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From the Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin, USA.
Address correspondence to: Dr. Adrian Matioc, VA Medical Center, Department of Anesthesiology, 2500 Overlook Terrace, Madison, Wisconsin 53705, USA. Phone: 608-280-7006; Fax: 608-280-7098; E-mail: aamatioc{at}facstaff.wisc.edu
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Abstract |
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Clinical features: We report two cases in which the LT was used to solve two unexpected difficult airway situations. The first case ("cannot intubate-inadequate mask ventilation") involved an undiagnosed lingual tonsillar hyperplasia and the LT provided the means to ventilate and administer the anesthetic. In the second case ("cannot ventilate-cannot intubate") we report the successful use of the LT to rescue the airway in a morbidly obese patient. In both cases an endotracheal tube was ultimately inserted using an awake fibreoptic technique with the patient in the sitting position.
Conclusions: In these clinical situations of unexpected difficult airway with significant periglottic obstruction the LT provided adequate ventilation after the first insertion. The LT may complement the laryngeal mask airway in difficult airway management. Further research is needed to define the role of the LT in the management of difficult airways.
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Introduction |
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TOPAbstractIntroductionCase reportsDiscussionReferences |
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Case reports |
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TOPAbstractIntroductionCase reportsDiscussionReferences |
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The first postoperative day the patient was brought to the OR for evaluation of the lingual mass observed during laryngoscopy. An initial attempt at awake fibre-optic intubation failed in the supine position because of excessive periglottic tissue. The ETT was successfully placed fibreoptically with the patient in the sitting position. The otolaryngology examination revealed a large tongue consistent with acromegaly and a significant lingual tonsillar hyperplasia (LTH) displacing the epiglottis posteriorly.
Case 2
A 50-yr-old morbidly obese man (weight, 275 kg; height, 172 cm; BMI = 93) was scheduled for bariatric surgery (open Rouxen Y gastric bypass). The patient had multiple medical problems: hypertension, insulin-dependent diabetes mellitus, venous insufficiency, and sleep apnea. He presented with normal airway anatomy, i.e., good mouth opening, three finger breadth thyromental distance, Mallampati class I but limited neck extension. Most of the weight was distributed on the lower trunk and body. The patient was optimally positioned on the OR bed for direct laryngoscopy (blankets under scapula, shoulders and neck raising the head and neck above the thorax) and noninvasive monitors were applied. After five minutes of preoxygenation rapid sequence induction (propofol, succinylcholine) was performed with cricoid pressure. Laryngoscopy revealed a grade 4 Cormack and Lehane view with no improvement after change of blades (Macintosh 3, 4 and Miller 3), release of cricoid pressure and thyroid manipulation.
The difficult airway cart and help were summoned to the OR. Initially a two-hand face mask ventilation with an oral airway was acceptable but quickly deteriorated after the third laryngoscopic attempt. In this "cannot ventilate-cannot intubate" (CV-CI) situation with the oxygen saturation in the high 70s a #4 LT was inserted and inflated to 60 cm H2O. Good ventilation was possible (positive capnographic tracing, leak pressure of 35 cm H2O, no gastric insufflation and tidal volumes 600 to 650 mL. The fibreoptic view was poor, with no visualization of the glottic opening. No LT manipulation was attempted to improve the view. Chin lift and semi-sitting position increased the tidal volume (~ 750 mL).Vital signs were stable and the oxygen saturation increased to 95% in five minutes. CPAP (5–10 cm H2O) was maintained to assist spontaneous ventilation. After the patient responded to commands the LT was deflated and removed and he recovered in the OR in the sitting position using his own bilevel positive airway pressure device. Surgery was rescheduled and the patient was intubated with an awake nasal fibreoptic technique in the sitting position.
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Discussion |
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The first patient ("cannot intubate - inadequate mask ventilation") had been intubated successfully three weeks prior to this surgery. In the three-week interval the periglottic anatomy and subsequently the laryngoscopic view changed dramatically. An asymptomatic LTH presented after induction as an unanticipated difficult airway.9 The association of significant LTH pathology and macroglossia created the premise of periglottic obstruction. The use of the LMA in patients diagnosed with LTH is controversial.10 We attempted but failed to ventilate the patient with a #5 Classic LMATM. A PSLMA was not immediately available.11
The LT #5 performed well as a ventilatory device -positive pressure and spontaneous ventilation -throughout the surgery (60 min). One benefit of the LT was its ability to ensure high leak pressures and subsequently our ability to maintain CPAP while assisting spontaneous ventilation.
The second patient ("cannot intubate-cannot ventilate") is an example that difficult tracheal intubation can be more common in obese than in lean patients. Additionally in obese patients the classic airway examination is less reliable in identifying risk factors for difficult airway.12 Ezri et al. consider that pretracheal soft tissue, as assessed by ultrasound, may be used as a predictor of difficult laryngoscopy in morbidly obese patients.13 This study has relevance to the use of alternative airways as rescue devices in obese patients in CV-CI situations as the abundant fat tissue distributed to the neck is blunting the anatomical landmarks and limits the cricothyroid rescue techniques mentioned in the ASA Practice Guidelines. In our quickly deteriorating morbidly obese patient we had to use an alternative ventilatory device. The PSLMA was not immediately available14 and the intubating LMATM was not used as intubation was not the priority. The Classic LMATM was not attempted considering the high airway pressures required for ventilation in a morbidly obese patient.
The LT #4 was inserted and used with positive pressure ventilation and then, as the muscle relaxant and the anesthetic wore off, as a conduit for spontaneous ventilation (CPAP ~ 5–10 cm H2O). Chin lift was described as a maneuver to reduce periglottic airway obstruction with the LT.6 In patients with increased BMI optimal LT positioning for ventilation may require more adjustments.15 In both patients there was no correlation between the poor fibreoptic view and the ability to ventilate.
