Anesth Analg 1999;89:1319
© 1999 International Anesthesia Research Society
BRIEF COMMUNICATION
Using the Intubating Laryngeal Mask Airway (LMA-FastrachTM) for Blind Endotracheal Intubation in Patients Undergoing Cervical Spine Operation
Koichi Nakazawa, MD*,
Naofumi Tanaka, MD*,
Seiji Ishikawa, MD*,
Susumu Ohmi, MD*,
Masato Ueki, MD*,
Yutaka Saitoh, MD ,
Koshi Makita, MD*, and
Keisuke Amaha, MD*
*Department of Anesthesiology and Critical Care Medicine, Tokyo Medical and Dental University, Bunkyo-ku; and
Department of Anesthesia, Tokyo Metropolitan Hospital of Fuchu, Fuchu-City, Tokyo, Japan
Address correspondence and reprint requests to K. Nakazawa, MD, Department of Anesthesiology and Critical Care Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. Address e-mail to nakazawa.mane{at}med.tmd.ac.jp
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Introduction
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The intubating laryngeal mask airway (ILMA; LMA-FastrachTM, Laryngeal Mask Company, Ltd., Henley on Thames, UK) has been recently introduced as a prototype of the laryngeal mask airway for blind endotracheal intubation (1–3). It allows for an endotracheal tube (ETT) of up to 8.0-mm inside diameter and does not require head and neck manipulations on insertion. The success rate of blind intubation using the ILMA was up to 99.3% in patients with or without airway problems (3). Therefore, the ILMA might be helpful for endotracheal intubation in patients with cervical spine disease. The purpose of this study was to investigate the utility of the ILMA for blind endotracheal intubation in patients undergoing cervical spine surgery.
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Methods
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After obtaining approval from the hospital’s ethics committee and informed consent from patients, we examined 40 ASA physical status I, II, or III adult patients scheduled to undergo surgery for cervical spine diseases. Neck extension and Mallampati classification were examined preoperatively. Neck extension was evaluated as follows: First, the patient’s head was placed in a neutral position with the line between mandibular angle and mentum parallel to the floor. Then, the patient was asked to maximally extend his or her neck, and the angle of the traveled line was measured. Patients who complained of neurological symptoms, such as numbness on neck extension, patients who were wearing a stabilizing device, and those whose extension was <30° were regarded as having "limited neck extension." Limited neck extension, or Mallampati class 3 or 4, was defined as "suspected difficult intubation."
The patient was supine with the head placed in the neutral position. Insertion of the ILMA and endotracheal intubation were performed without manipulating the head or neck. In patients with an unstable cervical spine, the cervical spine was kept immobilized with a rigid collar or a halo vest as necessary. After the patients breathed 100% oxygen for 3 min, anesthesia was induced with propofol 2–2.5 mg/kg followed by 10 mg · kg-1 · min-1. Sizes 3, 4, and 5 ILMA were available, however, the size 3 was the first choice for women and the size 4 for men. After insertion of the ILMA, the patients were ventilated with 100% oxygen. If the patient was not well ventilated, the ILMA was removed and reinserted. When adequate ventilation was established, patients were administered 0.2 mg/kg vecuronium IV. Two minutes later, a lubricated 8.0-mm inside diameter silicone ETT (ILM ETT, Euromedical, Kedah, Malaysia) was passed through the ILMA. When resistance was felt during intubation, intubation was again attempted by changing the position of the mask (upward or downward by the attached handle). If endotracheal intubation was not successful on the first manipulation of the ILMA, an appropriate management was undertaken based on the depth of resistance (5)("second manipulation"). Successful intubation was confirmed by chest wall movement, auscultation, and capnogram. If intubation was not successful within two manipulations ("failed intubation"), intubation was performed through the ILMA using a fiberoptic bronchoscope. Ease of the ILMA insertion and condition of ventilation through the ILMA or intubation of the ETT were evaluated, and patients were assessed postoperatively for sore throat and hoarseness.
