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Use of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders
Case Reports Use of the Intubating Laryngeal Mask Airway to Facilitate Awake Orotracheal Intubation in Patients with Cervical Spine Disorders Jenson K. Wong, BS,* W. Kendall Tongier, MD,† Steven C. Armbruster, MD,† Paul F. White, PhD, MD, FANZCA‡ Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation. © 1999 by Elsevier Science Inc. Key words: Intubation: fiberoptic-assisted, nasotracheal, technique of; laryngeal mask airway, intubating. *Medical Student II †Assistant Professor
Introduction
‡Professor and Holder of the Margaret Milam McDermott Distinguished Chair in Anesthesiology
The intubating laryngeal mask airway (ILMA) (LMA-Fastrach™, LMA North America, Inc., San Diego, CA) represents a further improvement on the capabilities of the original LMA for facilitating tracheal intubation,1,2 especially in patients with difficult airways or unstable cervical spines.3– 6 In contrast to the airway tube of the conventional LMA, the lumen of the ILMA is wider and constructed of stainless steel that is covered with a rubberized material, which allows it to maintain its anatomic shape.1 As a result of its larger internal diameter and hinged epiglottic elevating bar (“glottic flap”), the ILMA facilitates passage of a bronchoscope or tracheal tube. One of the major advantages of the ILMA over conventional intubation devices lies in its ability to facilitate intubation in patients with little or no manipulation of the patient’s head or cervical spine.1,6,7
Address correspondence to Dr. White at the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9068, USA. E-mail: [email protected] Received for publication December 24, 1998; revised manuscript accepted for publication April 20, 1999.
Journal of Clinical Anesthesia 11:346 –348, 1999 © 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/99/$–see front matter PII S0952-8180(99)00052-5
ILMA and unstable cervical spine: Wong et al.
Recent reports have described the use of the ILMA in patients with difficult airways.3– 6 However, in this report we describe the use of the ILMA for performing an awake orotracheal intubation in two patients with cervical spine disorders.
Case Reports Case 1 A 28-year-old, 64-kg, 172-cm woman was a restrained passenger involved in a rollover motor vehicle accident in which she sustained a fracture of the odontoid process at the C2 level, She was flown to Parkland Memorial Hospital for a surgical stabilization procedure. The patient was awake and alert; oriented to person, time, and place; and neurologically intact. She had a Mallampati class I airway in the supine position; otherwise she was healthy with no other underlying diseases. The surgical staff requested an awake intubation, with neurologic examination to follow. The patient was premedicated with glycopyrrolate 0.4 mg intravenously (IV). In preparation for an awake orotracheal intubation using the ILMA, the patient was administered 3 ml of nebulized 4% lidocaine over a 15-minute period prior to being brought to the operating room (OR). In the OR, she was sedated with midazolam 2 mg IV, sufentanil 5 g IV, and droperidol 0.625 mg IV. Benzocaine topical spray was administered to the back of the patient’s throat, and a transtracheal block was performed using 4 ml of 1% lidocaine to decrease the sensation associated with passage of the tracheal tube. The ILMA was easily inserted (WKT) by asking the patient to swallow as it was positioned in the pharyngeal area. The insertion procedure took less than 30 seconds, and the device was well tolerated without any coughing or gagging. A fiberoptic bronchoscope was inserted into a prewarmed, well-lubricated, 7.0-mm inner diameter HiLo® tracheal tube (Mallinckrodt, St. Louis, MO). The bronchoscope was introduced into the lumen of the ILMA. At 15 cm, as the bronchoscope and endotracheal tube emerged from the distal end of the ILMA, the vocal cords and carina were visualized clearly. On introduction of the tracheal tube, a weak cough was evoked, and the patient’s heart rate increased transiently to 138 bpm (from a baseline value of 83 bpm). The entire process from insertion of the ILMA to inflation of the cuff on the tracheal tube required approximately 5 minutes. On completion of the intubation, the patient was asked to move her fingers and toes, and she was able to cooperate for this examination. Subsequently, anesthesia was induced with propofol 120 mg IV, and rocuronium 50 mg IV was administered to facilitate mechanical ventilation and removal of the ILMA. No blood was observed on the ILMA device after removal. The patient subsequently recovered without any neurologic deficits.
