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Department of Anaesthesia, Royal United Hospital, Bath, England, timcook@ukgateway.net
To the Editor:
Keller and colleagues report use of the ProSealTM LMA (PLMA) for airway rescue after failed obstetric intubation (1). The authors cite no other case of PLMA use for obstetric airway rescue or ICU ventilation.
We reported PLMA use after failed obstetrical intubation and difficult ventilation (2). The PLMA enabled excellent airway maintenance and uneventful completion of urgent surgery. We also reported two PLMA uses for ventilation of patients on ICU followed by bronchoscopic-guided percutaneous tracheostomy (3).
Electively, the PLMA was used in a pregnant, previously difficult to intubate, patient requiring electroconvulsive therapy (4) and for laparotomy in a patient with bronchial tree tumor impeding intubation (5).
Cases of PLMA airway rescue include after failed rapid sequence induction (6), after failed routine intubation with gastric distension (7), and after accidental extubation with failed reintubation on ICU (8). In all cases, the PLMA enabled uncomplicated further management.
These recent cases inform this rapidly evolving area of practice. We agree with Keller that 1) after failed intubation with difficult ventilation in a patient with a full stomach, or 2) where controlled ventilation on ICU with a supraglottic airway is required, the PLMA has advantages over other available devices.
References
Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia, jbrimaco@bigpond.net.au Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria
In Response:
We thank Drs. Cook and Nolan for their interest in our case report. The reason why we did not cite these seven additional cases of ProSealTM LMA (PLMA) use for obstetric airway rescue or ICU ventilation was that none were published at the time we submitted our original manuscript on January 17, 2003 – all the additional cases, including one by our own group (1), were published in 2003 or 2004! Also, we recently described the successful use of the PLMA as part of a modified rapid sequence induction in a patient with a full stomach and a known difficult airway (2).
We concur with Drs. Cook and Nolan that the PLMA has a role in difficult airway management, particularly in those patients at risk of aspiration or requiring controlled ventilation (3). Perhaps the most promising PLMA insertion technique for airway rescue is to place a gum elastic bougie or tracheal tube guide into the esophagus under laryngoscope-guidance and then to railroad the PLMA into position along its drain tube, as this has a very high first attempt success rate and almost guarantees correct placement of the distal cuff (4,5), which is critical to airway protection (6). Interestingly, a similar technique using a fiberoptic scope placed down the drain tube has also been described for awake placement of the PLMA (7).
References
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