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LETTER TO THE EDITOR

Use of the CobraPLA^TM for Percutaneous Cricothyroidotomy and Tracheostomy

Department of Anaesthesia; Royal United Hospital; Bath, England; timcook{at}ukgateway.net

To the Editor:

Agro et al. describe use of the CobraPLA^TM for percutaneous dilatational cricothyroidotomy (1) as "an ideal teaching technique." I wish to raise two reservations.

Several supraglottic airways are described for percutaneous tracheostomy (2–5). Requirements are facility for pulmonary ventilation (even when lung compliance is reduced), tracheal access, and aspiration protection. The Proseal^TM LMA (PLMA) and Laryngeal tube sonda^TM (LTS) probably fulfill these criteria best. Data on the fiberoptic view from PLMA (6), LT (7), and LTS (8) suggest the PLMA provides the better view. We have performed 90 PLMA-assisted tracheostomies without complication (9).

There are limited data on the CobraPLA. Company data indicate an airway seal of 28 cmH₂O. However, CobraPLA design features might predispose to increased aspiration risk. First, the tip, without balloon or cuff, does not obdurate the esophagus; manufacturer’s instructions require the device to be "pulled back slightly" after full insertion (10). Second, the proximal balloon prevents venting of regurgitant matter potentially trapping it in the hypopharynx. Third, the CobraPLA shape creates a larger pharyngeal reservoir than LMAs (11). We have recently suspended clinical trials of the CobraPLA after two episodes of pulmonary aspiration during approximately 60 elective uses.

I would caution against extending the role of this device until safety is better established.

References

1. Agro F, Carassiti M, Magnani C. Percutaneous dilational cricothyroidotomy: airway control via the CobraPLA. Anesth Analg 2004;99:628.[Free Full Text]
2. Johnson R, Bailie R. Airway management device (AMD) for airway control in percutaneous dilatational tracheostomy. Anaesthesia 2000;55:596–7.[Web of Science][Medline]
3. Cook TM. Percutaneous dilational tracheostomy. Anaesthesia 1993;48:735.
4. Verghese C, Rangasami J, Kapila A, Parke T. Airway control during percutaneous dilatational tracheostomy: pilot study with the intubating laryngeal mask airway. Br J Anaesth 1998;8:608–9.
5. Cook TM, Taylor M, McKinstry C, et al. Use of the ProSeal laryngeal mask airway to initiate ventilation during intensive care and subsequent percutaneous tracheostomy. Anesth Analg 2003;97:848–50.[Abstract/Free Full Text]
6. 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]
7. Cook TM, McKinstry C, Hardy R, Twigg S. Randomized crossover comparison of the ProSeal laryngeal mask airway with the Laryngeal Tube during anaesthesia with controlled ventilation. Br J Anaesth 2003;91:678–83.[Abstract/Free Full Text]
8. Gaitini LA, Vaida SJ, Somri M, et al. A randomized controlled trial comparing the ProSeal ^TM Laryngeal Mask Airway with the Laryngeal Tube Suction in mechanically ventilated patients. Anesthesiology 2004;101:316–20.[Web of Science][Medline]
9. Craven RM, Laver SR, Cook TM, Nolan JP. Use of the Pro-Seal LMA facilitates percutaneous dilatational tracheostomy. Can J Anaesth 2003;50:718–20.[Web of Science][Medline]
10. CobraPLA product information. Indianapolis, IN: Engineered Medical Systems, 2003.
11. Brain AIJ. The laryngeal mask and the oesophagus. Anaesthesia 1991;46:701–2.

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