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Canadian Journal of Anesthesia 53:1063-1064 (2006)
© Canadian Anesthesiologists' Society, 2006

Correspondence

GlidescopeTM/gastric-tube guided technique: a back-up approach for ProSealTM LMA insertion

Massimo Micaglio, MD, Matteo Parotto, MD, Daniele Trevisanuto, MD, Vincenzo Zanardo, MD and Carlo Ori, MD

University of Padova, Padova, Italy, E-mail: m.micaglio{at}libero.it

To the Editor:

We read with interest the article by Garcia-Aguado et al.1 reporting the use of a suction catheter inside the drain tube as a guide for ProsealTM laryngeal mask airway (PLMA) positioning. This technique may improve the success rate of PLMA insertion with less trauma to the mouth. For several years, we have been performing PLMA insertion with digital or introducer tool techniques. Our first-attempt success rate with a midline or lateral approach technique is > 80 %, similar to that reported by Cook et al.2 We agree with the authors that priming the PLMA with a ‘guide’ may provide an advantage in assuming better anatomic conformation of the mouth. For example, a narrow palate or an angle < 90° between the oral and the pharyngeal axis of the posterior tongue may result in folding over the distal cuff of the PLMA, preventing its correct positioning. We also observe that the PLMA first-attempt success rate is lower for less experienced users, who often find that this ‘guide’ directs the distal PLMA cuff towards the oesophagus.

We generally use a 14 F gastric tube (GT) as a prime in the drain tube to facilitate positioning of the PLMA. To overcome the limitation of the "blind GT insertion" experienced by Garcia-Aguado, we perform GT positioning using direct visualization of the pharynx with the GlidescopeTM. The Glidescope may be less traumatic than direct laryngoscopy,3 and we have used this device to facilitate five cases of difficult PLMA positioning (TableGo) where the digital (either midline and lateral approach) and introducer tool insertion techniques failed. The Glidescope/GT guided technique facilitated correct PLMA positioning in all five cases.


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  		TABLE Demographic data, etiology of failed insertion and PLMA Glidescope/gastric-tube insertion time
 
Our technique may present several advantages over the ‘blind’ suction catheter technique and digital techniques when PLMA positioning is found to be difficult. We believe that our approach may be associated with a higher success rate while providing some protection against regurgitation. In addition, the distal cuff is less likely to fold over as the drain tube is stiffer (i.e., when the oropharyngeal axis is < 90°, the GT could guide the distal cuff into the oropharynx). Furthermore, the GT can be used as a guide for reinsertion if the PLMA is displaced, and finally, direct visualization of the GT advancement reduces the risk of misplacement, overcoming one of the limitations observed by Garcia-Aguado et al. and Drolet et al.4 The Glidescope/GT technique may also prove to be a more gentle procedure than use of the laryngoscope-guided gum elastic bougie technique advocated by Brimacombe et al.5 Our initial experience is encouraging and will be further explored though a randomized, controlled trial.

Footnotes

Accepted for publication June 23, 2006.

References

1 García-Aguado R, Viñoles J, Brimacombe J, Vivó M, López-Estudillo R, Ayala G. Suction catheter guided insertion of the ProSealTM laryngeal mask airway is superior to the digital technique. Can J Anesth 2006; 53: 398–403.[Abstract/Free Full Text]

2 Cook TM, Nolan JP, Verghese C, et al. Randomized crossover comparison of the ProSeal with the classic laryngeal mask airway in unparalysed anaesthetized patients. Br J Anaesth 2002; 88: 527–33.[Abstract/Free Full Text]

3 Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope®) in 728 patients. Can J Anesth 2005; 52: 191–8.[Abstract/Free Full Text]

4 Drolet P, Girard M. An aid to correct positioning of the ProSeal laryngeal mask (Letter). Can J Anesth 2001; 48: 718–9.[Free Full Text]

5 Brimacombe J, Keller C, Judd DV. Gum elastic bougie-guided insertion of the ProSealTM laryngeal mask airway is superior to the digital and introducer tool techniques. Anesthesiology 2004; 100: 25–9.[Medline]





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