATIENT PREPARATION
• Appropriate monitoring with electrocardiography (ECG), end-tidal CO2 monitoring,
noninvasive blood pressure cuff, and pulse oximetry
• Fully functioning suction apparatus.
• Insertion of the SAD requires an anesthetic depth or degree of unconsciousness
similar to that which allows placement and acceptance of an oropharyngeal
airway.
• Successful placement of the SAD is much more likely if the patient is unconscious,
premedicated, or sedated.
• The optimal induction agent should produce jaw relaxation and attenuation of
airway reflexes, permitting insertion of the SAD within 30 to 60 seconds of
induction and loss of consciousness
• Select the appropriate-size SAD based on patient length or weight.
• Inflate the cuff(s), if present, to ensure that there are no air leaks in the device.
• Deflate the cuff(s) and leave the air-filled syringe(s) attached to the SAD.
• Liberally lubricate the SAD with a water-soluble lubricant to aid in its insertion
and seating.
• Each cuffed SAD has a range of air required for proper cuff inflation.
• Inflate the cuff with the recommended volume of air.
• Injection of higher volumes of air over recommendations risks
-SAD migration out of position
- airway or esophageal trauma
-balloon herniation over the gas passage ports on the device
–cuff rupture, and eventual device failure.
• First-pass insertion success for the various SADs depends on the device,
the indication for placement, the setting
• Attach a bag-valve device to the SAD airway tube and begin ventilations.
• Minor manipulations of the SAD may be required to maximize the ease of
ventilation in each patient.
• Slightly rotate or withdraw the SAD with the nondominant hand while
ventilating through the device until ventilations are smooth and without
resistance
• can be used for pediatric patients.
ASSESSMENT
• appropriately placed and positioned SAD - allows for air movement into the
trachea, with varying degrees of potential air leakage into the digestive system
during positive-pressure ventilation.
• Successful placement will allow for relatively effortless gas movement between the
patient and the bag-valve device.
• Successful placement of the SAD is most accurately confirmed by auscultation of
bilateral breath sounds, chest wall rise and fall movement with ventilation, and
continuous end-tidal CO2 capnography waveforms.
• The successful insertion of the sump tubing will help verify that the tip of the
inserted device has not folded back upon itself, potentially obstructing gas flow.
• The sump tubing has the added benefit of decompressing the stomach
• W/F possibility of failure of insertion, migration of the device after correct
initial placement, and failure to maintain an adequate internal seal, which
prevents effective patient ventilation via positive-pressure ventilation.
• If the patient cannot effectively be ventilated or oxygenated, remove the
SAD and return to the BLS skills until additional expertise arrives or
another airway option is available and initiated.
AFTERCARE
• Secure the SAD to the patient similar to the process used for ET tubes.
• This may require device-specific tube ties or straps, twill tape, or adhesive
tape.
• Periodically reevaluate the SAD function and placement to ensure its
position has not changed and it is still providing appropriate oxygenation
and ventilation.
• The SAD may need an occasional position adjustment. Place the patient on a
ventilator.
• Use a flexible elbow between the SAD and ventilator circuit tubing to prevent
any potential for airway displacement during unsupervised use.
• Use the gastric suctioning channels, if present, to decompress the stomach
and limit the potential for subsequent aspiration.
• Replace the SAD with an ET tube or surgical airway once the airway
management has migrated from emergent to urgent.
COMPLICATIONS
• failure to place the device successfully or to obtain a satisfactory seal to
allow for efficient oxygenation and ventilation.
• The incidence of ventilation failure is quite low.
• Herniation of the epiglottis tip is a documented complication associated
with SAD use.
• potential of carotid artery compromise, even with correct anatomic
placement- actual clinical impact is uncertain.
• mucosal damage and abrasions, especially if not properly lubricated or
forcefully inserted.
• Unilateral vocal cord paralysis can occur secondary to traumatic insertion.
Bilateral vocal cord paralysis has not been reported.
• Dental trauma may occur during the insertion or during maintenance of
the airway.
• Cranial nerve palsies are rare.
• Lingual nerve injury is the most common cranial nerve injury.
• It is typically self-limiting and may take up to 6 months for resolution.
• Hypoglossal nerve damage is related to cuff position.
• Neurapraxia due to overinflation of the cuff at the level of the greater horn
of the hyoid bone results in nerve compression.
• Recurrent laryngeal nerve dysfunction is most devastating.
• compressed bilaterally against the cricoid cartilage where it enters the
larynx passing under the inferior constrictor muscles.
• The resulting nerve dysfunction allows for vocal cord paralysis with the
vocal cords stuck in the paramedian position.
• The large and thin cuffs may be torn during use.
• Overinflation of balloons and cuffs can result in tissue ischemia, erosion, and rupture.
• Herniation of pharyngeal and airway structures into the SAD has been documented
using fiberoptic airway evaluation.
• Trapping of the epiglottis in the distal aperture of the SAD may result in edema of the
epiglottis.
• The oropharyngeal balloons have been linked to the development of tongue swelling
secondary to venous congestion as a potential complication.
• Overinflation of balloons and cuffs can result in mucosal ischemia, erosion, and lumen
rupture. Soft tissue complications (e.g., sore throat, abrasions, and dysphagia) are
present after use in 15% to 30% of cases.
• SADs with an intact gag reflex can induce emesis and aspiration.
• Both are associated with decreased survival.
• Always be vigilant to suspect, prevent, and identify aspiration in these
patients.