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* From the Department of Anesthesia, Chang Gung Memorial Hospital, Taoyuan Hsien, and
the Department of Anesthesia and Intensive Care, University of Queensland, Cairns Base Hospital, Cairns, Australia.
Dr. Joseph Brimacombe, Department of Anesthesia and Intensive Care, University of Queensland, Cairns Base Hospital, The Esplanade, Cairns 4870, Australia. Phone: 61-7-40-506960; Fax: 61-7-40-506854; E-mail: jbrimacombe{at}austarnet.com.au
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Abstract |
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Methods: Nine patients undergoing a total of 11 procedures were enrolled in the study. Fentanyl 2 µg•kg–1, midazolam 0.035 mg•kg–1 and sevoflurane in oxygen 100% were used for induction. The ILM was inserted when the end-tidal sevoflurane concentration reached 3%. After an effective airway was established, atracurium 0.5 mg•kg–1 was given. A polyvinyl chloride tube in the reversed position using a blind technique was used to intubate the trachea.
Results: The ILM provided an effective airway on 11/11 occasions at the first attempt. Intubation was successful at the first attempt on 7/11 occasions, at the second attempt on 2/11 and at the third attempt in 1/11. Intubation failed in one patient. The mean (range) minimal oxygen saturation was 99.4% (97–100%). There were no problems with ILM removal.
Conclusion: Inhalational induction followed by ILM insertion and blind intubation is a reasonable option in patients with severe ankylosing spondylitis undergoing elective surgery who prefer airway management under anesthesia.
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Methods |
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A standard anesthesia protocol was followed and routine monitoring applied. Patients were in the supine position with the head and neck supported on pillows so that they were as close to the neutral position as possible within their comfort range. Patients were given 2 µg•kg–1 fentanyl and 0.035 mg•kg–1 midazolam and underwent inhalational induction by breathing sevoflurane, spontaneously and unassisted, in 100% oxygen delivered via a face mask. When the eyelash reflex disappeared, the jaw relaxed and the end-tidal sevoflurane concentration was 3%, the ILM was inserted using a single handed rotational technique. The size 4 ILM was used for males 75 kg and the size 3 for women and males <75 kg. The cuff was inflated to an intracuff pressure of 60 cm H2O using a cuff inflator-manometer and manually assisted ventilation commenced. If an effective airway was not obtained, the position of the ILM was adjusted by moving the cuff up, down, to the right or left, as judged by the operator. If ventilation was still ineffective after these adjustments, the ILM was removed and either the same size or a larger size inserted, as judged by the operator. An effective airway was judged by a square wave capnograph trace and no audible leak with peak airway pressures 15 cm H2O during gentle manual ventilation. A maximum of three ILM insertions was permitted. Once an effective airway was obtained, the position of the ILM was further adjusted by moving the cuff within the pharynx until the best seal was obtained, as judged by maximal chest expansion without an oropharyngeal air leak. Patients were then paralyzed with atracurium 0.5 mg•kg–1 and blind intubation attempted using a well-lubricated 7.0 mm polyvinyl chloride tracheal tube (Sheridan® tracheal tube, The Kendall Company, USA) inserted in the reversed position.8 Bilateral breath sounds and a square wave capnograph trace confirmed successful tracheal intubation. If resistance was encountered or esophageal intubation occurred (no resistance to insertion and no capnograph trace), the position of the ILM was adjusted by moving the cuff up, down, to the right or left before the next intubation attempt, as judged by the operator. A maximum of three intubation attempts was permitted. Once intubation was accomplished, the ILM was removed using an extender. One of the authors (P.L.), with prior experience of 100 uses of the ILM, performed all insertions and intubations.
The following data were collected: the number of insertion and intubation attempts; heart rate and mean blood pressure pre-induction, one minute after successful ILM insertion and one minute after successful intubation; and minimal oxygen saturation occurring between induction and one minute after intubation. The next day patients were questioned about their experience and sore throat. Hemodynamic data were compared using one-way analysis of variance. Significance was taken as P <0.05.
