If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
Use of a ProSealTM laryngeal mask airway and a Ravussin cricothyroidotomy needle in the management o
- Tim M Cook (1 March 2006)
-
When discussion lead to optimal management
- Davide Cattano (21 February 2006)
-
Use of a ProSeal laryngeal mask airway and a Ravussin cricothyroidotomy needle in the management of
- James H Low, Rebecca Smith (11 October 2005)
|
|
|||
|
Tim M Cook, consultant anaesthetist dept of anaesthesia, royal united hospital, combe park, bath, Uk
Send letter to journal:
|
Editor I thank both Drs Low and Smith and Dr Cattano for their comments. I appreciate the advice of Drs Low and Smith on these difficult cases. We agree with this principal and are also hoping to move to increased use of supraglottic catheters where possible – once we have purchased a suitable jet ventilator to replace hand-held jet ventilation. Law and Smith also suggest that it may be appropriate to use a non laser-safe tube during laser resection, suggesting that the risk of airway fire is acceptable when compared to the risk of airway bleeding from cricothyroidotomy. I have not seen these risks quantified, but airway fire is a life-threatening disaster, while the minor bleeding due to insertion of a tracheal cannulae is likely to be inconvenient at worst. My ‘unquantified analysis’ would be that this is not wise. Regarding the case we reported, the extent of narrowing of the airway by tumour would have made placing a supraglottic catheter potentially dangerous, due to the risk of obstructing the airway, with the consequent risk of barotrauma during ventilation. I do not think a microlaryngeal tube could not have been passed and the opinion of the surgeons was that they could not perform the surgery with this in place. As a result our options were rather limited! I also thank Dr Cattano for his comments. Unfortunately I do not have experience of anaesthetising patients with laryngeal tumours for ‘sedated tracheostomy’. Dr Cattano suggests use of a dedicated airway to allow fibreoscopy during the procedure. While we have used this technique, with the ProSeal LMA, for percutaneous tracheostomy in approximately 80 cases in our intensive care1 these were in anaesthetised and paralysed patients. I do not have experience of this technique during sedation and spontaneous ventilation. My only comments would be that the technique is more suited to controlled ventilation (the fibrescope is stimulating to the airway and the fibrescope considerably narrows the airway orifice) and I believe a device though which one can pass a fibrescope and so view the trachea, is likely to be more useful than the C-trach which only offers a view above the vocal cords. Yours sincerely Tim Cook Consultant Anaesthetist Royal United hospital Bath Conflict of interest I have been paid by the LMA company and Intavent Orthofix, distributors of the ProSeal LMA, for lecturing. Reference Craven R, Laver S, Cook TM, Nolan JP. Use of the Proseal LMA facilitates percutaneous tracheostomy. Can J Anaesth 2003; 50; 718-20. Conflict of Interest:I have been paid by the LMA company and Intavent Orthofix, distributors of the ProSeal LMA, for lecturing. |
|||
|
|
|||
|
Davide Cattano, Instructor of Anesthesiology Dept of Anesthesiology, WUSTL, School of Medicine
Send letter to journal:
|
To the editor, I would like to express my compliments to Dr Tim Cook and collegues for the interesting case reported in BJA (95(4):554-7 (2005)), that in a very complete and rational approach showed the optimal use of ProSeal LMA in cases of fibreoptic guided airway management. ENT, in particular, offers variety of occasions when more judicious, but not more complicated, work can be attempted for better results. First, the importance of discussing the case with surgeons. Secondly, the risk of manipulating a narrow and symptomatic airway. In this case report the tumor was not seen exposed from the laryngeal inlet but it caused hoarseness and displaced anatomic structures. So I would ask Dr Cook and collegues to clarify their position regarding a safe approach reserved for laryngeal tumors and specifically to the surgical tracheostomy with sedated but spontaneously breathing patient. My personal point and contribution deals with the possible use of a combined technique of LMA and fibrescopy in situ (FOB)at the insertion (maybe in future offered by the c-Trach LMA) or a combined technique of Glidescope and FOB, that I actually carried out in three ENT cases (data not published), with spontaneously breathing patients. Sincerely Dr Davide Cattano, MD 1. Moorthy SS, Gupta S, Laurent B et al. Management of airway in patients with laryngeal tumors. J Clin Anesth 2005; 17: 604-9 Conflict of Interest:None declared |
|||
|
|
|||
|
James H Low, Consultant None, Rebecca Smith
Send letter to journal:
|
Editor-We read with interest the article by Cook and colleagues discussing the management of the airway in a patient with a large airway tumour1. Laser debulking or resection is commonly used in our hospital for the definitive management of airway tumours. We previously used trans tracheal jet ventilation for some of these cases but our practise has now changed to use a supraglottic approach with a jet ventilation catheter passed through the cords. The external diameter of the catheter is 3mm; it is laser proof and stiffened so that it does not ‘whip’ with the large pressures used with jet ventilation. Many of these tumours have extensive submucosal spread and although may look macroscopically normal when viewed with a fibre optic laryngoscope, may be involved with the primary tumour and still cause seeding. It also decreases the risk of bleeding due to the trans tracheal insertion and of barotrauma with catheter displacement2. It may also be worth considering using a small Microlaryngeal tube, for example size 4 (External diameter 5.5mm), and providing a secure definitive airway. Haemorrhage during laser resection into an airway that is not protected with a cuffed endotracheal tube, may be more of a risk than the small chance of an airway fire due to using a non laser proof tube. Conflict of Interest:None declared |
|||