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Member, Anesthesia Medical Group; Nashville, TN; dalfery{at}dalfery.com
To the Editor:
Recently, Galvin et al. (1) compared the Cobra perilaryngeal airway (CobraPLATM) with the laryngeal mask airway-Classic (LMA-ClassicTM) during controlled ventilation in patients undergoing gynecological laparoscopy. In an apparent effort to avoid regurgitation, study patients were allowed a maximum head-down Trendelenberg’s position of only 15° while maximal intraabdominal pressure was limited to 15 mm Hg, and Galvin et al. are commended for this precaution.
Although both devices functioned well for these cases, using either the CobraPLA or the LMA-Classic to provide airway support for laparoscopy is not without controversy (2,3). Despite the remarkably safe clinical track record of the laryngeal mask airway, Bapat et al. noted a 1% incidence of regurgitation (with no aspiration) during gynecologic laparoscopy, although some study patients were obese or had a history of reflux (4). Statistical analysis of their 99 study patients calculated a true rate of regurgitation of <4.1%. In addition, a case of aspiration (with benign outcome) has been reported when using the CobraPLA for this type of procedure (5).
My concern, as the inventor of the CobraPLA, is that despite the best of intentions and planning to limit the amount of Trendelenberg’s position and intraabdominal pressure, there are times when it is difficult to do so, as intraoperative conditions might dictate the need for changing these parameters to allow better surgical exposure. In addition, while Engineered Medical Systems (EMS, Indianapolis, IN), the manufacturer of the CobraPLA, advises against delivering airway pressures greater than 20 cm H2O (6), a head down lithotomy position might require airway pressures greater than 20 cm H2O to provide adequate gas exchange. Despite their precautions, Galvin et al. state that some patients briefly received airway pressures as high as 40 cm H2O (1). Finally, the patient population for gynecologic laparoscopy often has comorbid medical conditions such as hiatal hernia, diabetes, or obesity that might not be fully appreciated preoperatively.
EMS and I have advocated "erring on the side of caution and using common sense" (3) when deciding whether or not to use the CobraPLA in any given situation, as it provides no protection against aspiration. I respect that these investigators took quite reasonable and appropriate precautions with their patients and that there are significant practice differences between clinicians residing in the United States and Europe (the Glavin study was conductered in The Netherlands). Still, one must weigh all individual patient, device, and surgical factors when deciding whether or not to use an extraglottic airway for these procedures. For my practice in the United States, given the above stated points, the answer for the CobraPLA is almost always "no" (5).
Dr. Alfery is the inventor of the CobraPLA and receives royalties on sales.
REFERENCES
This article has been cited by other articles:
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  E. M. Galvin Is the Cobra Perilaryngeal Airway (CobraPLATM) Appropriate for Use in Patients Undergoing Gynecological Laparoscopy? Anesth. Analg., August 1, 2007; 105(2): 546 - 547. [Full Text] [PDF]
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