Do Not Remove the Laryngeal Mask Airway

Abstract

In Response: "Airway, airway, airway … who lost the airway?" We appreciate Dr. Alexander's interest in our proposed technique for easy fiberoptic intubation via a laryngeal mask airway (LMA). We recognize his concern about accidental extubation of the patient. However, cutting endotracheal tubes to reduce dead space (common in management of pediatric or intensive care unit patients) or to keep airway equipment away from the surgical field (e.g., during otorhinolaryngologic procedures) is one of many standard airway management techniques. Similarly, most anesthesiologists are familiar with reattaching airway connectors after cutting an endotracheal tube, intubation using a double-lumen tube, or accidential disconnection. We agree that accidential extubation could be catastrophic for patients with difficult airways or those undergoing surgery in positions in which reintubation is impossible. For all tracheally intubated patients, we therefore recommend firmly securing the endotracheal tube and continuous vigilance throughout the period of intubation. We also agree with Dr. Alexander that, for some patients, leaving the LMA in the oropharynx provides an alternative, permitting the use of an endotracheal tube of normal length. However, in cases in which the LMA is present in the surgical field or likely to compromise tissue perfusion (e.g., prolonged intra- and/or postoperative intubation), we anticipate that patient outcome would benefit from LMA removal. Several excellent airway management techniques using a fiberscope are available to the clinician. We believe that we have developed an additional technique that will allow safe removal of the LMA from the oropharynx. The risks posed by Dr. Alexander are associated with all intubated cases and are appreciated by most anesthesiologists, for whom such risk management is familiar clinical experience. Pekka O. Talke, MD Huong Nguyen, RN Department of Anesthesia; University of California San Francisco; San Francisco, CA 94143-0648