Case 2 A 52-year-old, 116-kg, 170-cm woman presented for a laparoscopic Nissen fundoplication procedure. She had a
history of severe gastric reflux symptoms (secondary to her hiatal hernia), temporal mandibular joint disease, and bulging intervertebral disks at the C3–C4 and C5–C6 levels. On examination, she was observed to be an obese female with a Mallampati class II airway. She had limited range of movement of her neck secondary to the pain from her cervical disk disease. Flexion-extension of the neck caused bilateral paresthesia radiating down both arms. The patient was premedicated with metoclopramide 20 mg IV and glycopyrrolate 0.4 mg IV, and her airway was prepared with 4 ml of nebulized 4% lidocaine solution and benzocaine topical spray to the back of her throat. An attempted transtracheal block was not successful because of her obesity and limited neck mobility. She was sedated with of midazolam 2 mg IV and fentanyl 100 g IV. Insertion of the ILMA was uneventful and well tolerated, as described in Case 1. The fiberoptic bronchoscope and a 7.0-mm Hi-Lo® tracheal tube were introduced into the lumen of the ILMA. The vocal cords and carina were clearly visualized before the tracheal tube was advanced into the trachea. The patient experienced slight coughing following introduction of the tracheal tube. Induction of anesthesia was rapidly performed with propofol 160 mg IV. Rocuronium 50 mg IV subsequently was administered to facilitate assisted ventilation and removal of the ILMA device. No blood was observed on the device after removal. Suctioning of the patient’s hypopharynx revealed no evidence of gastric reflux during the intubation process.*
Discussion Blind nasotracheal intubation, fiberoptic orotracheal intubation, and orotracheal intubation by direct laryngoscopy with manual in-line stabilization of the head and neck are well-established techniques for managing patients with cervical spine dysfunction,8 –14 but the techniques are not without complications. With blind nasotracheal intubation, it is common for nasal intubation to cause mild-to-moderate nasal bleeding. More serious complications include sinusitis, bacteremia, aspiration pneumonitis, and retropharyngeal perforation.8,9 Fiberoptic orotracheal intubation is difficult because visualization often is hindered by oral and nasal secretions.10 Additionally, because there is nothing to guide the trajectory of the fiberoptic bronchoscope and tracheal tube, the technique can be extremely time-consuming, and it requires a skilled operator to successfully intubate patients with difficult airways.10 Both blind nasotracheal intubation and fiberoptic orotracheal intubation require the cooperation of the patient. Direct laryngoscopy is the quickest and least invasive technique, but its safety is controversial in patients with cervical spine injuries.8,10 –15 Although tracheal intubation could have been accomplished using the fiberoptic bronchoscopy without the ILMA, the ILMA provides a threefold advantage over conventional fiberoptic-assisted techniques: 1) it provides accurate and anatomically correct guidance of the tracheal tube toward the patient’s *The ILMA could interfere with pharyngeal suctioning should regurgitation of gastric contents occur during the intubation procedure. J. Clin. Anesth., vol. 11, June 1999
347
Case Reports
larynx, with easier visualization of the glottic opening; (2) the fiberoptic bronchoscope is kept free of oral secretions during the laryngoscopy process; and (3) the intubation procedure can be performed rapidly, with minimal distress to the patient. Obviously, future studies with the ILMA involving a larger number of patients with cervical spine disorders are needed. The availability of the ILMA gives the practitioner an alternative to the conventional fiberoptic approach for awake tracheal intubation, and it may reduce the risks and complications associated with direct laryngoscopy and nasotracheal intubation in patients with cervical spine pathology.15 The ability to provide for a simpler (and gentler) means of tracheal intubation with the head and neck in the “neutral” position would be preferable to risking a neurologic injury caused by unintentional manipulation of the head and cervical spine.16
References 1. Brain AI, Verghese C, Addy EV, Kapila A, Brimacombe J: The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997;79: 704 –9. 2. Kapila A, Addy EV, Verghese C, Brain AI: The intubating laryngeal mask airway: an initial assessment of performance. Br J Anaesth 1997;79:710 –3. 3. Joo H, Rose K: FastrachTM—a new intubating laryngeal mask airway: successful use in patients with difficult airways. Can J Anaesth 1998;45:253– 6. 4. Brimacombe JR: Difficult airway management with the intubating laryngeal mask. Anesth Analg 1997;85:1173–5.
