15 ENERO-2016

Sumario
Introduccin:

Origen del totaltrack VLM

Descripcin

Descripcin del totaltrack VLM.

Descripcin del Videotrack.
Tamaos.
Contenido de los kits

Modos de uso e indicaciones:

Uso

Uso

bsico:
Rescate de intubaciones y/o ventilaciones.
avanzado.
Va area difcil prevista.
Otras indicaciones.

Estudios Clnicos

Introduccin:
Laringoscopio: Manuel Garca 1854, Primera visualizacin con espejos.
Chevalier Jackson. 1913. Laringoscopio directo con luz en la punta distal.

Videolaringoscopio:
Glidescope: Dr. John Paley, 2001

Introduccin
Mscara Larngea: Dr. Archie Brain, 1987
Fastrach ILMA: Dr. Archie Brain, 1997

C-Trach: Dr. Archie Brain, 2003

Video Mscara Larngea:

Dr. Pedro Acha, 2014

Introduccin
Totaltrack VLM: Ventilacin + Intubacin +
Visualizacin
Adems:
Precio competitivo con los Videolaringoscopios.
Tiene un sistema anti-vaho.
Mscara larngea con un sello comparable a las LMAs de ltima generacin.
Pala rgida retirable permitiendo que la Mscara Larngea se pueda dejar para
ayudar en la extubacin.
Se puede utilizar un tubo endotraqueal estndar de PVC pre-curvado.
No necesita un dispositivo empujador para poder dejar el ETT solo en el
paciente, basta con el dedo del operador.
Nos permite realizar una extubacin en dos pasos, pasando por el modo
ventilacin.

Descripcin de la Pala
Rgida
Angulo de 90 estudiado y
utilizado ya en otros
dispositivos: facilita la
insercin

ngulo proximal de 25
para separar el dispositivo
del trax del paciente

90

90

25

Descripcin de la M.
Larngea
Silicona de calidad
mdica para obtener el
mejor sellado. Todos los
materiales utilizados
son Latex Free y los
PVC libres de Falatos.

Diseo de la
ML con mayor
volumen y
menor
presin

Bolsa para contener y proteger el

extremo distal de la pala

Descripcin de la M.
Larngea
Canal de aspiracin
larngea con salida
inmediatamente
anterior a la posicin
de la micro cmara

Protuberancia
lateral y otra
posterior para
dirigir el ETT
hacia el centro
de las cuerdas
vocales

Canal de aspiracin
gstrica: nos permite
pasar una sonda gstrica
de 12F.

Lente para aislar la

videocmara del
paciente. El canal de
la videocmara es
estanco y por tanto se
evita el riesgo de
contaminacin.

Descripcin del tubing

El tubing es de PVC para facilitar el
deslizamiento del ETT por su interior
Canal para
aspiracion gstrica
Canal para
aspiracin larngea

Tiene un
saliente para
ser encajado en
la pala y
asegurar la
correcta
posicin
respecto a la
pala.

Canal para introducir la microcmara

El baln piloto de la ML est rotulado

con las letras VLM para que no se
confunda con el baln piloto del ETT

El canal para el ETT est parcialmente

abierto para que cuando se quiere
retirar el totaltrack VLM dejando el ETT
se puede mantener en su sitio
mediante el dedo del operador del
dispositivo

Descripcin de la batera
Al conectar el Videotrack al
Totaltrack VLM la batera alimenta
a la videocmara

En el contenedor de la batera
hay unas marcas numeradas
para alinear con los nmeros
del tubo cuando se utiliza en
modo ventilacin

La batera est en un
pequeo contenedor
formando parte del totaltrack
VLM de un solo uso

La batera despus de su
uso se puede desechar de
una de las siguientes
formas:

La batera permite alimentar, al

menos durante 40 minutos, a la
videocmara en modo grabacin.

a) Desatornillando la tapa
de la batera y
retirndola.
b) Cortando el tubo que
sujeta el contenedor con
unas tijeras y desechando
el contenedor.

