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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 (CobraPLATM) in patients undergoing gynecological laparoscopy.
As stated by Dr. Alfery, the original supraglottic airway, the laryngeal mask airway (LMA-ClassicTM), 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
This article has been cited by other articles:
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  F. Martin and D. J. Buggy New airway equipment: opportunities for enhanced safety Br. J. Anaesth., June 1, 2009; 102(6): 734 - 738. [Full Text] [PDF]
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