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Facilitated insertion of the ProSeal^TM laryngeal mask airway using a lightwand

University of Manitoba, Winnipeg, Canada, E-mail: amutch{at}cc.umanitoba.ca

To the Editor:

The ProSeal^TM laryngeal mask airway (LMA) is an improvement over the classic LMA, especially for use during mechanical ventilation.¹ Since its introduction, the ProSeal^TM LMA has been noted to be more difficult to place properly, with common problems being retroversion of the bowl and erroneous insertion of the tip into the glottic introtus.² Brimacombe et al.³ have noted that the introducer tool available with the ProSeal^TM LMA offers no advantage to conventional insertion techniques to limit the incidence of improper placement. These authors have advanced a technique using a gum elastic bougie to improve placement. In this approach, the gum elastic bougie is placed into the esophagus under laryngoscope visualization. The drain tube of the LMA is threaded over the distal end of the bougie and the LMA is then "railroaded" into the correct position. Following placement, the LMA cuff is inflated and the bougie is removed. Using this sequence the authors were uniformly successful in proper placement of the ProSeal^TM LMA.

Described below is an approach using a lightwand as the bougie. The lighted stylet is mounted on the lightwand handle and advanced to the hilt. Initially, the stylet is kept straight and lightly lubricated with a water-soluble jelly. A 6-mm endotracheal tube connector is seated in the LMA drain tube. The lighted stylet of the lightwand is passed through the endotracheal tube connector and threaded down the drain tube of the ProSeal^TM LMA (Figure). Care is taken to advance the stylet through the drain tube, especially as it passes through the bowl of the LMA. When the stylet exits through the drain tube, the endotracheal tube connector is seated in the connector lock at the hilt of the lightwand. This action locks the orientation of the LMA on the lightwand. The posterior aspect of the LMA bowl is liberally lubricated. The end of the lightwand is then gently curved (Figure) to direct passage through the posterior oropharynx. Following induction of anesthesia, the combined lightwand and ProSeal^TM LMA apparatus is now readied for insertion. Room lights are dimmed, and the distal end of the lightwand is advanced into the oropharynx in the conventional manner. At this point it may be helpful to have an assistant hold the mandible in an open position while the operator’s right hand guides the distal end of the lightwand and bowl of the LMA into the patient’s mouth. The lighted end is adjusted to midline. Following advancement, if light is seen in the suprasternal notch, then the distal tip is withdrawn slightly and advanced more posteriorly until transillumination in the suprasternal notch disappears. In this way, the tip of the LMA does not become malpositioned in the glottis. When seated, the ProSeal^TM LMA is railroaded off the lightwand, after release of the connector clamp. The cuff of the LMA is now inflated to the desired amount. The lightwand and endotracheal tube connector are removed when placement is satisfactory. Removal of the endotracheal tube connector prevents inadvertent connection of the anesthetic circuit to the drain tube.

View larger version (40K): [in this window] [in a new window]   FIGURE The ProSealTM LMA (size #4 in this example) and lightwand combination ready for insertion. Note lighted stylet positioned at the hilt of the lightwand, a 6-mm endotracheal tube connector inserted in the end of the drain tube and secured in the connector lock of the light wand. Also note the gentle curve of the distal end of the lighted stylet.

To date, no formal study has been undertaken to examine the efficacy of this combined approach to placement of the ProSeal^TM LMA. However, the initial ten placements using this technique resulted in successful airway establishment in nine patients, each on the first attempt. In the remaining patient, the curvature on the lightwand as described precluded advancement beyond the base of the tongue. Retraction of the lightwand to the distal end of the drain tube permitted successful placement in this instance.

Footnotes

Accepted for publication March 9, 2006.

References

1 Cook TM, Lee G, Nolan JP. The ProSeal^TM laryngeal mask airway: a review of the literature. Can J Anesth 2005; 52: 739–60.[Abstract/Free Full Text]

2 O’Connor CJ Jr, Stix MS, Valade DR. Glottic insertion of the ProSeal^TM LMA occurs in 6% of cases: a review of 627 patients. Can J Anesth 2005; 52: 199–204.[Abstract/Free Full Text]

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

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