BJA Advance Access originally published online on January 5, 2008
British Journal of Anaesthesia 2008 100(2):275-277; doi:10.1093/bja/aem367
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Evidence of pulmonary aspiration during difficult airway management of a morbidly obese patient with the LMA CTrachTM
Department of Anaesthesiology and Intensive Care Medicine, Jean Verdier University Hospital of Paris (APHP), Av du 14 Juillet, 93143 Bondy, France. Paris 13 School of Medicine, 93000 Bobigny, France
* Corresponding author: Département d'Anesthésie et Réanimation, CHU (APHP) Jean Verdier, Av du 14 Juillet, 93143 Bondy, France. E-mail: gilles.dhonneur{at}jvr.aphp.fr
Accepted for publication November 6, 2007.
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Abstract |
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We describe a pulmonary aspiration that occurred during tracheal intubation with the LMA CTrachTM (SEBAC, Pantin, France) in a male morbidly obese patient (178 cm height, BMI=48 kg m–2) admitted for elective gastric banding. Our report suggests that manipulations of the CTrachTM such as Up-manoeuvre may lead to pulmonary aspiration in the case of regurgitated gastric content.
Keywords: airway, complications; complications, aspiration; complications, obesity
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Introduction |
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The LMA CTrachTM (SEBAC, Pantin, France) is a new ventilatory and intubating device which demonstrated beneficial airway management performance in difficult airway patients.1–3 We report a case of pulmonary aspiration that occurred during tracheal intubation with the CTrachTM in a morbidly obese patient.
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Case report |
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A 21-yr-old, Caucasian ASA II, morbidly obese (178 cm height, BMI=48 kg m–2) male patient suffering from asthma (controlled) and mild hypertension and treated for a symptomatic gastric reflux was admitted for elective gastric banding. A difficult airway was anticipated at the anaesthesia visit because of a Mallampati score grade 3, a short chin with a 5.5 cm thyromental distance, and a 3 cm limited mouth aperture. The patient was informed of potential difficult airway. The patient was premedicated orally (100 mg hydroxyzine and cimetidine 400 mg) and inhaled beta-2 agonists 1 h before admission to the operation room. After attaching the monitors including BIS and performing prolonged pre-oxygenation to reach exhaled oxygen concentration >90% over 1 min in a strictly lying position, anaesthesia was induced with bolus injection of propofol (2 mg kg–1) and sufentanil (0.2 µg kg–1) followed by succinylcholine (1 mg kg–1). Facemask ventilation with a Guedel airway (inspired oxygen concentration=100%) was applied for 90 s. Laryngoscopy with the Macintosh laryngoscope equipped with a reusable size 4 metallic blade revealed a grade 4 of Cormack and Lehane. Head manipulations and the BURP manoeuvre improved the view showing the tip of the epiglottis; however, two tracheal intubation attempts failed. A gum elastic bougie was also placed twice in the oesophagus. After 3.5 min failed tracheal intubation access, SpO2 dropped to 86% and facemask re-oxygenation was attempted. Although anaesthesia level was deepened using boluses of propofol (50 mg) to maintain BIS monitoring <50, four hands facemask ventilation was requested to reach and maintain SpO2=92%. Because of very difficult facemask ventilation and poor oxygenation quality, a size 5 CTrachTM was inserted following a standard insertion technique. The sealing optimizing manoeuvre described by Chandy was performed.4 Ventilation was optimized with no audible gas leak, large chest elevation amplitude, normal pulmonary auscultation, and standard end-tidal CO2 curve. Arterial oxygenation quality improved rapidly and SpO2 was 99% after some manual bag-ventilation cycles. Once attached, the viewer showed first plane bulky oedematous arytenoids. Tracheal intubation through the CTrachTM was attempted twice but failed. The flexible tip of the trachea tube was systematically directed towards the oesophagus after bumping on the arytenoids. Because the mask was probably too deeply inserted, a slow Up-manoeuvre was performed in order to improve the view towards the glottis. During this manipulation performed with the metal handle of the CTrachTM with the cuff maintained inflated, the view on the screen became blurred. Bag ventilation failed clearing the view. Suctioning, directly through the tracheal tube emerging in the bowl, allowed removing brown secretions spreading on the optics and partially cleared the view. The tracheal tube was then pushed in the presumed glottis inlet and the cuff was inflated. Capnography confirmed tracheal intubation. Post-intubation lung auscultation revealed diffuse sibilants associated with ronchi. Suctioning of these secretions showed that the brown secretions had entered the trachea. With a nasogastric tube placed for surgical purpose, 25 ml of brown liquid were suctioned. No arterial oxygenation desaturation occurred and sibilants rapidly resumed with sevoflurane. Room-air post-extubation arterial oxygenation was normal and chest X-ray revealed few bronchial infiltrates. The patient was discharged from hospital on the fourth postoperative day after 48 h of amoxicillin plus clavulanic acid oral treatment.
