Anesth Analg 2003;97:1773-1775
© 2003 International Anesthesia Research Society
CRITICAL CARE AND TRAUMA
The Use of the LMA-ProSealTM in Airway Resuscitation
William H. Rosenblatt, MD
Department of Anesthesiology and Surgery, Yale University School of Medicine, New Haven, Connecticut
Address correspondence and reprint requests to William H. Rosenblatt, MD, Department of Anesthesia and Surgery, Yale University School of Medicine, TMP-3, 333 Cedar St., New Haven, CT 06510. Address e-mail to will.rosenblatt{at}yale.edu
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Abstract
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IMPLICATIONS: Although the Laryngeal Mask Airway (LMATM) has become a standard tool in the airway resuscitation armamentarium, lack of access to the gastrointestinal tract can limit its utility. A new LMA (LMA-ProSealTM) overcomes this limitation. In the current case, reducing gastric distension reversed inadequate oxygenation after failed intubation and face mask ventilation.
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Introduction
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The laryngeal mask airways (LMATM, LMA-FastrachTM, and LMA-UniqueTM) (Laryngeal Mask Company, Henley-on-Thames, UK) are recognized to be vital tools in the management of the failed airway (1–10). A commonly cited failing of these devices is the lack of protection of the larynx and trachea from regurgitated gastric contents, as well as a lack of access to the alimentary tract.
In 2000, the LMA-ProSealTM (Laryngeal Mask Company) was introduced into clinical practice. This device incorporates a second lumen, arising from the tip of the laryngeal mask and terminating outside of the patient airway. This lumen, termed the gastric drain, has been demonstrated to effectively vent passively or actively regurgitated esophageal contents (11–13). A gastric tube can also be placed down this lumen to empty the stomach.
We report a case in which a patient whose trachea could not be intubated because of lingular tonsil hyperplasia (14) was resuscitated with a LMA-ProSealTM. The drain tube was used to decompress the stomach, which had become distended during mask ventilation, resulting in pulmonary compromise.
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Case Report
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A 50-yr-old woman presented for total abdominal hysterectomy under general anesthesia. She had refused a regional anesthetic. There was no history of previous anesthetics, sleep apnea symptoms, or gastroesophageal reflux disease. Findings on routine airway physical examination, induction of anesthesia, and face mask ventilation were unremarkable. A long-acting, nondepolarizing muscle relaxant was subsequently administered. Once full neuromuscular block was achieved, four attempts at direct laryngoscopy using both Macintosh and Miller blades resulted in grade 3 laryngeal views, and passage of a tracheal tube was unsuccessful. Attempts to visualize the larynx with a fiberoptic bronchoscope (FOB) were also unsuccessful: wet, pale, and edematous tissue was seen and definitive anatomic structures could not be recognized.
A size 3, and subsequently a size 4 LMA-FastrachTM was placed, and although the patient could be easily ventilated, attempts at intubation, both blind and with the aid of an FOB, were also unsuccessful (10). The fiberoptic view was as noted above. Between tracheal intubation attempts, the patient was ventilated by face mask. Oxyhemoglobin saturation, which had been 100% (fraction of inspired oxygen of 1.0) during the initial attempts at laryngoscopy, decreased to 85% as the left upper quadrant of the abdomen became distended and mask ventilation became progressively more difficult. A size 4 LMA-ProSealTM was prepared, inserted, and inflated as has been described (11). The anesthesia circuit was connected to the airway lumen, and the patient’s lungs were ventilated. Airway pressures of 25–30 cm of H2O were required to provide adequate ventilation (end-tidal CO2, modest chest movement), but the oxygen saturation did not improve. A 14F gastric tube was inserted through the gastric drain of the LMA-ProSealTM, and with the application of suction, the epigastric distension was reduced and the oxygen saturation returned to 95%. Subsequently, ventilation was adequate with <20 cm H2O pressure. Examination with the FOB through the airway lumen of the LMA-ProSealTM revealed normal laryngeal structures. Ten milligrams of dexamethasone was given IV. The patient was allowed to emerge fully and the LMA-ProSealTM was removed. The surgical case was deferred until the patient could be examined by an otolaryngology consultant.
