Correspondence
F. S. Xue* Q. Y. Yang X. Liao Beijing, People’s Republic of China *E-mail:
[email protected]
1 Benumof JL. Management of the difficult adult airway: With special emphasis on the awake tracheal intubation. Anesthesiology 1991; 75: 1087 – 110 2 Supbornsug K, Osborn IP. Topicalization of the airway using the glidescope. Anesth Analg 2004; 99: 1263 – 4 3 Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg 2000; 90: 745 – 56 4 Agro` F, Hung OR, Cataldo R, Carassiti M, Gherardi S. Lightwand intubation using the Trachlight: a brief review of current knowledge. Can J Anesth 2001; 48: 592 – 9 5 Higgins MS, Wherry TJ. Topical anesthesia of the airway using the lighted stylet [letter]. Anesthesiology 1993; 79: 1148 6 Bhardwaj A, Kidwai SN, Verma V, Nabi N, Ahmad M, Khan RM. Continuous anesthetic insufflation and topical anesthesia of the airway using Trachlight in chronic facial burns. Anesth Analg 2006; 102: 334 7 Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined nebulization and spray-as-you-go topical local anaesthesia of the airway. Br J Anaesth 2005; 95: 549 – 53 8 Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest 1992; 102: 704 – 7 doi:10.1093/bja/aem327
ProSeal laryngeal mask airway for laparoscopic gastric banding in a myasthenic, morbidly obese patient Editor—Although the actual incidence of difficult tracheal intubation in obese patients is questioned,1 a subset of morbidly obese patients with obstructive sleep apnoea, a large neck circumference, or a Mallampati score of 3 or higher,2 and restricted cranio-cervical movement3 is at greater risk of difficult tracheal intubation and hypoxia than normal-weight patients.4 Laryngeal masks have been recommended in the guidelines on difficult intubation and have been used in obese subjects, mostly as intubating or temporary ventilatory devices.5 – 8 We report the anaesthetic management of a morbidly obese patient for laparoscopic gastric banding using a ProSeal laryngeal mask airway (PLMA). The female patient (age 45 yr BMI 51.9) had a previous history of asthma, arterial hypertension, depression, and myasthenia gravis. Two years earlier, she underwent thymectomy after having been intubated awake as conventional tracheal intubation was very difficult. She subsequently had further weight gain and refused an awake intubation as a first approach and she would agree to this only if attempts with an endotracheal tube or PLMA while she was asleep had failed. On preoperative evaluation, the patient presented a mild weakness with fatigability on effort without signs of bulbar dysfunction, a short and thick neck (54 cm circumference) with rather limited extension, and a Mallampati score of 2. After overnight fasting, anaesthesia was induced i.v. with fentanyl 100 mg and propofol 250 mg. Laryngoscopy
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hyoid, indicating that its tip is in the epiglottic vallecula.3 At this time, 1 ml of lidocaine 2% was sprayed using the atomizer. The fine left or right rotation of the unit was then done to obtain a bright glow in the lateral aspect of the larynx, indicating tip is in the piriform recess, and 2 ml of lidocaine 2% was sprayed in two aliquots onto the bilateral piriform recess. This procedure was repeated after 5 min. After completion of the supraglottic spray, the unit was again inserted until a central, clear, and bright transillumination was seen on the cricothyroid membrane, suggesting correct positioning of the unit’s tip into the laryngeal inlet.3 At this time, 3 ml of lidocaine 2% was sprayed during inspiration to anaesthetize the laryngeal and tracheal area. After 5 min, tracheal intubation was attempted. All patients tolerated insertion of the unit without any discomfort or gagging. The mean time required for the supraglottic spray (36 times in all) was 39.3 (9.8) s, with a range of 32–53 s. The unit was successfully guided into the laryngeal inlet at the first attempt in all patients. During the laryngeal and tracheal spray, slight or moderate cough occurred in all patients and resolved spontaneously. After completion of the final spray, the average visual analogue scores for pain, anxiety, and gagging that the patients reported were 7.8, 6.5 and 7.2, respectively (where 0, absolutely awful and 10, enjoyable). The time required for the laryngeal and tracheal spray was 29.5 (8.5) s, with a range of 23–37 s. The median dose of lidocaine was 2.7 mg kg21, with a range of 2.3–3.2 mg kg21. Tracheal intubation was successfully completed using a TrachlightTM at the first attempt in a mean time of 23.7 (8.2) s. The slight cough was observed in four patients during tracheal tube insertion. Similar approaches have been attempted using an epidural catheter5 attached to a Surch-liteTM (Aaron Medical Industries, St Petersburg, FL, USA) and an infant feeding tube6 to a TrachlightTM -tracheal tube assembly. However, we believe that the MADgicw atomizer can provide more effective atomized topical solution to the airway mucosa. Unlike spray-as-you-go topical anaesthesia of the airway using a fibreoptic bronchoscope, this combined approach needs less preparation and is less affected by secretions or blood.7 8 Additionally, the lightwand can also be cleaned and sterilized readily.3 4 The previous studies also reported that the ‘spray-as-you-go’ technique did not give optimal topical anaesthesia for fibreoptic bronchoscopy.8 Our preliminary experience of 18 patients suggests that a combination of TrachlightTM and MADgicw atomizer can provide excellent topical anaesthesia of the airway for awake orotracheal intubation. The technique is easy to perform, well tolerated by the awake patient, and useful in difficult intubation.
