Use of a larynyngeal mask airway during aortic valve replacement

We report the elective use of a laryngeal mask airway during cardiac surgery for congenital tracheal stenosis. A 53-year-old woman with severe aortic valve stenosis was scheduled for aortic valve replacement. During anesthesia induction, the anesthesiologists attempted conventional intubation but failed. Fiberoptic tracheal examination and computed tomography showed a tracheal stenosis with 5 mm minimal diameter. A laryngeal mask airway was used at the patient's rescheduled surgery. The laryngeal mask airway use did not lead any surgical complication. We concluded that the laryngeal mask airway may be considered as an alternative to conventional intubation in patients with tracheal stenosis.     

Use of a larynyngeal mask airway during aortic valve replacement

We report the elective use of a laryngeal mask airway during cardiac surgery for congenital tracheal stenosis. A 53-year-old woman with severe aortic valve stenosis was scheduled for aortic valve replacement. During anesthesia induction, the anesthesiologists attempted conventional intubation but failed. Fiberoptic tracheal examination and computed tomography showed a tracheal stenosis with 5 mm minimal diameter. A laryngeal mask airway was used at the patient's rescheduled surgery. The laryngeal mask airway use did not lead any surgical complication. We concluded that the laryngeal mask airway may be considered as an alternative to conventional intubation in patients with tracheal stenosis.     

Airway management of a patient with tracheal stenosis for surgery in the prone position

PURPOSE: When tracheal intubation is required in a patient with an uncollapsible tracheal stenosis, the tip of the tube is usually positioned proximal to the stenosis. Only the tip of the tube may be in the trachea and the tube can be dislodged. We report the successful airway management of a patient with an uncollapsible tracheal stenosis who underwent cranial surgery in the prone position. CLINICAL FEATURES: A 49-yr-old man with the saber-sheath trachea (stenosis of the entire intrathoracic trachea) was scheduled for a posterior fossa surgery for resection of a cerebellar tumour. Anesthesia was induced by allowing the patient to inhale spontaneously oxygen and increasing concentrations of sevoflurane up to 5%, without airway obstruction. After injection of vecuronium, an airway exchange catheter was inserted orally into the trachea. A laryngeal mask airway was then inserted with the exchange catheter in place and, with the aid of a fibrescope, a 6.0-mm reinforced tracheal tube was passed through the laryngeal mask into the trachea so that the tip of the tube was about 1 cm proximal to the stenosis. The patient was turned to the prone position and the operation proceeded uneventfully. CONCLUSIONS: The laryngeal mask and an airway exchange catheter were used as backups to tracheal intubation in this patient with tracheal stenosis in the prone position. Should the trachea be extubated accidentally, it may be re-intubated through the laryngeal mask and ventilation may be possible through the laryngeal mask or the exchange catheter.     

Fiberoptisch unterstützte endotracheale Intubation durch die Larynxmaske im Kindesalter

Fibre optic-assisted tracheal intubation through the laryngeal mask airway is a simple and safe procedure for securing the airway in the paediatric patient with unexpected and known difficult tracheal intubation. Therefore, fibre optic-assisted tracheal intubation through the laryngeal mask airway represents a standard airway technique and must be part of clinical education and also regular training. However, the removal of the laryngeal mask airway over the tracheal tube is impaired by the short length of the tracheal tube, easily resulting in tube dislocation from the trachea. Among several techniques to overcome this problem, the Cook airway exchange catheter offers a reliable method not only for safe removal of the laryngeal mask over the tracheal tube but also for insertion of an adequate tracheal tube, particularly in paediatric patients. This is particularly important for cuffed tubes as the pilot balloon of the cuffed tube is too large to pass through laryngeal mask airway tubes size 2.5 and smaller. This presentation demonstrates fibre optic-assisted tracheal intubation through the laryngeal mask airway in children step-by-step and discusses its clinical implications. A list with compatible sizes of laryngeal mask airways, tracheal tubes and airway exchange catheters is also provided.     

