Skip Navigation LinksHome > November 2004 - Volume 101 - Issue 5 > Bleeding, Dysphagia, Dysphonia, Dysarthria, Severe Sore Thro...
Anesthesiology:
Correspondence

Bleeding, Dysphagia, Dysphonia, Dysarthria, Severe Sore Throat, and Possible Recurrent Laryngeal, Hypoglossal, and Lingual Nerve Injury Associated with Routine Laryngeal Mask Airway Management: Where Is the Vigilance?

Brimacombe, Joseph F.R.C.A., M.D*; Keller, Christian M.D

Free Access
Article Outline
Collapse Box

Author Information

Back to Top | Article Outline

In Reply:—

Dr. Reier’s aggressively titled letter demonstrates a lack of understanding of the aims of our study,1 the laryngeal mask concept, and the ProSeal™ laryngeal mask airway (PLMA; Laryngeal Mask Company, Henley-on-Thames, United Kingdom) literature and exposes a deep-rooted, unfounded belief that the endotracheal tube (ETT) and facemask are the undisputed accepted standards for modern airway management. We will respond to each of his many points in turn.
First, Dr. Reier is incorrect in stating that sore throats were excluded if they did not cause constant pain, because most patients with a nonconstant sore throat had pain on swallowing or speaking and were therefore included in these morbidity categories.
Second, the use of terminology such as dysarthria and dysphonia is somewhat confusing because there are a variety of conflicting definitions used by researchers. It is essential that these terms are therefore defined when used. We defined dysphonia as difficulty/pain on speaking. Further analysis of our data reveals that all patients with dysphonia had pain on speaking, and none had any impairment of vocal function. Patients with airway morbidity symptoms were all followed up, and none of these symptoms persisted beyond 72 h.
Table 1
Table 1
Image Tools
Third, Dr. Reier suggests that patients with normal airways have minimal airway morbidity when treated with the facemask and ETT. Airway morbidity is indeed low for the facemask (although postoperative jaw pain is more common than the LMA-Classic™ [Laryngeal Mask Company, Henley-on-Thames, United Kingdom]2), but this is certainly not the case for the ETT. An analysis of studies comparing the LMA-Classic™ and laryngoscope-guided tracheal intubation reveals that the incidence of sore throat is much higher for laryngoscope-guided tracheal intubation (39% vs. 17%; P < 0.00001; table 1). An article3 and accompanying editorial4 in the August 2003 issue of Anesthesiology highlight the dangers of routine tracheal intubation. The incidence of airway morbidity is similar for the PLMA and LMA-Classic™.5
Fourth, Dr. Reier considers that the etiology of airway morbidity with the PLMA was related to mucosal injury (abrasions during insertion and ischemia after insertion) and to regurgitation of gastric acid. Dr. Reier is clearly unaware of a study demonstrating that the PLMA exerts pressures against the surrounding mucosa that are lower than perfusion pressure6 and that the PLMA protects the patient from regurgitation when correctly positioned.7 By default, the most likely cause of airway morbidity with the PLMA is trauma during insertion. An important finding in our study was that trauma was less common with the gum elastic bougie–guided technique.1
Fifth, Dr. Reier considers that the PLMA has no role in the emergent airway because it is too slow to insert and has an inadequate seal to deal with noncompliant lungs. He also claims, without citing evidence, that the majority of emergent airway patients have noncompliant lungs. We consider that 25–34 s—which was the average time from picking up the PLMA to successfully inserting it into the pharynx, establishing correct positioning, and establishing effective ventilation—is rapid enough for the emergent airway. The PLMA has a seal that is 10 cm H2O higher than that of the LMA-Classic™,8 which is more than adequate to ventilate even morbidly obese patients9 and those undergoing laparoscopic surgery.10 A recent study showed that digital insertion of the PLMA has a success rate similar to that of the LMA-Classic™.11 The LMA-Classic™ has been recommended by the American Society of Anesthesiologists for the emergent airway since 1993.12 Unlike the ETT, the LMA does not trigger bronchospasm,13 so higher tidal volumes are possible for a given peak pressure for the LMA than for the ETT.
Sixth, Dr. Reier suggests that swapping a facemask with an oropharyngeal leak pressure of greater than 40 cm H2O for a PLMA with an oropharyngeal leak pressure of less than 25 cm H2O could prove fatal in the emergent airway. We never suggested making such an exchange in our article. However, to ventilate a patient with a facemask at airway pressures of greater than 40 cm H2O would inevitably lead to massive gastric dilatation (gastric insufflation begins with peak airway pressures of around 20 cm H2O7,14) unless cricoid pressure is simultaneous applied,14 in which case insertion of a PLMA and passage of a gastric tube might reduce morbidity and mortality.
Seventh, Dr. Reier presents previously unpublished, non–peer- reviewed data suggesting that the facemask and ETT are superior to the PLMA in terms of success on the first attempt, insertion time, failure rate, visible blood, airway morbidity, and the need for an assistant. It is beyond the scope of this reply to debate all these points; suffice it to say that most of the data presented by Dr. Reier are totally at odds with the plentiful, peer-reviewed published data. For example, the incidence of sore throat for laryngoscope-guided tracheal intubation is more like 40% rather than 0.4% (table 1), and the incidence of sore throat with the facemask is more like 4%2,15 than 0.1%. Also, such interstudy comparisons are difficult to interpret scientifically. Meaningful comparisons between the performance of the PLMA versus the ETT and the facemask will have to await the results of properly conducted clinical trials. The benefits of the LMA-Classic™ over the facemask and ETT, however, have been well established.16
Finally, Dr. Reier states than the PLMA has a failure rate of 1.25% and always requires an assistant. In fact, there were no overall failures, because the other techniques succeeded if the primary technique failed. Matioc and Arndt demonstrate how that technique can be easily conducted without an assistant.
Matioc and Arndt’s excellent technique for gum elastic bougie–guided insertion of the PLMA without an assistant extends its range of use to resuscitation and other single-operator situations. We would like to add that the gum elastic bougie–guided technique has an extremely high success rate. The author and colleagues have used it in more than 6,000 patients, with a first-time insertion failure rate of 0.07% (n = 4; failure to position the PLMA in the pharynx), and a first-time ventilation failure rate of 0.5% (n = 28; failure to ventilate once in the pharynx). The etiology of first-time insertion failure was limited mouth opening (n = 3) and unexpected pharyngeal pathology (n = 1). The etiology of first-time ventilatory failure was laryngospasm (which was treated with propofol or muscle relaxation), mechanical compression of the vocal cords (which was treated by applying jaw thrust or removing air from the cuff), infolding of the cuff (which was treated by removing air from the cuff or use of a smaller size), or epiglottic down-folding (which was treated by jaw thrust and reinsertion with maintained laryngoscopy). The overall ventilation failure rate for the technique was 0.08%. There have been no cases of esophageal or pharyngeal injury.
We thank Dr. El-Orbany et al. for pointing out our incorrect use of the term gum elastic bougie. We were aware of the terminology issue when we wrote the article but decided to use gum elastic bougie because we considered it the most commonly used and best-understood term. We would like to point out that the Eschmann endotracheal tube introducer/gum elastic bougie is not ideal for use with the PLMA because the distal portion does not have an atraumatic tip. The development of an atraumatic esophageal guide for use with the PLMA and other extraglottic airway devices is currently under way.
Joseph Brimacombe F.R.C.A., M.D.,*
Christian Keller M.D.
* James Cook University, Cairns Base Hospital, The Esplanade, Cairns, Australia. jbrimaco@bigpond.net.au
Back to Top | Article Outline

