Malposition of the epiglottis after tracheal intubation via the intubating laryngeal mask

Ease of endotracheal intubation with the conventional polyvinyl chloride endotracheal tube versus wire-reinforced flexometallic tube through the intubating laryngeal mask airway: A comparative study

Background The I-LMA ventilates while providing a port for blind insertion of an endotracheal tube. The ILMA Fastrach is used especially for intubating in a difficult airway scenario. Its accompanying endotracheal tube is not economical nor readily available. In comparison, two alternative endotracheal tubes - polyvinyl chloride and wire-reinforced tubes were used for tracheal intubation through the ILMA.

AIMS AND OBJECTIVES

The aim of our study was to compare the ease of intubation when using conventional PVC tubes versus the wire-reinforced flexometallic tubes with the ILMA-FastrachTM. The number of attempts, time taken and additional maneuvers were noted. Intra-operative hemodynamic changes, post-operative sore throat, bleeding and hoarseness of voice was recorded over a period of 24 hours.

METHODOLOGY

After informed consent, 60 ASA I-II patients undergoing elective surgeries under general anesthesia were allocated to undergo blind intubation with the PVC tube or the wire-reinforced flexometallic tube.

RESULTS

More attempts were required for successful intubation using the wire-reinforced tube than the PVC tube with 76.7% passing in the first attempt in the PVC, and 53.3% passing in the first attempt in the flexometallic group. (P = 0.4). Average time for intubation in the PVC group: 28.24 ± 7.22 seconds. Average time for intubation in the flexometallic tube: 45.8 ± 15.78 sec. Occurrence of post-operative sore throat was 13.3% in the PVC group and 26.6% in the flexometallic group, with minimal hoarseness of voice 3.3% in the PVC group and 10% in the flexometallic group. There was also a slightly higher hemodynamic response in those who were intubated with the flexometallic tube than a PVC tube.

CONCLUSION

Intubating via the ILMA-Fastrach with the PVC tube offered better intubating conditions with regards to lesser time taken, lesser attempts, less manipulation, and less hemodynamic variations as compared to the patients who were intubated using the wire-reinforced tube.

Downfolding of the epiglottis into the laryngeal inlet after tracheal intubation using the McGRATHTM MAC videolaryngoscope: a case report

Background

Downfolding of the epiglottis into the laryngeal inlet is considered to be a rare complication of tracheal intubation. We describe a case of epiglottic downfolding during tracheal intubation using a McGrath videolaryngoscope (McGRATH^TM MAC).

Case presentation

A 44-year-old female was scheduled for breast reconstruction surgery. Intubation was performed using a McGrath videolaryngoscope. After intubation, videolaryngoscopy revealed that the epiglottis was inverted and folded down into the laryngeal inlet. We elevated the larynx anteriorly using the McGrath videolaryngoscope, enabling the downfolded epiglottis to be pulled out from the laryngeal inlet and restored to its original position. After surgery, the patient was extubated without any complications.

Conclusions

When using the McGrath videolaryngoscope, both glottic exposure similar to that achieved with the Macintosh laryngoscope and careful observation of the epiglottis should enable the prevention, detection, and treatment of epiglottic downfolding into the laryngeal inlet.

Jaw lift causes less laryngeal interference during lightwand-guided intubation than combined jaw and tongue traction applied by single operator

Lightwand-guided intubation is a semi-blind technique that takes advantage of the anterior location of the trachea in relation to the oesophagus. Fibreoptic evaluation of lightwand-guided intubation has revealed a possibility of laryngeal interference and epiglottic distortion. Jaw lift, tongue traction or a combination of both have been used to assist in lightwand-guided intubation. This study fibreoptically evaluates lightwand-guided intubation using jaw lift and combined jaw and tongue traction. Eighty four patients with normal airway undergoing general anaesthesia were studied. This randomised, double blinded, cross over study was done in two phases. First phase – after achieving adequate depth of anaesthesia, a fibrescope was advanced nasally, and lightwand-guided intubation was carried out under direct fibreoptic visualisation with the aid of either jaw lift or combined jaw and tongue traction. Second phase – Extubation followed by reintubation using the other manoeuvre. Interference with laryngeal structures during intubation and position of the epiglottis at the end of intubation were noted. Epiglottic distortion (deviated to one side/infolded into trachea) was observed in 6 patients with jaw lift and 17 patients with combined jaw and tongue traction (P=0.003). Laryngeal interference was significantly higher (P=0.012) with combined manoeuvre (30/78) than with jaw lift alone (9/81). Although lightwand-guided intubation can be performed quickly and easily, interference with laryngeal structures and distortion of the epiglottis can occur. Jaw lift manoeuvre causes less laryngeal interference than combined jaw and tongue traction applied by a single operator.

