CJA
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Résumé de cet Article
Right arrow Full Text (PDF)
Right arrow Submit a scholarly reply
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Agrò, F.
Right arrow Articles by Alfery, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Agrò, F.
Right arrow Articles by Alfery, D.
Canadian Journal of Anesthesia 52:418-420 (2005)
© Canadian Anesthesiologists' Society, 2005
Cardiothoracic Anesthesia, Respiration and Airway

Airway control via the CobraPLATM during percutaneous dilatational tracheotomy in five patients

[Le contrôle des voies aériennes par le CobraPLATM pendant la trachéotomie dilatatrice percutanée chez cinq patients]

Felice Agrò, MD*, Massimiliano Carassiti, MD*, Caterina Magnani, MD* and David Alfery, MD{dagger}

* From the Department of Anesthesia, University School of Medicine Campus Bio-Medico, Rome, Italy; and
{dagger} the Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee, USA.

Address correspondence to: Prof. F. Agrò, University School of Medicine Campus Bio-Medico, Via E. Longoni 83 00155 Rome, Italy. Phone: +390622541522; Fax +390622541520; E-mail: f.agro{at}unicampus.it


   Abstract
TOP
 Abstract
Introduction
 Clinical features
 Discussion
 References
 
Purpose: To evaluate the use of the new supraglottic airway device CobraPLATM (CPLA) for performing percutaneous dilatational tracheotomy (PDT) utilizing continuous fibreoptic visualization of the larynx and trachea and uninterrupted airway control.

Clinical features: The percutaneous tracheotomies were carried out in five patients (four males and one female; mean age 72 yr, mean height 164.6 cm, mean weight 74 kg) following the Griggs technique under continuous fibreoptic vision and airway control provided by the CPLA. The mean time required for removal of the ETT, positioning of the CPLA, and confirmation of adequate ventilation and cuff seal was 78 sec. The mean time for the entire PDT procedure was six minutes and 57 sec. In one patient a 7-mm tracheostomy cannula was used, and in the other four patients an 8-mm cannula was used.

The hemodynamic and respiratory variables remained stable during the entire procedure; there were no adverse events.

At no point was there any significant difficulty in placing the CPLA or in providing ventilation or oxygenation. Each procedure could be observed easily in its entirety through the FOB.

Conclusions: This technique can be considered simple and safe because it is video-assisted and ensures a continuous airway control. The CPLA offers several advantages over some other supraglottic devices when performing this surgical procedure.


   Introduction
TOP
 Abstract
 Introduction
Clinical features
 Discussion
 References
 
PERCUTANEOUS dilatational tracheotomy (PDT) is an attractive and safe alternative to conventional open tracheostomy. This technique has become more prevalent and widespread in the last several years because it carries fewer complications and is accomplished at a lower overall cost than traditional open surgical tracheostomies.1

Nevertheless, the blind technique of PDT carries with it some complications such as hemorrhage, sc emphysema and tube displacement. Most of these complications can be avoided by performing PDT under direct fibreoptic visualization and airway control via an endotracheal tube (ETT),2 Intubating Laryngeal Mask Airway (LMA),3 LMA Classic,4 or ProSeal Laryngeal Mask Airway5,6 (The Laryngeal Mask Company Ltd., Maidenhead, Berkshire, UK) . To our knowledge, the use of any other supraglottic airway, besides those in the LMA class, during PDT has not yet been studied or reported.

The purpose of this study was to evaluate the use of the new supraglottic airway device CobraPLATM (CPLA; Engineered Medical System, Indianapolis, IN, USA) rather than an ETT or LMA-class device to provide airway control during PDT and to allow continuous visualization of the tracheostomy site.


   Clinical features
TOP
 Abstract
 Introduction
 Clinical features
Discussion
 References
 
We enrolled five patients (four males and one female; mean age 72 yr, mean height 164.6 cm , mean weight 74 kg) in whom PDT was carried out for the purpose of avoiding complications which might result from an extended period of endotracheal intubation. Informed written consent for a Griggs-type 10 PDT was obtained from each patient.

The CPLA consists of a proximal breathing tube with an inflatable circumferential cuff and a standard 15 mm adapter. The softened distal end of the breathing channel (Cobra head) is widened and is designed to be positioned in the hypopharynx opposite the laryngeal inlet in order to divert the inspiratory gas into the trachea through the slotted distal openings. Our preliminary studies7–9 showed that the CPLA could function as a successful supraglottic ventilatory device.