Correspondence
insertion. In spite of its potential advantages, however, most do not support the use of PLMA for the duration of a surgical procedure because of the current lack of knowledge regarding the risk of pulmonary aspiration and of difficult ventilation.1 In our experience, obese patients may present a rapid, sometimes life-threatening, arterial oxygen desaturation that can be aggravated by failed or even by a slow fibrescope guided intubation. In conclusion, in our case, PLMA was an effective ventilatory option and warrants further studies in obese surgical patients. U. Freo* M. Carron M. Micaglio C. Ori Padova, Italy *E-mail:
[email protected] 1 Collins JS, Lemmens HJ, Brodsky JB. Obesity and difficult intubation: where is the evidence? Anesthesiology 2006; 104: 617 2 Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94: 732 – 6 3 Calder I, Picard J, Chapman M, O’Sullivan C, Crockard HA. Mouth opening: a new angle. Anesthesiology 2003; 99: 799– 801 4 Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology 2005; 103: 429 – 37 5 Cook TM. Difficult airway in an obese patient managed with the ProSeal laryngeal mask airway. Eur J Anaesthesiol 2005; 22: 241 – 3 6 Keller C, Brimacombe J, Kleinsasser A, Brimacombe L. The laryngeal mask airway ProSeal(TM) as a temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation. Anesth Analg 2002; 94: 737 – 40 7 Natalini G, Franceschetti ME, Pantelidi MT, Rosano A, Lanza G, Bernardini A. Comparison of the standard laryngeal mask airway and the ProSeal laryngeal mask airway in obese patients. Br J Anaesth 2003; 90: 323 8 Maltby JR, Beriault MT, Watson NC, Liepert D, Fick GH. The LMA-ProSeal is an effective alternative to tracheal intubation for laparoscopic cholecystectomy. Can J Anaesth 2002; 49: 857 –62 9 Latorre F, Eberle B, Weiler N, et al. Laryngeal mask airway position and the risk of gastric insufflation. Anesth Analg 1998; 86: 867 –71 10 Cooper RM. The LMA, laparoscopic surgery and the obese patient—can vs. should. Can J Anaesth 2003; 50: 5 – 10
doi:10.1093/bja/aem328
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showed a Cormack – Lehane grade 3 view which did not improve after head repositioning or changing the blade. A size 5 PLMA was placed at the first attempt and its correct position was confirmed with a bronchoscope. The PLMA cuff was inflated to and maintained at 60 cm H2O and a 14 G Salem gastric tube was passed through the drainage tube of the PLMA and left in situ for deflation of the stomach. Anaesthesia was maintained with i.v. propofol infusion (6 – 8 mg kg21 min21) and i.v. fentanyl 150 mg. A single i.v. bolus of cisatracurium 0.025 mg kg21 was given. Ventilation was set to a 30/70 oxygen/air mixture, 12 breaths min21, and expiratory tidal volume 9 – 10 ml kg21. Peritoneum insufflation with CO2 to a preset intra-abdominal pressure of 2 kPa produced significant [baseline vs post-carboperitoneum means (SD), paired t-test, P,0.01] increases in end tidal CO2 [3.8 (0.2) vs 4.4 (0.1) kPa] and in peak airway pressure [22.2 (0.7) vs 27.1 (2.0) cm H2O] and declines in minute ventilation [9.7 (0.4) vs 8.6 (0.2) litre min21]. SpO2 remained .97% throughout anaesthesia. The laparoscopic gastric banding, emergence, and recovery were uneventful. PLMA may provide specific advantages over other ventilation modalities in patients with obesity, or myasthenia gravis. In obese patients, the successful use of PLMA for surgery has been reported both anecdotally in cases of failure of tracheal intubation5 6 and in two systematic studies on patients undergoing urological, gynaecological, or abdominal surgery.7 8 In those patients, PLMA effectively maintained the airway ventilation and gastric emptying.5 PLMA has been proposed as an alternative to endotracheal intubation in obese patients.6 In grossly and morbidly obese patients, experience is limited to the use of PLMA as a temporary ventilation device before laryngoscope-guided tracheal intubation.6 No report exists on laparoscopic gastric banding probably because of potential problems. The oro-gastric balloon tube cannot be inserted with the PLMA and its replacement with a Salem gastric tube must be agreed with the surgeon. The risk of regurgitation and of pulmonary aspiration of the gastric content is increased by gastric manipulation and insufflation and can be attenuated by correct placement of PLMA.6 8 – 10 Finally, although clinical evidence of pulmonary aspiration during anaesthesia using PLMA was comparable with that of endotracheal tube, many anaesthetists remain anxious about its ability to provide protection from aspiration.10 In myastenic patients, PLMA may have advantages over the endotracheal tube in that it causes lesser airway resistance and bronchospasm, and it does not require neuromuscular blocking agent drugs for its
