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LETTERS TO THE EDITOR

A Proposed Algorithm for the Management of Airway Obstruction with the Proseal^TM Laryngeal Mask Airway

Department of Anaesthesia and Intensive Care, James Cook University, Cairns Base Hospital, Cairns, Australia, jbrimaco@bigpond.net.au Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria

To the Editor:

Airway obstruction is a common problem after ProSeal^TM laryngeal mask airway insertion, with a frequency of between 2% (1) and 10% (2). The management depends on the etiology, which includes reflex glottic closure (deepen anesthesia or administer a muscle relaxant), epiglottic downfolding (reinsertion with maintained laryngoscopy (3) or jaw thrust (4)), glottic/supraglottic compression (5) (jaw thrust, cuff deflation or reinsertion using a smaller size), infolding of the ventral cuff (6) (cuff deflation or reinsertion using a smaller size), and malposition (reinsertion using a guided technique) (7). Distinguishing among these etiologies are the tests for malposition and mechanical obstruction. The malposition tests are only required after nonguided insertion and comprise: (i) checking for air leaks up the drain tube during positive pressure ventilation, (ii) assessing the position of the bite block in relation to the incisors (8), and (iii) the suprasternal notch tap test (9). The mechanical obstruction tests comprise: (i) jaw thrust, which decompresses the pharynx and elevates the epiglottis, and (ii) deflating the cuff, which decompresses the glottis and reduces cuff infolding (10). The algorithm synthesizes these tests to facilitate the diagnosis and management of airway obstruction with the ProSeal^TM laryngeal mask airway (Fig. 1).

View larger version (38K): [in this window] [in a new window]   Figure 1. Algorithm synthesizing tests to facilitate the diagnosis and management of airway obstruction with ProSealTM laryngeal mask airway.

1. Brimacombe J, Keller C, Fullekrug B, et al. A multicenter study comparing the ProSeal with the Classic laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology 2002; 96: 289–95.[Web of Science][Medline]
2. Keller C, Brimacombe J, Kleinsasser A, Brimacombe L. The laryngeal mask airway ProSeal^TM as a temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation. Anesth Analg 2002; 94: 737–40.[Abstract/Free Full Text]
3. Aoyama K, Takenaka I, Sata T, Shigematsu A. The triple airway manoeuvre for insertion of the laryngeal mask airway in paralysed patients. Can J Anaesth 1996; 42: 1010–6.
4. Elwood T, Cox RG. Laryngeal mask insertion with a laryngoscope in paediatric patients. Can J Anaesth 1996; 43: 435–7.
5. Brimacombe J, Richardson C, Keller C, Donald S. Mechanical closure of the vocal cords with the LMA ProSeal^TM [letter]. Br J Anaesth 2002; 89: 937.[Free Full Text]
6. Stix MS, Connor CJ. Maximum minute ventilation test for the ProSeal laryngeal mask airway. Anesth Analg 2002; 95: 1782–7.[Abstract/Free Full Text]
7. Brimacombe J. Laryngeal mask anesthesia: principles and practice. 2nd ed. London: WB Saunders, 2004.
8. Stix MS, O’Connor CJ. Depth of insertion of the ProSeal^TM laryngeal mask airway. Br J Anaesth 2003; 90: 235–7.[Abstract/Free Full Text]
9. O’Connor CJ, Borromeo CJ, Stix MS. Assessing ProSeal laryngeal mask positioning: the suprasternal notch test. Anesth Analg 2002; 94: 1374–5.[Free Full Text]
10. Brimacombe J, Richardson C, Keller C, Donald S. Mechanical closure of the vocal cords with the ProSeal laryngeal mask airway. Br J Anaesth 2002; 88: 296–7.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Brimacombe, J. Articles by Keller, C. Search for Related Content PubMed PubMed Citation Articles by Brimacombe, J. Articles by Keller, C.