An alternative method to intubate with laryngeal mask and see-through-bougie

BACKGROUND: Different ways of managing the difficult airway is an important issue for the anaesthetist. We have investigated a technique with a see-through-bougie and laryngeal mask for intubation. METHODS: We report our experience with intubation of 30 patients using a see-through-bougie guided through a laryngeal mask with a fibreoptic bronchoscope. The bougie is then used as a guidance for a tracheal tube. RESULTS: In 29 of the 30 investigated patients, this method could be used. In one patient the method had to be abandoned because of a tortuous trachea. Seventeen patients were intubated within 2 min, 11 between 2 and 5 min and 1 required 10 min. The time was mainly dependent on the endoscopic experience of the anaesthetist. No patient sustained arterial desaturation. CONCLUSION: We conclude that intubation using a see-through-bougie and a laryngeal mask is a valuable method in the difficult intubation situation, when a temporary airway can be achieved with laryngeal mask, since it permits continuous ventilation and visual control throughout the procedure.     

A French survey of paediatric airway management use in tonsillectomy and appendicectomy

BACKGROUND: There are no epidemiological data describing tracheal intubation and laryngeal mask airway (LMATM) use in paediatric anaesthesia. This analysis focused on the factors leading to the indication for an airway management procedure, i.e. tracheal intubation and laryngeal mask airway vs face mask during general anaesthesia for tonsillectomy and appendicectomy. METHODS: The data were recorded in the French survey of Practical Anaesthesia performed in 1996. Two main types of surgical procedures were selected: tonsillectomy and appendicectomy because of the number of patients and the need to use an invasive airway management technique. RESULTS: During a 1-year period, 627 anaesthetics for appendicectomy and 653 anaesthetics for tonsillectomy were recorded in the sample under consideration. Tracheal intubation or laryngeal mask airway was undertaken in 66% of tonsillectomies and 84% of appendicectomies. Univariate analysis showed that tracheal intubation/laryngeal mask were used significantly more often in older children, with long duration of anaesthesia, in nonambulatory procedures and in procedures performed at an academic centre. When these variables were included in a multivariate analysis, the duration of anaesthesia over 30 min was a factor linked to the use of tracheal intubation/laryngeal mask airway for the two types of surgery (P < 0.0001). For tonsillectomy, inpatients were 2.9 times more likely to be intubated (or have an laryngeal mask airway) than were outpatients. For appendicectomy, older children were 3.4 times more likely to be intubated (or have an laryngeal mask airway) than younger children. CONCLUSIONS: This large French survey shows that the use of tracheal intubation/laryngeal mask airway in this country is primarily related to a predicted long duration of anaesthesia.     

Bronchoscopic treatment for upper tracheal lesions with a laryngeal mask

A laryngeal mask provides maintaining airway with a larger inner diameter of the tube. A little information is available about bronchoscopic treatment for upper tracheal lesions. Three patients undergoing bronchoscopic treatment for upper tracheal lesions with a laryngeal mask were reviewed. The patients include 3 women, having 2 thyroid cancers and 1 thyroid goiter. The aims of the procedure were hemostasis and reduction of the tumor with subsequent endotracheal stenting in 2 patients, and endotracheal stenting in one patient. The treatment was performed under general anesthesia using a laryngeal mask. All cases were successfully treated without operative and postoperative complications related to the use of the laryngeal mask placement. Use of a laryngeal mask may facilitate insertion and retrieval of a flexible bronchoscope and instruments with an excellent manipulation in therapeutic bronchoscopy for subglottic and upper tracheal lesions.     

Perioperative management for placement of tracheobronchial stents

Tracheobronchial stenting was performed under general anesthesia, with (six patients) or without (two patients) muscle relaxant, in eight patients suffering from carcinoma. All patients had presented preoperatively with dyspnea, exhibiting Hugh-Jones grade 4 or 5. Three patients had been mechanically ventilated before the procedure. The procedure was performed under general anesthesia with flexible bronchoscopic guidance. Stent placement was performed either through an orotracheal tube (four patients) or through a transtracheal tube (two patients) in those who had no upper tracheal stenosis, while it was performed through a laryngeal mask airway in two patients with upper tracheal stenosis. During the procedure, arterial hemoglobin oxygen saturation (Sp_O2) decreased in all patients, despite fraction of inspired oxygen (FI_O2) being maintained at 1.0. Except for two patients, one of whom developed superior vena cava syndrome and one, tension pneumothorax after stent placement, there were no complications resulting from stent placement. Six patients were weaned from mechanical ventilation (0–24 days after the procedure). Two of the three patients who had been on mechanical ventilation preoperatively could not be weaned. Stent insertion is an effective treatment for tracheobronchial stenosis, but its indications in patients with malignancy who have been mechanically ventilated prior to stenting should further be evaluated.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Fibreoptic laryngotracheoscopy via the laryngeal mask airway in children

