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Glossopexy in Pierre Robin sequence using the laryngeal mask airway
Letters to the Editor
Severe Hypoventilation Resulting Improper Use of a Disposable Manual Resuscitator
from
1A
1B
The relief valve in the “ON” position
The relief valve in the “OFF” position
1c The relief valve poppet is lifted but is incompletely screwed
To the Editor: The disposable manual resuscitator (DMR) (Puritan Bennett, Lenexa, KS) is a manual lung ventilation device. It is attractively simple to use, particularly by relatively inexperienced personnel, because it can be operated even in the absence of a continuous oxygen source, and it does not have an expiratory valve that may require some training for optimal adjustment. The DMR has a pressure relief valve that is designed to open if airway pressure exceeds 40 + 5 cm HzO* (Figure IA). If airway pressure higher than 40 cm Hz0 is needed to ventilate the patient’s lungs, the relief valve function can be cancelled by lifting and rotating the valve poppet clockwise until it stops* (Figure IB). A black band will appear on the poppet as soon as it is lifted, whether or not it is completely turned. We would like to bring to the attention of the users of the DMR the fact that if, after lifting the poppet, it is not turned fully until it stops, the relief valve will be activated at a pressure much lower than 40 cm Hz0 (Figure 1C). This action will result in excessive air leak and can compromise ventilation. We realized the latter characteristic of the valve during ventilation of a critically ill adult with poor lung compliance. A DMR with the relief valve in the “ON” position was used with approximately 10 Wmin oxygen (0,) flowing into the device. The audible sound of 0s enriched air escaping through the relief valve was heard during peak inspiration. Since the chest movements were marginal, we turned the relief valve to the “OFF” position to generate higher airway pressure than 40 cm H,O and, consequently, be able to deliver a higher tidal volume. However, when the valve poppet was lifted and twisted, the generated airway pressure was felt to be significantly reduced, and chest movements became minimal. That was eventually realized to be caused by the valve poppet being incompletely turned, resulting in a major loss of tidal volume. Subsequently, we tested the pressures generated by the DMR at various relief valve poppet positions. As expected, the DMR generated pressures of approximately 40 cm Hz0 and more than 200 cm H,O when the valve was in the ON and OFF positions, respectively. However, when the valve poppet was pulled up but was incompletely turned, only a pressure of approximately 10 cm Hz0 was generated. In conclusion, if the DMR is used with the pressure relief valve poppet pulled up but is incompletely turned, the peak airway pressure it is capable of generating will be reduced significantly, which can result in serious hypoventilation. A valve with only ON and OFF, but no
*Disposable Manual Resuscitator promotional brochure. Puritan Bennett, Lenexa, KS 66215.
Figure 1. The pressure relief valve of the Disposable Manual Resuscitator. (A) When the relief valve is in the ON
position, it will be activated at a pressure of 40 + 5 cm H,O. (B) The relief valve can be turned off by lifting the poppet and rotating it clockwise until it stops. (C) If the poppet is lifted but is incompletely turned, the relief valve will be activated at a very low pressure, resulting in excessive air leak. intermediate positions, will avoid the potential for this problem. With the relief valve in the OFF position, the DMR is capable of generating excessively high airway pressures and can predispose to barotrauma. Extreme caution is, therefore, needed when the device is used with the relief valve in this position. George
Freeman,
MD
Resident in Anesthesia Medhat
Haxmallah,
MD, FFARCS
Associate Professor of Anesthesia Department of Anesthesia Georgetown University Medical Center Washington, D.C. SSDI 0952-8180(95)00015-A
Glossopexy in Pierre Robin Sequence Using the Laryngeal Mask Airway To the Editor: A 3,560 g male neonate was a home delivery at term to a 2%year-old. The neonate was initially vigorous, but when the mother attempted breast feeding, milk refluxed from the nose and the baby had difficulty breathing. When the neonate was seen at 6 hours of age, the triad of micrognathia, glossoptosis, and airway obstruction suggested the diagnosis of Pierre Robin sequence. J. Clin. Anesth., vol. 7, May 1995
267
Let&m to the Editor
