Use of CobraPLUS™ for airway management in a child with tracheomalacia

Abstract

Sir,A 6-month-old, 3195-g, former 24 weeks premature infant presented for diode laser retinal repair. He had undergone five previous surgeries complicated by prolonged ventilation as a result of agitation and airway collapse secondary to tracheomalacia.Anesthesia was induced and maintained with sevoflurane in 60% : 40% oxygen-air. A size 1/2 CobraPLUS TM (EMS, Indianapolis, IN) was easily placed and the cuff was inflated to an audible leak of 18 cmH 2 O. As a result of weak respiratory effort, ventilation was supported using the Narcomed 6400's SIMV mode with a rate of 20 breaths/min. Throughout the 65-min procedure, the peripheral oxygen saturation (S p O 2 ) was in the range 90-92%, the end-tidal CO 2 (ETCO 2 ) in the range 55-62 mmHg and the hemodynamics remained stable. The pharyngeal temperature, as measured by the thermistor on the CobraPLUS TM cuff, was in the range 35.8-37.6 8C. At the end of the procedure, the CobraPLUS TM was removed without complications.Tracheobronchomalacia in children is a serious condition which requires prolonged intubation and mechanical ventilation and is associated with high mortality (1). It refers to airway collapse during inspiration, when the negative intrathoracic pressure is transmitted to the upper airway, which then narrows, causing inspiratory stridor.There is little information in the anesthesia literature on this condition. Most of the publications are case reports with only one review article available (1). Although no evidence is available to support any particular technique, the avoidance of tracheal intubation by the use of a laryngeal mask airway (LMA) (2) may decrease coughing and the risk of airway collapse post-operatively. 'Deep' extubation may also allow a smoother recovery.Our patient required ventilatory support after previous anesthesias, extubation failing repeatedly as a result of agitation and airway collapsibility. There have been several reports of LMA use for diagnostic bronchoscopy with (3) or without (4) recognized tracheomalacia.The performance of the CobraPLA in pediatric patients has been reported in preliminary observations (5). The CobraPLUS TM (Fig. 1) has three features added to the original device: (i) a curved breathing tube which improves insertion; (ii) a temperature probe attached to the lateral posterior part of the cuff which measures the core temperature; and (iii) a distal ETCO 2 sampling site for more accurate capnography.We believe that the improved ease of placement and decreased stimulation with this new device was advantageous in the present case. This is the first report of the use of this device in a pediatric patient.

Supraglottic airways in difficult airway management: successes, failures, use and misuse

“…Also the ILMA, designed especially for the management of the difficult airway, has been described as being successfully used for ventilation in the anticipated [26][27][28][29][30][31][32] and unanticipated [33,34] difficult airway in 97-100% of cases. Case reports or series (level 4) of successful ventilation in patients with difficult airways have been described for many other SADs: the LMA PLMA [35][36][37][38][39][40][41], the SLMA [42][43][44], the i-gel [45][46][47][48][49][50], the Ambu-i TM [51], the Air-Q [52][53][54][55], the CobraPLA [56] and the CobraPLUS [57]. The Laryngeal Tube, designed for emergency ventilation, is also successfully described in difficult airway management in elective adult [58] and paediatric [59] patients in the operation room.…”