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Results |
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). Four patients had not been previously anesthetized, three had a history of difficult intubation and two had been intubated four and seven years previously. There were no episodes of loss of airway control during inhalational induction. The ILM provided an effective ventilatory device on 11/11 occasions at the first attempt. Intubation was successful at the first attempt on 7/11 occasions, at the second attempt on 2/11 and at the third attempt in 1/11. Success at the second and third attempts was accomplished by positional changes to the ILM. Intubation failed in one patient. Fibreoptic inspection revealed that this was due to a large downfolded epiglottis that was not displaced by the epiglottic elevating bar and could not be corrected by positional changes. No esophageal intubation occurred. Mean blood pressure was higher after intubation than after ILM insertion (mean ± SD: 103 ± 14 vs 82 ± 15 mmHg, P=0.01), but did not differ from baseline values (95 ± 17 mmHg). Heart rate was similar after intubation (85 ± 14 beats•min–1) and ILM insertion (80 ± 13 beats •min–1) and did not differ significantly from baseline values (70 ± 15 beats•min–1). The mean (range) minimal oxygen saturation was 99.4% (97–100%). There were no problems with ILM removal. All patients were content with the anesthetic technique. Two patients complained of a sore throat.
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Discussion |
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). Insertion failed in only one of these cases. The advantages of the LMA or ILM for AS are that insertion and intubation can be accomplished without head and neck movement or direct laryngoscopy, and ventilation can continue during intubation. The limitations of the LMA or ILM are that insertion may be difficult if mouth opening is limited (<1.2 cm9 for LMA; <2 cm for ILM10), if large cervical osteophytes are present,11 or if the patient has a fixed extension deformity.12 The ILM offers potential advantages over the LMA in patients with AS since it may be easier to insert in a patient with an immobile neck13 and the ILM is a better airway intubator.14 However, the LMA would be more suitable if mouth opening was less than 2 cm or intubation was not required. Our finding that blood pressure was higher after intubation through the ILM than after ILM insertion matches the findings of Kihara et al15. for normal patients.
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We conclude that inhalational induction followed by ILM insertion and blind intubation is a reasonable option in patients with severe ankylosing spondylitis undergoing elective surgery who prefer airway management under anesthesia.
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References |
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2 Williams PJ, Bailey PM. Management of failed oral fibreoptic intubation with laryngeal mask airway insertion under topical anaesthesia (Letter). Can J Anaesth 1993; 40: 287[Medline]
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Lu P-P, Yang C-H, Ho ACY, Shyr M-H. The intubating LMA: a comparison of insertion techniques with conventional tracheal tubes. Can J Anesth 2000; 47: 849–53.
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Maltby JR, Loken RG, Beriault MT, Archer DP. Laryngeal mask airway with mouth opening less than 20 mm. Can J Anaesth 1995; 42: 1140–2.
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Asai T, Wagle AU, Stacey M. Placement of the intubating laryngeal mask is easier than the laryngeal mask during manual in-line neck stabilization. Br J Anaesth 1999; 82: 712–4.
14 Lucas DN, Yentis SM. A comparison of the intubating laryngeal mask tracheal tube with a standard tracheal tube for fibreoptic intubation. Anaesthesia 2000; 55: 358–61.[Medline]
15 Kihara S, Watanabe S, Taguchi N, Suga A, Brimacombe JR. Tracheal intubation with the Macintosh laryngoscope versus intubating laryngeal mask airway in adults with normal airways. Anaesth Intens Care 2000; 28: 281–6.[Medline]
16 Rocchiccioli C, Blumen M, Chabolle F, Fischler M. Successful use of LMA FastrachTM (FT) in patients with obstructive sleep apnea syndrome and predictive signs of difficult airway. Anesthesiology 2000; 93: A1112 (abstract).
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21 Forestier J, Rotes Querol J. Senile ankylosing hyperostosis of the spine. Annals of Rheumatic Disease 1950; 9: 321–30.
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