Comparison of two face masks used to deliver early ventilation to laryngectomized patients.

Abstract

Emergency airway management of laryngectomized patients is inherently complicated by the altered contours of their necks, by the presence of awkwardly placed tracheostomas, and by stomal strictures. Effective ventilation can also be compromised by the presence of hypertrophic peristomal scar tissue and by tumor recurrence. One common method of airway management involves the use of a pediatric face mask attached to a standard ventilation bag. We conducted a study of 20 laryngectomized patients to determine if they could be adequately ventilated through two commonly used pediatric face masks--the Laerdal mask and the Ambu mask. Ten of these patients had had an end tracheostoma in place for at least 1 year, and the remaining 10 had undergone stoma placement only recently. We found that all 20 patients achieved an adequate peristomal seal when using the Laerdal mask, whereas only 11 adequate seals were achieved with the Ambu mask. Therefore, we recommend that the Laerdal pediatric mask be used for early ventilation in laryngectomized patients.

Introduction

The use of a pediatric face mask is a popular method of ventilating and resuscitating laryngectomized patients in some units. Two common types of pediatric face mask are the Ambu mask (Medicotest; St. Ives, Cambridgeshire, U.K.) and the Laerdal mask (Laerdal Medical Ltd.; Orpington, Kent, U.K.) (figure 1). No studies have been published that would suggest that one of these masks is preferable to the other. Experience in our unit has shown that the Ambu mask is less flexible than the Laerdal mask. The rigidity of the former can make it difficult to achieve an adequate seal with the peristomal skin.

[FIGURE 1 OMITTED]

According to some anecdotal reports, some laryngectomized patients have been ventilated by mouth rather than through their stoma at critical times, such as during the administration of basic life support and during the induction of anesthesia. Paramedics attending to laryngectomized patients use corrugated plastic tubing, which must be adapted before it can be used. However, the current guidelines in the U.K. that govern advanced life support include no reference to managing laryngectomized patients. (1) Similarly, no reference to laryngectomized patients could be found in the Advanced Trauma Life Support Manual produced by the American College of Surgeons. (2)

The purpose of this article is to highlight the potential difficulties that are encountered during basic resuscitation of laryngectomized patients and to report our assessment of the two types of pediatric face mask in ventilating such patients.

Patients and methods

Our study group was made up of 20 patients--10 who had undergone laryngectomy at least 1 year earlier and 10 who had undergone 1 aryngectomy only recently. Patient's in the former group were recruited from our hospital's Laryngectomee Club; all of them bad a well-formed tracheostoma. Informed consent was obtained prior to all assessmeuts.

We compared the effectiveness of both the Ambu and the small Laerdal pediatric face masks in helping deliver ventilation to all 10 patients in each group. All patients were assessed while they were relaxed and in the supine position with their neck extended. No tracheostomy tubes or stoma buttons were in place during testing. Each mask was attached to a standard reservoir ventilation bag and applied to the end tracheostoma of each patient. During the assessment, all patients were asked to inhale and hold their breath. A single compression of the ventilation bag enabled us to determine the adequacy of the seal around the surrounding skin by listening for escaping air.

Results

All 20 patients achieved an adequate seal (no air escape) with the Laerdal mask (figure 2). When the Amhu mask was evaluated, an adequate seal was achieved by only 6 of the 10 long-standing laryngectomy patients and 5 of the 10 recent laryngectomy patients.

[FIGURE 2 OMITTED]

Discussion

Based on these results, we recommend use of the Laerdal pediatric face mask (small size) for early ventilation in patients who have had a laryngectomy. We found that this mask was more compliant with the contours of each patient's neck. When adequate pressure was applied, the presence of any peristomal aberration (e.g., hypertrophic scarring, granulation, or a prominent medial head of the sternocleidomastoid muscle) made no difference in the quality of the seal.

Among the reasons that the Ambu mask failed to provide an adequate seal in all cases are that it is not as flexible and the density of the sorbo-rubber seal in its cuff was inadequate. The rigidity of the Ambu mask was particularly problematic because of the variable anatomy of these patients. Some of them had no stemocleidomastoid muscles while others had unilateral musculature. Moreover, some patients had short necks with contractures while others had long necks. Finally, some patients had an adequate amount of subcutaneous peristomal soft tissue, which allowed the face mask cuff to "bed in," and others had more bony projections.

We have forwarded the results of our study to the British National Association of Laryngectomee Clubs for dissemination in its quarterly newsletter. We have also notified the British Ambulance Service of our findings in order to provide guidance lot the early ventilation of laryngectomizcd patients.

Our intention is to extend this study to include laryngectomized patients who are admitted for procedures that require general anesthesia. Currently, most of these patients are "breathed down" with volatile induction agents until an endotracheal tube can comfortably be passed. We hope that a simpler, standardized method of ventilating this particular cohort of patients will allay the anxiety and apprehension that operating-room personnel feel when we are dealing with an unconscious laryngectomee.

References

(1.) Resuscitation Council (UK). Advanced Life Support Manual. 2nd ed., rev. London: Resuscitation Council & ERC, 1996,

(2.) Advanced Trauma Life Support Manual. Chicago: American College of Surgeons, 1994.

From the Department of Otolaryngology, University Hospital Aintree, Liverpool, U.K.

Reprint requests: Mr. R.K. Bhalla, 17 Withins Hall Rd., Woodhouses, Manchester M35 9SA, UK. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

The authors have no financial interest in any of the products mentioned in this article.