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Management of the ‘anesthetized but cannot-ventilate’ situation

Seoul, Korea

To the Editor:

I read with interest the case report by JR Boyce¹ entitled: "Poor Man's LMA: achieving adequate ventilation with a poor mask seal ". Mask ventilation could not be performed adequately because of the air leak due to the patient's beard and facial deformity. With the help of an assistant, the anesthesiologist could ventilate successfully by using a cuffed endotracheal tube like a cuffed oropharyngeal airway. Fortunately, intubation under direct laryngoscopy was accomplished easily.

There was a similar and earlier report on the ventilation through a cuffed endotracheal tube inserted in the pharynx.² With the technique described,^1,2 we can ‘buy time' only for a limited duration, a major disadvantage in the ‘cannot-ventilate, cannot-intubate' or ‘cannot-ventilate, hard-to-intubate' situation. Boyce described the laryngeal mask airway (LMA) as just one of the useful options.¹ We believe the LMA's utility and versatility is being underestimated. Use of the LMA frees the anesthesiologist's hands for other vital tasks.³ A LMA may be used repeatedly to preoxygenate before attempting to intubate,⁴ in the same way a conventional mask is used before direct laryngoscopy. According to the ASA difficult airway algorithm, the LMA can be used as a fibreoptic conduit or ventilatory device by itself during difficult airway management.³ Even if the intubating LMA is not available, a conventional LMA can be used as a conduit for tracheal intubation in a patient with a difficult airway.³ The flexible LMA, if available, can improve intraoral surgical access and, in addition, has a protective effect against blood aspiration during oral surgery.⁵ The recently introduced Proseal-LMA appears to improve our ability to apply positive pressure ventilation.

In brief, the LMA is not a special airway equipment anymore. It should be included in the anesthesiologists routine material, and, in the absence of periglottic pathology,³ we believe it should be the first choice in the ‘anesthetized but cannot-ventilate' situation.

References

1 Boyce JR. Poor Man's LMA: achieving adequate ventilation with a poor mask seal. Can J Anesth 2001; 48: 483–5.[Abstract/Free Full Text]

2 Panadero A, Monedero P, Olavide I, Fernandez-Liesa I, Mendieta JM, Marcias A. Inflation of the endotracheal tube cuff in the pharynx for ventilation of paralyzed patients with unanticipated difficult airway (Letter). Anesthesiology 1999; 91: 1178–9.[Medline]

3 Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996; 84: 686–99.[Medline]

4 Bahk JH, Kim JK, Kim CS. Use of the laryngeal mask airway to preoxygenate in a paediatric patient with Treacher-Collins syndrome (Letter). Paediatr Anaesth 1998; 8: 274–5.

5 Quinn AC, Samaan A, McAteer EM, Moss E, Vucevic M. The reinforced laryngeal mask airway for dento-alveolar surgery. Br J Anaesth 1996; 77: 185–8.[Abstract/Free Full Text]

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