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LETTERS TO THE EDITOR

ProSeal Laryngeal Mask Airway Foldover Detection

Department of Anesthesia, University of Manitoba, Winnipeg, Canada

To the Editor:

I read with interest the case report of aspiration during the use of a ProSeal laryngeal mask airway (PLMA) by Brimacombe et al. (1). Several techniques have been described to help diagnose and correct a foldover of the PLMA tip. I propose a very simple method for detection of the foldover position of the PLMA that utilizes the Trachlight ^TM (Laerdal Medical Corporation, NY). The stylet of the Trachlight ^TM is marked in 1-cm increments from 15 cm to 29 cm. The length of the drainage tube (DT) of the PLMA has been previously documented (Size 2, 19.5 cm; Size 3, 26.5 cm; Size 4, 27.5 cm; Size5, 28.5 cm) (1). The Trachlight ^TM wand must be well lubricated and the rigid inner stylet withdrawn into the proximal half of the device. Easy passage of the wand through the DT should be confirmed before inserting the PLMA. In simulated PLMA tip foldover experiments, the Trachlight ^TM wand meets resistance 1–2 cm from the tip of the DT. This is a simple and reliable means of detecting a PLMA tip foldover. A dull glow in the anterior neck with passage of the Trachlight ^TM wand beyond the DT tip indicates correct alignment of the PLMA with the upper esophageal sphincter.

Reference

1. Brimacombe J, Keller C. Aspiration of gastric contents during use of a ProSeal laryngeal mask airway secondary to unidentified foldover malposition. Anesth Analg 2003; 97: 1192–4.[Abstract/Free Full Text]

Response

Department of Anaesthesia and Intensive Care, James Cook University, Cairns Base Hospital, Cairns, Australia Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria

In Response:

Folding over of the cuff is certainly the most dangerous of the ProSeal ^TM laryngeal mask airway (PLMA) malpositions, as it prevents the drain tube from functioning (exposing the patient to the risk of aspiration and gastric insufflation) but can easily be missed (airway is usually clear and ventilation easy) (1). Dr Christoudoulou’s new method of detection is a most welcome addition to the established techniques of using a gastric tube or a fiberoptic scope (1). The disadvantages the Trachlight ^TM technique are (i) the potential for stimulation and trauma if the bulb protrudes beyond the end of the drain tube and it is not aligned with the upper esophageal sphincter, and (ii) it cannot be used with the pediatric sizes of PLMA, as it is too large. Another option might be to insert the Trachlight ^TMto the distal end of the drain tube before PLMA insertion, to prevent the cuff folding over and to provide information about position once inserted – in principle, the light glow should be seen at the level of the cricoid cartilage if it is sitting correctly in the hypopharynx. The flexible lightwand, first described by Dimitriou and Voyagis in 1999 (2), could also be used and has the advantage of not having a rigid stylet.

References

1. Brimacombe J. The ProSeal laryngeal mask airway for ventilation and airway protection. In: Laryngeal mask anesthesia: principles and practice. 2nd ed. London: WB Saunders, 2004.
2. Dimitriou V, Voyagis GS. Use of a prototype flexible lighted catheter for guided tracheal intubation through the intubating laryngeal mask. Anesth Analg 1999; 89: 257–8[Free Full Text]

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