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Discussion |
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This is the first report describing a pulmonary aspiration during difficult airway management with the CTrachTM device. Our observation suggests that standard manoeuvres applied to the CTrachTM performed to improve the view might increase the risk of aspiration in the case of regurgitation of the gastric content.
We have followed our algorithm for the management of difficult airway5 implemented in May 2005, when CTrachTM became available in France. In the present case, the CTrachTM was placed because of difficult facemask oxygenation associated with failed conventional tracheal access. Once the CTrachTM was inserted in the pharynx, it was manipulated in order to ventilate and intubate the trachea. We successfully performed the Chandy manoeuvre to restore ventilation and then ascended the position of the mask in the pharynx using a slow Up-manoeuvre. In contrast to the Chandy manoeuvre, which increases sealing of the airway, the Up-manoeuvre dislodged the distal tip of the mask from its protective place in the hypopharynx allowing upper oesophageal pressurized liquid flooding into the bowl of the LMA and into the trachea of our patient. Because viewing is possible with the CTrachTM, we immediately suctioned the refluxed liquid using the tracheal tube still pre-positioned in the airway, then reducing the volume and limiting the physiological consequences of this pulmonary aspiration. Failure to establish ventilation and intubation using the CTrachTM would have recommended trans-cricothyroid catheterization and ventilation using the ManuJetTM (VBM, Alleins, France).
Cases of pulmonary aspiration have already been described with the use of LMAs in patients at increased risk of aspiration.6 7 In the present case, although asymptomatic, our patient was treated for a gastroesophageal reflux. Interestingly, anaesthesiologists who consider that the LMA is contraindicated in patients with symptomatic gastroesophageal reflux would use the LMA in patients with a history of reflux oesophagitis or hiatus hernia, provided it was asymptomatic.8 Unfortunately, there are no data from which to make an evidence-based decision about whether or not symptoms are severe enough to reject LMA. However, in the conditions of our patient, the CTrachTM was not used as primary airway management device but rather after failed conventional tracheal intubation and because of difficulty in facemask ventilation.
We might have proposed to perform an awake intubation procedure in this morbidly obese patient because preoperative airway evaluation anticipated both difficult ventilation and intubation scenarios. Indeed, the American Society of Anesthesiology recommends awake intubation if both difficult mask ventilation and difficult intubation are anticipated. However, over the past 3 yr, only one morbidly obese female received an elective fibreoptic tracheal intubation because of a 2 cm mouth aperture. Among the 317 morbidly obese patients who received general anaesthesia, 19 out of these who could not be intubated conventionally were correctly ventilated and then intubated with the intubating laryngeal mask airways (LMAFastrachTM or CTrachTM). Because of the beneficial performance of the intubating laryngeal masks in this particular population of patients,9 10 we quite systematically manage the airways of our morbidly obese patients after general anaesthesia induction. Moreover, it is not certain that awake fibreoptic tracheal intubation which requires either intense pharyngeal, laryngeal, and proximal trachea sensory block or sedation (and sometimes both) would have prevented the pulmonary aspiration of regurgitated gastric content.
Finally, our recent experience in the morbidly obese patient11 12 suggests that primary tracheal intubation using the AirtraqTM laryngoscope (VYGON, Ecouen, France) after rapid sequence induction might have been an interesting alternative strategy to rapidly and definitely secure the airway of our patient.
In conclusion, our report suggests that manipulations of the CTrachTM such as the Up-manoeuvre may lead to pulmonary aspiration in the case of regurgitated gastric content.
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References |
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11 Dhonneur G, Ndoko S, Amathieu R, El Housseini L, Poncelet C, Tual L. Tracheal intubation using the Airtraq(R) in morbid obese patients undergoing emergency cesarean delivery. Anesthesiology (2007) 106:629–30.[CrossRef][Web of Science][Medline]
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