348
J. Clin. Anesth., vol. 11, June 1999
5. McQuibban GA: LMA-FasTrachTM [Letter]. Can J Anaesth 1998; 45:95–9. 6. Parr MJ, Gregory M, Baskett PJ: The intubating laryngeal mask. Use in failed and difficult intubation. Anaesthesia 1998;53:343– 8. 7. Brain AIJ, Verghese C, Addy EV, Kapila A: The intubating laryngeal mask. I: Development of a new device for intubation of the trachea. Br J Anaesth 1997;79:699 –703. 8. Shatney CH, Brunner RD, Nguyen TQ: The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am J Surg 1995;170:676 – 80. 9. Tintinalli JE, Claffey J: Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142– 4. 10. Hastings RH, Marks JD: Airway management for trauma patients with potential cervical spine injuries. Anesth Analg 1991;73:471– 82. 11. Scannell G, Waxman K, Tominaga GT, et al: Orotracheal intubation in trauma patients with cervical fractures. Arch Surg 1993;128:903– 6. 12. Criswell JC, Parr MJ, Nolan JP: Emergency airway management in patients with cervical spine injuries. Anaesthesia 1994;49:900 –3. 13. Knopp RK: The safety of orotracheal intubation in patients with suspected cervical-spine injury. Ann Emerg Med 1990;19:603– 4. 14. Wood PR, Lawler PG: Managing the airway in cervical spine injury. A review of the Advanced Trauma Life Support protocol. Anaesthesia 1992;47:792–7. 15. Fukutome T, Amaha K, Nakazawa K, et al: Tracheal intubation through the intubating laryngeal mask airway (LMA–FastrachTM) in patients with difficult airways. Anaesth Intensive Care 1998;26: 287–91. 16. Hastings RH, Kelley SD: Neurologic deterioration associated with airway management in a cervical spine-injured patient. Anesthesiology 1993;78:580 –3.
Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation. © 1999 by Elsevier Science Inc. Key words: Intubation: fiberoptic-assisted, nasotracheal, technique of; laryngeal mask airway, intubating. *Medical Student II †Assistant Professor
Introduction
‡Professor and Holder of the Margaret Milam McDermott Distinguished Chair in Anesthesiology
The intubating laryngeal mask airway (ILMA) (LMA-Fastrach™, LMA North America, Inc., San Diego, CA) represents a further improvement on the capabilities of the original LMA for facilitating tracheal intubation,1,2 especially in patients with difficult airways or unstable cervical spines.3– 6 In contrast to the airway tube of the conventional LMA, the lumen of the ILMA is wider and constructed of stainless steel that is covered with a rubberized material, which allows it to maintain its anatomic shape.1 As a result of its larger internal diameter and hinged epiglottic elevating bar (“glottic flap”), the ILMA facilitates passage of a bronchoscope or tracheal tube. One of the major advantages of the ILMA over conventional intubation devices lies in its ability to facilitate intubation in patients with little or no manipulation of the patient’s head or cervical spine.1,6,7
Address correspondence to Dr. White at the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9068, USA. E-mail: [email protected] Received for publication December 24, 1998; revised manuscript accepted for publication April 20, 1999.
Journal of Clinical Anesthesia 11:346 –348, 1999 © 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/99/$–see front matter PII S0952-8180(99)00052-5
ILMA and unstable cervical spine: Wong et al.
Recent reports have described the use of the ILMA in patients with difficult airways.3– 6 However, in this report we describe the use of the ILMA for performing an awake orotracheal intubation in two patients with cervical spine disorders.