Background: Fibreoptic laryngotracheoscopy via the laryngeal mask airway - previously reported in adults but not in children - gives a better endoscopic view of the upper airway than does endoscopy via an endotracheal tube.
Results: The laryngeal mask was found to enable laryngotracheoscopy with a flexible 5.0-mm fibreoptic endoscope with no technical difficulties. Spontaneous ventilation could be readily preserved throughout the endoscopic procedure.
Conclusions: In children anaesthetized with halothane, flexible fibreoptic laryngotracheoscopy via a laryngeal mask is a useful method - offering technical advantages not achieved otherwise - provided that generally approved restrictions to the use of a laryngeal mask airway are taken into account.     

A comparison of laryngeal mask airway with tracheal tube for intra-ocular ophthalmic surgery

The use of the laryngeal mask was compared with tracheal intubation in 30 patients who underwent intra-ocular ophthalmic surgery and who received intravenous anaesthesia with propofol. Changes in intra-ocular pressure, heart rate and mean arterial pressure after the insertion of the laryngeal mask airway or the tracheal tube were not significantly different. However, at the end of the procedure, a significantly higher percentage of patients with a tracheal tube coughed, reacted to head movement and suffered breath-holding. In addition, significantly more patients in this group complained of a sore throat (p less than 0.05). During intravenous propofol anaesthesia, the laryngeal mask airway does not offer any advantage over tracheal intubation in the control of intra-ocular pressure for intra-ocular ophthalmic surgery. However, there were fewer complications immediately following surgery in the laryngeal mask group.     

The effect of introducing fibreoptic bronchoscopes on gas flow in laryngeal masks and tracheal tubes

The laryngeal mask airway, reinforced laryngeal mask airway and tracheal tube were studied to determine (1) flow resistance during simulated inspiration and (2) the maximum size of fibreoptic scope which can he passed down the lumen at clinically useful ventilatory settings. In addition, the flow resistance imposed by the mask aperature bars was quantified. The laryngeal mask airway can accommodate a larger fibrescope than the corresponding sizes of reinforced laryngeal mask airway or tracheal tube. Mean (range)flow resistance was 2.3 (1.7-35) times higher with the reinforced laryngeal mask airway compared to the laryngeal mask airway, 2.1 (1.2-4.2) times higher with the tracheal tube compared with the laryngeal mask airway and 1.2 (0.7-1.8) times lower with the tracheal compared with the reinforced laryngeal mask airway. Removal of the mask aperture bars resulted in a mean decrease in flow resistance of 3.6%. Our data have shown that the laryngeal mask airway can accommodate a larger fibrescope than either the reinforced laryngeal mask airway or tracheal tube at clinically useful ventilatory settings and that the current recommendations for maximum size of fibrescope should be revised.     

CO2 laser excision of pediatric airway lesions

Treatment of life-threatening pediatric airway lesions has been greatly enhanced by development of the CO2 laser. Using this modality, endoscopic access and precise tissue destruction are possible with minimal local inflammation and subsequent edema of the narrow airway. From October 1986 through October 1988, 26 patients underwent 96 laser procedures for excision of airway lesions, in 23 patients via bronchoscopy and in three patients via microlaryngoscopy. Ages ranged from 1 day to 20 years, with most patients under 2 years of age. Diagnoses included: laryngeal cysts (1); cystic hygroma (3); tumor (neurofibroma, 1) subglottic hemangioma (1); excision of airway granulation tissue (8); and tracheal stenosis (13, including subglottic stenosis in 9). Therapy of the offending lesion required from one to eight laser procedures (mean, 2.8), excluding one patient with congenital long-segment tracheal stenosis who required 24 laser treatments for repeated excision of tracheal granulation tissue. Most lesions responded to only one or two laser treatments. No bleeding or perforation occurred secondary to laser use. Use of the laser was responsible for salvaging the airway or simplifying management of the airway in 21 of the 26 patients. In three patients with cystic hygroma affecting the laryngeal structures as well as soft tissues of the neck, laser excision was performed to maintain upper airway patency with a tracheostomy for airway control. Two patients with critical subglottic stenosis initially responded to laser excision, but moved away from the area and developed recurrence of their subglottic stenosis requiring tracheostomy, because further laser treatment was either unavailable or was deferred in their new locale.(ABSTRACT TRUNCATED AT 250 WORDS)     

