Safety and efficacy of laryngeal mask airways during tracheostomy

Abstract

We read Price et al.'s report discouraging use of the laryngeal mask (LMA) during percutaneous dilatational tracheostomy with interest 1, as we have used a LMA Unique™ for this technique as standard practice for over a year. None of the 32 unselected critically ill patients that we have treated so far have experienced significant deterioration of cardiorespiratory function, and we have only experienced problems with the airway seal in one patient, who had a body mass index of over 30 kg.m−2 and required high ventilatory pressures, for whom tracheal intubation was required. We have used the correct size of LMA according to the manufacturer's instructions, but stabilise it by routinely inserting a cylinder of gauze on each side and securing it with tape. This reduces air leak, avoiding any clinically relevant derecruitment during tracheostomy. Subsequent fibreoptic bronchoscopy enables transillumination of soft tissue and tracheal structures at the tracheostomy site, as previously identified by clinical and ultrasonographic examination, and confirms correct placement of the PercuTwist tracheostomy tube, under direct vision. We suggest, therefore, that the problems Price et al. report may be due to either their choice of the LMA Supreme™ or their patient selection. Furthermore, we disagree with the authors that positioning the tracheal tube above the vocal cords during tracheostomy is safe, because this ‘traditional’ method does not guarantee airway protection, can facilitate complete tracheal tube dislodgment with potentially severe consequences, and could lead to cuff-related damage to the laryngeal structures. Price et al. are to be congratulated on adding valuable evidence to the published data in this area, but as our experience shows, it is too early to discount LMA-assisted percutaneous dilational tracheostomy as a safe alternative to ‘traditional’ tracheostomy.