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".
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E-letters: Electronic letters published:
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Fastrach tubesTM – modifying the design for use with the LMA CTrachTM?
- Keith B. Greenland (1 May 2007)
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Response to "CTrach: the size 6 could be better"
- Eugene H.C. Liu (15 December 2006)
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cTrach: the size 6 could be better
- Davide Cattano, Barbara Pesetti Claudio Di Salvo Francesco Giunta (7 December 2006)
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Keith B. Greenland Royal Brisbane & Women's Hospital
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I would like to congratulate E.H.C. Liu and colleagues1,2and Timmermann and colleagues3 on their informative articles critically analyzing the LMA CTrachTM. I would like to point out that despite the significant improvements of the CTrachTM over the LMA FastrachTM, especially in the ability to observe the tracheal tube passing through the glottis, the manufacturer seems to have failed to make appropriate changes to the design of the FastrachTM tracheal tubes. In particular, the FastrachTM tube has no markings to assist the operator performing the intubation to correctly position the tracheal tube below the glottis. The majority of tracheal tubes currently available have either one or two black lines as intubating guides approximately 2-3 cms proximal to the tracheal tube cuff. These marks should be placed at the level of the glottis to avoid both endobronchial intubation and the tracheal tube cuff being too close to the glottis where it may cause inadvertent damage or partial extubation. The importance of these intubation guides was reviewed in a recent paper4. To assess the importance of intubation marks on the insertion of a FastrachTM tracheal tube, I have taken two photographs from the LCD viewer of the CTrachTM while intubating a manikin. Photograph 1 shows the tracheal tube without a mark passing through the glottis View Image . In comparison, photograph 2 shows the same tube with an intubation guide mark drawn with a permanent marker at 3 cms proximal to the tracheal tube cuff View Image .This mark assists an operator placing the tracheal tube to an appropriate depth within the trachea. I would suggest that the FastrachTM tube should have an intubation mark drawn on the posterior surface of the tube so it may be observed via the CCD camera in the bowl of the LMA by the operator as the tube is being inserted through the glottis. When using the LMA FastrachTM, the insertion of the tube is “blind” and therefore such an intubation guide mark is unnecessary. The advent of the LMA CTrachTM however requires a more appropriately designed Fastrach tracheal tube with visual triggers that assist tracheal intubation. Dr. K.B. Greenland Deputy Director (Research) Department of Anaesthesia and Perioperative Medicine Royal Brisbane and Royal Women’s Hospital Butterfield Street, Herston Brisbane, Qld., Australia. 4006. e-mail: french9a@yahoo.co.uk Mobile telephone: 0431498966 Telephone: 7 36368111, Fax: 7 36361308 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. Liu EH, Goy RW, Chen FG: The LMA CTrach, a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients. Br J Anaesth 2006; 96: 396-400 3. Timmermann A, Russo S, Graf BM: Evaluation of the CTrach--an intubating LMA with integrated fibreoptic system. Br J Anaesth 2006; 96: 516-21 4. Chong DY, Greenland KB, Tan ST, Irwin MG, Hung CT: The clinical implication of the vocal cords-carina distance in anaesthetized Chinese adults during orotracheal intubation. Br J Anaesth 2006; 97: 489-95 Photograph 1 and 2 here Conflict of Interest:None declared |
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Eugene H.C. Liu Department of Anaesthesia, National University of Singapore
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To the Editor. We thank Dr Cattano and his colleagues for their interest in our work. We understand their concerns about the need for a suitable CTrach mask for tall obese male patients, although the need in our population is less pressing. We had in fact discussed such a requirement with the Laryngeal Mask Airway company after our earlier work. Our understanding is that the company is working on a modified size 5 CTrach airway of suitable tube length and curvature specifically for such patients. We look forward to this development. E.H.C Liu, R.W.L.Goy, F.G.Chen Conflict of Interest:None declared |
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Davide Cattano, Assistant Professor of Anesthesiology Department of Surgery, University of Pisa, Pisa, Italy, Barbara Pesetti Claudio Di Salvo Francesco Giunta
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To the editor The recent article of Liu and collegues (An evaluation of poor LMA CTrachTM views with a fibreoptic laryngoscope and the effectiveness of corrective measures.Br J Anaesth. 2006 Dec;97(6):878-82) added a valuable experience to the mechanisms involved in poor views using the new video assisted ILMA cTrach. However they did not point the necessity of LMA company to provide with a better designed mask size for male adults, especially when obese and over 170 cm of height. In our experience of 15 consecutive adult (height 165 cm +/- 5)patients (11F/ 4M) scheduled for bariatric surgery (BMI 43.5+/-6.5) we faced 1 difficult ventilation and 2 patients requiring repositioning for optimal ventilation, and 3 difficult intubation through the cTrach resolved by direct laryngoscopy. All the mentioned patients were male. In 3 patients blind intubation was performed because of difficulties in visualizing the glottis besides proper handling. The positioning of the LMA was performed by two experienced anesthesiologists, used to the ILMA and applying all the manouvres necessary to accomplish a good positioning of the mask. Although the ability to ventilate anesthetized patients through the cTrach has been successfull in most of the reports and studies, its rate of success in visualizing the laryngeal inlet or appropriate lenght of the connector at the labial rim remain problematic. The small number of patients does not allow us to any significant conclusion, but on a clinical point of view, ee suggest, as recently discussed by Dhonneur et al. as well(Correspondence to Dhonneur G et al.Tracheal intubation of morbidly obese patients: LMA CTrach vs direct laryngoscopy.Br J Anaesth. 2006 Nov;97(5):742-5.)that a revision of the cTrach conformation due to anatomic variations in the "big adult" is due. Conflict of Interest:None declared |
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