There are limitations to the use of the LT. First, in both cases an experienced user inserted the device and the same outcome may not apply to less experienced users. Second, the interaction between the pharyngeal cuff and the "periglottic obstruction" is unknown and warrants further research before recommending the routine use of the device in patients with supraglottic pathology or morbid obesity. Third, gastric insufflation during positive pressure ventilation was assessed clinically by auscultation in the epigastric area although there is no validation of this technique in obese patients.
The 2003 ASA Practice Guidelines for Management of the Difficult Airway suggest the early use of the LMA as a rescue airway in the CV-CI situation, switching the focus from laryngoscopy and intubation to ventilation and oxygenation.16 Early and correct use of an alternative airway when mask ventilation is impossible or inadequate will minimize insufflation of the stomach, limit traumatic instrumentation of the upper airway, and assure ventilation and oxygenation, thus reducing patient morbidity.
The Practice Guidelines are not intended as standards; personal experience may determine the use of different airway devices than those specifically mentioned in the Algorithm - LMATM, CombitubeTM (Tyco-Kendall Company, Mansfield, MA, USA), rigid bronchoscope, and transtracheal jet ventilation - e.g., PSLMA, ILMA, LT, TrachlightTM (Laerdal Medical, Armonk, NY, USA), rigid fibreoptic laryngoscopes, GlideScopeTM (Saturn Biomedical Systems Inc., Burnaby, BC, Canada). The burden to appropriately understand a technique, train with the device and decide its use in critical situations falls on the anesthesiologist.17 The practitioner has to be comfortable with a new technique and device in non-emergent circumstances before using them in emergent situations.18 Airway management training in academic institutions faces new challenges as new alternative airways are developed19 and opportunities for teaching "classic" endotracheal intubation and regional techniques are shared.
In summary, the LT proved to be an effective ventilatory device in experienced hands after failed direct laryngoscopy and intubation attempts in a patient with acromegalic features and LTH and in a morbidly obese patient. In both cases the LT was easy to insert and generated an effective airway after the first attempt. The ability to maintain high leak pressures (at or above 30 cm H2O) was beneficial in these cases with significant periglottic obstruction. The LT design and characteristics differ from the LMA and the two devices seem to be complementary. Further research is needed to define the role of the LT in difficult airway management.
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Footnotes |
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References |
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2 Gaitini LA, Vaida SJ, Somri M, et al. An evaluation of the Laryngeal Tube® during general anesthesia using mechanical ventilation. Anesth Analg 2003; 96: 1750–5.
3 Genzwuerker H, Lojen M, Finteis T, Ellinger K. Airway management with the laryngeal tube in a patient with cervical spine injury (German). Notfallmedizin 2001; 27: 595–7.
4 Asai T, Moryama S, Nishita Y, Kawachi S. Use of the laryngeal tube during cardiopulmonary resuscitation by paramedical staff (Letter). Anaesthesia 2003; 58: 393–4.[Medline]
5 Ocker H, Wenzel V, Schmucker P, Steinfath M, Dorges V. A comparison of the laryngeal tube with the laryngeal mask airway during routine surgical procedures. Anesth Analg 2002; 95: 1094–7.
6 Brimacombe J, Keller C, Brimacombe L. A comparison of the laryngeal mask airway ProSealTM and the laryngeal tube airway in paralyzed anesthetized adult patients undergoing pressure-controlled ventilation. Anesth Analg 2002; 95: 770–6.
7 Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–11.[Medline]
8 Vollmer T, Genzwuerker HV, Ellinger K. Fibreoptic control of the laryngeal tube position (Letter). Eur J Anaesthesiol 2002; 19: 303–10.[Medline]
9 Ovassapian A, Glassenberg R, Randel GI, Klock A, Mesnick PS, Klafta JM. The unexpected difficult airway and lingual tonsil hyperplasia. A case series and review of the literature. Anesthesiology 2002; 97: 124–32.[Medline]
10 Fundingsland BW, Benumof JL. Difficulty using a laryngeal mask airway in a patient with lingual tonsil hyperplasia (Letter). Anesthesiology 1996; 84: 1265–6.[Medline]
11 Rosenblatt WH. The use of the LMA-ProSealTM in airway resuscitation. Anesth Analg 2003; 97: 1773–5.
12 Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg 2003; 97: 595–600.
13 Ezri T, Gewurtz G, Sessler DI, et al. Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia 2003; 58: 1101–8.[Medline]
14 Keller C, Brimacombe J, Kleinsasser A, Brimacombe L. The laryngeal mask airway ProSealTM as a temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation. Anesth Analg 2002; 94: 737–40.
15 Agro F, Galli B, Cataldo R, et al. Relationship between body mass index and ventilation with the Laryngeal Tube® in 228 anesthetized paralyzed patients: a pilot study (Letter). Can J Anesth 2002; 49: 641–2.
16 Anonymous. Practice Guidelines for management of the difficult airway. Anesthesiology 2003; 98: 1269–77.[Medline]
17 Hung O. Airway management: the good, the bad, and the ugly (Editorial). Can J Anesth 2002; 49: 767–71.
18 Eindhoven GB, Dercksen B, Regtien JG, Borg PA, Wierda JM. A practical clinical approach to management of the difficult airway. Eur J Anaesthesiol 2001; 18(Suppl. 23): 60–5.
19 Cook TM. Novel airway devices: spoilt for choice? (Editorial). Anaesthesia 2003; 58: 107–11.[Medline]
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