For each patient the procedure was carried out as follows: sedation was provided by an iv infusion of propofol, titrated to effect. After placing the patient on 100% oxygen, the indwelling ETT was removed and replaced with a CPLA, which was sized according to the patient’s weight.8 An adequate cuff seal was obtained and ventilation re-instituted at the previous settings for the patient. A fibreoptic bronchoscope (FOB) adapter was placed between the proximal end of the CPLA and the ventilator circuit and a FOB was advanced down to the distal end of the CPLA. The grill of the CPLA was identified and the FOB passed through it. The laryngeal inlet was easily viewed (in all patients) and the FOB was inserted through the vocal cords and advanced to the level of the second tracheal ring. An attendant constantly observed the surgical procedure through the FOB.

For the PDT, following sterile preparation the surgeon anesthetized the skin and sc tissues with a local anesthetic. A 1-cm vertical incision was made in the midline over the area of maximal trans-illumination, indicating the level of the second tracheal ring. The FOB was then withdrawn to a position just distal to the vocal cords in order to prevent damaging it during the remainder of the PDT. A needle was inserted into the trachea and its tip within the trachea was confirmed via the FOB view. Through the needle, a thin guide wire was advanced distally down the trachea, and then a single dilator passed over the wire. Finally, a tracheostomy tube was passed over the guide wire and the wire removed. Following confirmation of proper functioning of the tracheostomy tube the FOB and CPLA were removed.


   Discussion
TOP
 Abstract
 Introduction
 Clinical features
 Discussion
References
 
PDT has become increasingly popular over performing a traditional surgical tracheostomy in recent years because of its relative ease and low cost, as well as having fewer complications.1,10,11 However, because it is a blind technique (from the surgeon’s perspective) one must have assurance that the needle, guide wire, dilator, and tracheostomy tube all reside within the trachea. In the simplest form, aspiration through the needle advancing into the trachea indicates entry into that air-filled structure. However, subsequent steps of the procedure can still result in misplacement into soft tissue structures. Measuring end-tidal CO2 can confirm placement of the tracheostomy tube, but it does not monitor the previous steps of the procedure (although it is possible to analyze CO2 through the needle). Because of these limitations, continuous observation of the PDT via a FOB is used more and more frequently.1

This is the only technique that can assure successful completion of each stage of the PDT. In addition, one can monitor for excessive bleeding or perforation of the posterior wall of the trachea.

Given the potential problems when using an ETT to secure the airway during PDT, LMA-class devices are used during the procedure.3–6 When using an ETT during PDT, the tube must be withdrawn partially in order to insert the cannula so that there is a risk of removing the ETT accidentally or rupturing the cuff. To our knowledge, there have been no reports discussing the use of any other supraglotic device other than LMAs for managing the airway during PDT.

The CPLA is a relatively new supraglottic airway which is available in eight sizes, allowing it to be used in infants weighing as little as 2.5 kg and in adults over 130 kg. It differs from LMA-class airways in that it has a circumferential cuff that resides in the hypopharynx at the base of the tongue as opposed to the LMA cuff, which lies immediately behind the cricoid cartilage (FigureGo).



View larger version (138K):
[in this window]
[in a new window]
  		FIGURE CobraPLATM and Laryngeal Mask Airway.

 
The CPLA has been found to be easy to insert, with one series of 110 consecutive patients having this accomplished in 8 ± 2 sec.8 It has been used successfully in both elective surgical cases7–9 and has functioned well as a "rescue" airway.9 There are three features of the CPLA which make it potentially advantageous over the use of the LMA-class devices for providing airway support for PDT. First, the CPLA provides a better cuff seal than does the LMA Classic,8,12 and this might be important in patients receiving positive pressure ventilation. One limitation to the use of the CPLA (like other supraglottic devices), however, is to limit ventilation pressures so that insuflation of the stomach does not occur. Second, Gaitini13 has shown that the fibreoptic view of the vocal cords through the distal end is better with the CPLA than with the LMA Classic. Third, the larger lumen of the size 4–6 CPLAs (which can easily accommodate a size 8 ETT) might make passage of a FOB easier.

We have shown that a CPLA is suitable as an alternative for either ETT or LMA-class devices when performing PDT in this series of five patients. The confirmation of potential advantages of the CPLA in this and other situations deserves further study.


   Footnotes
 
Institution: University School of Medicine Campus Bio-Medico Rome, Italy.

Sources and financial support: none.

Accepted for publication October 12, 2004. Revision accepted January 19, 2005.