References

1. Brimacombe J, Keller C, Vosoba Judd D: Gum elastic bougie–guided insertion of the ProSeal™ laryngeal mask airway is superior to the digital and introducer tool techniques. Anesthesiology 2004; 100:25–9

2. Brimacombe J, Holyoake L, Keller C, Brimacombe N, Scully M, Barry J, Talbutt P, Sartain J, McMahon P: Pharyngolaryngeal, neck and jaw discomfort after anesthesia with the face mask and laryngeal mask airway at high and low cuff volumes in males and females. Anesthesiology 2000; 93:26–31

3. Tanaka A, Isono S, Ishikawa T, Sato J, Nishino T: Laryngeal resistance before and after minor surgery: Endotracheal tube versus laryngeal mask airway. Anesthesiology 2003; 99:252–8

4. Maktabi MA, Smith RB, Todd MM: Is routine endotracheal intubation as safe as we think or wish? Anesthesiology 2003; 99:247–8

5. Brimacombe J, Keller C, Fullekrug B, Agro F, Rosenblatt W, Dierdorf SF, Garcia de Lucas E, Capdevila X, Brimacombe N: A multicenter study comparing the ProSeal™ with the Classic™ laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology 2002; 96:289–95

6. Keller C, Brimacombe J: Mucosal pressure and oropharyngeal leak pressure with the Proseal versus the classic laryngeal mask airway. Br J Anaesth 2000; 85:262–6

7. Keller C, Brimacombe J, Kleinsasser A, Loeckinger A: Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000; 91:1017–20

8. Brimacombe J, Keller C: The ProSeal™ laryngeal mask airway: A randomized, crossover study with the standard laryngeal mask airway in paralyzed, anesthetized patients. Anesthesiology 2000; 93:104–9

9. Keller C, Brimacombe J, Kleinsasser A, Brimacombe L: The laryngeal mask airway ProSeal™ as a temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation. Anesth Analg 2002; 94:737–40

10. Lu PP, Brimacombe J, Yang C, Lin C, Li J, Chung P, Shry M: The ProSeal versus the Classic laryngeal mask airway for positive pressure ventilation during laparoscopic cholecystectomy. Br J Anaesth 2002; 88:824–5

