RevBrasAnestesiol.2016;66(5):539---542
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Awake
insertion
of
a
Laryngeal
Mask
Airway-Proseal
TM
as
alternative
to
awake
fiberoptic
intubation
in
management
of
anticipated
difficult
airway
in
ambulatory
surgery
Matilde
Zaballos
a,∗,
María
Dolores
Ginel
a,
Maite
Portas
a,
María
Barrio
a,
Ana
María
López
baDepartmentofAnesthesiology,HospitalUniversitarioGregorioMara˜nón,Madrid,Spain
bDepartmentofAnesthesiology,HospitalClinic,Barcelona,Spain
Received24February2014;accepted19March2014 Availableonline1May2014
KEYWORDS
Difficultairway; Ambulatorysurgery; LaryngealMask Airway
Abstract
Backgroundandobjectives: Thedecisionwhethertomanageanambulatorypatientwitha pre-viouslydocumenteddifficultairwaywithasupraglotticdeviceremaincontroversial.Wereport anawakeinsertionofaLaryngealMaskAirwayProsealTMinapatientwithknowndifficultairway
scheduledforambulatorysurgery.
Casereport: A 46-yr-old woman was programmed as a day case surgery for breast nodule resection.Heranestheticrecordincludedanimpossibleintubationwithcancelationofsurgery andsubsequentawakefibroscopicintubation.Shereportedemotionaldistresswiththeprevious
experienceanddeclinedthisapproach.Inviewofthepreviousexperience,anawakeairway
controlwithaLaryngealMaskAirwayProsealTMwasplannedafterexplainingandreassuringthe
patient.Afteradequatetopicalisation,asize4LaryngealMaskAirwayProsealTMwas
success-fullyinsertedaftertwoattempts,andtheirpatencywasconfirmedbycapnography.Anesthesia wasinducedintravenouslyandthesurgerywasuneventful.
Conclusion: Wedescribeafeasiblealternativestrategytoawakeintubationinapatientwith known difficult airway undergoing ambulatory surgery. In this specific clinical situation, if
trachealintubationisdeemed unnecessary,awakesupraglotticairwaymightallowadequate
ventilationandtheiruseshouldbeconsidered.
©2014SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:[email protected](M.Zaballos).
http://dx.doi.org/10.1016/j.bjane.2014.03.007
0104-0014/©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC
540 M.Zaballosetal.
PALAVRAS-CHAVE
Viasaéreasdifícil; Procedimentos Cirúrgicos Ambulatoriais; MáscarasLaríngeas
Inserc¸ãodemáscaralaríngeaProSealTMempacienteacordadocomoopc¸ão
paraintubac¸ãopormeiodefibraópticaparaomanejodeviaaéreadifícilprevista emcirurgiaambulatorial
Resumo
Justificativaeobjetivo:Adecisãoquantoaomanejodepacienteambulatorialcomviaaérea difícilpreviamentediagnosticadacomousodedispositivosupraglóticopermanececontroversa. Relatamosocasodeinserc¸ãodemáscaralaríngeaProSealTM empacienteacordado,comvia
aéreadifícilprevista,agendadoparacirurgiaambulatorial.
Relatodecaso:Pacientedosexofeminino,46anos,programadaparacirurgiaderessecc¸ãode nódulodemamacomaltahospitalarnomesmodia.Ahistóriaanestésicaincluíaumaintubac¸ão impossível,comocancelamentodacirurgiaeposteriorintubac¸ãocomousodefibroscópio,com
apacienteacordada.Apacienterelatouqueficouemocionalmenteabaladacomaexperiência
anteriorerecusouessaabordagem.Considerandoessaexperiênciaanterior,umaabordagemdas viasaéreascomapacienteacordadaeousodeumamáscaralaríngeaProSealTMfoiplanejada,
apósseexplicaroprocedimentoparaapacienteetranquilizá-la.Apóstopicalizac¸ãoadequada, umamáscaralaríngea(LMAProSealTM)detamanho4foiinseridacomsucessodepoisdeduas
tentativaseapermeabilidadefoiconfirmadaporcapnografia.Aanestesiafoiinduzidaporvia intravenosaeacirurgiafoifeitasemintercorrências.
