We read with interest the report by King et al. (1) describing a postoperative incident involving indentation damage of the wire-reinforced endotracheal tube used with the LMA-Fastrach™ (The Laryngeal Mask Company, Limited, Henley-on-Thames, England). We encountered a similar situation, although it was during intubation. A 65-yr-old man was scheduled for laparotomy. No difficulties with laryngoscopy and intubation were anticipated after a preoperative airway evaluation. The anesthesia induction consisted of lidocaine, propofol, and after a trial of mask ventilation an intubating dose of rocuronium was administered. We were unable to intubate after several attempts at laryngoscopy by two anesthesiologists. A size 4 LMA-Fastrach™ was inserted easily allowing proper lung ventilation. A previously used and tested flexible, wire-reinforced tube (LMA-Fastrach™-endotracheal tube) was advanced through the LMA-Fastrach™, but esophageal placement was suspected after two attempts. While the patient’s lungs were ventilated with the LMA-Fastrach™, a pediatric fiberoptic scope was introduced through the endotracheal tube in situ by using a self-sealing connector. We were unable to advance the fiberoptic scope because of an unidentified obstruction located distally on the tube and visualized with the fiberoptic scope. Under direct manual examination of the tube, an indentation was discovered beneath the intact cuff (Figure 1). Intubation was easily accomplished advancing the fiberoptic scope within a regular 7.5 tracheal tube by using the technique described in the LMA-Fastrach™ instruction manual (2).
It was remarkable that, after an indentation of that degree to a reinforced endotracheal tube, the cuff remained undamaged. This may have contributed to the damage oversight. The LMA-Fastrach™ instructional video (3) makes a complete description in how to test this particular tube before its use.
This includes looking through the tube to identify dents and internal deformities. Careful reexamination of our tube revealed the change in internal diameter. We agree with King et al. (1) about testing the integrity of reused tracheal tubes. Tube examination must include deflating the cuff and looking through the tube.
MD Rafael Miguel MD
1. King PK, Stolp BW, Borel CO. Damage to an armored endotracheal tube introduced via the intubating laryngeal mask airway induced by biting. Anesth Analg 1999; 89:1324–5.
2. Brain AIJ, Verghese Ch. LMA-Fastrach™ instruction manual. Henley-on-Thames, England: The Laryngeal Mask Company, Limited, 1998: 22–4.
3. LMA-Fastrach™ instructional video. Henley-on-Thames, England: The Laryngeal Mask Company, Limited, 1998.