To the Editor:—
The requirement for airway control in hypoxemic and unconscious emergency patients in a ward environment is both common and challenging. The situation is further complicated if the likelihood of successful direct laryngoscopy and tracheal intubation is low and if the risk of regurgitation and pulmonary aspiration is high. We describe such a case, which was managed successfully using a new laryngeal mask airway with an esophageal access port (fig. 1).1
A 59-yr-old, obese man (120 kg) was admitted to a general medical ward having experienced recurrent generalized tonic–clonic seizures secondary to alcohol withdrawal. The combination of the postictal state and benzodiazepine treatment rendered him unconscious, hypoxemic, and with a partially obstructed airway despite conventional airway maneuvers and a nasopharyngeal airway. When the anesthesia team arrived, the Glasgow Coma Score was 6/15, and oxygen saturation was 70% on 100% oxygen via a reservoir mask. Further airway maneuvers failed to further open the airway, and the patient resisted jaw opening. Preoxygenation was poorly effective, and it was clear that a rapid sequence induction would be high risk because of a judgment that emergent intubation was likely to be very challenging (the patient was obese and had a short, thick neck and a perceived reduction in mouth opening—although neck circumference and interdental gap were not formally measured). There were also limited facilities, and skilled assistance was not immediately available in the ward environment. The LMA-Supreme ™ (Laryngeal Mask Company, San Diego, CA) had recently been introduced into the hospital for both elective and emergency patients and was immediately available. A 50-mg bolus of propofol was administered intravenously, and a fully deflated and lubricated size 4 LMA-Supreme ™ was placed by the attending junior doctor (who had 12 months of anesthetic experience and had received previous teaching on the use of the LMA-Supreme ™). Manual ventilation with oxygen via the device was immediately successful, and a lubricated 14-CH (french gauge) gastric tube was easily placed down the esophageal drainage channel. Suction on the gastric tube produced 250 ml heavily bile-stained fluid, and this was then left on free drainage. The patient was rapidly transferred to the critical care unit, where the availability of the difficult intubation trolley and skilled assistance were immediately at hand. In the critical care unit, the patient was now fully preoxygenated via the LMA-Supreme ™, and a proportion of the fluid content of the stomach had been removed. With satisfactory control of the airway, 100 μg fentanyl, 80 mg propofol, and 50 mg atracurium were administered. After 5 min, the gastric tube and LMA-Supreme ™ were removed, and an initial grade 3 Cormack and Lehane laryngoscopy was improved to grade 2 by use of a McCoy blade laryngoscope and backward and upward manipulation of the larynx. Intubation was performed using an endotracheal tube introducer (bougie).
Supraglottic airways are increasingly being used for airway rescue in emergency situations and in hostile environments, particularly when tracheal intubation may be challenging or may delay oxygenation. There are potential advantages of supraglottic airways with integral esophageal drainage tubes for airway rescue and rapid oxygenation in selected patients. In this case, the LMA-Supreme ™ airway was easily placed when tracheal intubation would have been challenging. The fixed curve and elliptical cross-sectional design of the airway tube allowed placement without the need for the clinician’s digits to be placed in the mouth, and the airway passed satisfactorily through the narrowed interdental gap. Other brief reports have shown satisfactory use of this airway in elective cases1and in one case during cardiopulmonary resuscitation,2but clinical studies are required before formal recommendations can be made. First responders outside of the operating room and critical care may not have the opportunity to regularly practice advanced airway skills, may have limited assistance, and may not have immediate access to their preferred equipment, and yet may still be faced with the most challenging airways in time-critical situations. Ideally, a supraglottic device for airway rescue should also be easily placed by relatively novice users, and formal studies are needed to confirm whether the LMA-Supreme ™ will satisfy this requirement.
*Queen Elizabeth Hospital, King’s Lynn, United Kingdom. email@example.com