Descripcin del Videotrack

El Videotrack tiene un slot para
contener una tarjeta SD de
grabacin

La microcmara est situada en el extremo distal

de un tubo maleable para ser insertada en el
canal apropiado del totaltrack VLM.
La micro cmara dispone de un sistema anti
vaho que tarda unos 30 segundos en ser
efectivo una vez se enciende

La micro cmara queda orientada en el

interior del totaltrack VLM de modo que
la imagen que vemos en el centro del
monitor es la posicin tpica de la glotis
cuando la ML est bien situada en la
laringe.

Tambin tiene una salida BNC de Video para

poder conectar un monitor externo o un
sistema externo de grabacin

Descripcin del Videotrack

Led que indica el estado
del Videotrack

Botn On/Off para

encender y
apagar la cmara.
Hay que
presionarlo
durante un
segundo.

Botn STOP para

detener la grabacin
de vdeo en la tarjeta
SD

Botn REC para iniciar la

grabacin de vdeo en la tarjeta
SD

Tamaos

Actualmente disponemos de los tamaos #3 y

#4.
Los tamaos del totaltrack VLM hacen
referencia al tamao de la Mscara Larngea y
afecta a la longitud de la pala y al grosor.
Por tanto la eleccin del tamao debe
adaptarse al tamao de la laringe.
Los tamaos 3, 4 y 5 son equiparables a los
tamaos #3, #4 y #5 de las ML.
Tienen cdigo de colores: #3 es verde,
tamao #4 es azul y el #5 ser marrn.
La diferencia de longitud de la pala del #3
frente al #4 y al #5 es de 5 mm ms corta.
El perfil de la pala del tamao #3 es de 17,5
mm y el del #4 y el #5 es de 19,5 mm.
Como referencia (sometida a la experiencia
del operador) proponemos unas indicaciones
de tamaos con el peso del paciente:

Tamao 3: De 50 kg a 65 kg

Tamao 4: De 65 kg a 100 kg

Tamao 5: De 100 kg en adelante

Descripcin Kit Videotrack

Cable para video externo BNC-BNC

Adaptador BNC-RCA

Caja de aluminio y proteccin con

espuma para almacenarlo

Videotrack

Tarjeta SD

Descripcin Kit Totaltrack VLM

Gua bougie

Conector en
forma de Codo

Jeringa de 30 ml
Sobre con
gel
lubricante

Totaltrack VLM

Indicaciones
Va ara difcil imprevista en
quirfano, Emergencias y UCI. Uso
bsico:
Tratamos el totaltrack VLM como un
videolaringoscopio con canal de trabajo (para
el ETT y ante cualquier dificultad podemos
hinchar la ML y ventilar al paciente como con
una ML standard).

Va area difcil prevista: Uso

avanzado:
Definimos estrategia.
Mltiples opciones.
Usuario con experiencia

Clinical Studies
Janine Choonoo,1 Ross Hofmeyr,2 Niall Evans,3 Mike James,4 Nick Meyersfeld2
1Registrar, 2Specialist Anaesthesiologist, 4Emeritus Professor, Department of Anaesthesia, University of Cape Town
3Specialist Anaesthesiologist, Private Practice, Cape Town.

Correspondence to: Dr Ross Hofmeyr, ross.hofmeyr@uct.ac.za

Discussion

Introduction

The TotalTrack VLM (Video Laryngeal Mask;

Medcom Flow, Barcelona) is a novel videoassisted intubating supraglottic airway which
allows minimally interrupted ventilation during
tracheal intubation under continuous video
guidance. It has been proposed for use in routine
airway management, predicted difficult airways,
and as a rescue device for the unanticipated
difficult airway. It features a disposable laryngeal
mask and rigid introducer. The mask component
includes a supraglottic suction port and a conduit
for a gastric tube. A preloaded tracheal tube forms
the breathing tube when functioning as a laryngeal
mask. A reusable camera and video display
(Videotrack) inserted via an isolated channel with
a clear lens which protects against contact with
the patient allows video guidance. A battery pack
in the disposable portion of the mask provides
power.1 We report the first clinical study of the
TotalTrack, with primary endpoints of LMA seal
pressures and success of tracheal intubation.
Inclusion Criteria
ASA 1 or 2
Age >18 years
Lean body mass 50-80 kg
Suitable for size 4 TotalTrack
Elective surgery of 30 120
minutes duration

