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Gastric tube–guided insertion of laryngeal tube suction
Journal of Clinical Anesthesia (2016) 31, 291–292
Correspondence Gastric tube–guided insertion of laryngeal tube suction Laryngeal tube suction II (LTS-II; VBM Medizintechnik GmbH ,Sulz a.N, Germany ) is a commonly used supraglottic airway device in routine and emergency airway management. It is inserted blindly simply by opening the mouth and sliding its distal end along with the hard palate until the central incisor teeth are at a predetermined level (1 of the 3 lines) on LTS-II shaft. Although Esmarch maneuver (jaw thrust) has been described to facilitate its insertion, it may not be feasible or effective in case of limited mouth opening, reduced neck mobility, or cervical injury or a rigid cervical collar [1]. Although jaw thrust does provide enough retropharyngeal space and ensures easy and faster insertion of LTS-II, it does not guarantee the placement of its distal tip into the esophagus, nor does it ensure that the distal tip of LTS-II will not enter into the trachea or piriform sinuses, one of the commonest sites of malposition of tip of the LTS-II [2–6]. Furthermore, in 2% to 4% cases, one may fail to pass gastric tube through the drain tube of LTS-II despite their best efforts [7]. In their landmark article, Kikuchi et al [2] have shown that in 10% of the patients, the LTS-II entered either the tracheal inlet or the piriform fossa instead of the esophagus. They further observed that that this was due to hitting of the distal end of the drain tube to the posterior wall of the pharynx, with ventral bending of LTS-II at the junction of 2 coaxial tubes, resulting in its malposition. This has been attributable to the slimmer and more pointed distal end of LTS-II compared with original laryngeal tube and LTS, making LTS-II more likely to bend while negotiating in the pharynx. Similar malposition of LTS-II in piriform sinus has been described by Schalk et al [4] and Russo et al [3]. Interestingly, these authors have found that although in 80% of patients, this malposition could still be ventilated successfully, this would negate the basic advantage contributed by second-generation supraglottic devices with gastric channel, thereby making patients prone to gastric distention and aspiration. Advancement of gastric tube successfully after positioning of LTS-II offers the possibility to indirectly confirming the correct positioning of LTS-II. Bernhard et al [5] recommend that if problems are encountered in inserting a gastric tube soon after insertion of LTS-II has been placed, it 0952-8180/© 2016 Elsevier Inc. All rights reserved.
can be assumed that the part of LTS-II is bent or the outlet of gastric channel is occluded by anatomical structures like piriform fossa, pharyngeal tissue, or esophageal wall. Although ventilation may be possible, repositioning of LTS-II is strongly advised. However, these repeated attempts to reposition the LTS-II may not be conducive to the patients, especially in emergency situations with time constrains. We have recently started using gastric tube to prime the LTS-II to ease its insertion when we failed to introduce LTS-II in our 3 patients even after multiple attempts despite using jaw thrust. Drain tube of LTS-II is well lubricated with water-based gel, and it was primed 16F gastric tube protruding 10 to 15 cm beyond the drain tube. The LTS-II-gastric tube assembly is gently inserted into the patient's mouth, and the gastric tube is blindly inserted into the pharynx to a depth of 10 to 15 cm at the incisors. Slight changes and maneuvering are done if required to negotiate the gastric tube into the esophagus. The gastric tube acts as a guide, directing itself and the tip of the LTS-II toward the upper esophageal sphincter. Once gastric tube is advanced into the stomach, the laryngeal tube is negotiated into the esophagus by railroading over as per the standard inserting technique. Position of gastric tube is confirmed by detection of injected air by epigastric auscultation or suctioning of gastric secretions. Resistance was encountered to the passage in one case and jaw thrust was used while negotiating the LTS-II. In all these 3 cases, priming of LTS-II with gastric tube facilitated its successful placement in the first attempt after failed attempts. Similar use of gastric tubes has been extensively found to ease insertion of Proseal laryngeal mask airway, where it has been used not only to prevent distal cuff fold over by strengthening the distal weak part of Proseal laryngeal mask airway and but also to guide the positioning of the distal end of the drain tube into the esophagus, with increased success rate in fewer attempts and faster placement of Proseal laryngeal mask airway [6,7]. We have used this technique in 25 patients and have found that this facilitated faster insertion of LTS-II and with more ease with insertion being successful in all patients and in the first attempt in 21 patients. To conclude, we have observed that priming of LTS-II with 16F gastric tube eases insertion of LTS-II by avoiding the bending of distal part of LTS-II and by guiding it into the correct position into the esophagus, avoiding its going astray into adjoining pharynx or glottic/periglottic elastic structures.