There was an associated complete cleft of the secondary palate, but no other abnormality was noted. A clear airway was only possible in the prone position with complete upper airway obstruction occurring in the supine position. Attempts at securing a clear airway in the lateral position using a variety of nasopharyngeal or oropharyngeal airways resulted in cyanosis. Bottle feeding could not be introduced despite use of cleft palate teats, and oxygen saturation (SpO,) decreased alarmingly during these attempts. The neonate was nursed in the prone position in a high dependency area and gavage feeding commenced. Over the first week there was no improvement in the airway and thus a glossopexy (lip-tongue adhesion) as an interim procedure to stabilize the airway was indicated prior to formal repair of the cleft palate at 12 months. The neonate was premeditated with atropine 50 kg administered intramuscularly (IM). Venous access was secured with the neonate prone, and standard monitoring was applied. Full preparation was made for a difficult intubation and urgent tracheostomy. A further 25 mcg of atropine was given intravenously (IV) to prevent reflex bradycardia. Induction was commenced in the prone position using halothane and 100% oxygen (0,) with two anesthetists and a surgeon present. When the neonate was rotated into the right lateral position, the airway became obstructed. Continuous positive airway pressure (CPAP) and insertion of a size 00 Guedel airway failed to improve the situation. At this point, a #1 laryngeal mask airway (LMA) was inserted by an experienced pediatric anesthetist with the standard recommended technique and signs of obstruction immediately resolved, allowing the neonate to be placed fully supine for surgery. Since an adequate airway had been obtained with the LMA, no attempt was made at laryngoscopy or intubation. The surgeon inserted a traction suture in the posterior tongue to permit anterior traction had obstruction recurred, and a throat pack was placed above the LMA cuff. There was no deterioration in the airway. Following instillation of 1 ml 0.25% bupivacaine with adrenaline 1:400,000 to the tongue and lip, a double opposing flap was created to unite these structures, a more posterior traction suture was placed in the tongue, and the first traction suture was removed. Surgery lasted 25 minutes, during which the neonate spontaneously ventilated. Assisted ventilation via the LMA was occasionally required and adequate tidal volumes were achieved with leak pressures of 30 cm HsO. Rectal paracetamol60 mg was given prior to emergence. The LMA was removed with the neonate deeply anesthetized in the lateral POsition. Scant blood was seen above and below the cuff despite the use of the pack. Recovery was uneventful, with the neonate placed prone. SpOp was greater than 95% throughout the procedure and there was no evidence of aspiration. There was sufficient improvement in the airway to allow bottle feeds to commence at 24 hours. The neonate was discharged home after 1 week. The LMA has been successfully used in severe pediatric facial abnormalities such as Treacher Collins, Ed468
J. Clin. Anesth., vol. 7, May 1995
wards’,* Hurler’s,’ cri du chat,4 and GoldenharTs syndromes, and Burkitt’s lymphoma.6 Markakis et al.’ reported the successful use of the LMA in three awake infants with Pierre Robin sequence undergoing glossopexy or tracheostomy. Their anesthetic technique involved insertion of the LMA with topical anesthesia, followed by inhalational induction, LMA removal, laryngoscopy, and intubation. They found that the LMA allowed a smooth transition from the awake spontaneously breathing state to the anesthetized state while avoiding episodes of airway obstruction in the interim. Denny et al.* reported the successful use of the LMA on a 2.75 kg neonate with severe Pierre Robin sequence and complete airway obstruction who subsequently had a tracheostomy. In the current case, the LMA relieved an obstructed airway when the neonate was in the lateral position. Direct laryngoscopy would have required rotation into the supine position. Having obtained an adequate airway with the LMA, it was considered safer to procede than attempt intubation. The LMA has been shown to be a reliable throat pack, but in this instance blood was found on the inner surface of the cuff when the LMA was removed, although no adverse effects were observed. When a throat pack is introduced, meticulous placement is essential to prevent interference with the cuff, and it is possible that the cuff was transiently compromised during this procedure. There is now substantial evidence that the LMA may be useful in the management of Pierre Robin sequence and other syndromes that compromise the supraglottic airway. It is suggested that the experienced pediatric anesthetist should consider using the LMA, either as an interim measure or as definitive management for these difficult airways. Where tracheal intubation is considered necessary, the LMA may be used as an aid to intubation, but fiberoptic guided techniques are preferable to blind techniques. ’ The LMA should always be available in infants with Pierre Robin sequence for emergency use when other forms of airway management fail. David Me&em, MB BS, FANZCA Staff Anaesthetist Cairns Base Hospital Cairns 4870, Australia Joseph R. Brimacombe, MB ChB, FRCA, FACA Clinical Associate Professor in Anaesthesia University of Queensland Queensland, Australia Jenny Yarker, MB BS, FRACP Senior Registrar Department of Medicine Cairns Base Hospital Cairns 4870, Australia References 1. Ebata T, Nishiki S, Masuda A, Amaha K: Anaesthesia for Treacher Collins syndrome using a laryngeal mask airway. Can J Anuesth 1991;38:1043-5.
