To the Editor:
Dr. Breen reminds us that the laryngeal mask airway (LMA) can be used as a conduit or guide for an endotracheal tube, facilitating endotracheal intubation. He then describes a method of extricating the LMA while retaining endotracheal tube position . This task may carry the risk of endotracheal tube displacement . His premise is that the LMA should be removed prior to recovery because the patient "will likely not tolerate an LMA before achieving sufficient alertness." There is much evidence contrary to this. The earliest reports  showed that the LMA is usually well tolerated during patient recovery. This early finding has been validated during the past 10 years of its clinical use . The presence of an endotracheal tube is much less tolerated . Therefore, it may be prudent to leave both the LMA and the endotracheal tube in situ and remove them together when appropriate.
However, should one wish to remove the LMA before the endotracheal tube, other methods are available. The LMA can be split through its shaft and cuff (the cuff defects then seal either side of the split); this split LMA can then be peeled away from the endotracheal tube . An intubating LMA  and a double-lumen LMA  are under development.
David R. Ball, MB, BS (Lond), BA (Oxon), FRCA
Department of Anaesthesia and Intensive Care; Aberdeen Royal Infirmary; Aberdeen, UK AB9 2ZB
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