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Results
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Patient demographics are shown in Table 1. Thirty-four of 40 cases presented suspected difficult intubation. In 24 patients, neck extension was prohibited as a result of deterioration of neurological symptoms, and, in 8 patients, it was completely immobilized because of underlying diseases. Insertion of the ILMA was successful in all patients; however, 10 patients (4 patients wore a halo vest) required two attempts to obtain adequate ventilation. In 24 of 40 patients, intubation was successful on the first attempt, whereas 4 patients had failed intubation. Blind intubation was successful in 10 patients with a stabilizing device. Three patients were esophageally intubated, and 1 patient could not be intubated because resistance was felt on insertion of the ETT. All of these patients were eventually tracheally intubated using a fiberoptic bronchoscope through the ILMA. The vocal cords were fully viewed with fiberoptic bronchoscope from the aperture of the ILMA in those cases.
Postoperative sore throat and hoarseness occurred in 32.5% and 22.5% of patients, respectively, and, in all cases, these were transient. Three patients exhibited severe pharyngeal edema postoperatively (Figure 1). All these patients were tracheally intubated while the ILMA was kept in place in the pharynx during th 4-h period of anesthesia. After removing the ETT, the patients were ventilated through the ILMA until they recovered from anesthesia. Although those patients were successfully ventilated through the ILMA, they complained of dysphagia and sore throat lasting 2 to 4 days.
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Figure 1. Pharyngeal edema caused by placement of ILMA. A radiograph of a patient’s neck revealed that posterior pharyngeal wall at the level of C1 to C3 was thickened 6 times as much as before operation because of edema (space between arrows indicates posterior pharyngeal tissue at the level of C2). At the first case, we took this edema to be a consequence of the operation (this patient received anterior cervical spine fixation of C4-6). However, this phenomenon was recognized in three patients successively (the other two cases received anterior spine fixation of C4-6 and C5-6, respectively). Placement of ILMA during the operation was discontinued, and, since then, there were no cases of pharyngeal edema in this kind of surgery.
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Discussion
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Cervical supine disease is often associated with head and neck immobility, which can be associated with difficult endotracheal intubation at the time of surgery (6–8). In cases of cervical spine instability, direct laryngoscopy with neuromuscular blockade may be harmful (8). The present study demonstrated that ILMA enabled endotracheal intubation without manipulating the head and neck position under sufficient anesthesia with neuromuscular blockade in patients with cervical spine disease.
Success rates for blind endotracheal intubation using the ILMA have been reported to be from 82% to 99.3% (1,3,9,10). We previously examined patients receiving general anesthesia using a prototype ILMA and a polyvinyl chloride ETT, and intubation was successfully achieved in 82% of cases (10). The lower rate in our preliminary study might be a result of inexperience with the use of the ILMA or differences in the ETT material. As shown by Brain et al. (2), the silicone tube enters the trachea in a more anatomical direction after passing through the ILMA. In the present study, failure of blind intubation was mostly attributed to inappropriate ILMA size. The ETT was introduced into the esophagus in three patients despite using the smallest size ILMA (size 3), which indicated that even a size 3 was large for these patients.
For now, awake fiberoptic bronchoscopy is considered safe and is a first choice for patients with cervical spine disease with predicted difficult intubation (11). A comparison between the ILMA and fiberoptic bronchoscopy is required to establish the technique for intubating this patient population. The ILMA can be used for airway maintenance during surgery in cases of failed intubation, but our experience indicates that the placement should be limited to a short period. The rigid airway tube compresses the posterior pharynx wall (12), which may lead to mucosal ischemia or edema.
In conclusion, insertion of the ILMA and intubation through the ILMA can be achieved without manipulating the head and neck in patients with cervical spine diseases. Failure of blind intubation was mostly a result of inappropriate ILMA size, and all patients were tracheally intubated with the aid of a bronchofiberscope.
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References
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Brain AIJ, 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]
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Accepted for publication July 16, 1999.
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Introduction
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