Case Reports Case 1 A 28-year-old, 64-kg, 172-cm woman was a restrained passenger involved in a rollover motor vehicle accident in which she sustained a fracture of the odontoid process at the C2 level, She was flown to Parkland Memorial Hospital for a surgical stabilization procedure. The patient was awake and alert; oriented to person, time, and place; and neurologically intact. She had a Mallampati class I airway in the supine position; otherwise she was healthy with no other underlying diseases. The surgical staff requested an awake intubation, with neurologic examination to follow. The patient was premedicated with glycopyrrolate 0.4 mg intravenously (IV). In preparation for an awake orotracheal intubation using the ILMA, the patient was administered 3 ml of nebulized 4% lidocaine over a 15-minute period prior to being brought to the operating room (OR). In the OR, she was sedated with midazolam 2 mg IV, sufentanil 5 g IV, and droperidol 0.625 mg IV. Benzocaine topical spray was administered to the back of the patient’s throat, and a transtracheal block was performed using 4 ml of 1% lidocaine to decrease the sensation associated with passage of the tracheal tube. The ILMA was easily inserted (WKT) by asking the patient to swallow as it was positioned in the pharyngeal area. The insertion procedure took less than 30 seconds, and the device was well tolerated without any coughing or gagging. A fiberoptic bronchoscope was inserted into a prewarmed, well-lubricated, 7.0-mm inner diameter HiLo® tracheal tube (Mallinckrodt, St. Louis, MO). The bronchoscope was introduced into the lumen of the ILMA. At 15 cm, as the bronchoscope and endotracheal tube emerged from the distal end of the ILMA, the vocal cords and carina were visualized clearly. On introduction of the tracheal tube, a weak cough was evoked, and the patient’s heart rate increased transiently to 138 bpm (from a baseline value of 83 bpm). The entire process from insertion of the ILMA to inflation of the cuff on the tracheal tube required approximately 5 minutes. On completion of the intubation, the patient was asked to move her fingers and toes, and she was able to cooperate for this examination. Subsequently, anesthesia was induced with propofol 120 mg IV, and rocuronium 50 mg IV was administered to facilitate mechanical ventilation and removal of the ILMA. No blood was observed on the ILMA device after removal. The patient subsequently recovered without any neurologic deficits.
Case 2 A 52-year-old, 116-kg, 170-cm woman presented for a laparoscopic Nissen fundoplication procedure. She had a
history of severe gastric reflux symptoms (secondary to her hiatal hernia), temporal mandibular joint disease, and bulging intervertebral disks at the C3–C4 and C5–C6 levels. On examination, she was observed to be an obese female with a Mallampati class II airway. She had limited range of movement of her neck secondary to the pain from her cervical disk disease. Flexion-extension of the neck caused bilateral paresthesia radiating down both arms. The patient was premedicated with metoclopramide 20 mg IV and glycopyrrolate 0.4 mg IV, and her airway was prepared with 4 ml of nebulized 4% lidocaine solution and benzocaine topical spray to the back of her throat. An attempted transtracheal block was not successful because of her obesity and limited neck mobility. She was sedated with of midazolam 2 mg IV and fentanyl 100 g IV. Insertion of the ILMA was uneventful and well tolerated, as described in Case 1. The fiberoptic bronchoscope and a 7.0-mm Hi-Lo® tracheal tube were introduced into the lumen of the ILMA. The vocal cords and carina were clearly visualized before the tracheal tube was advanced into the trachea. The patient experienced slight coughing following introduction of the tracheal tube. Induction of anesthesia was rapidly performed with propofol 160 mg IV. Rocuronium 50 mg IV subsequently was administered to facilitate assisted ventilation and removal of the ILMA device. No blood was observed on the device after removal. Suctioning of the patient’s hypopharynx revealed no evidence of gastric reflux during the intubation process.*
