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Unexpected resistance during tracheal tube insertion through the intubating laryngeal mask


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European Journal of Anaesthesiology: June 1999 - Volume 16 - Issue 6 - p 419-420


The intubating laryngeal mask (ILM) is a modification of the conventional laryngeal mask airway which is designed to act as a ventilatory device and an aid for blind tracheal intubation (TI) in patients with normal and abnormal airways [1]. Tracheal intubation through the ILM is a 'blind-on-blind' technique [2], because both the ILM and the tracheal tube (TT) are inserted without direct vision of the larynx. Whenever resistance is felt during TT insertion a variety of strategies may be instituted depending on the likely cause [1]. Different malpositions may be detected by noting the indication of the depth in relation to the transverse marker at which passage of the TT became blocked [1]. According to this management strategy, when resistance is felt at a depth of more than 4 cm the use of a smaller size of ILM is suggested [1]. However, there are some rare causes of resistance which may not be included in this suggested strategy. We would like to report our experience where the use of a light-guided technique for TI through the ILM facilitated the diagnosis in a case of unexpected resistance during TT insertion.

A 75-year-old woman (weight 45 kg, height 152 cm) was scheduled to undergo cholecystectomy under general anaesthesia. After induction with propofol 2.0 mg kg−1, fentanyl 1 μg kg−1 and cisatracurium 0.15 mg kg−1 an ILM size 4 was inserted to act as a ventilatory device and an aid for light-guided intubation by using a prototype illuminated flexible catheter (IFC) [3]. The device of the IFC consists of a completely flexible thin plastic catheter (length 30 cm, external diameter 5 mm), without any metallic component, which at its distal end comprises a bulb of adequate brightness fixed with atoxic glue and silicone. The IFC was placed into a straight flexible TT (Rusch) 7.0 mm ID, in such a way that the bulb protruded from the distal end of the TT [3]. Successful placement of ILM was judged by chest wall movement and capnography, in addition to the ability to deliver a tidal volume of 8 mL kg−1 without a leak at an airway pressure of 20 cmH2O. During insertion of the TT via the ILM we observed a bright glow in the midline at the level of the laryngeal prominence that continued the downward movement, indicating correct placement of the TT in the trachea [4]. However, at the level of the suprasternal notch resistance was felt unexpectedly and although the TT was inside the trachea, the intubation was not completed. We exchanged the TT for a smaller one (6.5 mm ID) and on the second attempt, the TT was inserted without any resistance. Post-operatively, an X-ray of the soft tissues of the neck revealed a tracheal stenosis at the clavicular level.

The use of a light-guided methodology gave us the ability for exact localization of the TT tip. Thereafter the possible cause of resistance in TT passage was diagnosed and a possible TI failure via the ILM was avoided.




Department of Anaesthesiology, Gennimatas and Sotiria Hospitals, Athens, Greece


1 Brain AIJ, Vergese C, Addy EV, Kapila A. The intubating laryngeal mask. II. a preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997; 79: 704-709.
2 Kapila A, Addy EV, Vergese C, Brain AIJ. The intubating laryngeal mask airway: an assessment of performance. Br J Anaesth 1997; 79: 710-713.
3 Dimitriou V, Voyagis GS. Use of a prototype flexible lighted catheter for guided tracheal intubation through the intubating laryngeal mask. Anesth Analg 1999. (In press.)
4 Volmer TP, Stewart RD, Paris PM, Ellis DG, Berkebile PE. Use of a lighted stylet for guided orotracheal intubation in the prehospital setting. Ann Emerg Med 1985; 14: 324-328.
© 1999 European Society of Anaesthesiology