To the Editor: Most techniques for management of a difficult airway require interruption of ventilation. Sometimes, after multiple failed attempts at tracheal intubation, continuous manual ventilation of the patient becomes increasingly difficult. We suggest the combination of a laryngeal mask airway (LMA) and fiberoptic bronchoscope. Using assisted ventilation is a technique that may be useful as it permits intubation of the trachea without interrupting ventilation. The LMA and endotracheal tube (ETT) are preassembled. The 6-mm inner diameter (ID) microlaryngeal ETT (Sheridan Catheter Corp., Argyle, NY; model 5-11112) with its cuff deflated is positioned within the shaft of an LMA No. 4 (Gensia Pharmaceutical Inc., San Diego, CA) with its tip just above the grille. A swivel elbow with self-sealing suction port (Diemolding Healthcare Division, Canastota, NY; model 66-1991) is attached to the 15-mm adapter of the ETT and the other to the anesthesia circuit. The LMA assembly is positioned in the pharynx using a standard technique. An Olympus LF-2 Intubation Scope (Lake Success, NY) is inserted through the port of the swivel elbow into the ETT. As the fiberoptic bronchoscope is advanced, the grille of the LMA, the epiglottis, the arytenoid cartilages, the vocal cords, and the carina are observed in turn. The ETT is then advanced over the fiberoptic scope into the trachea and the scope is withdrawn Figure 1. The ETT is taped to the LMA. The translucent shaft of the LMA allows the ETT markings to be used in optimizing the tube position. The LMA is left in place with its cuff deflated to decrease pressure on the pharyngeal mucosa.Figure 1: Sagittal section line drawing of the fiberoptic bronchoscope-assisted tracheal intubation via the laryngeal mask airway.A LMA has proved to be a useful device in the management of a difficult airway. However, the LMA is not a replacement for an ETT because it does not remove the risks of airway obstruction, laryngospasm, and aspiration [1]. Without addressing the issue of continuous ventilation, tracheal intubation through a LMA has been accomplished with blind passage, an intubating stylet, or a fiberoptic bronchoscope [2]. There has been a recent report with a gum elastic bougie and a fiberoptic bronchoscope each passing through one of two right-angle elbows with membrane-covered access port in tandem [3]. The 6-mm ID microlaryngeal ETT, at 33.5 cm, is 5 cm longer than the standard ETT. When the microlaryngeal ETT is fully inserted into the LMA, it protrudes 12.5 cm past the grille, allowing its cuff to be optimally positioned in the trachea. Microlaryngeal tubes have cuff dimensions and inflation characteristics more appropriate for the normal sized adult. Also, the 6.0-mm ID ETT is preferred because it allows ventilation of the patient with the fiberoptic bronchoscope within its lumen. This trans-LMA placement technique shares the limitations of other trans-LMA techniques. It may be difficult to visualize the larynx if the LMA is not optimally positioned over the laryngeal aperture or if there is blockage by the epiglottis or tongue of the laryngeal aperture [4]. If the epiglottis flops down in front of the grille, the scope must first be directed at the posterior aspect of the LMA opening, advanced slightly, and then redirected anteriorly to view the arytenoid cartilage and vocal cords. In the clinical setting of a difficult intubation during which laryngoscopy has been unsuccessful, this trans-LMA technique for endotracheal intubation provides a reasonable alternative. Linda Chen, MD Scott A. Sher, MD Stanley J. Aukburg, MD University of Pennsylvania School of Medicine Philadelphia, PA 19104