Exclusion Criteria
ASA 3 or more
Inability to provide consent
BMI >35kg.m-2
Predicted difficult airway
Pregnancy or increased
aspiration risk

Methods

Investigators with at least 5 years anaesthetic

experience received training in the use of the
TotalTrack. Ethical approval and written informed
consent were obtained from 60 patients. A
standardised anaesthetic technique with IV
induction, neuromuscular blockade and volatile
maintenance was used.
Upon TotalTrack
insertion, adequacy of ventilation was assessed by
bilateral chest expansion, adequate expired tidal
volumes, oxygenation and normal capnograph
waveform. The time from first handling the device
until effective ventilation was recorded. Insertion
and intubation were limited to 2 attempts. Seal
pressure testing used a manometric stabilisation
technique. If no leak was generated by 40
cmHO, seal pressure was documented as such.
Presence of a leak was assessed in head flexion,
extension and 30 rotation to either side. Gastric
insufflation was assessed by auscultation and
glottic view graded using the Cormack-Lehane
and percentage of glottic opening (POGO)
scores., Upon optimal visualisation of the glottis,
intubation was performed with the pre-loaded
tracheal tube. Time for intubation was measured
from optimisation of view until cuff re-inflation. The
need for bougie or external laryngeal manipulation
was recorded. Insertion of a gastric tube through
the device was tested. At completion of surgery,
the supraglottic suction was used to remove any
secretions On return of spontaneous respiration,
the tracheal tube was withdrawn and vocal cord
function assessed using the camera. Soiling of the
device was documented on removal. Patients
were assessed postoperatively for sore throat,
dysphagia and hoarseness

References

Medcom Flow TotalTrack VLM catalogue

Keller C, Brimacombe JR, Keller K, Morris R. Comparison of four methods for assessing airway
seal pressure with the laryngeal mask airway in adult patients. Br J Anaesth. 1999; 82(2):286 -7
Park SH, Han SH, Do SH, Kim JW, Kim JH. The Influence of Head and Neck Position on the
oropharyngeal leak pressure and cuf position of three supraglottic airway devices. Anesth Anal
2009; 108 (1):112-7
Weiler N, Latorre F, Eberle B, Goedecke R, Heinrichs W. Respiratory mechanics, gastric insuf
lation pressure, and air leakage of the laryngeal mask airway. Anesth Analg 1997; 84(5):1025-8
Ochroch EA, Hollander JE, Kush S, Shofer FS, Levitan, RM. Assessment of laryngeal view:
Percentage of glottis opening score vs Cormack and Lehane grading. Can J Anesth 1999; 46(10):
987-90
Levitan RM, Ochroch EA, Kush S, Shofer, FS, Hollander JE. Assessment of airway visualisation:
validation of the percentage of glottis opening (POGO) scale. Acad Emer Med 1998; 5(9): 919-23
Evans NR, Gardner SV, James MFM, King JA, Roux P, Bennett P, Nattrass R, Llewellyn R, Visu,
D. The Proseal laryngeal mask: results of a descriptive trial with experience of 300 cases. Br J
Anaesth 2002; 88(4): 534-9
Mishra SK, Nawaz M, Satyapraksh MV, Parida S, Bidkar PU, Hemavathy B, Kundra P. Influence
of Head and Neck Position on Oropharyngeal Leak Pressure and Cuf Position with the ProSeal
Laryngeal Mask Airway and the I-Gel: A Randomized Clinical Trial. Anesthesiol Res P ract. 2015
Epub 2015 Jan 11
Kim MH, Hwang JW, Kim ES, Han SH, Jeon YT, Lee SM. Comparison of the size 3 and size 4
ProSeal laryngeal mask airway in anesthetized, non-paralyzed women: a randomized controlled
trial. J Anesth. 2014 Sep 24. [Epub ahead of print]
Chauhan G1, Nayar P, Seth A, Gupta K, Panwar M, Agrawal N. Comparison of clinical
performance of the I-gel with LMA Proseal. J Anaesthesiol Clin Pharmacol. 2013;29(1):56-60
Brain AJ, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask.II: A
preliminary clinical of a new means of intubating the trachea. Br J Anaesth 1997; 79:704-9
Kihara S, Watanabe S, Taguchi N, Suga A, Brimacombe JR. Tracheal intubation with the
Macintosh laryngoscope versus intubating laryngeal mask airway in patients with normal airways.
Anaesth Intensive Care. 2000; 28(3):281-6.

