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"Poor Man's LMA"

Portland Oregon

To the Editor:

Boyce¹ states that his patient "preferred to keep his full beard intact on religious grounds", but it appears that this was a hasty solution to an unexpectedly difficult mask airway.

Most disturbing was the scant disregard for caution in managing this patient's anesthetic induction. A morbidly obese, edentulous gentleman with a full beard and obstructive symptoms during sleep should set off alarm signals. Yet anesthesia was induced with thiopentone, fentanyl and rocuronium without ensuring the ability to maintain the airway or ventilate with a mask prior to inducing apnea.

To then rationalize the extra time available to intubate by the use of intermediate-acting depolarizing agents "where laryngoscopy or intubation are predicted to be challenging" is risky without having assessed the ability to ventilate by mask.

The 'Poor Man's LMA' brings to mind two potentially lethal consequences of placing a tube in the oropharynx and ventilating the lungs and, probably, the stomach. Gastric insufflation was a major hazard here with its attendant risks of pulmonary aspiration and gastric rupture. Strategies to improve the mask seal in patients with beards may have been successful had they been tried. A LMA would have facilitated effective ventilation prior to intubation and there is a good case for stating that it should have been available.

My contention is that, in the context described, this is a potentially dangerous manoeuvre from which the patient and the author are fortunate to have emerged without an adverse outcome.

Reference

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]

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