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Success Rate of Intubation Using Conventional Flexomettalic Tube with the Intubating laryngeal Mask Airway (ILMA)
Bikash Agarwal, Balkrishna Bhattarai, Binay K Biswas, Sumati Joshi, Tasleem Roshan Rahman, Shweta Koirala ABSTRACT Background: The Ilma has become an essential component in airway management. It is used with its special flexomettalic tube. But the tube comes in limited number with the Ilma, and also the cost of buying it, limits its use. So we undertook this study to see the success rate of conventional reinforced tube when they are used with the Ilma. Patients & Methods: 80 patients were divided into 2 equal groups; in the first group (ILMA-TT) intubation was done using the special reinforced tube that is supplied with the Ilma and in the second group (RTT) using conventional Rusch flexomettalic tube. Intubation time, number of attempts for intubations, need of additional manipulations, failed intubation, esophageal intubation and incidence of complications were recorded. Results: The success rate of intubation was 100% and 97.5% in the ILMA-TT and the RTT group. More time was required to intubate using the conventional tube(p=0.06).The number of attempts required, esophageal intubations, adjusting maneuvers used and the incidence of complications were comparable among the two groups. Conclusions: The conventional flexomettalic latex tracheal tube can be safely used for tracheal intubation with comparable success rate via the ILMA. KEY WORDS: ILMA, Flexomettalic Tube

The Intubating laryngeal mask airway [ILMA, (Fastrach), The Laryngeal Mask Company] has now become an indispensable component of airway equipments in modern anaesthetic practice and emergency care. It has been shown to be useful means of blind endotracheal intubations both in routine and difficult airway situations1-4 with high success rates in hospital, pre-hospital and difficult military environments5. Further, it has been shown to have reasonable success rates of blind tracheal intubation even in the hands of non-medical personnel6. A special reinforced endotracheal tube (ILMA-TT) has been made available by the manufacturer of ILMA to increase the success rate of tracheal intubation.1 However; the cost of this special tube is very high in the context of a developing country like Nepal. Buying such a costly new tube to replace the damaged one can be economically difficult and may not be always possible. This problem could be overcome if the conventional latex reinforced tube [(Silkolatex, Rusch,Willy Rusch,Kermel,Germany) (RTT)] could be used with acceptable success rate via the ILMA. They have the advantage of being cheaper and easily available. But reports on the experience of the use of conventional tracheal tubes via the ILMA are limited. Keeping this in mind, this study was designed and carried out to compare the success rate of endotracheal intubation using ILMA-TT to that using Rusch reinforced tube (RTT) via the ILMA. PATIENTS AND METHODS Eighty adult ASA I and II patients of either sex, undergoing various surgical procedures were enrolled in the study after obtaining approval from the institutional research committee and written informed consent from each patient. Patients with anticipated difficult

airway [i.e.: reduced mouth opening <3 cms, Malampatti class 3 and 4] and those undergoing oral or emergency procedures were excluded from the study .The patients were randomly divided into either ILMA-TT or RTT group with 40 patients in each using sealed envelope technique. Patients demographic parameters (age, sex, height and weight) and airway characteristics (Malampatti class, thyromental distance, sternomental distance) were recorded in a preformed proforma following randomization. All the patients were premedicated with oral diazepam 0.2 mg kg-1, the night before and two hours prior to surgery. After preoxygenation with 100% oxygen for 3 minutes, anaesthesia was induced with intravenous injection of pethidine 1 mg kg-1 and propofol 2 mg kg-1. Injection vecuronium bromide 0.1mg kg-1 was administered intravenously for muscle relaxation and the patients lungs were manually ventilated using Bains circuit with facemask. Further anaesthesia was maintained with 1.5% isoflurane in oxygen. After clinically conforming adequate neuromuscular block, a pre-lubricated ILMA (size 3 for women and size 4 for men) was inserted and the cuff was inflated with recommended volume of air (20 ml for size 3 and 30 ml for size 4). Optimal position of the ILMA was verified by adequate chest expansion, square shaped capnograph and absence of audible leak on ventilation. In case of inadequate positioning, the ILMA was manipulated by pulling it out and reinserting again and adjusting it until no audible leak was heard. After confirming the adequacy of ventilation and correct position of the ILMA, the respective tracheal tubes were passed through the ILMA. In the ILMA-TT group, 7mm and 7.5mm internal diameter tubes supplied with the ILMA were used. The tube was first passed through the ILMA until the black

