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Intubation using the ProSeal laryngeal mask airway and a Cook airway exchange catheter set

Madison, Wi

To the Editor:

The newest laryngeal mask airway (LMA), the ProSeal LMA (PSLMA, The Laryngeal Mask Company, San Diego CA, USA) was not designed as an intubation device but to increase the periglottic seal and to provide access to the gastrointestinal tract.^1–3 Nevertheless, the anesthesiologist may be confronted with the situation of having to intubate the trachea with the PSLMA in place. We report a method to change the PSLMA to an endotracheal tube.

Our initial experience in using the PSLMA in ten consecutive patients demonstrated an altered glottic view. Using a 3.4-mm OD pediatric fibreoptic bronchoscope (FOS, Pentax, Tokyo, Japan), we examined the glottic view with a #5 PSLMA installed. Using the scoring system described by Dr. Brain, et al.,¹ three patients had grade 1 view, four had a grade 2 view, and three had a grade 3 view. The PSLMA may induce anterior laryngeal structure movement and rotation of the arytenoids relative to the cricoid cartilage, potentially explaining the altered view.⁴

We used a Cook airway exchanger kit, Arndt set, to overcome these difficulties to exchange the #5 PSLMA for an endotracheal tube. We were requested to change a #5 PSLMA to an 8.0-mm ID endotracheal tube (ETT) for postoperative ventilation in a 55-yr-old, 82 kg male undergoing a right hemicolectomy. A #2 view was seen. The Cook airway exchange kit contains a 144-cm guide wire, a #11 French 70-cm exchange stylet, rapifit adapters and a bronchoscope adapter. Following bronchoscopy, the guide wire was advanced easily through the FOS suction port into the trachea under direct visualization. The FOS was removed and the exchange stylet advanced over the wire. The PSLMA was removed and an 8.0-mm ID ETT advanced over the stylet. The stylet was removed when carbon dioxide was detected and the lungs ausculted.

The role of the PSLMA in the difficult airway is yet to be defined. The double cuffed aperture bar free PSLMA has specific structural differences from the standard LMA that may increase the difficulty of using it as a conduit for intubation.

References

1 Brain AIJ, Verghese C, Strube PJ. The LMA ‘ProSeal’— a laryngeal mask with anesophageal vent. Br J Anaesth 2000; 84: 650–4.[Abstract/Free Full Text]

2 Brimacombe JR, Keller C. The ProSeal laryngeal mask airway: a randomized, crossover study with the standard laryngeal mask airway in paralyzed, anesthetized patients. Anesthesiology 2000; 93: 104–9.[Medline]

3 Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus laryngeal mask airway in anaesthetized paralyzed patients. Br J Anaesth 2000; 85: 262–6.[Abstract/Free Full Text]

4 Nandi PR, Nunn JF, Charlesworth CH, Taylor SJ. Radiological study of the laryngeal mask. Eur J Anaesth 1991; Suppl. 4: 33–9.

5 Walburn MB, Cornes J, Ryder IG. Fibreoptic intubation through a laryngeal mask airway facilitated by a guide wire. Anesthesia 2000; 55: 1027–8.

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