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LETTER TO THE EDITOR

Is the Cobra Perilaryngeal Airway (CobraPLA^TM) Appropriate for Use in Patients Undergoing Gynecological Laparoscopy?

Department of Anesthesiology; Erasmus University Medical Center; Rotterdam, The Netherlands; eilishgalvin{at}hotmail.com

In Response:

We appreciate Dr. Alfery’s (1) interest in our article (2). He highlighted the concerns which exist regarding the risk of regurgitation of gastric contents and aspiration when using supraglottic airway devices. More specifically, he questioned the use of the Cobra perilaryngeal airway (CobraPLA^TM) in patients undergoing gynecological laparoscopy.

As stated by Dr. Alfery, the original supraglottic airway, the laryngeal mask airway (LMA-Classic^TM), has an established safety record in nonlaparoscopic surgery. In more recent years, its use during laparoscopic procedures has been investigated, with positive outcomes (3,4); as already highlighted, the study group investigated by Bapat et al., (5) included known higher risk patients.

It is important to recognize that much of the research involving supraglottic airways, including our own study (2), uses strict inclusion criteria, namely fasting patients, with a body mass index (BMI) <30 and no evidence of active gastric reflux disease. Additional precautions include limiting the degree of maximal head down (Trendelenberg’s) positioning and in the case of laparoscopic procedures, the maximal intra-abdominal pressure.

New supraglottic airway devices are increasingly available and differ from the original LMA-Classic in terms of specific design features, which may offer advantages in certain circumstances. It is therefore important, that the potential usefulness of such devices is investigated through controlled clinical studies, in a variety of different settings, to establish individual device risks and benefits. In our study, as with other published studies (6,7) maximal airway pressures briefly exceeded manufacturer’s recommendations (8). This is not our everyday practice, but was used within the study protocol to establish ventilation characteristics of the devices under investigation. The results have shown that the maximal airway pressure, without air leakage at which ventilation can be achieved during pneumoperitoneum is higher for the CobraPLA than the LMA-Classic. However, as mentioned in the discussion section of our article (1), the use of such ventilation pressures "may result in greater flow of gases into the gastrointestinal tract with resultant gastric distension and a possibly increased risk of regurgitation and aspiration." Additionally, the circumferential, more proximally situated cuff of the CobraPLA might in theory, increase the chances of any regurgitated gastric secretions flowing toward the trachea rather than upwards toward the mouth.

In conclusion, we agree that there are many factors to be considered when selecting an appropriate airway device, not least of which is the information obtained from patient history taking and relevant examination.

REFERENCES

1. Alfery D. Is the cobra perilaryngeal airway (CobraPLA^TM) appropriate for use in patients undergoing gynecological laparoscopy? Anesth Analg 2007;105:546[Free Full Text]
2. Galvin EM, van Doorn M, Blazquez J, Ubben JF, Zijlstra FJ, Klein J, Verbrugge SJC. A randomized prospective study comparing the Cobra perilaryngeal airway and laryngeal mask airway-Classic during controlled ventilation for gynecological laparoscopy. Anesth Analg 2007;104:102–5[Abstract/Free Full Text]
3. Verghese C, Brimacombe J. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage. Anesth Analg 1996;82:129–33[Abstract]
4. Maltby JR, Beriault MT, Watson NC, Liepert DJ, Fick GH. LMA-Classic and LMA-ProSeal are effective alternatives to endotracheal intubation for gynecologic laparoscopy. Can J Anaesth 2003;50:71–7[Web of Science][Medline]
5. Bapat PP, Verghese C. Laryngeal mask airway and the incidence of regurgitation during gynecologic laparoscopies. Anesth Analg 1997;85:139–43[Abstract]
6. Gaitini L, Yanovski B, Somri M, Vaida S, Riad T, Alfery D. A comparison between the PLA Cobra and the Laryngeal Mask Airway Unique during spontaneous ventilation: a randomized prospective study. Anesth Analg 2006;102:631–6[Abstract/Free Full Text]
7. Akca O, Wadhwa A, Sengupta P, Durrani J, Hanni K, Wenke M, Yucel Y, Lenhardt R, Doufas AG, Sessler DI. The new perilaryngeal airway (CobraPLA) is as efficient as the laryngeal mask airway (LMA) but provides better airway sealing pressures. Anesth Analg 2004;99:272–8[Abstract/Free Full Text]
8. CobraPLA product information sheet. Available at www.engmedsys.com

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