Drs. Bikash Agarwal, Assistant Professor, Balkrishna Bhattarai, Associate Professor, Binay K Biswas, Associate Professor, Sumati Joshi, Assistant Professor, Tasleem Roshan Rahman, Associate Professor, Shweta Koirala, Resident, Department of Anesthesiology & Critical Care, B.P.Koirala Institute of Health Sciences, (B.P.K.I. H. S), Dharan, Nepal. Correspondence: Dr. Bikash Agarwal, E-mail: drbikash@yahoo.com

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mark of the ILMA TT could still be seen and it was checked if there was any resistance to further push. If no resistance was felt then the tubes were passed beyond the black mark of the ILMATT till adequate length was in. In the RTT group, latex reinforced endo-tracheal tube (SilkolatexTM, Rusch, Germany) size 28 and 30 Fr was used for female and male patients respectively. The tubes were passed through the ILMA till 15 cm mark on the tubes and checked whether there was any resistance to further push. If no resistance was felt, the tubes were passed beyond 15cm mark till adequate length of the RTT was in. Successful tracheal intubation in both the groups was confirmed by evidence of adequate ventilation (bilateral chest expansion and breath sounds on auscultation) and square shaped capnograph. If there was difficulty in negotiating the tubes through the ILMA or when esophageal intubation was suspected (inadequate chest expansion, no breath sound on auscultation and absent capnograph tracing) the tracheal tube was removed and further attempts were made subsequently by adopting the following manipulations in order. First, the ILMA was pulled towards the intubator holding its metal handle (Chandys maneuver)7 and attempt of advancing the tube further while rotating it. If this second attempt was also unsuccessful then third attempt of intubation was made after pulling the ILMA out and reinserting it again. If intubation was unsuccessful after all these attempts , no further attempts were made and intubation was done using direct laryngoscopy .After successful intubation of the trachea, the universal connector of the ILMA-TT and the RTT was removed. The ILMA was then removed while stabilizing the tracheal tube with the stabilizer (supplied by the ILMA manufacturer). The tracheal tube was fixed at appropriate mark with adhesive tape after verifying equal bilateral air entry and reconfirming it with capnography. Variables recorded included intubation time (from the insertion of tracheal tube to the confirmation of intubation with the capnograph), number of attempts for intubations, need of additional manipulations, failed intubation, esophageal intubation and incidence of complications including drop in oxygen saturation, trauma (indicated by blood staining of the tracheal tube which was judged after extubation of the trachea) and sore throat (documented postoperatively in the ward). Assuming a power of 80%, error of 5% and an expected difference in the primary outcome (overall success of intubation) between the groups of 25%, a sample size of 33 patients in each group was calculated, considering the errors and possible failure of procedure, 40 patients in each group were taken. The data was analyzed with SPSS version 10 (SPSS Inc, Chicago, IL). Continuous data were compared usingt test and values expressed in proportion were analyzed using Chi-square or Fishers exact with Yates correction. . A p value <0.05 was considered significant. RESULTS Age, sex, weight, height and airway characteristics were comparable in both the groups (Table 1). Intubation was possible in 79 out of total 80 patients; all 40 (100.0%) in ILMA-TT group and 39 (97.5%) in RTT group. Overall, tracheal intubation was possible in 63 patients in first attempt, 10 patients in second attempt and 6

patients in third attempt. In ILMA-TT group, intubation was possible in first, second and third attempts in 32, 4 and 4 patients respectively while the same was possible in 31, 6 and 2 in RTT group. In the ILMA TT group, out of the 8 patients in whom intubation was not possible in first attempt, in 6 patients esophageal intubation had taken place and in 2 it was difficult to negotiate the endotracheal tube. Intubation was possible in 4 of these 8 patients with the first manipulation technique and only in 4 patients third attempt was required for intubation. Out of 9 patients in whom intubation was not possible in first attempt in RTT group, esophageal intubation had occurred in 7 patients and in the remaining 2 patients, the endotracheal tube was not negotiable through the ILMA. Of these 9 patients, intubation was possible in the second attempt in 6 patients and in the third attempt in 2 patients. In one patient intubation was not possible through the ILMA even after third attempt and intubation was done under direct laryngoscopy .The mean time required for intubation in the ILMA-TT group was 16.705.12 seconds as compared to 20.0810.89 seconds in the RTT group(p =0.061). There was no statistical difference in the need of manipulations and maneuvers between the groups. The incidence of esophageal intubation, trauma and sore throat were similar in both the groups (Table 2).
Table 1 Demographic and Airway Characteristics Parameters Age (yrs) [Mean SD] Sex (M: F) Weight (kgs) [Mean SD] Height (cms) [Mean SD] Sternomental distance (cms) [Mean SD] Thyromental distance (cms [Mean SD] Malampati class 1/2/3/4 ASA grade 1/2 ILMA-TT n-40 35.4610.03 22:18 53.287.23 156.785.63 10.681.84 5.681.1.02 26/14/0/0 25/15 RTT n-40 357.037 24:16 57.959.05 152.505.58 11.681.73 5.401.05 28/12/0/0 30/10

