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Anesth Analg 2005;101:1889
© 2005 International Anesthesia Research Society

LETTER TO THE EDITOR

The LMA Is a Critical Rescue Device in Airway Emergencies

David T. Wong, MD

Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Toronto, ON, david.wong{at}uhn.on.ca

In Response:

We appreciate Dr. Atkins’ letter regarding our article (1). The incidence of the cannot intubate/cannot ventilate (CICV) situation is 0.01%–0.05% (2–4) and the incidence of CICV that can not be rescued by a LMA or other supraglottic devices is probably <0.02% (5). I completely agree with the recommendations of the Practice Guidelines of the ASA Task Force (6) and with Dr. Atkins that in the situation of cannot intubate/face mask ventilation inadequate, LMA insertion should be the immediate next step. However, supraglottic devices will never be 100% successful in overcoming CICV situations. I had performed percutaneous cricothyroidotomy on two CICV situations. The first patient was located on a surgical ward when a LMA was not available. The second patient had postoperative macroglossia, and LMA insertion was unsuccessful. I believe every clinician involved in airway management should be familiar with both the mental algorithm and practical skills in the insertion of an infraglottic airway during a CICV situation.

The primary purpose of our study was to determine the preferences, experience and the comfort level in using an invasive infraglottic device in a CICV scenario (1). We intentionally eliminated the option of LMA to obtain the participants’ opinion regarding invasive infraglottic devices. Rephrasing question 6 (1) as "In a CICV situation, LMA insertion/ventilation is ineffective, patient’s Spo2 is <50%, and you have decided to go for an ‘infraglottic airway,’ what will be your first and second choice devices be?" may be a more accurate description of the scenario.

Our results showed that many anesthesiologists are inexperienced with managing CICV situations and had no cricothyroidotomy training on mannequins (1). Simulation training on mannequins may improve the anesthesiologists’ mental algorithm and practical skills in the usage of invasive infraglottic devices and may enhance their performance in real-life CICV situations (7).

References

  1. Wong DT, Lai K, Chung FF, et al. Cannot intubate-cannot ventilate and difficult intubation strategies: results of a Canadian national survey. Anesth Analg 2005;100:1439–46.[Abstract/Free Full Text]
  2. Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth 1998;45:757–76.[Abstract/Free Full Text]
  3. Combes X, Le Roux B, Suen R, et al. Unanticipated difficult airway in anesthetized patients: prospective validation of a management algorithm. Anesthesiology 2004;100:1146–50.[ISI][Medline]
  4. Benumof JL. Management of the difficult adult airway. Anesthesiology 1991;75:1087–110.[ISI][Medline]
  5. Parmet JL, Colonna-Romano P, Horrow JC, et al. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation. Anesth Analg 1998;7:661–5.
  6. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 2003;98:1269–77.[ISI][Medline]
  7. Wong DT, Prabhu AJ, Coloma M, et al. What is the minimum training required for successful cricothyroidotomy? Anesthesiology 2003;98:349–53.[ISI][Medline]




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press