Anesth Analg 2000;91:1303-1305
© 2000 International Anesthesia Research Society
CASE REPORTS
Reinforcement of Laryngeal Mask Airway Cuff Position with Endotracheal Tube Cuff for Airway Control in a Patient with Altered Upper Airway Anatomy
Virendra K. Arya, MD,
Amitabh Dutta, MD, and
Pramila Chari, MD, MAMS, FAMS
Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Address correspondence and reprint requests to Virendra K. Arya, MD, Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh- 160012, India.
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Abstract
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Implications: This case report suggests that the laryngeal mask airway (LMA) cuff position may not be optimal in some difficult airway situations in which the anatomical position of the larynx is altered. Reinforcement of the LMA cuff position by an additional cuff on the dorsal side of the LMA cuff may prove helpful. In this case, in which a difficult airway was anticipated, a nasopharyngeal tube cuff placed behind the standard LMA cuff helped relieve upper airway obstruction.
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Introduction
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Adifficult airway, particularly the "cannot ventilate, cannot intubate" situation that usually warrants fiberoptic-guided tracheal intubation, becomes a challenging proposition when fiberoptic equipment and its expertise are not available. We faced a similar situation because of a fixed anterior and superior larynx as a sequel to extensive chemical burns in the head, neck, and upper thorax of a 32-yr-old male, ASA physical status I patient. The cicatrization of the burn wound followed by anatomical changes in the upper airway resulted in the aforesaid difficulty. The nonavailability of fiberoptic equipment led us to successfully manage this case with a laryngeal mask airway (LMA), whose position required reinforcement by placing a cuffed endotracheal tube behind the LMA cuff for effective ventilation.
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Case Report
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Our patient sustained 25%–30% second degree chemical burns with sulfuric acid distributed mainly over the head, face, neck, and upper thorax (Fig. 1). This patient underwent repeated surgeries and dressings under general anesthesia. Healing and fibrosis of the raw area over his neck had resulted in gradually increasing difficulty in mask ventilation and visualization of the larynx on each subsequent exposure to general anesthesia. Great difficulty in laryngoscopy and endotracheal intubation was encountered 1 mo previously, when ventilation via a face mask was difficult after an IV induction of anesthesia, leading to repeated episodes of hypoxia, and the airway was finally secured with 6.5-mm inside diameter cuffed endotracheal tube after multiple unsuccessful attempts.
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Figure 1. Distribution of raw area over face and neck of the patient along with decreased mentothyroid and mentohyoid distances.
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This time the patient presented for split skin grafting. His anterior neck contracture had further advanced with resultant minimal neck extension, mouth opening of 3 cm, Mallampati (1) class III, and mentohyoid and mentothyroid distances 2 and 3 cm, respectively. Right nare was patent. The patient did not complain of any difficulty in breathing when awake or while sleeping. Premedication consisted of IM glycopyrrolate and oral diazepam 5 mg at night and an hour before surgery. The patient was shifted to the operating room and the usual monitoring used. After upper airway anesthesia with 10% lidocaine spray, an "awake" look laryngoscopy was performed and showed a Cormack and Lehane (2) grade III view. In view of the previous experience of difficult intubation, airway control with a LMA was planned. After explaining and reassuring the patient, a LMA No. 4 was gently introduced in the awake state, and cuff seal was obtained. The patient maintained ventilation and oxygen saturation with this approach. Subsequently, anesthesia was induced with propofol 1 mg/kg, and anesthesia was further deepened with an oxygen-halothane mixture while the patient was breathing spontaneously through a Bain system. With increasing depth of anesthesia, the airway started obstructing even though the LMA was in position, and gentle synchronized positive pressure ventilation (PPV) attempts also failed to maintain ventilation and oxygenation.
