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- Anitha Nileshwar, Aditya Thudamaladinne (28 August 2007)
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Comparison of the Intubating Laryngeal Mask and Bullard Laryngoscope
- Chandy Verghese, Bhamini Ramaswamy (14 August 2007)
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Anitha Nileshwar, Anaesthesiologist Kasturba Medical College, Manipal, Aditya Thudamaladinne
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We thank Dr Chandy Verghese and Dr Bhamini Ramaswamy for their comments on our study. Our response to their comments: 1) We agree that comparing Bullard laryngoscope with a C-Trach may have been better than with Intubating laryngeal mask airway (ILMA) for the reasons mentioned by them. However, the LMA C-Trach has become available for clinical use only recently and is not yet available in our hospital (a tertiary referral centre). 2) We have only two sizes of ILMA available, size 3 and 4 ILMA. Our patients are generally less well-built than in the West and those sizes may be appropriate for our patients. The dedicated silicon tube for ILMA is not widely available and hence we used the Portex polyvinyl chloride (PVC) tube. That could certainly have contributed to our success rate with the ILMA. We were using a PVC tube with the Bullard laryngoscope too. 3) We have observed that a slightly inflated ILMA (5 ml) is less traumatic than a completely deflated one. When intubating a patient with restricted neck movements, it helps to open the mouth widely and give a little jaw thrust with the left hand while inserting the ILMA with the right. The study was done in patients with simulated restriction of neck movements and hence the head could not have been placed in ‘neutral’ position. 4) It is certainly prudent to ensure good ventilation through ILMA in these situations as it can be used as a ventilatory device in the event of failed intubation. During the course of our study, we always checked the ability to ventilate through ILMA. However, in one or two previous occasions, we have noticed that we were able to intubate blindly through ILMA even when ventilation was indequate. As mentioned in the article, when intubation failed, we followed the manoeuvres suggested by Dr Verghese et al to improve the success rate. Conflict of Interest:None declared |
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Chandy Verghese , Bhamini Ramaswamy
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Dear Editor, We read with interest the study by Nileshwar and colleagues comparing two devices recommended for use in ‘difficult airway’ management. We would like to make a few comments regarding this study: 1. Their study compares two airway devices, recommended for use in the ‘difficult to manage’ airway which differ significantly in design. The Intubating Laryngeal Mask Airway (ILMA™) is designed to provide a secure airway during attempts at tracheal intubation in which the specially designed airway tube facilitates ‘blind’ tracheal intubation using a dedicated tracheal tube (1,2) . The Bullard Laryngoscope is used to directly visualize the trachea and enable the visualized intubation of the trachea with a tracheal tube. A more accurate comparison would have been with the LMA-CTrach™, which also allows direct visualization of the glottis prior to tracheal intubation(3) . 2. The authors record a low success rate with the ILMA™ (74%), which is lower than those published in other studies(4).The following factors may have contributed to this low level of success: • The authors used a size 3 ILMA for females and a size 4 ILMA for males whereas the recommended sizes are 4 for females and 5 for males. The epiglottic elevating bar (EEB) in a size 3 ILMA is 4 mm shorter than in size 4 and 8 mm shorter than the EEB in a size 5 ILMA, which may lead to difficulty in intubation through the ILMA if the appropriate size is not used. • The cuff of the ILMA should be fully deflated (not partly inflated) and the head should be placed in the ‘neutral position’ before insertion of the ILMA(2). In this study, the pillow was removed implying that the head and neck were not in the optimal/neutral position. There is no requirement to open the mouth fully or use a jaw thrust for insertion of the ILMA. • In the study, the authors do not mention the use of clinical maneuvers to optimize ventilation through the ILMA before attempting ‘blind’ tracheal intubation such as the ‘up-down’ or Chandy’s manoeuvre(5). • The reasons for designing a dedicated tracheal tube, to achieve optimum results with ‘blind’ tracheal intubation with the ILMA™ have been outlined by its inventor Dr AIJ Brain(1) We think that addressing these factors may lead to a higher success rate with the ILMA™ in the future. B.Ramaswamy C. Verghese Reading, UK. E-mail : chandy.verghese@virgin.net Reference: Brain AJ, Verghese C, Addy EV, Kapila A. The intubating laryngeal mask I : development of a new device for intubation of the trachea.Br J Anaesth 1997; 79: 699-703 Brain AJ, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask II; a preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997;79: 704-9 3 E.H. C. Liu , R. W. L. Goy and F. G. Chen .The LMA CTrach™ a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients. British Journal of Anaesthesia 2006. 96;3:396-400 4 Chan YW, Kong CF, Kong CS, Hwang NC, Ip-Yam PC. The intubating laryngeal mask airway (ILMA): initial experience in Singapore. Br J Anaesth 1998; 81:610-611 5 Ferson D Z, Rosenblatt W H, Johansen /m J, Osborn I. Use of the intubating LMA-Fastrach in 254 patients with difficult to manage airways. Anesth 2001.95: 1175-81 Conflict of Interest:Dr.C.Verghese receives an annual honorarium from the LMA Company. |
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