Results
Patient Demographics
Age (yrs)
Weight (kg)
Height (cm)
BMI (kg.m-1)
Neck Circumference (cm)

Mean (SD)
41 (14)
71 (14)
167 (10)
25 (5)
37 (3)

Range
18-73
42-101
145-189
14-34
31-47

Insertion and ventilation was successful in 98.3%

(59/60), with mean time to adequate ventilation
16.8 seconds (range 4.052.0, SD 10.8). Insertion
failed in one case. One patient desaturated to 92%
during insertion. Median static leak and maximal
inflation pressures of the laryngeal mask
component were 32 cmHO (range 10.0 - 40.0)
and 40 cmHO (range 16.0 - 40) respectively.
Intubation Success Rates(n=60)
6

Overall success

95%
51

1 Attempt
2 Attempts
Abandoned

Glottic view was possible in 59/60 cases.

Tracheal intubation was successful in 95%
(57/60), with a first attempt success rate of 86%
(51/60). Mean time for intubation was 9.5 seconds
(95% CI 14.019.7/SD 10.8). In two cases,
tracheal intubation was not achieved in two
attempts. The need for repositioning to gain
appropriate view occurred in 25% (15/60). Mean
total apnoea time (calculated as the sum of LMA
insertion and tracheal intubation times) was 25.6
seconds (95% CI 20.430.9/SD 19.9).
Gastric tube insertion was successful in 91%
(52/57). Supraglottic secretions were present at
completion in 79%, and the suction port effective
in 91%. Vocal cord assessment was possible in
75% (43/57). Where the cords were not visualised,
the majority had secretions on the interior of the
mask, obscuring the view on the VideoTrack.
The device was easily removed in all cases and
there was no soiling of the device in 77% (44/57).
On the day of procedure, 35% (21/60) reported
sore throat, 15% (9/60) dysphagia and 8.3% (5/60)
hoarseness.
At 24 hours 21% (13/60) still
experienced sore throat, 8.3% (5/60) had
dysphagia and 11.6% (7/60) were hoarse.

Halwagi AE, MAssicotte N, Nallo A, Gauthier A, Boudreault D, Ruel M, Girard F. Tracheal

intubation through the I-gel Supraglottic airway and the LMA Fastrach: A randomised control
trial. Anesth Analg 2012; 114:152-6
Karim YM, Swanson DE. Comparison of blind tracheal intubation through the intubating laryngeal
mask airway (LMA Fastrach) and the Air-Q. Anaesthesia 2011; 68:185-90
Chan PL, Lee TW, Lam KK, Chan WS. Intubation through intubating laryngeal mask with and
without a lightwand: a randomized comparison. Anaesth Intensive Care 2001; 29:255-9
Maurtua MA, Fernando M, Finnegan PS, Wu J, Perilla, Zura A, Doyle DJ. Use of the CTrach
Laryngeal Mask Airway in adult patients: a retrospective review in 126 cases. J Clin Anesth. 2012;
24(5):370-2
Timmerman A, Russo S, Graf BM. Evaluation of the CTrach - an intubating LMA with integrated
fibreoptic system. Br J Anaes 2006; 96(4): 51621
Liu EHC, Goy RWL, Chen FG. The LMA CTrach, a new laryngeal mask airway for endotracheal
intubation under vision: evaluation in 100 patients. Br J Anaes 2006; 96(3):396400
Lui EH, Goy RW, Lim Y, Chen FG. Success of tracheal intubation with intubating laryngeal mask
airways: a randomized trial of the LMA Fastrach and LMA CTrach. Anaesthesia 2008; 108:
621-6
Arslan ZI, zdamar D, Yildiz TS, Solak ZM, Toker K. Tracheal intubation in morbidly obese
patients: a comparison of the Intubating Laryngeal Mask Airway and Laryngeal Mask Airway
CTrach. Anaesthesia 2012; 67: 261-5
Khazin V, Ezri T, Yishai R, Sessler, DI, Serour F, Szmuk P, Evron S. Gastroesophageal
regurgitation during anesthesia and controlled ventilation with six airway devices. J Clin Anesth
208; 20(7): 508-13
Perlas A, Davis L, Khan M, Misakakis N, Chan VW. Gastric sonography in the fasted surgical
patient: a prospective descriptive study. Anesth Analg 2011; 113(1): 93-7
Brimacombe JR, et al. A comparison of the laryngeal mask airway and cufed oropharyngeal
airway in anesthized adult patients. Anesth Analg 1998; 87(1): 147-52
Galgon RE, Schroeder KM, Han S, Andrei A, Jofe AM. The air-Q intubating laryngeal airway vs
the LMA-ProSeal: a prospective, randomised trial of airway seal pressure. Anaesthesia 2011; 66:
1093-1100
Kim MH, Hwang JW, Kim ES, Han SH, Jeon YT, Lee SM. Comparison of the size 3 and size 4
ProSeal laryngeal mask airway in anesthetized, non-paralysed women: a randomized controlled
trial. J Anesth 2014 Sep 24