Repositioning of the LMA and replacing it a with a LMA No. 3 also failed to achieve satisfactory ventilation. Mask ventilation with an oropharyngeal airway was not possible after removal of LMA, and by this time, oxygen saturation decreased below 80%. A cuffed endotracheal tube was passed into the pharynx through the right nare, and ventilation was attempted through this tube with the mouth and opposite nare tightly occluded. Ventilation became possible with this maneuver, and oxygen saturation improved. Attempts to advance this tube into the trachea under laryngoscopy were unsuccessful. A LMA No. 4 was reintroduced while keeping the endotracheal tube in situ. The Bain system was attached to LMA and PPV was attempted, which was not possible because of an airway obstruction and a leak around the LMA cuff. The cuff of the endotracheal tube was inflated, which resulted in relieving the upper airway obstruction during spontaneous as well as intermittent PPV respiration. The LMA and endotracheal tube were appropriately secured (Fig. 2). Paralysis was induced with atracurium 0.5 mg/kg, and PPV was commenced with 66% nitrous oxide in oxygen. Morphine 0.l mg/kg was given IV. A Ryles tube was passed through the endotracheal tube into the stomach and air with gastric contents was aspirated. The further intraoperative period was uneventful. After 2 h, when the surgical procedure was over, the residual neuromuscular block was reversed with atropine (0.02 mg/kg) and neostigmine (0.05 mg/kg). Once the patient started responding to verbal commands while still drowsy, any attempt to remove the endotracheal tube after cuff deflation from the pharynx resulted in the reappearance of airway obstruction on spontaneous breathing. Hence, the patient was shifted to the recovery room with the LMA and endotracheal tube with inflated cuffs. After 2 h when the patient regained full consciousness, deflation of the endotracheal tube cuff was retried, and this time, the patient was able to maintain upper airway. The endotracheal tube was removed, followed by successful removal of LMA.
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Figure 2. Final position of the laryngeal mask airway and endotracheal tube with inflated cuffs. A Ryle’s tube is passed into stomach through the endotracheal tube
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Discussion
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Experience with the use of a LMA is limited in patients with unanticipated difficult airway, and elective use in such situations may result in a significant incidence of suboptimal placement. However, a LMA has been used successfully as an emergency airway in adult (3) and pediatric (4) patients in whom difficult airway is unanticipated. In the present difficult airway situation with an anteriorly and superiorly displaced larynx (Fig. 3), the spontaneous respiratory efforts under anesthesia augmented upper airway obstruction, most likely as a result of decreased muscle tone and the negative pressure pulling the base of the tongue and epiglottis toward the laryngeal inlet and posterior wall of the pharynx, thus accentuating obstruction. In addition, there was an inefficient seal of the larynx by the LMA cuff, possibly in the area of the hypopharynx where the tip of the LMA lies. The inflated cuff of the nasopharyngeal tube pushed the entire LMA cuff anteriorly, thus resulting in a forward displacement of the epiglottis and the base of the tongue akin to externally applied jaw-lift maneuver. The forward displacement of the LMA cuff also led to an effective seal at the laryngeal inlet. A prototype LMA with dorsal cuff has been described in the literature for pediatric patients (5), which offers an increased seal pressure of the glottic mask, good anatomical alignment of the ventilatory tube and glottis, and some protection against gastric insufflation. In our case, the endotracheal tube cuff probably acted like a dorsal cuff as described for a pediatric LMA
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Figure 3. Lateral radiograph neck in maximum extension, showing restricted neck extension and an acute angle between pharyngeal and laryngeal axis as a result of an anatomically displaced larynx.
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In patients with altered anatomical locations of larynx, as in our case, the dorsal cuff of the LMA may be helpful in maintaining adequate ventilation and alleviating upper airway obstruction. We therefore suggest that an LMA with dorsal cuff, if made available in adult sizes, may prove useful in certain difficult airway situations with a displaced larynx in adults.
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References
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Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429–34.[Web of Science][Medline]
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Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–11.[Web of Science][Medline]
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White A, Sinclair M, Pillai R. Laryngeal mask airway for coronary artery bypass grafting [letter]. Anaesthesia 1991; 46: 234.[Web of Science][Medline]
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Castresana MR, Stefansson S, Cancel AR, Hague KJ. Use of the laryngeal mask airway during thoracotomy in a pediatric patient with Cri-du-chat syndrome [letter]. Anesth Analg 1994; 78: 817.
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Lopez-Gil M, Brimacombe J, Brain AIJ. Preliminary evaluation of a new prototype laryngeal mask in children. Br J Anaesth 1999; 82: 132–4.[Abstract/Free Full Text]
Accepted for publication July 7, 2000.
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Abstract
Introduction
