Le masque laryngé prévient les fuites supraglottiques durant la ventilation via une cricothyrotomie sans ballonnet

Abstract

Purpose: A 'cannot intubate-cannot ventilate' situation requires emergency insertion of an infraglottic surgical airway. We present a case of postoperative macroglossia requiring emergency insertion of an uncuffed percutaneous cricothyroidotomy tube. The supraglottic leak was eliminated by the insertion of a laryngeal mask airway with an occluded 15-mm connector. Clinical features: A 49-yr-old man underwent clipping of a left posterior inferior cerebellar artery aneurysm and his tracheal tube was removed postoperatively. Two hours later, he became dyspneic and developed significant macroglossia. After application of topical anesthesia, direct laryngoscopy, oral fibreoptic bronchoscopy and laryngeal mask insertion were unsuccessful. The patient became progressively hypoxemic, pulseless electrical activity ensued, and cardiopulmonary resuscitation was initiated. An uncuffed percutaneous cricothyroidotomy tube was inserted. Oxygenation and hemodynamics were restored. As the cricothyroidotomy tube was uncuffed, there was a large supraglottic leak with manual ventilation. A laryngeal mask airway was inserted and the cuff was inflated. The 15-mm connector was occluded by a piece of tape. Subsequently, there was no further supraglottic leak with manual ventilation. He was taken to operating room and a surgical tracheotomy was performed. Conclusion: In a patient with postoperative macroglossia in a 'cannot intubate-cannot ventilate' situation, effective oxygenation was restored by insertion of an uncuffed cricothyroidotomy, but ventilation was affected by a substantial supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby restoring effective lung ventilation.

Equipment and strategies for emergency tracheal access in the adult patient

“…However, reliable ventilation can only be guaranteed with a cuffed tube, as use of an uncuffed tube may lead to gas leakage to the upper airway [62]. Some advocate the use of uncuffed tubes with simultaneous attempts to create upper airway obstruction [53,63]. However, we believe that during a CICO situation, only techniques that guarantee rapid re-oxygenation should be used and that there is no place for use of uncuffed tubes.…”

Elective use of an uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway

“…[22][23][24] In our experience, once the MT is placed, it is beneficial to use an SGA with occlusion of the 15-mm connector until insertion of the surgical laryngoscope. Simpler methods, including manual occlusion of the patient's nose and mouth and neck flexion without head extension also facilitated ventilation via the MT.…”

Use of a laryngeal mask airway to stop a supraglottic air leak which prevented adequate ventilation via a tracheostomy in a patient with cerebral palsy and pneumonia

“…Laryngeal mask airway (LMA) devices have been used to control subgrottic leakage in an endotracheal tube with a broken cuff or uncuffed cricothyroidotomy tube in critical situations [5][6][7]. They have also been used to prevent a leak during ventilation via a microlaryngeal tube or a Montgomery T-tube which was inserted through the tracheostoma during anesthetic management [8,9].…”