   References
TOP
 Abstract
 Introduction
 Clinical features
 Discussion
 References
 
1 Griggs WM, Myburgh JA, Worthley LI. A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991; 17: 261–3.[Medline]

2 Ciaglia P. Video-assisted endoscopy, not just endoscopy, for percutaneous dilatational tracheostomy. Chest 1999; 115: 915–6.[Free Full Text]

3 Verghese C, Rangasami J, Kapila A, Parke T. Airway control during percutaneous dilatational tracheostomy: pilot study with the intubating laryngeal mask airway. Br J Anaesth 1998; 81: 608–9.[Abstract/Free Full Text]

4 Dosemeci L, Yilmaz M, Gurpinar F, Ramazanoglu A. The use of the laryngeal mask airway as an alternative to the endotracheal tube during percutaneous dilatational tracheostomy. Intensive Care Med 2002; 28: 63–7.[Medline]

5 Craven RM, Laver SR, Cook TM, Nolan JP. Use of the Pro-Seal LMA facilitates percutaneous dilational tracheostomy. Can J Anesth 2003; 50: 718–20.[Abstract/Free Full Text]

6 Cook TM, Taylor M, McKinstry C, Laver SR, Nolan JP. Use of the ProSeal Laryngeal Mask Airway to initiate ventilation during intensive care and subsequent percutaneous tracheostomy. Anesth Analg 2003; 97: 848–50.[Abstract/Free Full Text]

7 Agrò F, Barzoi G, Carassiti M, Gallì B. Getting the tube in the oesophagus and oxygen in the trachea: preliminary results with the new supraglottic device (CobraPLATM) in 28 anaesthetised patients (Letter). Anaesthesia 2003; 58: 920–1.[Medline]

8 Agrò F, Barzoi G, Gallì B. The CobraPLATM in 110 anaesthetized and paralysed patients: what size to choose? (Letter). Br J Anaesth 2004; 92: 777–8.[Free Full Text]

9 Agro F, Carassiti M, Barzoi G, Millozzi F, Gallì B. A first report on the diagnosis and treatment of acute postoperative airway obstruction with the CobraPLATM (Letter). Can J Anesth 2004; 51: 640–1.[Free Full Text]

10 Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA. A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 1990; 170: 543–5.[Medline]

11 Hinerman R, Alvarez F, Keller CA. Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance. Intensive Care Med 2000; 26: 1850–6.[Medline]

12 Akca O, Wadhwa A, Sengupta P, et al. The new perilaryngeal airway (CobraPLATM) is as efficient as the laryngeal mask airway (LMATM) but provides better airway sealing pressures. Anesth Analg 2004; 99: 272–8.[Abstract/Free Full Text]

13 Gaitini LA, Somri MJ, Kersh K, et al. A comparison of the Laryngeal Mask Airway Unique, Pharyngeal Airway X press and the Perilaryngeal Airway Cobra in paralysed anaesthetized adult patients. American Society of Anesthesiologists, Meeting, San Francisco, USA, 2003.




This article has been cited by other articles:


Home page
 Br J AnaesthHome page
P. V. Dimitrov, C. Verghese, G. M. Haslam, S. Laver, J. P. Nolan, K. Gupta, T. M. Cook, U. Linstedt, F. Moller, N. Grote, et al.
Intubating laryngeal mask as a ventilatory device
Br. J. Anaesth., April 1, 2008; 100(4): 561 - 564.
[Full Text] [PDF]

Home page
 Canadian J. AnesthesiaHome page
H. Hooshangi and D. T. Wong
Brief Review: The Cobra Perilaryngeal Airway (CobraPLA(R)) and the Streamlined Liner of Pharyngeal Airway (SLIPATM) supraglottic airways: [Article de synthese court : Les dispositifs supraglottiques Cobra Perilaryngeal Airway (CobraPLA(R)) et Streamlined Liner of Pharyngeal Airway (SLIPATM)]
Can J Anesth, March 1, 2008; 55(3): 177 - 185.
[Abstract] [Full Text] [PDF]

Home page
 Canadian J. AnesthesiaHome page
O. Hung and J. A. Law
Advances in airway management
Can J Anesth, June 1, 2006; 53(6): 628 - 631.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Résumé de cet Article
Right arrow Full Text (PDF)
Right arrow Submit a scholarly reply
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Agrò, F.
Right arrow Articles by Alfery, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Agrò, F.
Right arrow Articles by Alfery, D.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS