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Use of the Laryngeal Tube® in a patient with an unstable neck

Osaka, Japan.

To the Editor:

I used the Laryngeal Tube® (LT; VBM, Medizintechnik, Sulz, Germany) to allow ventilation during attempts at nasotracheal intubation in a patient with an unstable neck. A 57-yr-old woman (height 150 cm, weight 46 kg) with acutely progressive quadriplegia due to subluxation at the atlanto-axial level, was scheduled for surgical fixation of the joint. The orthopedic surgeon requested that, if possible, awake intubation (since it can produce bucking), lifting the chin or thrusting the jaw forward during mask ventilation, be avoided to minimize movement of the fragile neck and worsening of the quadriplegia.

After induction of anesthesia and neuromuscular blockade, a size 3 LT was inserted into position without difficulty while the patient's head and neck were stabilized. A 6.5-mm internal diameter reinforced tracheal tube was then passed through a nostril into the oral cavity. The glottis, which was just anterior to the distal cuff of the LT entering the hypopharynx, was identified easily with a fibrescope. The fibrescope was advanced into the trachea and the trachea intubated while the lungs were ventilated adequately through the LT.

When the LT is used, there is generally no need to support the jaw to obtain a patent airway.^1–3 In this case, insertion of the LT was accomplished easily during manual in-line stabilization. A theoretical risk of the use of the LT (and other airway devices) is that inflated cuffs could damage an unstable neck. Although the cuffs should not exert undue pressure on the upper cervical spine (Figure), this possible risk should be weighed against the usefulness of the device in a difficult situation.

View larger version (122K): [in this window] [in a new window]   FIGURE A correctly positioned laryngeal tube. Note that the proximal cuff is inflated in the oral cavity and thus should not exert undue pressure on the upper cervical spine.

References

1 Dôrges V, Ocker H, Wenzel V, Schmucker P. The laryngeal tube: a new simple airway device. Anesth Analg 2000; 90: 1220–2.[Free Full Text]

2 Asai T, Murao K, Shingu K. Efficacy of the laryngeal tube during intermittent positive pressure ventilation. Anaesthesia 2000; 55: 1099–102.[Medline]

3 Asai T, Kawashima A, Hidaka I, Kawachi S. Laryngeal Tube®: its use for controlled ventilation. Masui 2001; 50: 1340–1.[Medline]

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