Use of the Laryngeal Mask Airway and Bi-Level Positive Airway Pressure in Postoperative Airway Management

Abstract

To the Editor A 134 kg (body mass index, 39 kg/m2) male with severe obstructive sleep apnea, multiple comorbidities, and inconsistent use of continuous positive airway pressure was scheduled for extensive spine surgery.1 After an uneventful induction of anesthesia and tracheal intubation, he was positioned prone on a Jackson frame. After 4.5 hours of surgery, during which he received 3600 mL crystalloid, he was turned supine and his trachea was extubated when he was fully awake and the residual neuromuscular block was reversed. His eyes and face were swollen and we did not perform a “leak test” to assess whether significant laryngeal edema was present. After 30 minutes in the recovery room, the patient was exhibiting signs of partial airway obstruction (SpO2, 92%–98%) despite a nasopharyngeal airway and manually applied mandibular advancement. Bilevel positive airway pressure (BiPAP Vision, Respironics, Murrysville, PA) using a full facemask with a (titrated) 20/10 cm H2O with 60% oxygen was applied, with little improvement.2 After an hour in the recovery room, his airway and level of consciousness had not improved, still being responsive to loud verbal stimuli. Although carbon dioxide retention was suspected, arterial blood gases were not measured. We did not administer naloxone because of his risk of coronary artery disease. Because we anticipated a likely difficult intubation if we attempted to place an endotracheal tube, we elected to insert a #5 LMA Unique™ (LMA North America, San Diego, CA) to treat the partial airway obstruction. With verbal stimulation and without topical anesthesia or additional sedation, he cooperated by swallowing during insertion of the LMA. Spontaneous ventilation was then assisted with BiPAP 10/5 cm H2O and 60% fraction of inspired oxygen.3,4 Two hours later, without opioids or sedatives, he was alert, cooperative, and comfortable, and facial edema had receded. The LMA was removed with no further complications. This case represents an example of the temporary use of a “supraglottic airway BiPAP” system to treat the postextubation airway obstruction and respiratory failure in an awake, spontaneously breathing, obese patient with obstructive sleep apnea after unsuccessful application of “facemask BiPAP.” When correctly positioned, supraglottic airways will provide an oropharyngeal seal compatible with the use of noninvasive positive pressure ventilation and may be better tolerated and more effective than the nasal or facial mask BiPAP/continuous positive airway pressure interface. John Boncyk, MD Adrian A. Matioc, MD Kathleen Harden, CRNA William S. Middleton Memorial Veterans Medical Center Department of Anesthesiology University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [email protected]