Letters to the Editor 2. Bailey C, Chung R: Use of the laryngeal mask airway in a patient with Edward’s syndrome [Letter]. Anaesthesia1992;47:713. 3. Goldie AS, Hudson I: Fibreoptic tracheal intubation through a modified laryngeal mask. Paediatr Anaesth 1992;2:344. 4. Castresana MR, Stefansson S, Cancel AR, Hague KJ: Use of the laryngeal mask airway during thoracotomy in a pediatric patient with cri-du-chat syndrome [Abstract]. AnesthA&g 1994; 78:817. 5. Johnson CM, Sims C: Awake fibreoptic intubation via a laryngeal mask in an infant with Goldenhar’s syndrome. Anaesth IntensiveCure 1994;22: 194-7.
6. Stott SA: Use of the laryngeal mask airway in the developing world [Letter]. Anuesthesiu1993;48:450. 7. Markakis DA, Sayson SC, Schreiner MS: Insertion of the laryngeal mask airway in awake infants with the Robin sequence. Anesth An&g 1992;75:822-4. 8. Denny NM, Desilva KD, Webber PA: Laryngeal mask airway for emergency tracheostomy in a neonate [Abstract]. Anaesthesia 1990;45:895. 9. Zagnoev M, McCloskey J, Martin T: Fiberoptic intubation via the laryngeal mask airway [Letter]. AnesthAndg 1994;78:813-4. SSDI 0952-8180(95)00016-B
J. Clin. Anesth., vol. 7, May 1995
‘269
Severe Hypoventilation Resulting Improper Use of a Disposable Manual Resuscitator
from
1A
1B
The relief valve in the “ON” position
The relief valve in the “OFF” position
1c The relief valve poppet is lifted but is incompletely screwed
To the Editor: The disposable manual resuscitator (DMR) (Puritan Bennett, Lenexa, KS) is a manual lung ventilation device. It is attractively simple to use, particularly by relatively inexperienced personnel, because it can be operated even in the absence of a continuous oxygen source, and it does not have an expiratory valve that may require some training for optimal adjustment. The DMR has a pressure relief valve that is designed to open if airway pressure exceeds 40 + 5 cm HzO* (Figure IA). If airway pressure higher than 40 cm Hz0 is needed to ventilate the patient’s lungs, the relief valve function can be cancelled by lifting and rotating the valve poppet clockwise until it stops* (Figure IB). A black band will appear on the poppet as soon as it is lifted, whether or not it is completely turned. We would like to bring to the attention of the users of the DMR the fact that if, after lifting the poppet, it is not turned fully until it stops, the relief valve will be activated at a pressure much lower than 40 cm Hz0 (Figure 1C). This action will result in excessive air leak and can compromise ventilation. We realized the latter characteristic of the valve during ventilation of a critically ill adult with poor lung compliance. A DMR with the relief valve in the “ON” position was used with approximately 10 Wmin oxygen (0,) flowing into the device. The audible sound of 0s enriched air escaping through the relief valve was heard during peak inspiration. Since the chest movements were marginal, we turned the relief valve to the “OFF” position to generate higher airway pressure than 40 cm H,O and, consequently, be able to deliver a higher tidal volume. However, when the valve poppet was lifted and twisted, the generated airway pressure was felt to be significantly reduced, and chest movements became minimal. That was eventually realized to be caused by the valve poppet being incompletely turned, resulting in a major loss of tidal volume. Subsequently, we tested the pressures generated by the DMR at various relief valve poppet positions. As expected, the DMR generated pressures of approximately 40 cm Hz0 and more than 200 cm H,O when the valve was in the ON and OFF positions, respectively. However, when the valve poppet was pulled up but was incompletely turned, only a pressure of approximately 10 cm Hz0 was generated. In conclusion, if the DMR is used with the pressure relief valve poppet pulled up but is incompletely turned, the peak airway pressure it is capable of generating will be reduced significantly, which can result in serious hypoventilation. A valve with only ON and OFF, but no
*Disposable Manual Resuscitator promotional brochure. Puritan Bennett, Lenexa, KS 66215.
