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The laryngeal mask airway prevents supraglottic leak during ventilation through an uncuffed cricothyroidotomy

  • David T. Wong
  • Ashok Kumar
  • Atul Prabhu
Case Reports/Case Studies

Abstract

Purpose

A ‘cannot intubate-cannot ventilate’ situation requires emergency insertion of an infraglottic surgical airway. We present a case of postoperative macroglossia requiring emergency insertion of an uncuffed percutaneous cricothyroidotomy tube. The supraglottic leak was eliminated by the insertion of a laryngeal mask airway with an occluded 15-mm connector.

Clinical features

A 49-yr-old man underwent clipping of a left posterior inferior cerebellar artery aneurysm and his tracheal tube was removed postoperatively. Two hours later, he became dyspneic and developed significant macroglossia. After application of topical anesthesia, direct laryngoscopy, oral fibreoptic bronchoscopy and laryngeal mask insertion were unsuccessful. The patient became progressively hypoxemic, pulseless electrical activity ensued, and cardiopulmonary resuscitation was initiated. An uncuffed percutaneous cricothyroidotomy tube was inserted. Oxygenation and hemodynamics were restored. As the cricothyroidotomy tube was uncuffed, there was a large supraglottic leak with manual ventilation. A laryngeal mask airway was inserted and the cuff was inflated. The 15-mm connector was occluded by a piece of tape. Subsequently, there was no further supraglottic leak with manual ventilation. He was taken to operating room and a surgical tracheotomy was performed.

Conclusion

In a patient with postoperative macroglossia in a ‘cannot intubate-cannot ventilate’ situation, effective oxygenation was restored by insertion of an uncuffed cricothyroidotomy, but ventilation was affected by a substantial supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby restoring effective lung ventilation.

Keywords

Laryngeal Mask Airway Difficult Airway Manual Ventilation Superior Vena Cava Syndrome Pulseless Electrical Activity 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Le masque laryngé prévient les fuites supraglottiques durant la ventilation via une cricothyrotomie sans ballonnet

Résumé

Objectif

Dans les cas où l’intubation et la ventilation sont impossibles (« cannot intubate — cannot ventilate »), l’accès urgent aux voies aériennes est pratiqué de façon chirurgicale au niveau infraglottique. Nous présentons un cas de macroglossie postopératoire ayant nécessité l’insertion percutanée et urgente d’un tube de cricothyrotomie sans ballonnet. La fuite supraglottique a été éliminée grâce à l’insertion d’un masque laryngé muni d’un connecteur de 15 mm bouché.

Eléments cliniques

Un homme de 49 ans a subi une ligature d’un anévrisme de l’artère cérébelleuse inféro-postérieure gauche et a été extubé à la fin de l’opération. Deux heures plus tard, il est devenu dyspnéique et a développé une macroglossie importante. Après application d’anesthésie topique, la laryngoscopie directe, la bronchoscopie flexible par voie orale et l’insertion d’un masque laryngé ont échoué. Le patient est progressivement devenu hypoxémique, entraînant dissociation électro-mécanique nécessitant les manœuvres de réanimation cardio-pulmonaire. Un tube de cricothyrotomie percutané sans ballonnet a été inséré. L’oxygénation et l’hémodynamie ont été rétablies. Comme le tube de cricothyrotomie ne comportait par de ballonnet, il y a eu une fuite supraglottique importante durant la ventilation manuelle. Un masque laryngé a été inséré et son ballonnet gonflé. Le connecteur de 15 mm a été bouché par un morceau de ruban adhésif. Par la suite, il n’y a plus eu de fuite supraglottique lors de la ventilation manuelle. Le patient a été emmené au bloc opératoire où une trachéotomie chirurgicale a été effectuée.

Conclusion

Chez un patient avec une macroglossie postopératoire, dans une situation où l’intubation et la ventilation sont impossibles, l’oxygénation a été rétablie de façon efficace grâce à l’insertion d’une cricothyrotomie sans ballonnet; toutefois, une fuite supraglottique substantielle a gêné la ventilation. Une nouvelle stratégie comportant un masque laryngé gonflé et un connecteur bouché a permis de colmater la fuite supraglottique avec succès, restaurant ainsi la ventilation pulmonaire adéquate.

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Copyright information

© Canadian Anesthesiologists 2007

Authors and Affiliations

  1. 1.Department of Anesthesiology, Toronto Western Hospital, University Health NetworkUniversity of TorontoTorontoCanada

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