292 Rajesh Mahajan MBBS, MD (Consultant)⁎ Ashufta Rasool MBBS, MD (Senior Resident) Smriti Gulati MBBS, MD (Consultant) Robina Nazir MBBS, MD (Consultant) Department of Anesthesia and ICU, GMC, Jammu Jammu and Kashmir, India ⁎Corresponding author at: Quarter No. c-3 Medical College Enclave, Bakshi Nagar Jammu, Jammu and Kashmir 180001 India. Tel.: +91 9419141263; fax: +91 1912549948 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.12.009
References [1] Schalk R, Engel S, Meininger D, Zacharowski K, Holzer L, Scheller B, et al. Disposable laryngeal tube suction: standard insertion technique versus two modified insertion techniques for patients with a simulated difficult airway. Resuscitation 2011;82:199-202.
Correspondence [2] Kikuchi T, Kamiya Y, Ohtsuka T, Miki T, Goto T. Randomized prospective study comparing the laryngeal tube suction II with the ProSeal laryngeal mask airway in anesthetized and paralyzed patients. Anesthesiology 2008;109:54-60. [3] Russo SG, Cremer S, Galli T, Eich C, Bräuer A, Crozier TA, et al. Randomized comparison of the i-gel™, the LMA Supreme™, and the Laryngeal Tube Suction-D using clinical and fibreoptic assessments in elective patients. BMC Anesthesiol 2012;12:18. [4] Schalk R, Seeger FH, Mutlak H, Schweigkofler U, Zacharowski K, Peter N, et al. Complications associated with the prehospital use of laryngeal tubes—a systematic analysis of risk factors and strategies for prevention. Resuscitation 2014;85:1629-32. [5] Bernhard M, Beres W, Timmermann A, Stepan R, Greim CA, Kaisers UX, et al. Prehospital airway management using the laryngeal tube. An emergency department point of view. Anaesthesist 2014;63:589-96. [6] Martínez-Pons V, Madrid V. Ease placement of LMA Proseal with a gastric tube inserted. Anesth Analg 2004;98:1816-7. [7] Nagata T, Kishi Y, Tanigami H, Hiuge Y, Sonoda S, Ohashi Y, et al. Oral gastric tube–guided insertion of the Proseal™ laryngeal mask is an easy and noninvasive method for less experienced users. J Anesth 2012; 26:531-5.
Correspondence Gastric tube–guided insertion of laryngeal tube suction Laryngeal tube suction II (LTS-II; VBM Medizintechnik GmbH ,Sulz a.N, Germany ) is a commonly used supraglottic airway device in routine and emergency airway management. It is inserted blindly simply by opening the mouth and sliding its distal end along with the hard palate until the central incisor teeth are at a predetermined level (1 of the 3 lines) on LTS-II shaft. Although Esmarch maneuver (jaw thrust) has been described to facilitate its insertion, it may not be feasible or effective in case of limited mouth opening, reduced neck mobility, or cervical injury or a rigid cervical collar [1]. Although jaw thrust does provide enough retropharyngeal space and ensures easy and faster insertion of LTS-II, it does not guarantee the placement of its distal tip into the esophagus, nor does it ensure that the distal tip of LTS-II will not enter into the trachea or piriform sinuses, one of the commonest sites of malposition of tip of the LTS-II [2–6]. Furthermore, in 2% to 4% cases, one may fail to pass gastric tube through the drain tube of LTS-II despite their best efforts [7]. In their landmark article, Kikuchi et al [2] have shown that in 10% of the patients, the LTS-II entered either the tracheal inlet or the piriform fossa instead of the esophagus. They further observed that that this was due to hitting of the distal end of the drain tube to the posterior wall of the pharynx, with ventral bending of LTS-II at the junction of 2 coaxial tubes, resulting in its malposition. This has been attributable to the slimmer and more pointed distal end of LTS-II compared with original laryngeal tube and LTS, making LTS-II more likely to bend while negotiating in the pharynx. Similar malposition of LTS-II in piriform sinus has been described by Schalk et al [4] and Russo et al [3]. Interestingly, these authors have found that although in 80% of patients, this malposition could still be ventilated successfully, this would negate the basic advantage contributed by second-generation supraglottic devices with gastric channel, thereby making patients prone to gastric distention and aspiration. Advancement of gastric tube successfully after positioning of LTS-II offers the possibility to indirectly confirming the correct positioning of LTS-II. Bernhard et al [5] recommend that if problems are encountered in inserting a gastric tube soon after insertion of LTS-II has been placed, it 0952-8180/© 2016 Elsevier Inc. All rights reserved.
