The Laryngeal Mask Airway for Airway Management During Percutaneous Tracheostomy: Everything Should Be Made as Simple as Possible but Not Simpler

Abstract

To the Editor: In a retrospective study of 274 critically ill patients, Cattano et al. (1) compared the complication rate of the classic laryngeal mask airway (LMA) and the endotracheal tube for airway management during percutaneous tracheostomy. They reported that acute complications were significantly more frequent when an endotracheal was used for airway management during percutaneous tracheostomy (6 of 66 [LMA] vs 4 of 188 [endotracheal tube]), and concluded from their data that “the classic LMA is a safe and effective alternative to the endotracheal tube for airway management during guidewire dilating forceps percutaneous tracheostomy in selected patients.” We have two major concerns regarding these conclusions. First, it seems imprudent to remove a secure airway in critically ill patients as this population is at high risk for difficult intubation (2). Second, the endotracheal tube during percutaneous tracheostomy may become life-saving in case of severe bleeding or posterior tracheal wall perforation by bridging the defect (3). The results of retrospective study by Cattano et al. (1) are biased toward a lower incidence of complications in the LMA group as treatments were not randomized. The LMA was not used “if the anesthesiologist preferred an endotracheal tube.” Thus, more experienced anesthesiologists may have chosen the LMA approach, whereas less experienced colleagues chose the more traditional method using the endotracheal tube. Additionally, patients in the endotracheal tube group had more difficult airways, as outlined by the authors. Finally, the complication rate of approximately 10% in the endotracheal tube group is high, suggesting that the authors were still learning the technique (4). The authors study design does not allow to us draw any conclusion as to whether or not percutaneous tracheostomy with an LMA is a “safe and effective alternative to the endotracheal tube.” Even in the hand of the most experienced anesthesiologists, percutaneous tracheostomy is associated with a risk of life-threatening complications such as bleeding and air leakage. An endotracheal tube provides a safe and adaptable airway throughout the procedure, whereas the LMA puts the patient at additional aspiration risk. The use of a LMA for airway management during percutaneous tracheostomy may be simple during an uncomplicated procedure, but too simple if the procedure is compromised by life-threatening complications. Martin Beiderlinden, MD Matthias Eikermann, MD Klinik für Anästhesiologie und Intensivmedizin Universitätsklinikum Essen Essen, Germany [email protected]