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Correspondence |
University School of Medicine Campus Bio Medico, Rome, Italy. E-mail: f.agro{at}unicampus.it
To the Editor:
The Intubating Laryngeal Mask Airway (ILMA; The Laryngeal Mask Company, LMA North America, Inc., San Diego, CA, USA) has been designed to allow easier intubation than the LMA.1 A fibrescope is useful in facilitating intubation via the ILMA, but when it is not available, the "Shikani Flexible Seeing StyletTM" (Clarus Medical, Minneapolis, MN, USA; Figure
) presents a useful alternative.2–4 We assessed the efficacy of the ILMA and Shikani Flexible Seeing StyletTM associated technique using an ILMA endotracheal tube, or a standard endotracheal tube.
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Twelve patients in Group A were successfully intubated: ten during the first attempt and two during the second attempt with an "up-down maneuvre". In one woman the technique failed after two attempts and she was intubated successfully by direct laryngoscopy (Cormack-Lehane 1). In Group B the technique failed in four patients during the second attempt; they too, were intubated by direct laryngoscopy. In one patient, intubation was interrupted during the first attempt (blood in the airway tube) and intubation was achieved by direct laryngoscopy. One patient in this group, was successfully intubated during the second attempt, with "up-down maneuvres".
The technique we describe does not seem to be useful with a standard endotracheal tube. This is unfortunate, as it may have been useful in an emergency situation. Jaw elevation was used for every patient, suggesting that experience with the ILMA is necessary. Our findings suggest that the ILMA is not indicated when the patient has a low posterior larynx (easy direct laryngoscopy, Cormack-Lehane 1), but does confer benefits when the glottis is high and anterior (difficult direct laryngoscopy).1
The major limitation of the Shikani Flexible Seeing StyletTM is that it cannot be orientated in a precise direction, unlike the fibrescope, although it is cheaper, portable and malleable. The Seeing Stylet provides excellent illumination of the neck like a lightwand,5 permitting direct visualization too. In summary, the Shikani Flexible Seeing StyletTM may facilitate intubation via the ILMA because it offers the advantages of the fibrescope technique with the characteristics of the lighted stylet. However, it does have technical limitations, and is more useful with an ILMA endotracheal tube compared to a standard endotracheal tube.
References
1 Agrò F, Brimacombe J, Carassiti M, Marchionni L, Morelli A, Cataldo R. The intubating laryngeal mask. Clinical appraisal of ventilation and blind tracheal intubation in 110 patients. Anaesthesia 1998; 53: 1084–90.[Medline]
2 Liem EB, Bjoraker DG, Gravenstein D. New options for airway management: intubating fibreoptic stylets. Br J Anaesth 2003; 91: 408–18.
3 Pfitzner L, Cooper MG, Ho D. The Shikani Seeing StyletTM for difficult intubation in children: initial experience. Anaesth Intensive Care 2002; 30: 462–6.[Medline]
4 Shikani AH. New "seeing" stylet-scope and method for the management of the difficult airway. Otolaryngol Head Neck Surg 1999; 120: 113–6.[Medline]
5 Agrò F, Brimacombe J, Carassiti M, Morelli A, Giampalmo M, Cataldo R. Use of a lighted stylet for intubation via the laryngeal mask airway. Can J Anaesth 1998; 45: 556–60.
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