One hour later in the Postanesthetic Care Unit, nasopharyngeal endoscopy revealed hyperplastic and edematous tissue at the base of the tongue.
The patient returned for surgery 2 wk later, and was tracheally intubated without incident, using an FOB before the induction of anesthesia.
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Discussion
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The LMATM has proved to be a vital tool for the resuscitation of the failed airway. There have been many reported as well as unreported cases of failed tracheal intubation and failure to ventilate by mask in which the airway was "rescued" with a LMATM, although neither a controlled trial nor metaanalysis has been published (1). Ovassapian et al. (14) have recently reported that lingular tonsil hyperplasia is a common etiology of unanticipated difficult laryngoscopy.
The underlying characteristic of the LMATM that makes it a superior tool in the unanticipated difficult airway armamentarium is that its insertion follows an intrinsic pathway, not requiring tissue displacement and distortion (as with laryngoscopy). It is a blind technique, not hindered by blood, secretions, debris, and base of the tongue/epiglottis edema from previous attempts at laryngoscopy.
The major disadvantage of the LMA-ClassicTM in resuscitation (i.e., in the cannot-intubate situation) is the lack of mechanical protection from regurgitation and aspiration. Despite this, there are less frequent rates of regurgitation during cardiopulmonary resuscitation with a LMATM (3.5%) than with the bag-valve mask ventilation (12.4%) (2,7,8,15). Even in the case of regurgitation, pulmonary aspiration is a rare event with the LMA-ClassicTM (12,13). A second disadvantage of the LMATM in resuscitation is its relatively low seal pressure of approximately 20 cm H2O pressure.
The gastric drain of the LMA-ProSealTM originates at the distal tip of the mask and emerges from the patient lateral to the airway barrel (Fig. 1) (11). A gastric tube can be inserted into the stomach via this lumen. This design reduces the risk of both gastric inflation (by providing a vent for gas transmitted to the esophagus) and the risk of aspiration of refluxed gastric contents (by providing an outlet) (11–13). The design of the LMA-ProSealTM reliably allows positive pressure ventilation up to 30–40 cm H2O pressure (16).
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Figure 1. The bowl of the LMA-ProSealTM. The gastric drain can be seen passing through the bowl of the mask, and exiting at the distal tip.
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In the case reported, the LMA-ProSealTM served two vital roles. First, it allowed the anesthesia staff to secure a patent airway for oxygenation/ventilation without the further distension of the stomach with face mask ventilation. Second, the gastric drain was used to facilitate decompression of the stomach with an immediate decrease of the airway peak positive pressure, and a prompt improvement of the oxygen saturation. Placing a gastric tube with LMA-ClassicTM in situ can be difficult (17). As is expected with LMATM airway use, there was no coughing or straining on emergence (18).
In this case, attempts to intubate with direct laryngoscopy, the LMA-FastrachTM, and an FOB all failed because of hyperplasia at the base of the tongue. It is possible that a size 5 LMA-FastrachTM would have been adequate for blind or fiberoptically aided intubation (the epiglottis could be seen distal to the LMA-FastrachTM lifting bar), but one was not available at the time of this case.
The current case illustrates a resuscitative advantage of the LMA-ProSealTM as compared with other LMATM devices (11). The LMA-ProSealTM does not serve to "dam" the upper esophagus, but rather provides access to the esophagus and stomach. It was only by virtue of this facility that the patient could be adequately resuscitated. The improved seal pressure of the LMA-ProSealTM (up to 40 cm H2O) (16) also allowed supralaryngeal ventilation of a patient with a transient reduction in airway compliance (caused by gastric distension.)
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References
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Accepted for publication June 19, 2003.
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Abstract
Introduction
