Impossible insertion of the laryngeal mask airway and oropharyngeal axes

Airway management using laryngeal mask airway (LMA) in a patient in a lateral decubitus position: A case report

RATIONALE

Airway management of patients in a lateral decubitus position (LDP), who cannot lie supine is challenging for anesthesiologists. In a previous study, laryngeal mask airway (LMA) was found to be superior to conventional endotracheal intubation in LDP.

PATIENT CONCERNS

A 38-year-old man diagnosed with type I neurofibromatosis presented with pain caused by a large hematoma (28 × 8 cm) located in the left upper back. On arrival at the operating theater, he was in a right LDP because of the aggravation of pain in the supine position.

DIAGNOSES

Laryngoscopy-guided endotracheal intubation was expected to be difficult in LDP.

INTERVENTIONS

After the induction of anesthesia, a non-inflatable LMA was introduced into the laryngopharynx with the patient in LDP. He was then maneuvered into a supine position and removal of the LMA was followed by endotracheal intubation.

OUTCOMES

The surgery for the removal of the hematoma was performed in a prone position. The airway intubated with an endotracheal tube was well maintained during the entire surgery.

LESSONS

LMA is a useful device for airway management in patients in LDP who cannot lie supine.

Assessment before airway management

It is wise to plan and prepare for the unexpected difficult airway. Although it is essential to take a history and examine every patient prior to airway management, preoperative anticipation of a difficult airway occurs in only 50% of patients subsequently found to have a difficult airway. Bedside screening tests lack accuracy. The modified Mallampati test and the measurement of thyromental distance are unreliable for prediction of difficult tracheal intubation. Knowledge of risk factors for various airway management techniques may help when devising an airway management plan.

Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report

PURPOSE

We present a case of upper airway obstruction in a patient with an unstable cervical spine fracture in a halo orthosis. We also describe the mechanism by which the obstruction occurred and identify features that predispose patients in a halo orthosis to upper airway obstruction.

CASE

An 81-yr-old female presenting to hospital with an unstable cervical spine fracture was scheduled for spinal fusion. She was fitted with a halo traction device in a flexed position, and an awake tracheal intubation was planned. The patient's airway was topicalized and 1 mg of midazolam was administered. Her oxygen saturation dropped, and mask ventilation was difficult and insufficient. She then became unresponsive and pulseless. Emergency release of the halo orthosis device was carried out and her neck was held in a neutral position. Mask ventilation was successfully performed and oxygenation improved. The patient's trachea was intubated via video laryngoscopy, and she was resuscitated and taken to the intensive care unit. The degree of cervical spine flexion resulting from the halo fixation was examined in subsequent radiographs, as defined by the occiput to C2 (O-C2) angle, and the oropharyngeal cross-sectional area was measured. Spine flexion from halo fixation in concert with the topical treatment and sedation predisposed the patient to acute airway obstruction.

CONCLUSION

In this case, external cervical spine fixation in flexion resulted in a change to the O-C2 angle, which reduced the oropharyngeal area and predisposed to upper airway obstruction. This highlights the need for anesthesiologists to evaluate the degree of cervical spine flexion in patients with halo devices and to have the surgical team present during airway management in the event of acute airway obstruction.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway

BACKGROUND

Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.

METHODS

To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.

PRINCIPAL FINDINGS

Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy.

CONCLUSIONS

With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

Airtraq® optical laryngoscope for tracheal intubation in a patient with giant lipoma at the nape: a case report

BACKGROUND AND OBJECTIVES

Lipoma is a progressively increasing disease which may appear anywhere in the body. Its appearance at the back of the neck, especially when it is large enough to cause restriction of neck extension, poses challenges to anesthesiologists in airway management whenever needed. This paper evaluates the role of Airtraq® in restricted neck movement.

CASE REPORT

Case with a huge lipoma of 14×12cm at the nape, and its surgical removal during an elective operation theatre posed difficulty in securing the airway by conventional laryngoscopy. To overcome the problem we successfully used a newly developed device, the Airtraq®, which is an optical laryngoscope for securing the airway.

CONCLUSION

Airtraq® can be used for elective intubation in patients with restricted neck movements.

Oral gastric tube-guided insertion of the ProSeal™ laryngeal mask is an easy and noninvasive method for less experienced users

PURPOSE

The ProSeal™ laryngeal mask airway (PLMA) can be more difficult to insert than the classic laryngeal mask, especially in patients who have a thin palate with a steep oropharyngeal curve. Here, an oral gastric (OG) tube-guided technique is considered as a method that makes it easier to successfully insert a PLMA.

METHODS

Sixty patients who were scheduled to undergo general anesthesia without neuromuscular blocking were randomly allocated into two groups: 30 patients with PLMA inserted by the standard digital technique, and 30 with the PLMA inserted by an OG tube-guided technique. Most PLMA insertions were performed by less experienced users. The success rate at the first attempt, the time taken to insert the PLMA, the difficulty of the procedure, and the incidence of oropharyngeal trauma and postoperative sore throat were compared between the two groups.