can be assumed that the part of LTS-II is bent or the outlet of gastric channel is occluded by anatomical structures like piriform fossa, pharyngeal tissue, or esophageal wall. Although ventilation may be possible, repositioning of LTS-II is strongly advised. However, these repeated attempts to reposition the LTS-II may not be conducive to the patients, especially in emergency situations with time constrains. We have recently started using gastric tube to prime the LTS-II to ease its insertion when we failed to introduce LTS-II in our 3 patients even after multiple attempts despite using jaw thrust. Drain tube of LTS-II is well lubricated with water-based gel, and it was primed 16F gastric tube protruding 10 to 15 cm beyond the drain tube. The LTS-II-gastric tube assembly is gently inserted into the patient's mouth, and the gastric tube is blindly inserted into the pharynx to a depth of 10 to 15 cm at the incisors. Slight changes and maneuvering are done if required to negotiate the gastric tube into the esophagus. The gastric tube acts as a guide, directing itself and the tip of the LTS-II toward the upper esophageal sphincter. Once gastric tube is advanced into the stomach, the laryngeal tube is negotiated into the esophagus by railroading over as per the standard inserting technique. Position of gastric tube is confirmed by detection of injected air by epigastric auscultation or suctioning of gastric secretions. Resistance was encountered to the passage in one case and jaw thrust was used while negotiating the LTS-II. In all these 3 cases, priming of LTS-II with gastric tube facilitated its successful placement in the first attempt after failed attempts. Similar use of gastric tubes has been extensively found to ease insertion of Proseal laryngeal mask airway, where it has been used not only to prevent distal cuff fold over by strengthening the distal weak part of Proseal laryngeal mask airway and but also to guide the positioning of the distal end of the drain tube into the esophagus, with increased success rate in fewer attempts and faster placement of Proseal laryngeal mask airway [6,7]. We have used this technique in 25 patients and have found that this facilitated faster insertion of LTS-II and with more ease with insertion being successful in all patients and in the first attempt in 21 patients. To conclude, we have observed that priming of LTS-II with 16F gastric tube eases insertion of LTS-II by avoiding the bending of distal part of LTS-II and by guiding it into the correct position into the esophagus, avoiding its going astray into adjoining pharynx or glottic/periglottic elastic structures.
292 Rajesh Mahajan MBBS, MD (Consultant)⁎ Ashufta Rasool MBBS, MD (Senior Resident) Smriti Gulati MBBS, MD (Consultant) Robina Nazir MBBS, MD (Consultant) Department of Anesthesia and ICU, GMC, Jammu Jammu and Kashmir, India ⁎Corresponding author at: Quarter No. c-3 Medical College Enclave, Bakshi Nagar Jammu, Jammu and Kashmir 180001 India. Tel.: +91 9419141263; fax: +91 1912549948 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.12.009
References [1] Schalk R, Engel S, Meininger D, Zacharowski K, Holzer L, Scheller B, et al. Disposable laryngeal tube suction: standard insertion technique versus two modified insertion techniques for patients with a simulated difficult airway. Resuscitation 2011;82:199-202.
Correspondence [2] Kikuchi T, Kamiya Y, Ohtsuka T, Miki T, Goto T. Randomized prospective study comparing the laryngeal tube suction II with the ProSeal laryngeal mask airway in anesthetized and paralyzed patients. Anesthesiology 2008;109:54-60. [3] Russo SG, Cremer S, Galli T, Eich C, Bräuer A, Crozier TA, et al. Randomized comparison of the i-gel™, the LMA Supreme™, and the Laryngeal Tube Suction-D using clinical and fibreoptic assessments in elective patients. BMC Anesthesiol 2012;12:18. [4] Schalk R, Seeger FH, Mutlak H, Schweigkofler U, Zacharowski K, Peter N, et al. Complications associated with the prehospital use of laryngeal tubes—a systematic analysis of risk factors and strategies for prevention. Resuscitation 2014;85:1629-32. [5] Bernhard M, Beres W, Timmermann A, Stepan R, Greim CA, Kaisers UX, et al. Prehospital airway management using the laryngeal tube. An emergency department point of view. Anaesthesist 2014;63:589-96. [6] Martínez-Pons V, Madrid V. Ease placement of LMA Proseal with a gastric tube inserted. Anesth Analg 2004;98:1816-7. [7] Nagata T, Kishi Y, Tanigami H, Hiuge Y, Sonoda S, Ohashi Y, et al. Oral gastric tube–guided insertion of the Proseal™ laryngeal mask is an easy and noninvasive method for less experienced users. J Anesth 2012; 26:531-5.