Editorial Comment: Postoperative Uvular Edema in a Child After General Anesthesia via a Laryngeal Mask Airway
A
s with most of the devices used to manage the airway, the use of supraglottic airways (SGA) in children (and adults) is not risk free. Potential problems include airway hyperresponsiveness, inadequate ventilation, aspiration of gastric contents, and compression of airway structures. This case of delayed uvular edema demonstrates that complications may occur even though the SGA device appears to be properly positioned. While it is true that an inappropriately positioned SGA may result in compression of airway structures, mucosal injury may still occur when the device is positioned correctly, or when the anesthesiologist does not realize that the device is compressing vulnerable structures, such as the uvula outside of their view. Inflation of the cuff as suggested by the manufacturer may result in inappropriately high intracuff pressures, and seal pressures should be titrated to the minimum necessary to allow adequate ventilatory support. In fact, we have
often observed that the use of lower pressures facilitates molding of the SGA inside the pharynx and may improve the seal. Although seemingly counterintuitive, sometimes when there is a leak around an SGA, the appropriate intervention may be to remove air from the cuff rather than add more air. Monitoring and regulating SGA cuff pressures may minimize the risk of uvular edema. Even so, uvular compression is difficult to diagnose while it is occurring. Therefore, we usually perform a brief reassessment of the position of the SGA after insertion to ensure that it is not compressing sensitive structures. The device should allow proper ventilation and should easily move slightly within the airway without resistance. E John E. Fiadjoe, MD Ronald S. Litman, DO Department of Anesthesiology and Critical Care The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania [email protected]
Accepted for publication August 12, 2013. Copyright © 2014 International Anesthesia Research Society DOI: 10.1097/XAA.0000000000000024
February 15, 2014 • Volume 2 • Number 4
cases-anesthesia-analgesia.org
39
A
s with most of the devices used to manage the airway, the use of supraglottic airways (SGA) in children (and adults) is not risk free. Potential problems include airway hyperresponsiveness, inadequate ventilation, aspiration of gastric contents, and compression of airway structures. This case of delayed uvular edema demonstrates that complications may occur even though the SGA device appears to be properly positioned. While it is true that an inappropriately positioned SGA may result in compression of airway structures, mucosal injury may still occur when the device is positioned correctly, or when the anesthesiologist does not realize that the device is compressing vulnerable structures, such as the uvula outside of their view. Inflation of the cuff as suggested by the manufacturer may result in inappropriately high intracuff pressures, and seal pressures should be titrated to the minimum necessary to allow adequate ventilatory support. In fact, we have
often observed that the use of lower pressures facilitates molding of the SGA inside the pharynx and may improve the seal. Although seemingly counterintuitive, sometimes when there is a leak around an SGA, the appropriate intervention may be to remove air from the cuff rather than add more air. Monitoring and regulating SGA cuff pressures may minimize the risk of uvular edema. Even so, uvular compression is difficult to diagnose while it is occurring. Therefore, we usually perform a brief reassessment of the position of the SGA after insertion to ensure that it is not compressing sensitive structures. The device should allow proper ventilation and should easily move slightly within the airway without resistance. E John E. Fiadjoe, MD Ronald S. Litman, DO Department of Anesthesiology and Critical Care The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania [email protected]
Accepted for publication August 12, 2013. Copyright © 2014 International Anesthesia Research Society DOI: 10.1097/XAA.0000000000000024
February 15, 2014 • Volume 2 • Number 4
cases-anesthesia-analgesia.org
39
