Kinking of the proximal end of a nasal RAE tube after intubation via laryngeal mask airway: an alternative stabilization approach.

Abstract

Department of Anesthesiology and General Intensive Care, University of Vienna, Wahringer Gurtel 18–20, Vienna, A-1090, Austria.To the Editor:-Tracheal insertion of an endotracheal tube (ETT) via laryngeal mask airway (LMA) to manage the difficult airway has been recently described. [1] This method requires additional custom-made tools. One drawback or disadvantage in using a 34- to 35-cm long nasal RAE (developed by the medical professionals Ring, Adair, and Elwyn) to perform tracheal intubation via LMA is kinking of the 2- to 5-cm long protruding part of the ETT at the proximal connector of the LMA as described by Roth and Benumof. [2] To avoid this kinking, Roth and Benumof [2] suggest the use of a readily available standard 15-mm internal diameter, male-to-male anesthesia circle hosing adapter to stabilize the proximal part of the ETT protruding from the LMA shaft. [2] Although simple and useful, this solution is not perfect. If the patients's trachea is very short, the proximal part of the 34- to 35-cm nasal RAE may be more than 5 cm outside of the LMA shaft. In these patients, the anesthesia circle hosing adapter is not long enough to stabilize the tube, and it may act as a fulcrum, possibly kinking the proximal part of the ETT. Further, when the LMA is removed, the patient's upper teeth may act as another fulcrum, risking a kink of the ETT still in place.Additionally, the extra length of the ETT increases the danger of kinking caused by the weight of the heat and moisture exchanger, y-piece, and breathing tubes.To avoid kinking of the ETT as described previously, we would recommend using a commercially available special support (Holder Ulm Pattern, Rusch Incorporated, GA;Figure 1), which is fixed to the standard rails of the operation table with a clamp. The level of this support is adjustable according to the length of the protruding part of the tube. This guarantees that the ETT can be guided straight, regardless of its length.In addition, the Holder Ulm Pattern carries the weight of the heat and moisture exchanger, y-piece, and breathing tubes. Electrocardiogram, pulse oximetry, and other lines can be fitted comfortably at the holder's recesses. In our experience, the Holder Ulm Pattern is an extremely useful device in clinical anesthetic routine as it completely avoids the problem of kinking the ETT.Carsten A. Preis, M.D.Department of Anesthesiology and General Intensive Care; University of Vienna; Wahringer Gurtel 18–20; Vienna, A-1090; Austria(Accepted for publication April 25, 1997.)