Figure 1. The pressure relief valve of the Disposable Manual Resuscitator. (A) When the relief valve is in the ON
position, it will be activated at a pressure of 40 + 5 cm H,O. (B) The relief valve can be turned off by lifting the poppet and rotating it clockwise until it stops. (C) If the poppet is lifted but is incompletely turned, the relief valve will be activated at a very low pressure, resulting in excessive air leak. intermediate positions, will avoid the potential for this problem. With the relief valve in the OFF position, the DMR is capable of generating excessively high airway pressures and can predispose to barotrauma. Extreme caution is, therefore, needed when the device is used with the relief valve in this position. George
Freeman,
MD
Resident in Anesthesia Medhat
Haxmallah,
MD, FFARCS
Associate Professor of Anesthesia Department of Anesthesia Georgetown University Medical Center Washington, D.C. SSDI 0952-8180(95)00015-A
Glossopexy in Pierre Robin Sequence Using the Laryngeal Mask Airway To the Editor: A 3,560 g male neonate was a home delivery at term to a 2%year-old. The neonate was initially vigorous, but when the mother attempted breast feeding, milk refluxed from the nose and the baby had difficulty breathing. When the neonate was seen at 6 hours of age, the triad of micrognathia, glossoptosis, and airway obstruction suggested the diagnosis of Pierre Robin sequence. J. Clin. Anesth., vol. 7, May 1995
267
Let&m to the Editor
There was an associated complete cleft of the secondary palate, but no other abnormality was noted. A clear airway was only possible in the prone position with complete upper airway obstruction occurring in the supine position. Attempts at securing a clear airway in the lateral position using a variety of nasopharyngeal or oropharyngeal airways resulted in cyanosis. Bottle feeding could not be introduced despite use of cleft palate teats, and oxygen saturation (SpO,) decreased alarmingly during these attempts. The neonate was nursed in the prone position in a high dependency area and gavage feeding commenced. Over the first week there was no improvement in the airway and thus a glossopexy (lip-tongue adhesion) as an interim procedure to stabilize the airway was indicated prior to formal repair of the cleft palate at 12 months. The neonate was premeditated with atropine 50 kg administered intramuscularly (IM). Venous access was secured with the neonate prone, and standard monitoring was applied. Full preparation was made for a difficult intubation and urgent tracheostomy. A further 25 mcg of atropine was given intravenously (IV) to prevent reflex bradycardia. Induction was commenced in the prone position using halothane and 100% oxygen (0,) with two anesthetists and a surgeon present. When the neonate was rotated into the right lateral position, the airway became obstructed. Continuous positive airway pressure (CPAP) and insertion of a size 00 Guedel airway failed to improve the situation. At this point, a #1 laryngeal mask airway (LMA) was inserted by an experienced pediatric anesthetist with the standard recommended technique and signs of obstruction immediately resolved, allowing the neonate to be placed fully supine for surgery. Since an adequate airway had been obtained with the LMA, no attempt was made at laryngoscopy or intubation. The surgeon inserted a traction suture in the posterior tongue to permit anterior traction had obstruction recurred, and a throat pack was placed above the LMA cuff. There was no deterioration in the airway. Following instillation of 1 ml 0.25% bupivacaine with adrenaline 1:400,000 to the tongue and lip, a double opposing flap was created to unite these structures, a more posterior traction suture was placed in the tongue, and the first traction suture was removed. Surgery lasted 25 minutes, during which the neonate spontaneously ventilated. Assisted ventilation via the LMA was occasionally required and adequate tidal volumes were achieved with leak pressures of 30 cm HsO. Rectal paracetamol60 mg was given prior to emergence. The LMA was removed with the neonate deeply anesthetized in the lateral POsition. Scant blood was seen above and below the cuff despite the use of the pack. Recovery was uneventful, with the neonate placed prone. SpOp was greater than 95% throughout the procedure and there was no evidence of aspiration. There was sufficient improvement in the airway to allow bottle feeds to commence at 24 hours. The neonate was discharged home after 1 week. The LMA has been successfully used in severe pediatric facial abnormalities such as Treacher Collins, Ed468
