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From the Department of Anesthesiology, Kingston General Hospital, Kingston, Ontario, Canada.
Address correspondence to: Dr. David A. Mark, Department of Anesthesiology, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada. Phone: 613-548-7827; Fax: 613-548-1375; E-mail: markd{at}kgh.kari.net
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Abstract |
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Clinical features: A 27-yr-old female underwent bilateral reduction mammoplasty under general anesthesia utilizing a PLMA for airway management. During transfer to the postanesthesia care unit, she had an episode of active vomiting with the PLMA still in situ. The vomitus was expelled via the drain tube bypassing the pharynx entirely. Clinically, there was no evidence of aspiration and the patient had an uneventful recovery.
Conclusion: This case provides evidence that the drain tube of the PLMA directs vomitus away from the airway when properly positioned and may have prevented aspiration in an anesthetized patient.
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Case report |
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The patient had no solid food after midnight and last had clear fluids four hours preoperatively. She received oral naproxen 550 mg and acetaminophen 975 mg 90 min preoperatively with sips of water. She underwent bilateral reduction mammoplasty under general anesthesia utilizing a PLMA #4 for airway management. The PLMA was easily inserted and inflated with 30 mL of air. Gas leak from the drain tube was assessed according to the manufacturers instructions (LMA-ProSealTM instruction manual): a small amount of gel was placed at the proximal end of the drain tube and observed for bubbles while manually ventilating through the PLMA. After ensuring an absence of gas leak from the drain tube at 30 cm H2O pressure, the patient was ventilated via the PLMA with the following settings: tidal volume = 550 mL, respiratory rate = 10•min-1 with a resultant peak inspired pressure of 10 cm H2O. The surgery proceeded uneventfully. After resuming spontaneous ventilation, the patient was transferred to the postanesthesia care unit (PACU) in the lateral position breathing room air through the PLMA. Her O2 saturation (SpO2) was 97% upon leaving the operating room. As the patient reached the PACU, she vomited copious amounts of bile stained fluid through the drain tube of the PLMA forcefully enough to splatter the PACU doors. She didn’t cough either before or after vomiting. A pulse oximeter was immediately applied and measured an SpO2 of 95%. The oropharynx was suctioned for scant clear secretions but no bile stained fluid was obtained. After oral suctioning, the patient regained consciousness and the PLMA was removed with the cuff inflated. Inspection of the surface of the PLMA over the glottis (and of the entire mask) revealed no evidence of bile stained fluid other than in the drain tube lumen and on the tip of the mask immediately surrounding this orifice. Initial vital signs in the PACU were: SpO2 = 95% on room air, heart rate = 85•min-1, blood pressure = 150/65 mmHg. Auscultation of the lungs revealed good air entry bilaterally with no adventitial sounds heard. Her SpO2 remained 96–97% on room air. The remainder of her stay was unremarkable and she was discharged home the next morning as planned.
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Discussion |
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Two case reports1,3 have suggested the LMA may "reflect" gastric contents into the trachea during vomiting. While Brain13 has suggested that the LMA may limit the amount of fluid aspirated by physically obliterating the pharynx, Nanji and Maltby1 suggest the opposite in their case report of a near fatal pulmonary aspiration.
While the design of the PLMA addresses this concern by providing a "drainage tube" or gastric lumen to allow for escape of gastric contents,6 published reports supporting or refuting its effectiveness in this regard are scant. Keller et al.7 showed that the PLMA (cuff inflated) allowed esophageal fluid to bypass the pharynx and mouth in a cadaver model. Agrò et al.14 described the successful use of a double lumen gastric LMA for upper gastrointestinal endoscopy in a patient with achalasia under general anesthesia. Brimacombe described a case where a prototype PLMA effectively shielded the glottis from gastric contents during an episode of intraoperative regurgitation.15 Evans et al.16 have reported a case where passive regurgitation through the drain tube occurred intraoperatively with no evidence of aspiration. In that case report, the PLMA was left in place and the procedure was completed uneventfully.
The effects of vomiting in the presence of the PLMA remain unclear. In the present report, the gastric lumen of the PLMA directed vomitus away from the airway with possible prevention of aspiration in an anesthetized patient. Brimacombe and Berry9 suggests that aspiration is less likely with vomiting than regurgitation since the glottis is closed. This argument cannot alone account for the absence of signs of aspiration in this patient since there was no evidence of bile stained fluid in the glottic bowl of the PLMA.
