Anesth Analg 2000;91:635-636
© 2000 International Anesthesia Research Society
CRITICAL CARE AND TRAUMA
The Laryngeal Mask for Percutaneous Endoscopic Gastrostomy
J. Brimacombe, MB, ChB, FRCA, MD,
S. Newell, MB BS, FANZCA,
A. Bergin, MB BS,
J. McCarthy, MB BS, and
J. Barry, MB BS, FFARCSI FANZCA
Department of Anaesthesia and Intensive Care, University of Queensland, Cairns Base Hospital, Australia
Address correspondence and reprint requests to J. Brimacombe, MB, ChB, FRCA, Department of Anaesthesia and Intensive Care, University of Queensland, Cairns Base Hospital, The Esplanade, Cairns 4870, Australia.
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Abstract
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Implications: We report the successful use of the laryngeal mask airway for percutaneous endoscopic gastrostomy in an adult patient with a known difficult airway and severe cerebral palsy.
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Introduction
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The laryngeal mask airway (LMA) has been used to facilitate gastroscopy in an awake patient and for placement of a nasogastric tube in a tracheally intubated, anesthetized patient (1). We report the successful use of the LMA for percutaneous endoscopic gastrostomy (PEG) (2) in an adult patient with a known difficult airway and severe cerebral palsy.
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Case Report
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A 37-yr-old, 19 kg, 120 cm man with severe cerebral palsy presented for insertion of a gastrostomy feeding tube because of inadequate oral intake. Four months previously, he had a general anesthetic for dental surgery, and laryngoscope-guided intubation had failed despite two attempts with a gum elastic bougie. It was noted at the time that the patient was easy to ventilate via a face mask, but had limited mouth opening and was Cormack and Lehane grade III (3). Airway rescue had been with a size 3 flexible LMA, and the dental procedure was successfully completed. Preoperative examination revealed that the intercisal distance was 16 mm and that the patient was continually chewing and biting. An awake fiberoptic intubation was not considered a feasible option. The patient was fasted and was not at risk of aspiration.
The patient underwent an inhaled induction with sevoflurane in oxygen with the inspired concentration of sevoflurane increased by 1% every 5–10 breaths. Two minutes after a sevoflurane concentration of 8% was reached and the lash reflex was absent, a size 3 LMA was inserted without difficulty. The standard recommended insertion technique was used (4), but to allow for the small intercisal distance, the finger tip was placed on the anterior cuff-tube junction from the side of the mouth rather than between the incisors. The cuff was inflated with 10 mL of air. Ventilation was easy with an airway sealing pressure of 15 cm H2O. A 1-cm external diameter, well lubricated gastroscope was placed in the mouth behind the LMA and passed into the esophagus with ease (Fig. 1). The endoscopist noted that the stomach was empty. The guidewire was inserted through the abdominal wall into the stomach, gripped by a polypectomy snare, and withdrawn from the mouth. A 20F gastrostomy tube was attached to the wire and pulled behind the LMA cuff back into the stomach. There was no displacement of the LMA or loss of seal during these maneuvers. When the gastroscope was in situ, it was noted that the airway sealing pressure had increased to 25 cm H2O. Cardiorespiratory variables were stable throughout. At the end of the procedure, spontaneous breathing was allowed to resume, and the LMA was removed with the patient deeply anesthetized. Emergence was uneventful, and the endoscopist was satisfied with the surgical conditions.
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Discussion
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This case illustrates that PEG is feasible during airway management with the LMA. Although some authors consider that difficult airway patients should be tracheally intubated (5), we felt that LMA use was justified, because previous face mask ventilation and LMA insertion were easy, and the patient was not at risk of aspiration. Fiberoptic oral and nasal intubation after the induction of anesthesia would have been another practical option, but airway control can be difficult with these techniques. We could also have used the LMA as an airway intubator, but this was unnecessary. It has been suggested that one of the risks of gastroscopy with the LMA is loss of seal caused by mask displacement (1), but this has not been reported. Interestingly, the efficacy of seal increased when the gastroscope was in situ. We speculate that the gastroscope pushed the cuff more firmly into the periglottic tissues, a phenomenon that might also explain the increase in seal during application of pressure over the front of the neck (6), during neck flexion (7), or when using an LMA with a second cuff on the dorsal surface (8). In our patient, the mouth opening was 16 mm. Maltby et al. (9) reported use of the LMA in patients with a mouth opening from 12 to 20 mm. We removed the LMA with the patient still deeply anesthetized in anticipation of the patient’s biting during emergence and making removal difficult.
Possible limitations of LMA usage for PEG are that 1) it is unsuitable for patients at risk of aspiration, because protective reflexes are lost and the airway is not secured, and 2) it should only be attempted by a skilled LMA user with experience in anesthesia for PEG and only after discussion with the gastroenterologist. The decision to use the LMA for PEG in a known difficult airway should only be made after a careful analysis of the risks and benefits when compared with fiberoptic intubation.
In summary, this case illustrates the successful use of the LMA for PEG in an adult patient with a known difficult airway and severe cerebral palsy.
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Acknowledgments
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We would like to thank Dr. Peter Boyd for his assistance.
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References
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Accepted for publication May 5, 2000.
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Abstract
Introduction