J. Clin. Anesth., vol. 7, May 1995
wards’,* Hurler’s,’ cri du chat,4 and GoldenharTs syndromes, and Burkitt’s lymphoma.6 Markakis et al.’ reported the successful use of the LMA in three awake infants with Pierre Robin sequence undergoing glossopexy or tracheostomy. Their anesthetic technique involved insertion of the LMA with topical anesthesia, followed by inhalational induction, LMA removal, laryngoscopy, and intubation. They found that the LMA allowed a smooth transition from the awake spontaneously breathing state to the anesthetized state while avoiding episodes of airway obstruction in the interim. Denny et al.* reported the successful use of the LMA on a 2.75 kg neonate with severe Pierre Robin sequence and complete airway obstruction who subsequently had a tracheostomy. In the current case, the LMA relieved an obstructed airway when the neonate was in the lateral position. Direct laryngoscopy would have required rotation into the supine position. Having obtained an adequate airway with the LMA, it was considered safer to procede than attempt intubation. The LMA has been shown to be a reliable throat pack, but in this instance blood was found on the inner surface of the cuff when the LMA was removed, although no adverse effects were observed. When a throat pack is introduced, meticulous placement is essential to prevent interference with the cuff, and it is possible that the cuff was transiently compromised during this procedure. There is now substantial evidence that the LMA may be useful in the management of Pierre Robin sequence and other syndromes that compromise the supraglottic airway. It is suggested that the experienced pediatric anesthetist should consider using the LMA, either as an interim measure or as definitive management for these difficult airways. Where tracheal intubation is considered necessary, the LMA may be used as an aid to intubation, but fiberoptic guided techniques are preferable to blind techniques. ’ The LMA should always be available in infants with Pierre Robin sequence for emergency use when other forms of airway management fail. David Me&em, MB BS, FANZCA Staff Anaesthetist Cairns Base Hospital Cairns 4870, Australia Joseph R. Brimacombe, MB ChB, FRCA, FACA Clinical Associate Professor in Anaesthesia University of Queensland Queensland, Australia Jenny Yarker, MB BS, FRACP Senior Registrar Department of Medicine Cairns Base Hospital Cairns 4870, Australia References 1. Ebata T, Nishiki S, Masuda A, Amaha K: Anaesthesia for Treacher Collins syndrome using a laryngeal mask airway. Can J Anuesth 1991;38:1043-5.
Letters to the Editor 2. Bailey C, Chung R: Use of the laryngeal mask airway in a patient with Edward’s syndrome [Letter]. Anaesthesia1992;47:713. 3. Goldie AS, Hudson I: Fibreoptic tracheal intubation through a modified laryngeal mask. Paediatr Anaesth 1992;2:344. 4. Castresana MR, Stefansson S, Cancel AR, Hague KJ: Use of the laryngeal mask airway during thoracotomy in a pediatric patient with cri-du-chat syndrome [Abstract]. AnesthA&g 1994; 78:817. 5. Johnson CM, Sims C: Awake fibreoptic intubation via a laryngeal mask in an infant with Goldenhar’s syndrome. Anaesth IntensiveCure 1994;22: 194-7.
6. Stott SA: Use of the laryngeal mask airway in the developing world [Letter]. Anuesthesiu1993;48:450. 7. Markakis DA, Sayson SC, Schreiner MS: Insertion of the laryngeal mask airway in awake infants with the Robin sequence. Anesth An&g 1992;75:822-4. 8. Denny NM, Desilva KD, Webber PA: Laryngeal mask airway for emergency tracheostomy in a neonate [Abstract]. Anaesthesia 1990;45:895. 9. Zagnoev M, McCloskey J, Martin T: Fiberoptic intubation via the laryngeal mask airway [Letter]. AnesthAndg 1994;78:813-4. SSDI 0952-8180(95)00016-B
J. Clin. Anesth., vol. 7, May 1995
‘269