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LETTERS TO THE EDITOR

Use of a Laryngeal Mask in a Patient with an Unstable Neck: At Induction or During Emergence?

Department of Anaesthesia Shizuoka Red Cross Hospital Shizuoka, Japan

I read with interest the brief report by Asai and Shingu (1) describing the use of a laryngeal mask airway (LMA) during emergence after cervical spine surgery. I fully agree that meticulous airway care is essential to prevent patients’ responses to a tracheal tube, thus minimizing the risk of dislodgement of bone graft. However, I wonder whether a LMA could and perhaps should be placed at the induction of anesthesia, rather than at the end of the case, in this clinical scenario (2).

Although they recommend placing a LMA before tracheal extubation because of fear of losing the airway, LMA insertion in the presence of a tracheal tube may not always be straightforward in unexperienced hands, particularly when manual in-line neck stabilization is applied (3). Moreover, the procedure itself may cause undesirable movements and straining if attempted under light anesthesia.

Placement of a tracheal tube through either a conventional or an intubating LMA is widely reported (4–7). At the end of surgery, gentle removal of a tube through the LMA in situ would be far easier and less stimulating. After extubation, patients are allowed to breathe spontaneously until ready for LMA removal, and smooth recovery is the norm.

References

1. Asai T, Shingu K. Use of the laryngeal mask during emergence from anesthesia in a patient with an unstable neck. Anesth Analg 1999;88:469–70.[Free Full Text]
2. Kiyama S. Intubation via a laryngeal mask airway and cervical spine surgery. Anaesthesia 1995;50:83.
3. Asai T, Neil J, Stacey M. Ease of placement of the laryngeal mask during manual in-line neck stabilization. Br J Anaesth 1998;80:617–20.[Abstract/Free Full Text]
4. Heath ML, Allagain J. Intubation through the laryngeal mask: a technique for unexpected difficult intubation. Anaesthesia 1991;46:545–8.[Web of Science][Medline]
5. Asai T. Use of the laryngeal mask for fibrescope-aided tracheal intubation in an awake patient with a deviated larynx. Acta Anaesthesiol Scand 1994;38:615–6.[Web of Science][Medline]
6. Brain AI, Verghese C, Addy EV, et al. The intubating laryngeal mask. II. A preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997;79:704–9.[Abstract/Free Full Text]
7. Joo H, Rose K. Fastrach: a new intubating laryngeal mask airway—successful use in patients with difficult airways. Can J Anaesth 1998;45:253–6.[Web of Science][Medline]

Response

Department of Anesthesiology Kansai Medical University Moriguchi City, Osaka, Japan

Dr. Kiyama made a useful suggestion that, in the patient with an unstable neck, the trachea could have been intubated through the laryngeal mask (leaving both the endotracheal tube and laryngeal mask in place during the operation), and at the end of surgery, the endotracheal tube could have been removed easily with the laryngeal mask in place. There were two reasons why we did not do so in our patient (1). First, we used the intubating laryngeal mask for tracheal intubation but removed the mask afterward, because the device has a rigid metal tube that might produce unduly pressures on a fragile cervical spine if the device is left in place for a prolonged period (2). Second, as in our previous report (3), the presence of the cuff of the laryngeal mask might have interfered with surgery (anterior fixation of the cervical spine).

The presence of an endotracheal tube should not impede placement of the laryngeal mask (4); stabilization of the head and neck does not markedly decrease the success rate of ventilation through the laryngeal mask (although placement may be more difficult) (5,6). However, we have found that placement may often fail in both circumstances if the mask is placed without using the correct method as described by the inventor (unpublished observation). Therefore, we believe that any technique, such as one we report (1), should be applied to the actual patient only by people who have gained enough skill through proper training.

References

1. Asai T, Shingu K. Use of the laryngeal mask during emergence from anesthesia in a patient with an unstable neck. Anesth Analg 1999;88:469–70.
2. Brimacombe J, Keller C. Cervical spine instability and the intubating laryngeal mask: a caution. Anaesth Intensive Care 1998;26:708.
3. Asai T. Fiberoptic tracheal intubation through the laryngeal mask in an awake patient with cervical spine injury. Anesth Analg 1993;77:404.
4. Koga K, Asai T, Vaughan RS, Latto IP. Respiratory complications associated with tracheal extubation: timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia 1998;53:540–4.[Web of Science][Medline]
5. Asai T, Neil J, Stacey M. Ease of placement of the laryngeal mask during manual in-line neck stabilization. Br J Anaesth 1998;80:617–20.
6. Brimacombe J, Berry A. Laryngeal mask airway insertion: a comparison of the standard versus neutral position in normal healthy patients with a view to its use in cervical spine instability. Br J Anaesth 1993;48:670–1.

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