LETTERS TO THE EDITOR
5. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR,
D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R.
Decompressive craniectomy in diffuse traumatic brain injury.
N Engl J Med 2011;364:1493–502
DOI: 10.1213/ANE.0b013e31825b2369
In Response
I fully agree with Prof. Myles that there is a need to support
large randomized trials for many of our current practices.1
As his own research has shown, however, there are many
more variables to control in our complex patients than
there are in laboratory animals.2 It is exceedingly difficult
to perform “Framingham” level studies in anesthesia, and
until such time as these are available, we will have to make
do with pathophysiological reasoning to guide us. I would
also point out that his remarks on preemptive analgesia
may need to be reconsidered in light of the recent white
paper on the subject by Katz, Clarke, and Seltzer.3
Ronald J. Gordon, MD, PhD
Department of Anesthesiology
US Naval Medical Center
San Diego, California
rjgordonmd@gmail.com
REFERENCES
1. Myles PS. Large randomized trials to overcome barriers to
patient safety. Anesth Analg 2012;115:479 – 80
2. Myles PS, Peyton P, Silbert B, Hunt J, Rigg JR, Sessler DI.
Perioperative epidural analgesia for major abdominal surgery
for cancer and recurrence-free survival: randomized trial. BMJ
2011;342:d1491
3. Katz J, Clarke H, Seltzer Z. Preventive analgesia: quo vadimus?
Anesth Analg 2011;113:1242–53
DOI: 10.1213/ANE.0b013e31825b238f
Stylet-Assisted Tracheal Intubation
Through an ILMA in a Patient with
an Anterior Larynx
To the Editor
A lthough the intubating laryngeal mask airway
(ILMA) has been described for use in morbidly
obese patients,1 despite its correct placement, tra-
cheal intubation may be unsuccessful. An obese male
patient (body mass index [BMI] ! 34) in the intensive care
480 www.anesthesia-analgesia.org
unit with a right middle cerebral artery territory stroke
required urgent tracheal intubation owing to poor Glasgow
coma scale (E1V1M2). After sedation and paralysis, ventila-
tion via a mask was adequate but intubation using a #4
Macintosh blade, external laryngeal manipulation, and a
bougie was not possible. An ILMA (#4 LMA-Fastrach™,
The Laryngeal Mask Company Limited, Le Rocher, Victo-
ria, Mahé, Seychelles) was placed and ventilation resumed.
Tracheal intubation using the flexometallic tube provided
with the ILMA failed as the tube tip was repeatedly
displaced into the esophagus. Repositioning of the ILMA
and Chandy’s maneuver part 22 were attempted but also
unsuccessful. Intubation with a 7.0-mm internal diameter
cuffed Portex polyvinyl chloride (PVC) endotracheal tube
(ETT) (Smiths Medical, UK), together with a flexion ma-
neuver, also did not help because of the anteriorly posi-
tioned larynx. Size 5 ILMA and Fiberoptic Bronchoscope
were unavailable. Hence, using a stylet, the tip of the portex
tube was bent as shown in Figure 1 and reintroduced
through ILMA, and the ETT could be easily advanced off
the stylet into the trachea.
In cases of extremely anterior larynx, accentuating the
angle of emergence of the tracheal tube from the ILMA may
facilitate intubation.3 This may be safely done by ensuring
that the tip of the stylet remains within the ETT, about 1 to
2 cm proximal to the tip of ETT. We measured the angle of
emergence (using a protractor) of Flexometallic and Portex
PVC ETT through ILMA and found them to be 35° and 45°,
respectively (Fig. 1A & 1B). Introducing a stylette as
suggested increases the angle of emergence to 65° (Fig. 1C),
which aids in placement of the tracheal tube tip through
ILMA in patients with anterior larynx. Damage to the
arytenoids and trachea is a potential complication of blind
intubation. Difficulty in advancing the tube due to im-
pingement upon the anterior surface of the larynx is
another possibility. Using the Parker flexitip PVC tube is an
option in this scenario. The centered, tapered, and flexible
distal tip gently flexes when resistance is encountered,
thus enabling successful introduction minimizing airway
trauma.4
PATIENT CONSENT STATEMENT
Written permission from the patient’s first degree relative
was obtained because the patient passed away at home owing
to unrelated causes, months after treatment, prior to this
Figure 1. Angle of emergence formed by the
tracheal tubes on emerging from the distal
aperture of the intubating laryngeal mask
airway (ILMA). A, LMA-Fastrach silicone wire-
reinforced tube (7.5-mm internal diameter).
B, Portex polyvinyl chloride tracheal tube
(7.5-mm internal diameter). C, Portex polyvi-
nyl chloride tracheal tube with stylet (PVCT;
7.5-mm internal diameter).
ANESTHESIA & ANALGESIA