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Correspondence |
The Richmond Hospital, Richmond, Canada, E-mail: lwlee{at}shaw.ca
To the Editor:
The ProSealTM laryngeal mask airway (PLMA; LMA North America, San Diego, CA, USA) has a bulky stiff body and an angled tip that may complicate its passage into the oropharynx. To address this problem, we have adapted a technique using a well lubricated, moderately stiff, malleable stylet (Satin-Slip® intubating stylet no. 85865, Mallinckrodt Inc., St. Louis, MO, USA) inserting it into the proximal end of the ProSeal’s esophageal lumen, and advancing it until the tip is 0.5 cm from the lumen’s distal end. After bending the stylet’s proximal end anteriorly 180° to prevent the stylet from sliding further, the tip of the ProSeal/stylet unit is angled anteriorly 45° by forming a curve at the distal 2 cm (Figure
). The PLMA is lubricated and the cuff is then inflated to a soft pressure.
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This technique was used in 100 consecutive patients with normal airways scheduled for elective surgery where the LMA was deemed appropriate for airway management. Following anesthesia induction with propofol but no muscle relaxants, the appropriately-sized ProSeal LMA was inserted easily within ten seconds or less in all patients, without complications. Two junior medical students were able to insert easily and atraumatically the ProSeal after one demonstration.
The use of a stylet with the LMA ClassicTM (Classic) has been reported.1 The tubing is stiffened and configured appropriately, but different maneuvers are required to advance the tip caudad behind the tongue. Insertion of the PLMA using direct laryngoscopic placement of a gum-elastic bougie into the esophagus2 has a nearly perfect success rate, but requires enough neck and jaw movement for laryngoscopy. Another approach utilizes a lighted stylet3 where the unprotected tip is advanced into the esophagus. Blind advancement of a suction catheter4 was effective in one series, but required a 40-sec insertion time. With all three of these techniques, the PLMA slides on a guide placed into the esophagus. With our new technique, the ProSeal slides off the stylet within the bowl of the mouth, but never goes any further.
A PLMA may obstruct the glottic inlet.5 This problem did not occur in any of these attempts, possibly because the softly inflated cuff blunts the tip, is stiffer, or gently displaces the glottis anteriorly. A smaller size LMA may be required to enter the mouth, but functional positioning is easily achieved. Using this technique, the PLMA has become my preferred elective LMA. In patients without fixed anatomical upper airway obstruction and normal mouth opening, this approach may work as a rescue airway. Formal study is warranted.
Footnotes
Accepted for publication October 23, 2006.
References
1 Yodfat UA. Modified technique for laryngeal mask airway insertion. Anesth Analg 1999; 89: 1327.[Medline]
2 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]
3 Mutch WA. Facilitated insertion of the ProSealTM laryngeal mask airway using a lightwand (Letter). Can J Anesth 2006; 53: 635–6.
4 Garcia-Aguado R, Vinoles J, Brimacombe J, Vivo M, Lopez-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.
5 O’Connor CJ Jr, Stix MS, Valade DR. Glottic insertion of the ProSealTM LMA occurs in 6% of cases: a review of 627 patients. Can J Anesth 2005; 52: 199–204.
This article has been cited by other articles:
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  M. Beriault Another technique to facilitate insertion of the ProSealTM laryngeal mask airway Can J Anesth, May 1, 2007; 54(5): 399 - 399. [Full Text] [PDF]
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