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The PAxpress^TM is an effective ventilatory device but has an 18% failure rate for flexible lightwand-guided tracheal intubation in anesthetized paralyzed patients

[Le PAxpress^TM est un appareil de ventilation efficace, mais présente un taux d’échec de 18 % pour l’intubation trachéale sous guidage lumineux flexible chez les patients anesthésiés paralysés]

Vasilios Dimitriou, MD DEAA^*, Gregory S. Voyagis, MD, Christos Iatrou, MD^* and Joseph Brimacombe, MB CHB FRCA MD

^* From the Departments of Anaesthesia, University of Thrace, Greece;
the Department of Anaesthesia and Intensive Care, Sotiria Hospital, Greece, Athens; and
the University of Queensland and James Cook University, Cairns Base Hospital, Cairns, Australia.

Address correspondence to: Prof. J. Brimacombe, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Cairns 4870, Australia. Fax: 61 7 40311628; E-mail: jbrimaco{at}bigpond.net.au

Purpose: The PAxpress^TM is a new, single-use, extraglottic airway device. We evaluate: 1) insertion success rates; 2) airway sealing pressure, ventilatory capability and calculated mucosal pressures (in vitro minus in vivo intracuff pressure) at 30–60 mL cuff inflation volume; 3) the feasibility of lightwand-guided tracheal intubation; and 4) the incidence of mucosal trauma.

Methods: Ninety anesthetized, paralyzed adults were studied. Airway management was by senior anesthesiologists with no prior experience with the PAX, but considerable experience with extraglottic airway devices and the flexible-lightwand.

Results: Insertion was successful at the first attempt in 95.5% (86/90) and at the second attempt in 4.5% (4/90). Mean ± SD airway sealing pressure at 30, 40, 50 and 60 mL cuff inflation volume was 27 ± 8, 29 ± 9, 32 ± 9 and 35 ± 7 cm H₂O respectively; expired tidal volume at airway sealing pressure was 16 ± 6, 18 ± 6, 19 ± 5 and 19 ± 6 mL•kg^-1; and calculated mucosal pressure was 38 ± 14, 55 ± 20, 56 ± 19 and 57 ± 20 cm H₂O. Airway sealing pressure, expired tidal volume at airway sealing pressure and calculated mucosal pressures increased with cuff inflation volume (all: P 0.0002). Esophageal leak was detected in 9% (8/90), but only at peak pressures 35 cm H₂O and cuff inflation volumes 40 mL. Lightwand-guided intubation was successful in 82% (74/90) of patients. Mild, moderate and severe blood staining was detected in 40% (36/90), 15% (13/90) and 1% (1/90) respectively. Blood staining was more frequent after adjusting maneuvers (22/54 vs 32/36, P = 0.002).

Conclusion: The PAX has a high insertion success rate and is an effective ventilatory device with a low risk of gastric insufflation, but has a moderately high failure rate for lightwand-guided intubation and is associated with a relatively high incidence of mucosal trauma. Mucosal pressures may exceed pharyngeal perfusion pressure.

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