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Anesth Analg 2003;97:921
© 2003 International Anesthesia Research Society

LETTERS TO THE EDITOR

A New Connector Assembly with the Potential to Make Endotracheal Intubation Using the Intubating Laryngeal Mask Airway Faster and Safer

Rakesh Kumar, MD, Sunil Kumar, DA, and Nirupma Bansal, MBBS

Department of Anesthesiology and Intensive Care, Maulana Azad Medical College and Associated Hospitals, New Delhi, India

To the Editor:

We have designed a new endotracheal tube connector assembly for the wire-reinforced endotracheal tube that is provided for use with the intubating laryngeal mask airway (ILMA-ETT). On preliminary evaluation under simulated conditions, this connector assembly (provisionally named MAMC-connector-assembly or MCA after the name of our institute) reduced the time required to intubate through an intubating laryngeal mask airway (ILMA), and decreased potentially deleterious events.

The ILMA has been used to manage expected and unexpected difficult airways (1–5) since its first clinical use to "facilitate the passage of endotracheal tube (ETT) while maintaining ventilation during and between intubation attempts" (6). However, a number of potentially harmful events, such as alarming ETT movement and periods of no oxygenation and ventilation, can occur during intubation. These are mostly due to the fact that the ETT connector provided with the ILMA-ETT fits so snugly with it that both detachment of a well-fitted connector and its proper reconnection are clumsy. If fitted gently to start, the connector leaves a nonarmored area that can kink because of the weight of the attached circuit. Also, one or two assistants are required if the ventilation is to continue during most of the intubation process. The MCA circumvents these problems.

The MCA (Fig. 1A) has two portions: the MALE portion is an approximately 3-cm long connector made by slicing off both the ends of a 2-mL syringe barrel after its plunger has been removed. The FEMALE portion is a size-10 straight ETT connector (PortexTM). Half of the length of the MALE portion is kept affixed into the nonarmored portion of any of the three sizes of the ILMA-ETTs. This does not compromise the ILMA-ETT lumen or its movement through the ILMA. The other half of the MALE portion easily, yet snugly, fits into the tapered patient end of the FEMALE portion, which then connects with the anesthesia circuit (Fig. 1B).



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  		Figure 1. (A) The MALE portion of the MAMC connector assembly (MCA), made out of a 2-mL syringe (top) fits snugly into the intubating laryngeal mask airway-endotracheal tube (bottom); and allows the FEMALE portion of the connector assembly (size-10 endotracheal tube connector) to mount quickly and firmly over it (middle). (B) The MALE portion mounted beforehand on the intubating laryngeal mask airway-endotracheal tube does not leave any nonarmored area where the tube can kink due to the weight of the anesthesia circuit attached to it through the FEMALE portion, even when not supported by an assistant.

 
We compared the MCA with the usual connector during intubation through a size-4 ILMA inserted into an intubation trainer (AMBUTM). Forty intubations (20 each with ILMA-ETT having either MCA or the usual connector) were carried out in 10 sessions of 2 insertions each by two experienced operators on different days. The time taken for the intubation procedure was significantly less with the MCA than with the standard connector (mean ± SD, 28 ± 4 s vs 51 ± 9 s, P < 0.001; paired t-test), (Mean difference [95% confidence interval]; 23 s [19.6–26.4 s]). ETT kinking, ETT movement, need to disconnect the anesthesia circuit from the connector during its reattachment to the ETT, and need for dry gauze pieces during connector reattachment occurred significantly more often during intubations using the usual connector (P < 0.001 for all; Fisher’s exact test). The change in depth of ETT during circuit reconnection after the removal of ILMA was significantly more with the usual connector (P = 0.0018; paired t-test) (Mean difference [95% confidence interval]: 1 cm [0.46–1.54 cm]). In clinical terms, these differences mean a shorter period without oxygenation and ventilation, reduced airway stimulation, less chance of endobronchial intubation and accidental extubation, and reduced need for assistant(s) with MCA. The MCA may thus facilitate faster and safer intubations through the ILMA.

Acknowledgments

We thank C. K. Dua, MD and Sonia Sood, MD for their help in the projects involving the use of the ILMA, Shashi Sharma, MA (Stats) for statistical guidance, and Raminder Sehgal, MD.

References

  1. Kumar R, Prashast, Wadhwa A, Akhtar S. The upside-down intubating laryngeal mask airway: a technique for cases of fixed flexed neck deformity. Anesth Analg 2002; 95: 1454–8.[Abstract/Free Full Text]
  2. Asai T, Shingu K. Tracheal intubation through the intubating laryngeal mask in a patient with fixed flexed and a deviated larynx. Anaesthesia 1998; 53: 1199–208.[Web of Science][Medline]
  3. Smart NG, Varveris DA, Jacobs P. Use of the Intubating Laryngeal Mask in failed intubation associated with amyloid macroglossia. Br J Anaesth 2002; 89: 186–7.[Free Full Text]
  4. Martel M, Reardon RF, Cochrane J. Initial experience of emergency physicians using the intubating laryngeal mask airway. a case series. Acad Emerg Med 2001; 8: 815–22.[Medline]
  5. Schuschnig C, Waltl B, Erlacher W, et al. Intubating laryngeal mask and rapid sequence induction in patients with cervical spine injury. Anaesthesia 1999; 54: 787–97.[Medline]
  6. 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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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2003 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press