To the Editor:—
The LMA-Fastrach ™ (LMA North America, San Diego, CA) has been used in patients with a difficult airway, including those with an unstable cervical spine.1,2We report a case of a successful intubation via the LMA-Fastrach ™ in a patient with severe ankylosing spondylitis and an unstable C5–C6 fracture dislocation with subsequent leak around the silicone, dedicated endotracheal tube (ETT), resulting in desaturation.
The 40-yr-old male patient was awake, alert, and spontaneously breathing at the time of admission. During the course of his evaluation, his breathing became progressively laborious, and tracheal intubation was requested by the trauma team. After multiple failed attempts at awake nasal and oral fiberoptic intubation and awake direct laryngoscopy, tracheal intubation was performed blindly via a size 4 LMA-Fastrach ™ after intravenous administration of 17 mg etomidate by the trauma team. The patient was transferred to the trauma intensive care unit, where the 7.0-mm-ID, silicone, dedicated ETT was secured at 26 cm at the lips with a SecureEasy® ETT holder (Smiths Medical, Dublin, OH). Four hours after the initial intubation, mechanical tidal volumes were noted to decrease slowly (200–300 ml/breath). The presumed diagnosis was a cuff leak; deflation and reinflation of the pilot balloon with 3–5 ml air attested to the integrity of the cuff. The breathing circuit was also checked and found to be intact. The leak eventually resolved. However, the problem recurred and persisted the following days in an inconsistent pattern and at variable intervals. ETT exchange was contemplated but not attempted in light of the initial difficult intubation. The patient subsequently underwent both anterior and posterior fusions of the cervical spine with halo traction placement; no intraoperative leaks were noted. On admission day 9, however, increasing leakage and episodes of desaturation led to the decision to perform a tracheostomy. In the operating room, careful listening determined the leak to be at the level of the 15-mm male connector. Application of electrical tape to the proximal end of the ETT corrected the problem.
After insertion of a No. 8 Shiley® tracheostomy tube (Tyco Healthcare, Mansfield, MA), the ETT was removed, and close examination revealed several holes at the proximal end of the ETT that lined up with the metal prongs of the SecureEasy® device (fig. 1). The ETT cuff was found to be intact. It was also noted that the 15-mm connector was from a 6.5-mm-ID ETT.
The LMA-Fastrach ™ manufacturer was contacted and informed of the events. After reviewing all relevant information and photographs, the manufacturer of the LMA-Fastrach ™ stated that the problem we encountered had never been previously reported to LMA North America (as of October 2005). Several factors seem to have contributed to the leak in the ETT. The soft medical grade silicone of the dedicated ETT supplied with the LMA-Fastrach ™ can be torn or perforated by prolonged contact with sharp or pointed objects. The respiratory care department at our institution has used the SecureEasy® for some time without incident. We assume that the metal prongs do not perforate or otherwise damage the standard polyvinylchloride ETT. Moreover, tension exerted on the soft silicone ETT by inadequately supported ventilator tubing could have stretched open the small perforations and may have accounted for the inconsistent nature of the leak. Finally, the leak was further compounded by the inadvertent use of an incorrectly sized 15-mm male ETT connector.
In conclusion, our unique case raises concerns about the long-term use of the silicone ETT packaged with the LMA-Fastrach ™ in the critical care unit in conjunction with the SecureEasy® ETT holder.
*Advocate Illinois Masonic Medical Center, Chicago, Illinois. email@example.com