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CRITICAL CARE AND TRAUMA

Use of the ProSeal Laryngeal Mask Airway to Initiate Ventilation During Intensive Care and Subsequent Percutaneous Tracheostomy

Department of Anaesthesia, Royal United Hospital, Bath, United Kingdom

Address correspondence and reprint requests to T.M. Cook, Department of Anaesthesia, Royal United Hospital, Combe Park, Bath BA1 3NG, England. Address e-mail to timcook{at}ukgateway.net

	Abstract

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The ProSeal Laryngeal Mask Airway is a supraglottic airway that aims to provide improved airway seal and separation of the gastrointestinal and respiratory tracts. We report two cases in which the ProSeal Laryngeal Mask Airway was used to initiate controlled ventilation in the intensive care unit and subsequently provide airway maintenance during percutaneous dilational tracheostomy. The first case involved a patient with a known difficult airway who had previously been impossible to intubate conventionally. In both cases, airway management and subsequent tracheostomy were performed without complication.

IMPLICATIONS: This report details the management of two patients requiring mechanical ventilation in an intensive care unit. Both were managed with a new airway device, the ProSeal Laryngeal Mask Airway. This device allowed mechanical ventilation and performance of a tracheostomy at the bedside without requiring placement of a tube inside the patient’s trachea.

	Introduction

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The ProSeal Laryngeal Mask Airway (PLMA) (Intavent Orthofix, Maidenhead, United Kingdom) is a supraglottic airway designed to allow ventilation of the lungs with improved laryngeal seal compared with a classic LMA (Laryngeal Mask Company, Henley-on-Thames, United Kingdom) (1,2). The intrinsic drain tube allows separation of the respiratory and alimentary tracts (1). Use of the PLMA during anesthesia has been described (2–4). We report the use of the PLMA for initiation of positive-pressure ventilation in two patients with respiratory failure requiring ventilation in the intensive care unit and subsequent percutaneous tracheostomy under bronchoscopic control.

	Case Reports

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Case 1
A 49-yr-old woman was referred to the intensive care team with increasing respiratory distress and hypoxia from septic shock 36 h after a laparotomy for perforated peptic ulcer. Her medical history included dermatomyositis, insulin-controlled diabetes mellitus, and hypertension. Eighteen months before this admission, during anesthesia for a gynecological procedure, laryngoscopy had revealed a Grade 4 view (5), and intubation had been impossible despite the use of multiple airway adjuncts. She had prominent upper incisors, a receding jaw, and a Mallampati Class 4 airway (6). For the laparotomy, her airway was secured with awake fiberoptic intubation. Subsequent laryngoscopy confirmed a Grade 4 view.

On referral to the intensive care team, she had a respiratory rate of 35 breaths/min and an arterial oxygen saturation of 89% on high-flow face mask oxygen. Her chest radiograph was consistent with acute respiratory distress syndrome. On transfer to the intensive care unit (ICU), her condition deteriorated rapidly. Her oxygen saturation by pulse oximetry (SpO₂) decreased to 78% despite high-flow oxygen and continuous positive airway pressure of 10 cm H₂O via a tight fitting face mask. She was exhausted and close to respiratory arrest. She was anesthetized with propofol 50 mg, alfentanil 1.0 mg, and paralyzed with succinylcholine 100 mg. A size 4 PLMA was inserted on the first attempt using the introducer tool, and controlled ventilation was initiated. A tidal volume of 400 mL (peak inspiratory pressure 24 cm H₂O) was achieved with no airway leak as measured by spirometry. An orogastric tube was passed into the stomach. Preparation was made to perform percutaneous tracheostomy. Further sedation and analgesia with propofol and fentanyl infusions were administered. A 5-mm fiberoptic bronchoscope was passed through the airway tube of the PLMA until it lay just distal to the vocal cords. The bronchoscope was used to confirm placement of a cannula and guidewire in the midline between the first and second tracheal rings. A size 8 tracheostomy tube was inserted after tracheal dilation using a Blue Rhino dilator (Cook Critical Care, Letchworth, Herts, United Kingdom).

Ventilation of the patient’s lungs was continued via the tracheostomy. She remained ventilated for 4 days. She was discharged from the ICU after 6 days and from the hospital after a further 5 days, having made a full recovery.

Case 2
A 22-yr-old male IV drug user was admitted with a 24-h history of dysphonia, dysarthria, dysphagia, and diplopia associated with difficulty in micturition. He had a 24-h history of diarrhea. Over the next 12 h, he developed a descending paralysis affecting neck, upper limbs, and proximal lower limbs. Bulbar symptoms were prominent with a weak cough. Peripheral reflexes were retained, and sensation was normal. He had a forced vital capacity of 1.2 L. He was afebrile and fully conscious. Differential diagnoses included Guillain-Barré syndrome, botulism, myasthenia gravis, a cerebrovascular accident, or infection. Investigations revealed a normal magnetic resonance image of the head and spine, normal cerebrospinal fluid examination, and a negative Edrophonium test.