RESULTS

PLMA insertion was successfully achieved at the first attempt using the OG tube-guided technique in all 30 patients. The OG tube-guided insertion required fewer attempts (P = 0.04) and led to a less difficult insertion procedure (P = 0.02) than the standard digital insertion. Effective ventilation during anesthesia was achieved in all patients, with a lower mean cuff pressure in the OG tube-guided technique group (P = 0.02). The frequency of blood sticking to the PLMA tube (P < 0.001) and the incidence of postoperative sore throat (P = 0.003) were lower in the OG tube-guided group than the standard digital technique group.

CONCLUSIONS

OG tube-guided PLMA insertion is easier for less experienced users, trainees, and experts as well as less invasive for patients than the standard digital insertion.

[Use of the flexible laryngeal mask in rheumatoid arthritis with the patient in lateral decubitus position]

Rheumatoid arthritis is a chronic inflammatory disease leading to synovitis and joint deformities. The hands are often affected but in some cases there may be involvement of the temporomandibular, the atlantoaxial, and cricoarytenoid joints. For insertion of the mask, a patient may be placed in supine, lateral, or prone position with minimal complications. A 46-year-old woman with long-standing rheumatoid arthritis and mild atlantoaxial joint involvement was programed for removal of a large tumor from soft tissue near the right scapula. She was placed on her left side for surgery. After induction of anesthesia a flexible laryngeal mask was inserted without shifting her spinal column. At the end of the procedure, the mask was removed without complications and she orally assessed pain as 0. The flexible laryngeal mask can be used in patients with rheumatoid arthritis with little need to move the cervical spine. Insertion can take place in lateral decubitus position, thus avoiding movements that might worsen the patient's underlying disease.

Preoperative planning of airway management in critical care patients

OBJECTIVE

The aim of this article is to review aspects of airway evaluation that may affect the care of the critical care patient whose airway is to be managed. This information must then be incorporated into the decision-making process of the "airway manager."

DESIGN

Literature review.

RESULTS

Historically used indexes of airway evaluation suffer from low sensitivity and only modest specificity in identifying the difficult-to-intubate patient. Using each index in isolation of others contributes to their poor predictive power. An understanding of anatomical relationships that these indexes measure should help the clinician in evaluating the airway. The clinician's impression of the airway, as well as the likelihood of trouble with supraglottic ventilation, the patient's inability to take food orally, and the patient's general condition can be used to formulate a management plan. This plan should be consistent with the American Society of Anesthesiologist's difficult airway algorithm.

CONCLUSIONS

Rote decision making on airway management, based on commonly used indexes, is not adequate. The vital role of airway in anesthetic management of the critical care patient demands thoughtful consideration. Patient conditions including the need for airway control, the likelihood of difficult laryngoscopy or supraglottic ventilation, the patient's inability to take food orally, and the medical state of the patient must be incorporated.

The upside-down intubating laryngeal mask airway: a technique for cases of fixed flexed neck deformity

IMPLICATIONS

When the neck is fixed in extreme flexion, access to the windpipe becomes very difficult. The intubating laryngeal mask airway (ILMA) appears unsuitable for guiding the breathing tube into the windpipe in such cases because of its rigid, preformed shape. However, the ILMA introduced upside down may provide the answer, even if the mouth opening is smaller than normal.

A comparison of two tracheal intubation techniques with Trachlight and Fastrach in patients with cervical spine disorders

Optimal airway management strategies in patients with an unstable cervical spine remain controversial. A newly designed lightwand device (Trachlight) or an intubating laryngeal mask (Fastrach) may avoid hyperextension of the neck. However, there are few objective data that guide us in selecting the appropriate devices. We conducted a prospective randomized study in 148 patients who received general anesthesia for whom the operations were related to the clinical and/or radiographic evidence of cervical abnormality. Trachlight or Fastrach was used for tracheal intubation with the head and neck held in a neutral position. In the Trachlight group, intubation was successful at the first attempt in 67 of 74 (90.5%) cases and at the second attempt in 5 (6.8%) cases. In contrast, in the Fastrach group, 54 of 74 (73.0%) patients were intubated within our protocol. The mean time for successful tracheal intubation at the first attempt was significantly shorter in the Trachlight group than in the Fastrach group. The Trachlight may be more advantageous for orotracheal intubation in patients with cervical spine disorders than the Fastrach with respect to reliability, rapidity, and safety.

IMPLICATIONS

The Trachlight may be more advantageous for orotracheal intubation in patients with cervical spine disorders than the Fastrach with respect to reliability, rapidity and safety.

