A Proposed Algorithm for the Management of Airway Obstruction with the Proseal??? Laryngeal Mask Airway

Abstract

To the Editor: Airway obstruction is a common problem after ProSeal™ laryngeal mask airway insertion, with a frequency of between 2% (1) and 10% (2). The management depends on the etiology, which includes reflex glottic closure (deepen anesthesia or administer a muscle relaxant), epiglottic downfolding (reinsertion with maintained laryngoscopy (3) or jaw thrust (4)), glottic/supraglottic compression (5) (jaw thrust, cuff deflation or reinsertion using a smaller size), infolding of the ventral cuff (6) (cuff deflation or reinsertion using a smaller size), and malposition (reinsertion using a guided technique) (7). Distinguishing among these etiologies are the tests for malposition and mechanical obstruction. The malposition tests are only required after nonguided insertion and comprise: (i) checking for air leaks up the drain tube during positive pressure ventilation, (ii) assessing the position of the bite block in relation to the incisors (8), and (iii) the suprasternal notch tap test (9). The mechanical obstruction tests comprise: (i) jaw thrust, which decompresses the pharynx and elevates the epiglottis, and (ii) deflating the cuff, which decompresses the glottis and reduces cuff infolding (10). The algorithm synthesizes these tests to facilitate the diagnosis and management of airway obstruction with the ProSeal™ laryngeal mask airway (Fig. 1).Figure 1.: Algorithm synthesizing tests to facilitate the diagnosis and management of airway obstruction with ProSeal™ laryngeal mask airway.J. Brimacombe, MD Department of Anaesthesia and Intensive Care James Cook University Cairns Base Hospital Cairns, Australia [email protected] C. Keller, MD Department of Anaesthesia and Intensive Care Medicine Leopold-Franzens University Innsbruck, Austria