Use of the Pro-Seal LMA facilitates percutaneous dilatational tracheostomy

Abstract

P Pu ur rp po os se e: : To study the feasibility of using the Pro-Seal laryngeal mask airway (LMA) for airway maintenance during bronchoscopic guided percutaneous tracheostomy.M Me et th ho od ds s: : Observational study of 23 patients in an 11-bed general intensive care unit. The patient's tracheal tube was exchanged for a Pro-Seal LMA before undertaking percutaneous tracheostomy.R Re es su ul lt ts s: : Inspiratory pressure and tidal volumes achieved during the procedure were recorded. The median peak inspiratory pressure was 25 (standard deviation 4.2) cm H 2 O. There was no loss of tidal volume in 11 patients, a loss of less than 100 mL·breath -1 in 11, and loss of more than 100 mL in one. A Pro-Seal LMA successfully maintained the airway and allowed adequate ventilation during percutaneous tracheostomy in all 23 patients. In all patients bronchoscopy through the Pro-Seal LMA provided a clear view of the cords and trachea and there was no laryngeal or tracheal soiling at any stage of the procedure.C Co on nc cl lu us si io on n: : The Pro-Seal LMA provides a reliable airway and allows effective ventilation during percutaneous tracheostomy. The passage of a fibrescope through the Pro-Seal LMA and glottis is easy and provides a clear view of the upper trachea. URING percutaneous dilatational tracheostomy (PDT) the patient's airway is usually maintained with a tracheal tube, which is pulled back until the cuff is lying across the vocal cords. 1,2 In this position, the tracheal tube is unstable and may become dislodged with loss of the airway and risk of aspiration. Most commonly, bronchoscopy is undertaken during the procedure to aid correct placement of the guidewire. 3 An assistant is generally required to stabilize the tracheal tube while fibreoptic examination is performed and, as the glottis is not seen, it can be very difficult to determine the level at which the cannula enters the trachea. The tip of the tracheal tube may still lie low enough within the trachea to risk cuff puncture or tube transfixion by the needle. Use of the classic laryngeal mask airway (LMA) 4-6 or the intubating LMA 7 during PDT circumvents many of these problems. However, patients requiring PDT often have poorly compliant lungs requiring high inflation pressures. Gas leak from between the LMA and glottis increases as inspiratory airway pressure rises, particularly above 20 cm H 2 O. 8 This leads to a risk of hypoventilation in patients with poorly compliant lungs. Objectif : Étudier la faisabilité de l'utilisation du masque laryngé (ML) Pro-Seal pour maintenir la perméabilité des voies aériennes pendant la trachéotomie percutanée à guidage bronchoscopique. Méthode : L'étude par observation comportait 23 patients d'une unité de soins intensifs généraux. Un ML Pro-Seal a remplacé le tube trachéal avant la trachéotomie percutanée. Résultats : La pression inspiratoire et les volumes courants obtenus pendant l'intervention ont été notés. La moyenne de la pression inspiratoire maximale a été de 25 cm H 2 O (écart type de 4,2). Il n'y a...

The proseal™laryngeal mask airway: a review of the literature

“…There are 15 reported cases of regurgitation without aspiration with the PLMA 36,[55][56][57][58][59][60][61][62][63] In all cases the DT vented liquid or solid gastric contents without airway soiling.…”

“…89 The PLMA was used during bronchoscopic guided percutaneous tracheostomy in 25 patients. 63 Potential advantages of the PLMA over other laryngeal masks include increased seal pressure (important in non-compliant lungs) and the absence of glottic aperture bars, enabling bronchoscopic tracheal access. A 'leak test' to identify supraglottic edema is recommended before PLMA insertion and tracheal extubation.…”

A prospective randomised controlled trial of the LMA Supreme vs cuffed tracheal tube as the airway device during percutaneous tracheostomy

“…A number of other studies examining the use of LMA devices for airway control during percutaneous tracheostomy have been limited by being performed in single institutions, using a variety of different LMA devices and being of an observational trial design [3,6,8]. Before our study, there were only three randomised trials, all of which used first-generation LMA devices and gave conflicting outcomes.…”

Airway challenges in critical care

“…Routine use of endoscopy during the procedure [31], use of ultrasound to identify midline vessels [32] and use of a laryngeal mask airway (LMA) [33] or ProSeal LMA [34] to improve visibility of intratracheal structures may all improve safety.…”