Chin Up

Patients undergoing sedation and monitored anaesthesia care for diagnostic or therapeutic procedures are at a risk of airway obstruction [1]. Sedation relaxes the tongue and soft tissues which can lead to obstruction of the airway. Existing solutions such as an oral or nasal airway may require deeper anaesthesia as they can cause coughing, gagging and occasionally, bleeding.

Preventing airway obstruction is critical for patient safety: in the United States of America, more than 40% of insurance claims associated with monitored anaesthesia care (MAC) involve failures to ventilate that have led to death or permanent brain damage [2].

Arepelli et al [3] reviewed prospective data over a 5-month period to identify respiratory, sedative or major adverse events (AE) in patients undergoing conscious sedation for an interventional radiology procedure. Respiratory AE’s were defined as those that required oral airway placement, ambu-bag, or jaw thrust. Of the 541 procedures reviewed, 4.7 per cent were classified as respiratory, compared to 4.2 per cent (sedative AEs) and 2 per cent major.

Airway management
While manually moving the jaw to maintain a patient airway may be simple, it is not always practicable. This may be due to factors such as lack of space around the patient, having to avoid radiological fields, physician fatigue [1], patient obesity and cervical spine problems. Manual jaw elevation requires both hands, thus limiting the productivity of the person holding the jaw; if the jaw thrust is released or only one hand is used, ventilation may be compromised, leading to hypoxia.

Jaw Elevation Device

A simple but effective answer is the jaw elevation device (JED) (Hypnoz Therapuatic Devices, San Diego). This is an externally applied, non-invasive device which holds the patient in the proper position for mask ventilation or fibre-optic intubation. It aids both airway maintenance and in situations when breathing may be compromised, forced extension of the mandible [4].

The JED may be used during any diagnostic or therapeutic procedure requiring analgesics or sedatives for patient comfort. It is applicable in:

• operating rooms
• office practices
• oral surgery/dental offices
• interventional radiology suites
• Magnetic Resonance Imaging
• Ambulances

To assist airway maintenance, the JED may also be left in situ in the recovery room..

The JED comprises a three-way adjustable apparatus that mechanically creates jaw-thrust. It works by lifting the patient’s head to flex the neck, then elevating the mandible while rotating the head backwards, thereby creating the classic sniffing position [5]. Once the JED has been locked into place, the airway is held open, permitting the provider to maintain an airway without the need to manually hold the jaw open (Figure 1)

Efficacy
Its benefit in deep sedation was demonstrated in a small study presented by Davila-Moriel and Whiting [6]. They observed 50 patients undergoing deep sedation for egg retrieval. Twenty eight of these patients required the JED due to apnoea, of which, eight required additional airway adjustment. The authors concluded that while further work was required,

“…the JED is a useful airway adjunct that successfully maintains a patent airway during deep sedation with minimal additional input for the anesthesia provider”.

This reflects the findings of Narron et al’s quality audit [1].

Importantly, the JED can contribute to patient comfort and safety; using oral or nasal airways can cause coughing, gagging and bleeding. The JED eliminates these risks, providing a safer and more comfortable experience for the patient. In addition, delivering a comfortable level of analgesia and sedation is made safer and easier during MAC anaesthesia because the airway remains open and unobstructed.
JED is also invaluable in a number of emergency care situations.
The benefits of the JED are summarised in Box 1

For ordering information about the jaw elevation device (JED) contact Pentland Medical Ltd.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

1. Narron J, Dalal P, Dhar P, Budde A et al. Effectiveness of the Jaw Elevation Device in Prevention of Desaturation During Sedation and Monitored Anesthesia Care: A Prospective QA Audit. 2012. Presentation at the ASA meeting. Available at: http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=5C14DA87E326397F5D288BACD28EEC02?absnum=5010&index=15&year=2012
2. Beeton AG. Expensive anaesthesia complications. South Afr J Anaesth Analg. 2012. 18;(2):77-85
3. Arepelli A, Oechsle D, Kirkwood S, Savader SJ. Safety of conscious sedation in interventional radiology. Cardiovasc Intervent Radiol. 2001. 24;(3):185-90
4. Cattano D, Cavallone L. Airway Management And Patient Positioning: A Clinical Perspective. Anesthesiology News. 2012. Available at: http://www.anesthesiologynews.com/download/positioning_angam12_wm.pdf
5. El-Orbany M, Woehlck H, Salem MR. Head and neck position for direct laryngoscopy. Anesth Analg. 2011. 113;(1):103-9. doi: 10.1213/ANE.0b013e31821c7e9c. Epub 2011 May 19
6. Davila-Moriel E, Whiting JA. Use of the Jaw Elevation Device in Deep Sedation. 2015. Presentation at the ASA meeting. Available at: http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=7915A0A8C2D0F59B8B82CD405575139E?year=2015&index=8&absnum=3961