The intubating laryngeal mask airway in severe ankylosing spondylitis

PURPOSE

To evaluate the use of inhalational induction followed by intubation through the intubating laryngeal mask (ILM) for patients with severe ankylosing spondylitis undergoing elective surgery who prefer airway management under anesthesia.

METHODS

Nine patients undergoing a total of 11 procedures were enrolled in the study. Fentanyl 2 microg*kg(-1), midazolam 0.035 mg*kg(-1) and sevoflurane in oxygen 100% were used for induction. The ILM was inserted when the end-tidal sevoflurane concentration reached 3%. After an effective airway was established, atracurium 0.5 mg*kg(-1) was given. A polyvinyl chloride tube in the reversed position using a blind technique was used to intubate the trachea.

RESULTS

The ILM provided an effective airway on 11/11 occasions at the first attempt. Intubation was successful at the first attempt on 7/11 occasions, at the second attempt on 2/11 and at the third attempt in 1/11. Intubation failed in one patient. The mean (range) minimal oxygen saturation was 99.4% (97-100%). There were no problems with ILM removal.

CONCLUSION

Inhalational induction followed by ILM insertion and blind intubation is a reasonable option in patients with severe ankylosing spondylitis undergoing elective surgery who prefer airway management under anesthesia.

Failed tracheal intubation using a laryngoscope and intubating laryngeal mask

PURPOSE

To report unexpected failed tracheal intubation using a laryngoscope and an intubating laryngeal mask, and difficult ventilation via a facemask, laryngeal mask and intubating laryngeal mask, in a patient with an unrecognized lingual tonsillar hypertrophy.

CLINICAL FEATURES

A 63-yr-old woman, who had undergone clipping of an aneurysm seven weeks previously, was scheduled for ventriculo-peritoneal shunt. At the previous surgery, there had been no difficulty in ventilation or in tracheal intubation. Her trachea remained intubated nasally for 11 days after surgery. Preoperatively, her consciousness was impaired. There were no restrictions in head and neck movements or mouth opening. The thyromental distance was 7 cm. After induction of anesthesia, manual ventilation via a facemask with a Guedel airway was suboptimal and the chest expanded insufficiently. At laryngoscopy using a Macintosh or McCoy device, only the tip of the epiglottis, but not the glottis, could be seen, and tracheal intubation failed. There was a partial obstruction during manual ventilation through either the intubating laryngeal mask or conventional laryngeal mask; intubation through each device failed. Digital examination of the pharynx, after removal of the laryngeal mask, indicated a mass occupying the vallecula. Lingual tonsillar hypertrophy (1 x 1 x 2 cm) was found to be the cause of the failure. Awake fibrescope-aided tracheal intubation was accomplished.

CONCLUSIONS

Unexpected lingual tonsillar hypertrophy can cause both ventilation and tracheal intubation difficult, and neither the laryngeal mask nor intubating laryngeal mask may be helpful in the circumstances.

A Review of Oral Transmucosal Fentanyl Citrate: Potent, Rapid and Noninvasive Opioid Analgesia

The physiochemical characteristics of the potent synthetic opioid agonist fentanyl make it ideal for noninvasive transmucosal delivery. Studies of oral transmucosal fentanyl citrate (OTFC), a candied matrix formulation administered orally as a palatable lozenge on a stick, have investigated and determined this analgesic's pharmacokinetics and pharmacodynamics in a number of clinical settings, including premedication before surgery, acute analgesia for painful medical procedures, and, most recently, for the control of breakthrough cancer pain. The onset to meaningful pain relief in patients with acute pain from surgery or breakthrough pain from cancer is between 5 and 10 minutes after initiating OTFC use, equivalent to intravenous morphine. Analgesic dose equivalency studies suggest that OTFC is, on average, about 10 times more potent than morphine, although, in randomized, controlled, and blinded studies, many patients who were using relatively high doses of opioid anlagesics on an around the- clock schedule for control of cancer pain reported that even a low dose of OTFC (i.e., 200 microg) provided adequate relief from breakthrough pain. Side effects from OTFC are similar in character and frequency to other opioids, including sedation, nausea, and pruritus. These effects appear to wane rapidly with repeated use of this medication. To date there have been no reported serious adverse events in any of the population groups studied or treated with OTFC.

The view of the glottis at laryngoscopy after unexpectedly difficult placement of the laryngeal mask

In 12 patients to whom a non-depolarising neuromuscular relaxant had been given and in whom placement of the laryngeal mask had failed unexpectedly, the view of the larynx at laryngoscopy and the ease of tracheal intubation were examined. The glottis was only partially seen at laryngoscopy in three patients and was not seen at all in another three patients. Tracheal intubation was difficult in three of them. It would appear that in some patients both placement of the laryngeal mask and tracheal intubation are difficult. It is thus inadvisable to paralyse patients electively and rely on the laryngeal mask to secure a clear airway when tracheal intubation is predicted to be difficult.