Displacement of the epiglottis during intubation with the Pentax-AWS Airway Scope

The Pentax-AWS system is a rigid indirect video laryngoscope with integrated tube guidance. Complications associated with this device are not well understood. We report two cases of epiglottis malposition during intubation with the Pentax-AWS. The standard technique of using the Pentax-AWS system involves direct elevation of the epiglottis for exposure of the vocal cords. The blade tip should be passed posterior to the epiglottis for laryngeal exposure, but pressure on the anterior surface of the epiglottis by the tip can rarely happen even during the correct maneuver. Although the Pentax-AWS provides clear images of the airway structures, it is sometimes difficult to observe the epiglottis continuously because the camera is located beneath the blade tip. Consequently, the view of the epiglottis from the camera may be impeded by the blade tip and may result in undiagnosed epiglottis malposition. The AWS's structural feature and its approach to the larynx can be associated with increased chance of unexpected epiglottis folding. It is particularly important to confirm normal position of the epiglottis during withdrawal of the device to prevent this complication.

Malposition of the epiglottis associated with fiberoptic intubation

A case in which the epiglottis was tucked into the laryngeal inlet by advancement of an endotracheal tube (ETT) during fiberoptic intubation, is presented. In this case, pulling the fibroscope, which was advanced under the displaced epiglottis, was effective for restoration.

Tracheal intubation using the ILMA, C-TrachTM or McCoy laryngoscope in patients with simulated cervical spine injury

A study of 90 patients was undertaken to compare intubation success rates of using either ILMA, C-Trach or McCoy laryngoscope in patients with simulated cervical spine injury. Insertion and intubation success rates, time taken to achieve intubation, airway complications and haemodynamic parameters were recorded. Insertion of ILMA and C-Trach was successful at the first attempt in all patients. Intubation success rates were higher in the C-Trach (100%) and McCoy (100%) groups than in the ILMA (87%) group. Total intubation time was significantly longer in the ILMA (63 s, SD 36.5) group than in the C-Trach (41 s, SD 15.8) and McCoy (30 s, SD 7.4) groups (p < 0.05, p < 0.05, respectively). There were no significant differences in haemodynamic parameters among the groups at any time.

Folding of the epiglottis - an unusual complication to be recognized after laryngoscopic endotracheal intubation

We report a case of folding of the epiglottis during endotracheal intubation, an unusual complication of intubation. A 36-year-old female patient underwent laryngeal microsurgery for a vocal polyp. Following anesthesia induction, an endotracheal tube (ID = 6.0 mm, cuffed) was advanced through an intubating laryngoscope via the oropharyngeal route. At the beginning of the surgery, the otolaryngologist noted that the patient's epiglottis was folded under the view of the surgical laryngoscopy. The endotracheal tube was adjusted immediately by withdrawing it 0.5 cm with the cuff deflated. Slight edema of the upper ridge of the epiglottis was noted. There were no sequelae such as laryngeal spasm or vocal cord palsy after the surgery. The "peardrop" phenomenon is suggested as a possible cause of this event. Potential adverse outcomes of this unusual occurrence are reviewed.

The intubating laryngeal-mask airway may be an ideal device for airway control in the rural trauma patient

A review of the literature on advanced airway management indicates that the intubating laryngeal-mask airway (ILMA) may be an ideal device for airway control in the rural trauma patient. The ILMA is an advanced laryngeal-mask airway designed to allow oxygenation of the unconscious patient as well as blind tracheal intubation with an endotracheal tube. The ILMA is an easy-to-use airway with a high success rate of insertion, and requires little training. For the rural physician managing a difficult airway in a trauma patient, the ILMA has been found to be reliable and successful when other techniques fail, such as fiberoptic intubation and direct laryngoscopy. The ILMA has also been reported to cause less hemodynamic change and less injury to the teeth and lips than direct laryngoscopy. Further, the ILMA was found to be easier and faster to use with a higher success rate than either the combitube or endotracheal tube for unskilled healthcare providers. Limitations and complications of the ILMA may include aspiration, esophageal intubation, damage to the larynx or other tissues during blind passage of a tracheal tube, and edema of the epiglottis.

Intubating laryngeal mask airway

The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in "routine" cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting. Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence. The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.

The intubating laryngeal mask airway: suggestions for use in the emergency department

With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.

Intubating laryngeal mask for fibreoptic intubation--particularly useful during neck stabilization

PURPOSE

To assess the ease of fibrescope-assisted tracheal intubation while the patient's head and neck were placed in the neutral or the manual in-line position, and to determine if the intubating laryngeal mask facilitated fibreoptic intubation in these positions.

METHODS

In 84 patients, the patient's head and neck were placed in the neutral position (pillow placed under occiput), and in another 40 patients the head and neck were stabilized by the manual in-line method (no pillows under occiput). In both groups, after induction of anesthesia with 2.0-2.5 mgxkg(-1) propofol, 50-100 microg fentanyl and 1.0 mgxkg(-1) vecuronium, patients were allocated randomly into two groups: in Group C tracheal intubation was attempted using only a fibrescope, whereas in Group L fibreoptic intubation through the intubating laryngeal mask was attempted.

RESULTS

In group C the success rate of fibreoptic tracheal intubation within two minutes was higher in the neutral position (31 of 42 patients (73%)) than in the manual in-line position (8 of 20 patients (40%)). In contrast, in group L the success rate was similar between the two positions. Tracheal intubation was easier in group L than in group C (P < 0.01 or 0.001) and the time for intubation was shorter in group L than in group C in both head and neck positions.

CONCLUSIONS

Fibreoptic tracheal intubation was more difficult in the manual in-line position than in the neutral position. The intubating laryngeal mask facilitated fibreoptic intubation in both positions.