CobraPLA as a conduit for flexible bronchoscopy in a child under general anaesthesia

Abstract

Editor—A 2-yr-old, 17 kg girl presented with episodes of cough and stridor. The chest X-ray was negative. No other significant medical history was reported. A possible diagnosis of foreign body aspiration was made and a bronchoscopy under general anaesthesia was planned. Anaesthesia was induced with sevoflurane in oxygen 100%, i.v. access was established and a size 2 LMA® †LMA® is the property of Intavent Limited. was inserted without difficulty. Ventilation was easy, with a leak pressure of 17 cm H2O. A paediatric bronchoscope was introduced through the LMA while the patient was breathing spontaneously isoflurane 1.5% in oxygen 100% but the vocal cords could not be visualized—score 1 on the Brimacombe scale.1Brimacombe J Berry A A proposed fiber-optic scoring system to standardize the assessment of laryngeal mask airway position.Anesth Analg. 1993; 76: 457PubMed Google Scholar The LMA was removed and reinserted, ventilation was satisfactory, but vocal cord visualization failed again. At this stage a CobraPLA size 1.5 was inserted without difficulties, ventilation was easy with a leak pressure of 28 cm H2O. The bronchoscope was introduced through the CobraPLA, the cords visualized (score 4 on the Brimacombe scale) and advanced into the larynx. No foreign body was found. The isoflurane was discontinued, the CobraPLA was removed and the patient recovered without complications. †LMA® is the property of Intavent Limited. CobraPLA (Engineered Medical System, Indianapolis, IN, USA) is a new supraglottic device that may have some advantages over the LMA: (i) it may be easier to insert than the LMA with no need for any airway manipulation;2Agro F Barzoi G Carassiti M Galli B Getting the tube in the oesophagus and oxygen in the trachea: preliminary results with the new supraglottic device (Cobra) in 28 anaesthetised patients.Anaesthesia. 2003; 58: 920-921Crossref PubMed Scopus (30) Google Scholar3Agro F Barzoi G Galli B The CobraPLA™ in 110 anaesthetized and paralysed patients: what size to choose?.Br J Anaesth. 2004; 92: 777-778Crossref PubMed Scopus (32) Google Scholar (ii) it may be more stable owing to the CobraPLA's ‘head’, which lies on the posterior pharynx and does not allow rotation; (iii) it has a good airway seal, permitting use of higher airway pressure in case positive pressure ventilation is necessary;3Agro F Barzoi G Galli B The CobraPLA™ in 110 anaesthetized and paralysed patients: what size to choose?.Br J Anaesth. 2004; 92: 777-778Crossref PubMed Scopus (32) Google Scholar and (iv) larger tube diameter and shorter tube length than the LMA permitting positioning of a larger endotracheal tube.3Agro F Barzoi G Galli B The CobraPLA™ in 110 anaesthetized and paralysed patients: what size to choose?.Br J Anaesth. 2004; 92: 777-778Crossref PubMed Scopus (32) Google Scholar An LMA is a safe and effective adjunct to fibreoptic bronchoscopy under general anaesthesia in children.4Yazbeck-Karam VG Aouad MT Baraka AS Laryngeal mask airway for ventilation during diagnostic and interventional fibreoptic bronchoscopy in children.Paediatr Anaesth. 2003; 13: 691-694Crossref PubMed Scopus (28) Google Scholar In one study,5Rowbottom SJ Simpson DL Grubb D The laryngeal mask airway in children. A fibreoptic assessment of positioning.Anaesthesia. 1991; 46: 489-491Crossref PubMed Scopus (123) Google Scholar appropriate positioning, as judged by fibreoptic laryngoscopy, was achieved in 49% of patients. CobraPLA was compared with the LMA and PAXexpress in adult patients, and proved to have a more effective seal and a better fiberoptic score.6Gaitini LA Somri MJ Kersh K A comparison of Laryngeal Mask Airway Unique™, Pahryngeal Airway Xpress™, and Perilaryngeal Airway Cobra™ in paralyzed anesthetized adult patients.Anesthesiology. 2003; 99: A1495Google Scholar In adults, Akça and colleagues7Akça O Wadhwa A Sengupta P et al.The new perilaryngeal airway (CobraPLA) is as efficient as the laryngeal mask airway (LMA) but provides better airway sealing pressures.Anesth Analg. 2004; 99: 272-278Crossref PubMed Scopus (86) Google Scholar found both LMA and PLA gave an equally good laryngeal view. In children, the there are no comparative data available and conclusions cannot be drawn from a single case. Nevertheless, with the new supraglottic devices on the market, anaesthesiologists have another option available. In conclusion, CobraPLA can be used as an alternative to LMA for flexible bronchoscopy in children under general anaesthesia.