In the event of an unexpected difficult laryngoscopy the Laryngeal Mask Airway (LMA) has been advocated by many prominent authorities as a conduit for the fibreoptic laryngoscope1. In an anaesthetised patient, this approach offers advantages over attempting either a blind intubation via a LMA or a fibreopticassisted endotracheal intubation. However, even this approach has drawbacks, which are eliminated through the use of the Aintree Intubation Catheter. • The cuff of the endotracheal tube might be above or over the vocal cords. A standard endotracheal tube will only protrude for 8cm beyond the grille of the LMA. If the distance from the grille to the vocal cords is then more than 3cm, the endotracheal tube cuff will be situated over the vocal cords. This could result in an incomplete seal and damage to the vocal cords • The smaller endotracheal tube may not allow adequate ventilation. A Size 4 LMA will accept a 6.5mm internal diameter endotracheal tube, whilst a Size 5 LMA will accept a 7mm endotracheal tube. When considering the appropriate body weights for which these LMAs, then it may be difficult to achieve an adequate minute volume without unacceptably high airway pressures. • Risk of extubation if removing the LMA

Dr. Michael Lim Dr. Julian Hunt-Smith Intensive Care Centre St. Vincent’s Hospital Melbourne Victoria 3065 Australia

For Fibreoptic Assisted Endotracheal Intubation via the Laryngeal Mask Airway

1. Insert the Laryngeal Mask Airway
Meanwhile load the Aintree Intubation Catheter over the fibreoptic intubating bronchoscope

Problems with Blind Intubation Through the Laryngeal Mask Airway
The ease of correctly positioning a LMA is independent of the difficulty of laryngoscopy. This confers a significant advantage in the difficult airway situation. The logical next step would then seem to be to insert a gum-elastic bougie through the LMA, as its aperture should be directly over the glottis if the LMA is positioned correctly. However, even if the LMA is providing a clinically acceptable airway, it may not be in an anatomically correct position. Hence the blind passage of a bougie through the LMA may be unsuccessful. Furthermore, it is as likely that the bougie may pass through one of the lateral slits as it would pass between the two central slits. Clearly, if it passes through one of the lateral slits, it will deviate away from the laryngeal outlet. In one study, the success rate with this technique was only 28%2. First-time insertion rates via the Intubating LMA 3 have been found to be 80% . In addition, the blind passage of a bougie has the potential for trauma to the upper airway in a similar way to the injuries caused by repeated attempts at laryngoscopy.

2. Pass the bronchoscope with the Aintree Intubation Catheter through the Laryngeal Mask Airway into the trachea

The Aintree Intubation Catheter
This is an adaptation of the Cook Airway Exchange Catheter® with a larger internal diameter (4.8mm) to allow it to be pre-loaded onto a 4.0mm fibreoptic laryngoscope 5. Its external diameter (6.5mm) allows its use with endotracheal tubes whose inner diameter is 7mm or larger. It is 56cm long so that once loaded onto the fibre-optic laryngoscope, the directable distal 3cm of the laryngoscope is left free. The catheter also has removable Rapi-Fit connectors, which allows the use of a ventilatory device if necessary during the exchange procedure. As can be seen from the figures on the right, it allows full control of the airway throughout the intubation procedure. Clearly, a larger endotracheal tube can be inserted without being impeded by the LMA. The risk of accidental extubation if the LMA is removed is also eliminated as the LMA is removed before the endotracheal tube is actually inserted. In summary, the Aintree Intubation Catheter offers an elegant solution to the problems associated with fibreopticguided endotracheal intubation using a laryngeal mask airway as a conduit.

3. Remove the fibreoptic intubating bronchoscope leaving the Aintree Intubation Catheter in the trachea

Problems with Fibreoptic Endotracheal Intubation in an Anaesthetised Patient
Whilst awake fibreoptic laryngoscopy is generally considered to be the gold standard for difficult intubations, by providing a high success rate with a low level of complications, once the patient is anaesthetised and so loses tone in the upper airway, it becomes considerably more difficult. This loss of upper airway tone will result in the walls of the upper airway opposing each other, preventing a clear passage for the fibreoptic laryngoscope and obscuring its view.

4. Remove the Laryngeal Mask Airway then load the endotracheal tube onto the Aintree Intubation Catheter

1. Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996; 84(3): 686-99. 2. Gabbott DA, Sasada MP. Tracheal intubation through the laryngeal mask using a gum elastic bougie in the presence of cricoid pressure and manual in line stabilisation of the neck. Anaesthesia 1996; 51(4): 389-90. 3. Baskett PJF, Parr MJA and Nolan JP. The intubating laryngeal mask. Results of a multicentre trial with experience of 500 cases. Anaesthesia 1998; 53(12): 1174-1179 4. Asai T, Latto IP, Vaughan RS. The distance between the grille of the laryngeal mask airway and the vocal cords. Is conventional intubation through the laryngeal mask safe? Anaesthesia 1993; 48(8): 667-9. 5. Atherton DPL, O’Sullivan E, Lowe D, Charters P. A ventilation-exchange bougie for fibreoptic intubations with the laryngeal mask airway. Anaesthesia 1996; 51: 11231126.

Problems with Fibreoptic Endotracheal Intubation through the Laryngeal Mask Airway
Fibreoptic assisted endotracheal intubation through the LMA overcomes the problems mentioned above by providing an airway for the fibreoptic laryngoscope, whilst the fibreoptic laryngoscope can act as a “directable bougie” once it exits the LMA. Indeed, this technique has a success rate as high as for awake fibre-optic intubation. However, this technique also has its pitfalls4:

5. Railroad the endotracheal tube over the Aintree Intubation Catheter and pass into the trachea

6. Remove the Aintree Intubation Catheter, leaving the endotracheal tube in the trachea
The fibreoptic bronchoscope can then be used to confirm correct endotracheal tube placement in the trachea

Dr DY Williams and the ICU nursing staff, St. Vincent’s Private Hospital, Melbourne.

These recommendations are intended to serve as a general guideline only. Please refer to the manufacturer’s instructions prior to use

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