Caution is essential when using a tracheal tube as a stabilizing rod to remove the Intubating Laryngeal Airway (ILA™) after tracheal intubation in children

Abstract

To the Editor, Use of a supraglottic airway device as a conduit for tracheal intubation has changed the practice of pediatric anesthesia, especially in the management of patients with difficult airways. For many years, the Laryngeal Mask Airway (LMA) Classic (LMA North America, San Diego, CA, USA) was the device most commonly used for this purpose in pediatric anesthesia. However, there are some limitations when the LMA is used to facilitate fibreoptic intubation with a cuffed endotracheal tube (ETT), particularly during subsequent removal of the LMA. The Intubating Laryngeal Airway (ILA) (Cookgas LLC, St. Louis, MO, USA) is a new supraglottic airway device that is comparable to the LMA in terms of its ease of insertion and functionality, but with a conduit sufficient in size to accommodate a larger cuffed ETT. There are no intubating LMAs currently available for patients weighing \30 kg, and the ILA, which is available in pediatric sizes, can be used to facilitate tracheal intubation in these patients. A Stabilizer Rod is used to facilitate removal of the LMA after successful tracheal intubation. Like the LMA, the ILA has a Removal Stylet available to steady the ETT during removal of the ILA device. The ILA lumen is of sufficient size to accommodate the Stylet and the pilot balloon of the ETT during withdrawal of the ILA (Figure 1A-C). In clinical practice, however, an uncuffed ETT is often used in lieu of the manufacturer’s removal stylet when removing the LMA or ILA after using either as a conduit for tracheal intubation in children (Figure 1D-F). The ILA lumen cannot accommodate both the pilot balloon and the ETT during ILA withdrawal (Figure 1F), and entrapment of the pilot balloon within the airway tube may lead to cuff line rupture if the ILA is withdrawn further in that situation. The disadvantages of using two tracheal tubes include the potential for cuff line rupture or inadvertent ETT dislodgement upon removal of the ILA. To avoid either situation, control of the distal cuffed ETT must be maintained while the proximal ETT is first removed from the ILA (Figure 1E). After that, the cuff line and the pilot balloon can pass through the ILA airway tube unhindered. This is of particular importance in the management of the difficult airway, where the initial securing of the airway may have been difficult and where re-intubation may be accompanied by untoward problems. It is convenient to use a second ETT as a stabilizing rod for removal of the ILA after successful tracheal intubation, because an ETT is readily available in the operating room and is used commonly when removing the LMA-Classic after tracheal intubation in pediatric patients. As the ILA and tracheal intubation with cuffed ETTs become more common in pediatric anesthesia, awareness of the limitations of using an ETT as a stabilizing rod to assist in removal of the ILA is clinically important. In our clinical experience of more than 100 ILA-guided tracheal intubations, we have used a tracheal tube primarily as a stabilizing rod when removing the ILA. However, we have encountered difficulty when removing the ILA with the use N. Jagannathan, MD (&) M. F. Kho, MS Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA e-mail: simjag2000@yahoo.com