To the Editor:
In Dr. Breen's letter describing a technique for removal of the laryngeal mask airway (LMA) after it has been used as a guide during a difficult endotracheal intubation, he correctly states that patients with difficult airways should be extubated while they are awake . Unfortunately, he then goes on to say that patients "will likely not tolerate a LMA before achieving sufficient alertness [to allow safe tracheal extubation]" and uses this assumption to justify attempts to remove the laryngeal mask while leaving the endotracheal tube in situ. It is well known that the laryngeal mask is much better tolerated than an endotracheal tube. We agree with Bogetz  that having secured a difficult airway using this technique, the solution to the problem of what to do with the laryngeal mask is quite simply to leave it in situ. The endotracheal tube and the LMA can then be removed together at the end of the procedure with the patient awake. Breen's maneuver, which carries the risk of dislodging the endotracheal tube, is not easily justified except perhaps in cases in which the LMA would physically obscure the surgical field.
Gareth Kessell, MRCP (UK), FRCA
Cavin Gray, FRCA
Department of Surgical and Anaesthetic Sciences; Royal Hallamshire Hospital; Sheffield S10 2JF, UK
1. Breen PH. Simple technique to remove laryngeal mask airway "guide" after endotracheal intubation [letter]. Anesth Analg 1996;82:1302.
2. Bogetz MS. The laryngeal mask airway-role in managing the difficult airway. Int Anesthesiol Clin 1994;32:107-17.