A LMA CTrachTM for large patients
Singapore
* E-mail: analiue{at}nus.edu.sg
Editor—The LMA CTrachTM system (CTrach) (The Laryngeal Mask Company, Singapore) enables viewing of the glottis, alignment of the laryngeal mask conduit with the glottis, and tracheal intubation under vision. In earlier work with the CTrach, it was frequently difficult to view the glottis, and epiglottic downfolding was the most common cause.1 This may limit the CTrach's usefulness in managing difficult airways and may be a particular problem in tall obese male patients.2 A CTrach airway modified for use in big patients may be needed and hence the size 5L CTrach airway was recently developed.
The size 5L airway has similar cuff size and tube curvature as the size 5, but has a 2.2 cm longer tube (outer curvature length). This enables deeper insertion which may prevent or aid correction of epiglottic downfolding. We report our experience with the size 5L CTrach in three patients whose airways were difficult to manage.
Patient 1 was a 58-yr-old man (1.78 m, 80 kg) having lumbar spine surgery. He had several missing and loose teeth. He had a Cormack and Lehane grade 3 larynx on direct laryngoscopy with both standard and long blade Macintosh laryngoscopes. We inserted a size 5 CTrach and achieved ventilation after application of the up-down manoeuvre. We failed to view the glottis because of persistent epiglottic downfolding, despite using several up-down manoeuvres, and removal and reinsertion of the CTrach. An attempt at tracheal intubation through the CTrach failed. We then used a CTrach 5L and immediately were able to achieve ventilation. There was still partial epiglottic downfolding blocking the anterior third of the glottis, but we easily corrected this by pushing the CTrach deeper into fully view the glottis. We succeeded in tracheal intubation at the first attempt.
Patient 2 was a 60-yr-old man (1.82 m 85 kg) having lumbar spine surgery. He had a receding chin, his teeth were in very poor condition, and a grade 4 larynx on direct laryngoscopy. We used a size 5 CTrach and easily achieved ventilation, but again failed to view the glottis due to persistent downfolding of the epiglottis. We then used a size 5L CTrach and immediately obtained a full view of the glottis and successfully intubated his trachea.
Patient 3 was a 22-yr-old man (1.84 m, 86 kg) having cervical spine surgery. He had marked cervical spinal canal stenosis and we applied manual inline stabilization during all airway procedures. He had a grade 4 larynx on direct laryngoscopy. With the size 5L CTrach, we were able to achieve ventilation and a glottis view without the need for any manoeuvres, and to intubate his trachea at the first attempt.
The concept of CTrach visualization is promising for difficult airway management and may improve the success rate of intubation through a laryngeal mask conduit.3 Provided the glottis can be seen, the success of intubation at the first attempt is very high. The CTrach may be an efficient device for intubation in morbidly obese patients, but glottis visualization can be difficult even in experienced hands.4 In two of our patients here, the size 5L CTrach enabled full glottis views after failure with the size 5. Although our patients were not exceptionally tall and were not obese, our early experience suggests that the 5L may meet the need for a suitable CTrach conduit in big patients with longer oral-pharyngeal-laryngeal distances.
The author has no financial relationship with or interests in the Laryngeal Mask Company or any competing company.
References
1 Liu EH, Goy RW, Chen FG. An evaluation of poor LMA CTrach views with a fibreoptic laryngoscope and the effectiveness of corrective measures. Br J Anaesth (2006) 97:878–82.
2 Cattano D, Pesetti B, Di SC, Giunta F. Evaluation of the LMA CTrach. Br J Anaesth (2007) 98:409.
3 Liu EH, Goy RW, Lim Y, Chen FG. Success of tracheal intubation with intubating laryngeal mask airways: a randomized trial of the LMA Fastrach and LMA CTrach. Anesthesiology (2008) 108:621–6.[Web of Science][Medline]
4 Dhonneur G, Ndoko SK, Yavchitz A, et al. Tracheal intubation of morbidly obese patients: LMA CTrach vs direct laryngoscopy. Br J Anaesth (2006) 97:742–5.
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