Conclusão:Descrevemosuma estratégia opcionalviável para aintubac¸ão em uma paciente acordadacomviaaéreadifícilpreviamentediagnosticadasubmetidaacirurgiaambulatorial. Nessasituac¸ãoclínicaespecífica,quandoaintubac¸ãotraquealéconsideradadesnecessária,a viaaéreasupraglóticaempacienteacordadopodepermitirumaventilac¸ãoadequadaeseuuso deveserconsiderado.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum
artigoOpen Accesssobumalicenc¸aCCBY-NC-ND(
http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
The Laryngeal Mask Airway is a well established airway device for most adult and pediatric patients, and its use indaycaseanesthesiahasbecomemoreandmorecommon asa part of typicalambulatory surgical procedures.1 The
numbersofpatientspresentingforambulatorysurgerywith predicteddifficultairwayisincreasing.2Inthisspecific
clin-icalsituation,iftrachealintubationisdeemedunnecessary, theuseofasupraglotticairwaymightallowadequate ven-tilation.Drolet proposed the insertion of the supraglottic device under sevoflurane anesthesia maintaining sponta-neousventilationifitsefficacyisnotcertainaftercareful evaluationofthepatient.3
We report the successful awake insertion of a Laryn-geal Mask Airway ProsealTM (LMA Proseal, Laryngeal Mask
CompanyLimited,Singapore)inapatientwithrecognized difficult airway undergoing breast surgery in our ambula-toryfacility.Thepatientgavewritteninformedconsentfor publicationofthisarticle.
Case
report
A46-yr-old,100-kg,163cm,BMI36.51kg/m2,womanwitha
breastlumpwasscheduledasadaycasesurgeryfornodule resection.Pasthealth history included tuberous sclerosis, epilepsy, and hypothyroidism under treatment. Her anes-theticrecordinvolvedanimpossibleintubationinaprevious mastectomythatwascanceledandsubsequentlyperformed underanawakefibroscopicintubation.Inadditionshehad
featuressuggestingapotentiallydifficultairway,including aMallampati ClassIII, thyromentaldistance of4cm,neck circumference>40cm,andupperlipbitetestClassIII.The patientreportedconsiderable emotionaldistressfromthe previous experiencewith the awake fiberoptic intubation anddeclinedthisapproach.Sherejectedthepossibilityto performtheprocedureunderlocalanesthesia.Owingtothe negativepreviousexperience,weofferedhertheoptionof an awake insertionof theLMA Proseal usingtopical anes-thesia and slight sedation, and we obtained her consent. Ouralternativeplanforfailedinsertionwastoperforman awaketrachealintubationusingtheAirtraqorfiberscope.An Aintreecatheterwaspreparedincaseoffailedventilation duringtheprocedure.
AwakeLMAinsertionindaysurgerydifficultairway 541
wasintravenouslyinduced withpropofoland remifentanil and a 16 French orogastric tube was easily introduced throughthe drainage tube of the LMA Proseal. A fiberop-ticbronchoscopewasinsertedthroughtheairwaylumenof theLMAProsealrevealinganomega-shapedepiglottis.The procedurewasdonebyananesthesiologistwithexperience inhandlingsupraglotticdevices.Surgerylasted45minand wasuneventful,whenthepatientregainedfull conscious-nesstheLMAProsealwassuccessfulremoved.InPACUthe patientwascalmanddeniedfeelinguncomfortableduring procedure, she wasdischargedhome 3h aftersurgery. At 24hwedidtheroutinetelephoneinterviewandthepatient claimedtobeverysatisfiedwiththeanestheticcare.
