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Use of the laryngeal mask airway and a modified sequential intubation technique for the management of an unanticipated difficult airway in a remote location

Milano, Italy

To the Editor:

We report the successful management of a difficult airway with the Laryngeal Mask Airway® (LMA; Nicosia, Cyprus) and a modified sequential intubation technique. We employed this technique, first described for difficult airway management in pediatric patients^1–3 during an emergency situation outside the operating room.

A lengthy procedure of endovascular radiofrequency ablation, performed in the electrophysiology laboratory in a 160-kg patient with dilated cardiomyopathy and atrial fibrillation, was followed by acute respiratory failure due to pulmonary edema. Manual ventilation was ineffective and attempts at intubation by direct laryngoscopy failed (Cormack-Lehane grade 4). The patient was comatose, hypercapnic and hypoxic (arterial blood gases drawn during the event revealed a PaO₂ 50 mmHg, a PaCO₂ 85 mmHg, a pH 7.31 and SpO₂ 78%). Prompt insertion of a size 5 LMA allowed recovery of SpO₂ to 95% with FIO₂ 100%.

Subsequently, a modified sequential intubation technique was employed:

1) an endotracheal tube (ET) ID 6.5 mm was inserted over a fibreoptic bronchoscope (FOB), inserted through the LMA and the trachea was intubated; 2) the FOB was withdrawn after ensuring correct positioning of the ET (tracheal rings and carina visualized) and ventilation resumed (FIO₂ 100%) until SpO₂ was greater than 97%; 3) a tube exchanger catheter was inserted through the ET; 4) the LMA® and ET were withdrawn together; 5) an ET size ID 8 mm was threaded over the tube exchanger.

With an unhurried approach we achieved safe control of the airway, with adequate oxygenation and mechanical ventilation in a few minutes.

Use of the LMA plus a modified sequential technique proved to be an appropriate strategy to achieve airway control in this patient with an unanticipated difficult airway in an environment where all ancillary equipment and personel for managing this unexpected complication may not be available.

References

1 Hasan MA, Black AE. A new technique for fibreoptic intubation in children. Anaesthesia 1994; 49: 1031–3.[Medline]

2 Walker RW, Allen DL, Rothera MR. A fibreoptic intubation technique with mucopolysaccharidoses using the laryngeal mask airway. Paediatr Anaesth 1997; 7: 421–6.[Medline]

3 Selim M, Mowafi H, Al-Ghamdi A, Adu-Gyamfi Y. Intubation via LMA in pediatric patients with difficult airways. Can J Anesth 1999; 46: 891–3.[Abstract/Free Full Text]

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