A ventilation-exchange bougie for fibreoptic intubations with the laryngeal mask airway

The ventilation-exchange bougie is a new airway device which can be mounted on a fibreoptic laryngoscope for passage through the larynx into the trachea via a laryngeal mask airway. Subsequent removal of the fibreoptic laryngoscope and laryngeal mask airway allows a tracheal tube to be railroaded into position over the ventilation-exchange bougie. This study described the use of this technique for elective tracheal intubation in two groups of 12 subjects in whom difficulty with intubation was not expected. All the subjects were successfully intubated by one of two anaesthetists, one experienced and the other inexperienced with fibreoptic intubation techniques. Neither had had prior experience with the ventilation-exchange bougie. Because ventilation was maintained throughout the procedure, intubation did not need to be hurried. Cusum analysis confirmed the impression of a learning curve and the technique could be considered learnt after four and six intubations for the experienced and inexperienced fibreoptic larvngoscopists respectively. No difficulty was found either in intubating the larynx with the fibreoptic laryngoscope and ventilation-exchange bougie or when railroading the tracheal tube over the ventilation-exchange bougie. It is suggested that this new device could have an important role in teaching fibreoptic techniques, management of the difficult airway and failed intubations.     

Anesthesia in an adult patient with tracheal hemangiomas: one-lung ventilation for lung lobectomy

Primary tracheal tumors are rare in adults, and careful airway management is required during anesthesia for affected patients. We report the case of a patient with tracheal hemangiomas undergoing nontracheal operation. A 61-year-old woman was scheduled for a lung operation. During preoperative examination, hemangiomas were detected on the tracheal mucosa. As she was asymptomatic and the degree of airway stenosis was small, treatment was not required for the hemangiomas, and left upper lobectomy for lung cancer was scheduled. After induction of general anesthesia, a regular tracheal tube was inserted under fiberoptic bronchoscopy, with care taken to prevent damage to the hemangiomas. An endobronchial blocker was inserted for one-lung ventilation. The operation was performed uneventfully, and the tracheal tube was replaced postoperatively with a laryngeal mask airway while the patient was under deep anesthesia and neuromuscular blockade. The mask was removed after confirming lack of bleeding from the hemangiomas. No hypoxia or other complications occurred during or after the operation.     

Comparison of the GlideScope video laryngoscope vs. the intubating laryngeal mask for females with normal airways

BACKGROUND AND OBJECTIVE: In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope in terms of successful intubation times. METHODS: Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded. RESULTS: Time to successful intubation was longer (mean 68.4 s +/- 23.5 vs. 35.7 s +/- 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 +/- 16.3 vs. 7.3 +/- 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group. CONCLUSION: The GlideScope improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.     

SLIPA喉罩对腹腔镜胆囊切除术围拔管期躁动及血流动力学的影响

目的 比较腹腔镜胆囊切除术应用SLIPA喉罩和气管导管行全麻通气对拔管期躁动及血流动力学的影响.方法 将腹腔镜胆囊切除术患者60例随机分为喉罩组和气管导管组,每组30例.两组患者均用咪达唑仑+异丙酚+舒芬太尼+顺式阿曲库铵静脉诱导,麻醉诱导后喉罩组插入SLIPA喉罩,气管导管组插入气管导管.比较两组患者拔管期血流动力学变化、躁动评分及不良反应发生例数.结果 喉罩组躁动评分显著低于气管导管组(P<0.05),两组患者血流动力学变化差异有统计学意义(P<0 05);气管导管组苏醒后30 min自诉喉部不适例数多于喉罩组(P<0 05).结论 全麻下腹腔镜胆囊切除术采用SLIPA喉罩通气比气管插管通气在拔管期循环动力学更稳定,患者耐受程度好,安全有效.     