Discussion
The decision whether to manage an ambulatory patient withapreviouslydocumenteddifficultairwaywitha supra-glottic device remains controversial, despite the proved efficacy of the LMA to rescue ventilation in unpredicted difficult airways.Manyfactorswill influencethe decision: the cause of the airway difficulty, the type and duration of surgery,the experienceof theoperator andfinally the patientpreferences.3
Inthecase presentedwe hadapreviouslydocumented difficult airway in a patient withseveral anatomical fea-tures related with difficult airway management. Local or regional anesthesia may have been a reasonable choice but the patient rejected this option. Awake fiberoptic bronchoscopy is recommended in patients with known or predicted difficult airway,but a supraglotticdevice could beareasonable firstoption inthecontextof the ambula-torysurgery,dependingonseveralfactors.3---5Inourreport
wehaveananticipatedshortdurationoftheprocedure,a conventionalsupinepositionofthepatientduringthe oper-ation,andasurgeryroutinelymanagedwithasupraglottic airwayinourdepartment.
Therearenoclearcriteriatopredictsuccess orfailure withsupraglottic device except situations asvery limited mouth opening,or anatomicalanomalies.6Recently a
ret-rospectiveobservationalstudyof15,795patientsmanaged with the LMA UniqueTM (uLMA) reported several
predic-torsoffaileduLMAfunction.TheuLMAfailurewasdefined asany acuteairwayevent occurringbetween insertionof uLMAand completion of surgical procedure that required uLMA removal and rescue endotracheal tube placement. TheauthorsshowedincidenceofuLMAfailureof1.1%and four independent predictors of uLMA failure: intraopera-tivesurgical tablerotation,malesex,poor dentition,and increased body mass index.7 The Mallampati score 3---4,
reduced thyromental distance, and thick neck present in ourpatientwerenotpredictorsofuLMAfailure.These find-ingswereconsistentwithpreviousstudiesthatshowedthat thereisnocorrelationbetweenanatomicaland/ortechnical factors making mask ventilation and laryngoscope-guided tracheal intubation difficult and ease of LMA insertion and function.6,8,9 Our patient had an elevated BMI of
36.51kg/m2;howeverincontrastwiththementionedstudy,
wedidnotobservedifficultiesneitherduringinsertionnor inthefunctionoftheLMAProseal.Moreover,several stud-iesandclinicalreportshavedemonstratedthesuitabilityof
theLMA Proseal for morbidly obesepatient.9 However to
date,therearenotstudiesthatreportclinicalpredictorsof theLMA Prosealfailure,and we donotknow ifthese are similartothosereflected withthe use of other laryngeal masks.
In order to maintain patient safety, we decided to performanawakeinsertionandensurethatadequate venti-lationwasachievedbeforeanesthetizingthepatient.Awake insertionofintubatingLMA andCTrachhas been reported tobeeasy andwell tolerated indifferentdifficult airway conditions,helpingsuccessfulmanagementwhile maintain-ingspontaneousrespiration.10---13Ourcasediffersinthatwe
choosetheLMA Prosealfor ventilation asourfirstoption, considering that it was an ambulatory procedure usually managedwithsupraglotticdevicesin ourunit.Asasafety measure,wehadadditionalairwayequipmentreadily avail-ableandweleftthegastrictubeinsitubecauseitcanbe usedtoguidetheLMAProsealbackintopositionincaseof displacement.5
Weconsiderthatthedecisiontoproceedwithanawake insertionandmaintenanceoftheLMAProsealinthe ambu-latorydifficultairwaypatientshouldbebasedonpersonal experienceinairwayassessment,andpracticalknowledge ofsupraglotticairwaydevices.
In conclusion patients with a known difficult airway undergoingambulatorysurgerymaybenefitfromanawake insertionofaLMAProseal,wheneverwehaveasystematic approachanawellpredefinedrescueplan.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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