Discussion Blind nasotracheal intubation, fiberoptic orotracheal intubation, and orotracheal intubation by direct laryngoscopy with manual in-line stabilization of the head and neck are well-established techniques for managing patients with cervical spine dysfunction,8 –14 but the techniques are not without complications. With blind nasotracheal intubation, it is common for nasal intubation to cause mild-to-moderate nasal bleeding. More serious complications include sinusitis, bacteremia, aspiration pneumonitis, and retropharyngeal perforation.8,9 Fiberoptic orotracheal intubation is difficult because visualization often is hindered by oral and nasal secretions.10 Additionally, because there is nothing to guide the trajectory of the fiberoptic bronchoscope and tracheal tube, the technique can be extremely time-consuming, and it requires a skilled operator to successfully intubate patients with difficult airways.10 Both blind nasotracheal intubation and fiberoptic orotracheal intubation require the cooperation of the patient. Direct laryngoscopy is the quickest and least invasive technique, but its safety is controversial in patients with cervical spine injuries.8,10 –15 Although tracheal intubation could have been accomplished using the fiberoptic bronchoscopy without the ILMA, the ILMA provides a threefold advantage over conventional fiberoptic-assisted techniques: 1) it provides accurate and anatomically correct guidance of the tracheal tube toward the patient’s *The ILMA could interfere with pharyngeal suctioning should regurgitation of gastric contents occur during the intubation procedure. J. Clin. Anesth., vol. 11, June 1999
347
Case Reports
larynx, with easier visualization of the glottic opening; (2) the fiberoptic bronchoscope is kept free of oral secretions during the laryngoscopy process; and (3) the intubation procedure can be performed rapidly, with minimal distress to the patient. Obviously, future studies with the ILMA involving a larger number of patients with cervical spine disorders are needed. The availability of the ILMA gives the practitioner an alternative to the conventional fiberoptic approach for awake tracheal intubation, and it may reduce the risks and complications associated with direct laryngoscopy and nasotracheal intubation in patients with cervical spine pathology.15 The ability to provide for a simpler (and gentler) means of tracheal intubation with the head and neck in the “neutral” position would be preferable to risking a neurologic injury caused by unintentional manipulation of the head and cervical spine.16
References 1. Brain AI, Verghese C, Addy EV, Kapila A, Brimacombe J: The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997;79: 704 –9. 2. Kapila A, Addy EV, Verghese C, Brain AI: The intubating laryngeal mask airway: an initial assessment of performance. Br J Anaesth 1997;79:710 –3. 3. Joo H, Rose K: FastrachTM—a new intubating laryngeal mask airway: successful use in patients with difficult airways. Can J Anaesth 1998;45:253– 6. 4. Brimacombe JR: Difficult airway management with the intubating laryngeal mask. Anesth Analg 1997;85:1173–5.
348
J. Clin. Anesth., vol. 11, June 1999
5. McQuibban GA: LMA-FasTrachTM [Letter]. Can J Anaesth 1998; 45:95–9. 6. Parr MJ, Gregory M, Baskett PJ: The intubating laryngeal mask. Use in failed and difficult intubation. Anaesthesia 1998;53:343– 8. 7. Brain AIJ, Verghese C, Addy EV, Kapila A: The intubating laryngeal mask. I: Development of a new device for intubation of the trachea. Br J Anaesth 1997;79:699 –703. 8. Shatney CH, Brunner RD, Nguyen TQ: The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am J Surg 1995;170:676 – 80. 9. Tintinalli JE, Claffey J: Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142– 4. 10. Hastings RH, Marks JD: Airway management for trauma patients with potential cervical spine injuries. Anesth Analg 1991;73:471– 82. 11. Scannell G, Waxman K, Tominaga GT, et al: Orotracheal intubation in trauma patients with cervical fractures. Arch Surg 1993;128:903– 6. 12. Criswell JC, Parr MJ, Nolan JP: Emergency airway management in patients with cervical spine injuries. Anaesthesia 1994;49:900 –3. 13. Knopp RK: The safety of orotracheal intubation in patients with suspected cervical-spine injury. Ann Emerg Med 1990;19:603– 4. 14. Wood PR, Lawler PG: Managing the airway in cervical spine injury. A review of the Advanced Trauma Life Support protocol. Anaesthesia 1992;47:792–7. 15. Fukutome T, Amaha K, Nakazawa K, et al: Tracheal intubation through the intubating laryngeal mask airway (LMA–FastrachTM) in patients with difficult airways. Anaesth Intensive Care 1998;26: 287–91. 16. Hastings RH, Kelley SD: Neurologic deterioration associated with airway management in a cervical spine-injured patient. Anesthesiology 1993;78:580 –3.