The TotalTrack VLM allows supraglottic ventilation,

video-assisted laryngoscopy and intubation,
placement of a gastric tube, and supraglottic
suctioning. We found it simple to insert, with only
one case abandoned due to the laryngeal mask
folding over itself. Insertion was graded as easy in
77%, and the short insertion time impacted
favourably on total apnoea time. We also
assessed haemodynamic parameters including
mean arterial pressures and heart rates during the
insertion and intubation through the device. While
there was a statistical difference in the data, it was
considered to have no clinical significance.
The laryngeal mask component resembles the
ProSeal LMA, which is the current gold
standard. Literature on the ProSeal describes
sealing pressures varying between 22 and 29.5
cmHO. The TotalTrack VLM was shown to
have static leak and maximal inflation pressures of
above 30 cmHO, demonstrating excellent
function as a supraglottic airway.
The TotalTrack VLM is also a video intubating
laryngeal mask. Whilst the current gold standard
for intubating laryngeal masks is the LMAFastrach, the TotalTrack is most comparable to
the LMA-CTrach due to its video capabilities.
The LMA Fastrach has been widely assessed,
with studies showing intubation success rates
ranging from 70% to 100%. The CTrach has
reported tracheal intubation success rates
between 89.7% and 96% .
A direct
comparison of the LMA Fastrach and the
CTrach by Lui, Goy, Lim and Chen showed an
overall intubation success rates of 96% for the
Fastrach and 100% for the CTrach9. In a smaller
study of morbidly obese patients, intubation was
equivalent in both the CTrach and the LMA
Fastrach.20 Our study revealed a similar rate.
Although no ventilation occurs during placement of
the TotalTrack, ventilation did continue during
intubation, although a leak was present due to
tracheal tube cuff deflation. Total apnoea time was
thus calculated from the insertion and intubation
times. In the study by Goy et al the insertion times
of the laryngeal mask component averaged 23
and 25 seconds and tracheal intubation times
averaged 100 seconds for the Fastrach and 116
seconds for the CTrach respectively.19 Thus, the
short total apnoea time for the TotalTrack may be
advantageous.
Incidence of patient reported side-effects
diminished on Day 1 post anaesthesia from Day 0.
The findings on day 1 correlate with results
published on other supraglottic devices.7 23-25

Conclusions

The TotalTrack VLM was shown to function well

as a laryngeal mask, with excellent seal
pressures. It allowed continuous ventilation while
optimising the view for tracheal intubation.
Intubation success rates are comparable to those
reported for the gold standards in the literature.
Whilst we have elucidated the basic performance
of the device, direct comparative trials and
research in patients with known or predicted
difficult airways is needed.

Acknowledgments& Conflicts of Interest

The authors wish to acknowledge MedCom Flow (Barcelona, Spain) and Consept
Medical (Cape Town, South Africa) for donation of the materials to perform the trial.
There are not conflicts of interest to declare.