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Use of the laryngeal mask airway in a patient with a difficult airway during supra-stoma granuloma removal

Chung Shan Medical University and Hospital, Taichung, Taiwan, E-mail: cthntw{at}yahoo.com.tw

To the Editor:

Supra-stoma granuloma can be treated effectively via rigid bronchoscopy.¹ General anesthesia is required and ventilation can be controlled through the bronchoscope’s side port or a cuffed tracheostomy tube. However, rigid bronchoscopy may be impossible in patients with a difficult airway. We describe a modified surgical approach of supra-stoma granuloma removal and our anesthetic management in a patient with a difficult airway.

A 60-yr-old patient had speech limitation due to a tracheostomy tube and supra-stoma granuloma. She had a difficult airway, which made two attempts at rigid bronchoscopy abort. To improve her speech, the surgeons planed to remove the granuloma directly through the tracheostomy stoma, followed by insertion of a Montgomery T-tube. However, the tracheostomy tube would be removed and no secure airway existed during the procedure.

Under total iv anesthesia, a cuffed tracheostomy tube was first used for ventilation. We inserted a laryngeal mask airway (LMA) as a conduit to introduce the flexible fibrescope, and found the trachea was partially occluded. We then tried to ventilate through the LMA after temporary removal of the tracheostomy tube and occlusion of the stoma, and found that ventilation was possible. The peak inspiratory pressure was 35 cm H₂O for a tidal volume of 400 mL with minimal air leakage. We then decided to hyperventilate the lungs via the LMA (HV-LMA) between surgical manipulations, during periods when the airway could not be accessed.

After a period of hyperventilation, the surgeons removed the tracheostomy tube and proceeded with removal of the granuloma through the stoma. When the oxygen saturation (SpO₂) declined below 95%, HV-LMA was performed. Surgery continued after the SpO₂ reached 99%. The procedure lasted about ten minutes and the SpO₂ was kept above 92%.

In this patient, the success of HV-LMA depended both on partial obstruction by the granuloma, and an excellent seal with the LMA. In a previous report, leak pressure was found to be 29 cm H₂O (SD 6) for the ProSeal LMA and 19 cm H₂O (SD 4) for the classic LMA.² The patient’s narrow oropharyngeal/hypopharyngeal space might explain the excellent seal observed. To prevent stomach inflation and aspiration, we used a stethoscope over the epigastrum to monitor stomach inflation. Fortunately, granuloma removal was brief and only two periods of HV-LMA were required, attenuating the risk of gastric inflation. Nevertheless, we were well prepared and would have reinserted a cuffed tracheostomy tube for conditions like uncontrolled airway bleeding, inability to ventilate, or unstable vital signs.

Footnotes

Support was provided solely from Institutional and/or Departmental sources.

References

1 Beamis JF. Modern use of rigid bronchoscopy. In: Bolliger CT, Mathur PN (Eds). Interventional Bronchoscopy. Karger Publisher; 2000: 22–30.

2 Lu P, Brimacombe J, Yang C, Shyr M. ProSeal versus the Classic laryngeal mask airway for positive pressure ventilation during laparoscopic cholecystectomy. Br J Anaesth 2002; 88: 824–7.[Abstract/Free Full Text]

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