Use of the intubating laryngeal mask in children: an evaluation using video-endoscopic monitoring

BACKGROUND AND OBJECTIVE: The intubating laryngeal mask is designed to act as a ventilatory device and as an aid to blind tracheal intubation in adults. The aim of this study was to evaluate the efficacy of the intubating laryngeal mask for ventilation of the lungs and tracheal intubation in children using video-endoscopic control. METHODS: The handling and efficacy of the size 3 intubating laryngeal mask for tracheal intubation in 80 children weighing > or = 25 kg were assessed under video-endoscopic control. Ease of intubating laryngeal mask insertion, adequacy of lung ventilation through the intubating laryngeal mask and airway sealing pressures were recorded. Tracheal intubation was performed blindly by the intubator, while the supervisor observed the procedure on the video display. If blind intubation failed at the first attempt, the monitor view was used to guide the tracheal tube into the trachea. The success rate and time required for successfully placing the tracheal tube were recorded. RESULTS: Insertion of the intubating laryngeal mask was easy in all children. Lung ventilation through the intubating laryngeal mask was uniformly excellent. Blind tracheal intubation at the first attempt was successful in 53 children (66%) within 18.8 +/- 4.1 s. Twenty-four of the 27 failed blind intubation attempts were successfully intubated with video-endoscopic guidance within 28.6 +/- 9.4 s. Two children required replacing the intubating laryngeal mask, one child had to be intubated conventionally. CONCLUSIONS: The size 3 intubating laryngeal mask provides an airway that is easy to establish in children > or = 25 kg with excellent ventilation conditions and allows blind tracheal intubation at the first attempt with a high success rate. Endoscopic monitoring improves its safety and intubation success rate.     

Comparison of fibrescope guided intubation via the classic laryngeal mask airway and i‐gel in a manikin*

We compared the classic laryngeal mask airway and i‐gel as adjuncts to fibrescope guided intubation in a manikin. Two methods of intubation were compared with each device: the tracheal tube directly over the fibrescope; and the tracheal tube over an Aintree Intubation Catheter. Thirty‐two anaesthetists took part in this randomised crossover study. Each anaesthetist performed two intubations with each method via each device. The mean (SD) time for the first intubation using the tracheal tube over the fibrescope was 43 (24) s with the classic laryngeal mask airway and 22 (9) s with the i‐gel (95% CI for the difference 12–30 s, p < 0.0001). The mean (SD) times for the first intubation when using the Aintree Intubation Catheter was 46 (24) s with the classic laryngeal mask airway and 37 (9) s with the i‐gel (95% CI for the difference 5–12 s, p < 0.0001). We recorded five (5/64, 8%) oesophageal intubations when using the classic laryngeal mask airway and none when using the i‐gel. The participants rated the ease of railroading of the tracheal tube and railroading the Aintree Intubation Catheter over the fibrescope to be significantly easier (p < 0.0001 and p = 0.002 respectively) when using the i‐gel than when using the classic laryngeal mask airway. Furthermore, 30/32 (94%) of anaesthetists reported preference for the i‐gel over the classic laryngeal mask airway for fibrescope guided tracheal intubation when managing a difficult airway. We conclude that the i‐gel is likely to be a more appropriate conduit than the classic laryngeal mask airway for fibrescope guided intubation irrespective of the intubation method used.     

Use of an illuminated flexible catheter for light-guided tracheal intubation through the intubating laryngeal mask by nurses

We evaluated the ability of inexperienced personnel in using a prototype illuminated flexible catheter to assist tracheal intubation through the intubating laryngeal mask in anaesthetised, paralysed patients. The device consists of a completely flexible thin plastic catheter, a bulb attached to its distal end and a 15-mm concentric adapter at its proximal end. The illuminated catheter is placed into a straight silicone tracheal tube in such a way that the bulb is placed at the distal end of the tracheal tube. Six nurses inexperienced in tracheal intubation followed a 2-hr training program by using the device through the intubating laryngeal mask in a mannequin and then intubated 10 patients each, with instruction from an anaesthetist. All patients (n=60) were ASA 1-2, scheduled to undergo general anaesthesia for elective surgery. After fentanyl/propofol induction the intubating laryngeal mask was inserted. When an adequate airway was established, patients received atracurium and the endotracheal tube preloaded with the device was inserted through the intubating laryngeal mask and by observing the glow in the neck was advanced into the trachea. The final outcome and the duration of the procedure were recorded. The intubating laryngeal mask was inserted successfully in all patients. The success rate of intubation was 57/60 (95%); 38 patients at first attempt and 19 after two or three attempts. The mean (+/-SD) duration of the procedure in the first five patients in the series of each nurse was 74+/-40 s while in the last five patients it was diminished to 52+/-23 s (P=0.01). We conclude that the described methodology has the potential for more widespread use of tracheal intubation through the intubating laryngeal mask even by inexperienced personnel.