Strategies to decrease the incidence of aspiration include an appropriate preoperative assessment for risk factors, establishment of preoperative fasting guidelines, verification of patient compliance with these guidelines and pharmacologic therapies to decrease gastric volume and/or acidity. Although silent aspiration around cuffed endotracheal tubes (ETT) has been well documented,17,18 awake intubation or a rapid sequence induction with a cuffed ETT remains the gold standard for patients at risk of aspiration requiring a general anesthetic. A gastric tube may be used to decrease the volume of gastric contents but does not guarantee complete emptying of the stomach and may interfere with gastroesophageal sphincter integrity.19 A gastric tube may also be inserted through the drain tube of the PLMA to facilitate emptying of gastric contents. While this may help confirm correct positioning of the drain tube orifice of the PLMA, these gastric tubes would have the same limitations as those inserted without the benefit of the PLMA. Unlike a gastric tube or ETT, the PLMA allowed gastric contents to completely bypass the pharynx during vomiting in this case. Susceptibility of the drain tube to blockage by solids remains to be determined and should be considered when selecting a PLMA for airway management. How this strategy for decreasing risk of aspiration compares with a cuffed ETT merits further consideration.
Although aspiration remains a concern, the LMA has proven itself to be an invaluable airway device. The new design features of the PLMA should decrease the risk of aspiration. This case demonstrates that in contrast to standard ETT or gastric tubes, the PLMA may allow regurgitated or vomited gastric contents to completely bypass the pharynx when the drain tube is correctly positioned to vent the esophagus. Whether this feature allows the PLMA to meet or even exceed the degree of protection from aspiration provided by cuffed ETT remains to be determined. As with any airway device, appropriate patient selection remains essential.
Revision received September 9, 2002. Accepted for publication June 3, 2002.
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2 Griffen RM, Hatcher IS. Aspiration pneumonia and the laryngeal mask airway. Anesthesia 1990; 45: 1039–40.
3 Koehli N. Aspiration and the laryngeal mask airway (Letter). Anaesthesia 1991; 46: 419.[Medline]
4 Maroof M, Khan RM, Siddique MS. Intraoperative aspiration pneumonitis and the laryngeal mask airway (Letter). Anesth Analg 1993; 77: 409–10.[Medline]
5 Cyna AM, MacLeod DM. The laryngeal mask: cautionary tales (Letter). Anaesthesia 1990; 45: 167.[Medline]
6 Brain AIJ, Verghese C, Strube PJ. The LMA "ProSeal"– a laryngeal mask with an oesophageal vent. Br J Anaesth 2000; 84: 650–4.
7 Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000; 91: 1017–20.
8 Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78: 56–62.[Medline]
9 Brimacombe JR, Berry A. The incidence of aspiration associated with the laryngeal mask airway: a meta- analysis of published literature. J Clin Anesth 1995; 7: 297–305.[Medline]
10 Barker P, Langton JA, Murphy PJ, Rowbotham DJ. Regurgitation of gastric contents during general anaesthesia using the laryngeal mask airway. Br J Anaesth 1992; 69: 314–5.
11 Rabey PG, Murphy PJ, Langton JA, Barker P, Rowbotham DJ. Effect of the laryngeal mask airway on lower oesophageal sphincter pressure in patients during general anesthesia. Br J Anaesth 1992; 69: 346–8.
12 Ho BYM, Skinner HJ, Mahajan RP. Gastro-oesophageal reflux during day case gynaecological laparoscopy under positive pressure ventilation: laryngeal mask vs. tracheal intubation. Anaesthesia 1998; 53: 921–4.[Medline]
13 Brain AI. The laryngeal mask and the eosophagus (Letter). Anaesthesia 1991; 46: 701–2.
14 Agro F, Brain A, Gabbrielli A, et al. Prevention of tracheal aspiration in a patient with a high risk of regurgitation using a new double-lumen gastric laryngeal mask airway. Gastrointest Endosc 1997; 46: 257–8.[Medline]
15 Brimacombe J. Airway protection with the new laryngeal mask prototype. Anaesthesia 1996; 51: 602–3.
16 Evans NR, Llewellyn RL, Gardner SV, James MFM. Aspiration prevented by the ProSealTM laryngeal mask airway: a case report. Can J Anesth 2002 49: 413–6.
17 Bernhard WN, Cottrell JE, Sivakumaran C, Patel K, Yost L, Turndorf H. Adjustment of intracuff pressure to prevent aspiration. Anesthesiology 1979; 50: 363–6.[Medline]
18 Petring OU, Adelhoj B, Jensen BN, Pedersen NO, Lomholt N. Prevention of silent aspiration due to leaks around cuffs of endotracheal tubes. Anesth Analg 1986; 65: 777–80.
19 Priano LL. Trauma and burns. In: Barash PG, Cullen BF, Stoelting RK (Eds.). Clinical Anesthesia, 2nd ed. Philadelphia: J.B. Lippincott Co.; 1992: 1417–29.
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