11. Coulson A, Brimacombe J, Keller C, Wiseman L, Ingham T, Cheung D, Popwycz L, Hall B: A comparison of the ProSeal and Classic laryngeal mask airways for airway management by inexperienced personnel after manikin-only training. Anaesth Intensive Care 2003; 31:286–9

12. Practice Guidelines for Management of the Difficult Airway: A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993; 78:597–602

13. Berry A, Brimacombe J, Keller C, Verghese C: Pulmonary airway resistance with the endotracheal tube versus laryngeal mask airway in paralyzed anesthetized adult patients. Anesthesiology 1999; 90:295–7

14. Brimacombe J, Berry A: Cricoid pressure. Can J Anaesth 1997; 44:414–25

15. Smith I, White PF: Use of the laryngeal mask airway as an alternative to a face mask during outpatient arthroscopy. Anesthesiology 1992; 77:850–5

16. Brimacombe J: Laryngeal Mask Anesthesia: Principles and Practice, 2nd edition. London, WB Saunders, 2004

17. Alexander CA, Leach AB: Incidence of sore throats with the laryngeal mask (letter). Anaesthesia 1989; 44:791

18. Akhtar TM, McMurray P, Kerr WJ, Kenny GNC: A comparison of laryngeal mask airway with tracheal tube for intra-ocular ophthalmic surgery. Anaesthesia 1992; 47:668–71

19. Tabo E: The LMA and sore throat [in Japanese]. J Clin Anesth (Rinsho-Masui) 1991; 15:1146–8
20. Wulf H, Siems R, Beckenbach S, Lippert B, Froschl T, Werner J: Objective damage and subjective discomfort after general anesthesia: A comparison of intubation and laryngeal mask [in German]. Anasthesiol Intensivmed Notfallmed Schmerzther 1994; 29:288–9

21. Joshi GP, Inagaki Y, White PF, Taylor-Kennedy L, Wat LI, Gevirtz C, McCraney JM, McCulloch DA: Use of the laryngeal mask airway as an alternative to the tracheal tube during ambulatory anesthesia. Anesth Analg 1997; 85:573–7

22. Arndt M, Hofmockel R, Benad G: Sore throat after use of the laryngeal mask and intubation [in German]. Anaesthesiol Reanim 1998; 23:44–8

23. Saeki H, Morimoto Y, Yamashita A, Nagusa Y, Shimizu K, Oka H, Miyauchi Y: Postoperative sore throat and intracuff pressure: Comparison among endotracheal intubation, laryngeal mask airway and cuffed oropharyngeal airway [in Japanese]. Masui 1999; 48:1328–31

24. Oczenski W, Krenn H, Bahaba AA, Binder M, El-Schahawi-Kienzl I, Kohout S, Schwarz S, Fitzgerald RD: Complications following the use of the Combitube, tracheal tube and laryngeal mask airway. Anaesthesia 1999; 54:1161–5

25. Rieger A, Brunne B, Has I, Brummer G, Spies C, Striebel HW, Eyrich K: Laryngo-pharyngeal complaints following laryngeal mask airway and endotracheal intubation. J Clin Anesth 1997; 9:42–7

26. Higgins PP, Chung F, Mezei G: Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002; 88:582–4

27. Klockgether-Radke A, Gerhardt D, Muhlendyck H, Braun U: The effect of the laryngeal mask airway on the postoperative incidence of vomiting and sore throat in children [in German]. Anaesthesist 1996; 45:1085–8

28. Splinter WM, Smallman B, Rhine EJ, Komocar L: Postoperative sore throat in children and the laryngeal mask airway. Can J Anaesth 1994; 41:1081–3

Cited By:

This article has been cited 4 time(s).

Resuscitation
New airways for resuscitation?
Cook, TM; Hommers, C
Resuscitation, 69(3): 371-387.
10.1016/j.resuscitation.2005.10.015
CrossRef
Anesthesia and Analgesia
Propofol causes less postoperative pharyngeal morbidity than thiopental after the use of a laryngeal mask airway
Chia, YY; Lee, SW; Liu, K
Anesthesia and Analgesia, 106(1): 123-126.
10.1213/01.ane.0000297292.84620.2c
CrossRef
Resuscitation
Early experience with the iGEL (TM)
Dinsmore, J; Maxwell, W; Ickeringill, M
Resuscitation, 74(3): 574-575.
10.1016/j.resuscitation.2007.05.004
CrossRef
European Journal of Anaesthesiology (EJA)
Flexible laryngeal mask as an alternative to reinforced tracheal tube for upper chest, head and neck oncoplastic surgery
Martin-Castro, C; Montero, A
European Journal of Anaesthesiology (EJA), 25(4): 261&hyhen;266.
10.1017/S0265021507002980
PDF (80) | CrossRef
Back to Top | Article Outline

© 2004 American Society of Anesthesiologists, Inc.

Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.
Login

Article Tools

Images

Share