The patient was transferred to the ICU for further management. Over the next 12 h, his facial, upper body, and proximal weakness worsened. A presumptive diagnosis of botulism was made. His forced vital capacity decreased to 0.5 L. Arterial blood gases revealed good oxygenation with an increasing PCO₂. He was treated with antibiotics and botulinum antitoxin.

Because of his inability to cough and clear secretions, compounded by worsening respiratory function, it was decided to initiate controlled ventilation. He had a fine-bore gastric tube in place, and he had not been fed by mouth for 12 h. Anesthesia was induced with propofol 150 mg, alfentanil 2 mg, and rocuronium 50 mg. A size 5 PLMA was inserted on the first attempt using the introducer tool, and controlled ventilation was initiated. A tidal volume of 400 mL (peak inspiratory pressure 12 cm H₂O/positive end-expiratory pressure 5 cm H₂O) was achieved with no airway leak. A 5-mm fiberoptic bronchoscope was passed through the airway tube of the PLMA until it lay just distal to the vocal cords, giving a perfect view of the trachea. The bronchoscope was used to observe and guide the performance of percutaneous tracheostomy. Observing from the level of the vocal cords, the endoscopist was able to instruct the intensivist performing the tracheostomy to change the site of needle insertion because initial attempts were too low (below the seventh tracheal ring).

The diagnosis of botulism was subsequently confirmed with a mouse inoculation test. The patient required controlled ventilation for 14 days and remained in the ICU for 17 days. During his stay, he was weaned off his drugs of dependence. By Day 18, his muscle strength was improved, he was weaned from respiratory support, and the tracheostomy was removed.

	Discussion

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The two cases illustrate slightly different uses of the PLMA in intensive care. In the first case, the PLMA was used to manage a patient in extremis who was known to be impossible to intubate conventionally. We considered attempted fiberoptic intubation in her critical condition to be hazardous. In the second case, the patient had no anticipated major airway problems, but use of the PLMA allowed rapid control of his failing ventilation without need for translaryngeal intubation. In both cases, subsequent percutaneous tracheostomy was facilitated considerably by use of the PLMA rather than a tracheal tube.

The use of a laryngeal mask in intensive care is not unique. There have been two reports of the use of a classic LMA for brief periods of controlled ventilation in intensive care (7–9). The PLMA has potential advantages over the classic LMA because it may functionally separate the respiratory and gastrointestinal tracts. The improved airway seal achieved with the PLMA compared with other laryngeal masks and the facility to drain the stomach and vent esophageal gases are advantages. The PLMA has not been proven to provide absolute protection against aspiration of regurgitated gastric contents, but design features and available evidence suggest it is likely to reduce risk and increase protection compared with a classic LMA (1–3,10,11). We would not consider the PLMA to be a routine substitute for the tracheal tube, but in these two cases, it had distinct advantages.

The use of the PLMA for percutaneous tracheostomy has not been previously described. It has been our routine tool for airway maintenance for at least a year. We have successfully used this technique in more than 50 patients. The use of a supraglottic airway rather than a tracheal tube during percutaneous tracheostomy allows bronchoscopic visualization of the whole of the larynx and trachea while avoiding the possibility of damage to the airway device. The classic LMA (12) and intubating ILMA (13) have been used for airway maintenance during percutaneous tracheostomy. Use of the PLMA allows a better seal with the larynx to be achieved, facilitating reliable ventilation, even in patients with reduced lung compliance (1,2). The drain tube of the PLMA allows a gastric tube to be passed, the stomach to be drained where required, and reduces the likelihood of gastric insufflation. Should regurgitation occur during the procedure, the drain tube should direct regurgitant matter away from the laryngeal inlet (10,11), and we have seen this on one occasion (14). The absence of bars or epiglottic elevator in the bowl of the PLMA is a further advantage in the PLMA facilitating unimpeded bronchoscopic observation. Finally, for a given pharyngeal seal, the PLMA exerts less pressure on the airway mucosa than the ILMA and classic LMA (15,16). One caveat with using any supraglottic airway during percutaneous tracheostomy is that patients who have been intubated for prolonged periods of time may have considerable upper airway edema. This may lead to difficulty with establishing an airway seal. In these cases, the PLMA is likely to perform better than the classic LMA or ILMA.

Clearly, in most circumstances, the airway of choice for a critically ill patient is likely to be the tracheal tube. However, in a small minority of circumstances where intubation might be hazardous or unnecessary, particularly when early tracheostomy is planned, the PLMA is a useful alternative.

	Footnotes

 
Dr. Cook has received a small honorarium for addressing a meeting at Intavent Orthofix (manufacturers of the ProSeal Laryngeal mask airway).

	References

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15. Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus laryngeal mask airway in anaesthetised paralyzed patients. Br J Anaesth 2000; 85: 262–6.[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (11) Citing Articles via Google Scholar Google Scholar Articles by Cook, T. M. Articles by Nolan, J. P. Search for Related Content PubMed PubMed Citation Articles by Cook, T. M. Articles by Nolan, J. P. Related Collections Critical Care Airway