Table 2 Intubation data, Adjusting maneuvers and Complications ILMA-TT n-40 n-40 Intubation success: 40 Attempts for intubation 1/2/3: 32/4/4 Intubation time (SECS) 16.705.12 Esophageal intubations 6 Adjusting maneuvers used 8 CHANDYS 6 REINSERTION 2 Trauma 4 Sore Throat 5 RTT 39 31/6/3 20.0810.89 7 9 7 2 4 6 P value 1.00 1.00 0.06 0.61 1.00 1.00 1.00 1.00 0.67

DISCUSSION The specially designed endotracheal tube is supplied by the manufacturer of the ILMA to enhance the success rate of intubation. High overall success rate of tracheal intubation has been reported with its use via ILMA in large number of patients.8 Tracheal intubation

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It can be concluded that the conventional autoclavable, reusable, flexible reinforced latex tracheal tube can be safely used for ztracheal intubation with comparable success rate via the ILMA if the recommended silicone tracheal tubes supplied with the ILMA are not available. Conventional reinforced latex tracheal tubes are not associated with increased complication rates and have the advantages of being less expensive and readily available. REFERENCES 1) Brain AIJ, Verghese C, Addy EV et al.The Intubating laryngeal mask airway I. Development of a new device for intubation of the trachea. Br J Anaesth 1997; 79: 699-703. 2) Thienthong S, Horatanarung D, Wongswadiwat M et al. An experience with intubating laryngeal mask airway for difficult airway management: report on 38 cases. J Med Assoc Thai 2004; 87: 1234-8. 3) Ramachandran K, Kannan S. Laryngeal mask airway and the difficult airway. Curr Opin Anaesthesiol. 2004; 17: 4913. 4) Minville V, Guyen LN, Coustet B, Fourcade O, Samii K. Difficult airway in obstetrics using ILMA-FastrachR. Anesth Analg 2004; 99: 1873. 5) Wedmore IS, Talbo TS, Cuenca PJ. Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment. Mil Med 2003; 168: 876-9. 6) Levitan RM, Ochroch EA, Stuart S, Hollander JE. Use of the intubating laryngeal mask airway by medical and non-medical personnel. Am J Emerg Med. 2000; 18: 12-6. 7) Ferson DZ, Rosenblatt WH, Johansen MJ, et al. Use of the Intubating LMA-Fastrach in 254 patients with difficult to manage airways .Anesthesiology 2001; 95: 1175-81 8) Caponas G. Intubating laryngeal mask airway. Anaesth Intensive Care 2002; 30: 551-69. 9) Lu PP, Yang CH, Ho AC, Shyr MH. The Intubating LMA : a comparison of inserting techniques with conventional tracheal tubes .Can J Anesth 2000; 47: 849-53 10) Kundra P, Sujata N, Ravishankar M. Conventional tracheal tubes for intubation through the Intubating laryngeal mask airway. Anesth Analg 2005; 100: 284-8.

Figure 1 The Rusch fexomettalic tube maintaining its emergence angle as it is advanced through the ILMA

with this special tube was possible in all the patients in our study also. However, major concerns about this special tube are its cost and availability, particularly, in a developing country like Nepal. The ILMA may become useless once the tube gets damaged or becomes functionless. Uses of various other endotracheal tubes (PVC, flexible latex or silicone) through the ILMA have been reported with varying success rates.1,9,10 Kundra et al 10 reported success rate of nearly eighty-two percent of tracheal intubation with the use of Rusch latex armored tube which is lower than our success rate of nearly ninety-eight percent with the same tube.Rotation of the tube while advancing it and use of smaller sized tubes in RTT group may have helped us in better negotiating the tube into the trachea. The same reasons may explain lower incidence (17%) of esophageal intubations in our study as compared to their incidence of nearly thirty percent. Although we also found similar (40) emerging angles of both ILMA-TT and RTT to the plane of ILMA cuff as shown by Kundra et al, we did not find buckling of the RTT when pushed ahead in contrast to their finding. It maintained the direction and did not bend posteriorly (Fig 1). This may have further contributed to less esophageal intubations and better success rate in our study. Longer mean time required for intubation in the RTT group in our study could be because of RTT being much softer and more flexible than the ILMA-TT and taking more time to negotiate through the ILMA. However, this longer time may be of very little clinical significance.