Case ReportsUse of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders
Introduction
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, 4, 5, 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
Recent reports have described the use of the ILMA in patients with difficult airways.3, 4, 5, 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.
Section snippets
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
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, 9, 10, 11, 12, 13, 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,
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Cited by (36)
Awake tracheal intubation in anticipated difficult airways: LMA Fastrach vs flexible bronchoscope: A pilot study
2017, Journal of Clinical AnesthesiaCitation Excerpt :In contrast, the low cost, portability, reusability, and lack of need for a light source offered by the Fastrach ILMA, as well as the ability to ventilate while securing the airway, make it an attractive tool for difficult airway management. Its placement is not affected by blood or secretions, and causes minimal cervical spine mobility [23-26]. It has been used successfully in a variety of difficult airway scenarios [17], and has been shown to have a high success rate of placement by practitioners of all levels.
The Difficult Airway in Neurosurgery
2013, Benumof and Hagberg's Airway ManagementThe Difficult Airway in Neurosurgery
2012, Benumof and Hagberg's Airway Management: Third EditionRigid indirect laryngoscopy and optical stylets
2010, Continuing Education in Anaesthesia, Critical Care and PainCitation Excerpt :Frequently, this means awake flexible fibrescopic intubation (AFFI), but this technique is not without risk of complications such as failure, hypoxaemia, and increasing airway obstruction.4 There are other ‘awake’ alternatives, including cricothyrotomy, blind nasal intubation, the intubating laryngeal mask airway,5 and even awake RIL.6 If AFFI is not possible (e.g. lack of equipment, insufficient operator skill, or an uncooperative patient), then RIL performed under general anaesthesia may provide an alternative technique for tracheal intubation.
Management of Difficult Endotracheal Intubation and Challenging Transesophageal Echocardiography Probe Insertion in a Patient With Ankylosing Spondylitis
2008, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Other techniques in AS patients have included use of various customized laryngoscope blades,5 blind nasopharyngeal intubation,7 retrograde intubation,4 intubating stylets,4,7 or a classic or intubating laryngeal mask airway (LMA).6,15 Several reports recommend the LMA as an alternative to awake FOI in patients with AS and airway abnormalities.6,15,16 However, in patients with cervical ankylosis in flexion, LMA placement may be difficult; Pennant and White17 suggested that the LMA is contraindicated in AS patients who are unable to extend the neck, whereas Ishimura et al18 suggested that when the oropharyngeal axis angle is <90°, LMA placement will be technically impossible.
The Difficult Airway in Neurosurgery
2007, Benumof's Airway Management