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Transilluminated ProSeal[TM] laryngeal mask airway insertion.

The usefulness of the ProSeal[TM] laryngeal mask airway (PLMA, Laryngeal Mask Company, San Diego, CA, USA) as a rescue airway device following difficult or failed intubation has been recognised in numerous case reports (1-3). However, malpositioning of PLMA is common in clinical practice. To overcome the problem, various insertion aids have been described, such as a curved metal introducer tool or the use of a gum elastic bougie (GEB) (4). We would like to report a novel and simple technique to guide a PLMA into a correct position in cases of failure of conventional techniques. This involves using transillumination of neck tissue by a lightwand (Light Wand[TM] Orotracheal Lighted Stylet, Vital Signs Inc., NJ, USA). The patient gave permission for the details of this case and Figure 2 to be published.

After inducing anaesthesia in an adult male for elective urological surgery, a size 4 PLMA was placed using the introducer tool technique with a lateral approach. However, the PLMA could not be inserted correctly in two attempts. In a third attempt, we decided to use a lightwand as a guide in the drainage tube of PLMA (due to the absence of sterilised GEB). Initially, a 6 mm endotracheal tube connector was seated snugly into the proximal end of the drainage tube. A well-lubricated lightwand was passed through the endotracheal tube connector and threaded down the drainage tube of PLMA until its distal end was close to, but not protruding beyond the tip of the drainage tube (Figure 1). The endotracheal tube connector was tightened on the connector lock of the lightwand to lock the orientation of the PLMA on the lightwand. The posterior aspect of the PLMA bowl was lubricated with lignocaine jelly. The distal end of the lightwand-PLMA combination unit was then gently curved to facilitate its smooth passage through the oropharynx. The technique involved the following steps: 1) following the dimming of room lights, the patient's lower jaw was drawn gently forward by the anaesthetist's left hand and the distal end of the lightwand and bowl of the PLMA assembly were gently guided into the oral cavity by the anaesthetist's right hand; 2) placed adjacent to the surface of the tongue, the PLMA bowel was slipped along the curve of the oropharynx into the pharynx by a simple wrist motion; 3) the lighted end was adjusted to midline of the patient's neck and the combined lightwand-PLMA apparatus was then advanced until a cone-shaped diffuse glow of light projecting caudally toward the thyroid cartilage was seen at the level of the suprasternal notch; 4) the alignment of the PLMA with the upper esophageal sphincter opening and the glottis was confirmed by observing the symmetrical distribution of transmitted light intensity in the suprasternal notch (Figure 2); and 5) once the bite block of the PLMA was correctly located between the teeth, the lightwand was removed while the PLMA was held in position. The cuff of the PLMA was inflated to the desired amount and the patient could be easily ventilated without an oropharyngeal or esophageal leak. Subsequent passage of a gastric tube was easy. Anaesthesia management was otherwise uneventful and there was no postoperative pharyngolaryngeal discomfort.

The combined use of the lightwand and PLMA in our case offered an advantage over the GEB technique to facilitate insertion and prevent retro-version of PLMA bowl. Moreover, in contrast to the blind placement of a GEB technique, this novel approach may also help us to ensure correct positioning of the PLMA in the hypopharynx and possibly may improve the alignment of the tip of the drainage tube with the oesophageal opening, thereby preserving reliable gastroesophageal drainage function.

We speculate that the lightwand is a relatively easy approach to PLMA insertion, because in our case it eliminated the need for laryngoscopy and an assistant. However, the safety of placing a combined lightwand-PLMA apparatus has not been established, although it has been recognised for some time that lightwand-guided endotracheal intubation is safe and well tolerated (5). Furthermore, unlike other guiding techniques that involved protrusion of the guiding instrument beyond the tip of the drain tube, the lightwand was kept within the drain tube of the PLMA, which also decreased the probability of trauma. We have subsequently used this technique in several patients with successful PLMA placement in all cases on the first attempt.




K.-Z. LU

Chongqing, P. R. China


(1.) Halaseh BK, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H. The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases. Anaesth Intensive Care 2010; 38:1023-1028.

(2.) Cook TM, Silsby J, Simpson TP. Airway rescue in acute upper airway obstruction using a ProSeal laryngeal mask airway and an Aintree catheter: a review of the ProSeal laryngeal mask airway in the management of the difficult airway. Anaesthesia 2005; 60:1129-1136.

(3.) Awan R, Nolan JP, Cook TM. Use of a ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed tracheal intubation. Br J Anaesth 2004; 92:144-146.

(4.) Brimacombe J, Keller C, Vosoba Judd D. Gum elastic bougie-guided insertion of the ProSeal[TM] laryngeal mask airway is superior to the digital and introducer tool techniques. Anesthesiology 2004; 100:25-29.

(5.) Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: A review. Anesth Analg 2000; 90:745-756.
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Title Annotation:Correspondence
Author:Chen, J.; Lu, K.-Z.
Publication:Anaesthesia and Intensive Care
Article Type:Letter to the editor
Geographic Code:9INDI
Date:Mar 1, 2012
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