Correspondence
Anaesthesia 2015, 70, 997–1010
References 1. Sinner B, Becke K, Engelhard K. General anaesthetics and the developing brain: an overview. Anaesthesia 2014; 69: 1009–22. 2. Rappaport BA, Suresh S, Hertz S, Evers AS, Orser BA. Anesthetic neurotoxicity – clinical implications of animal models. New England Journal of Medicine 2015; 372: 796–7. doi:10.1111/anae.13152
Suction tube-facilitated videolaryngoscopic intubation We thank Kelly and Seller for sharing their gum-elastic bougie ‘snail’ technique for aiding successful placement of bougies during videolaryngoscopy [1]. Similarly, we frequently find the problem of a superior view but difficulty passing a tracheal tube or bougie when using a curved-blade videolaryngoscope without a conduit (e.g. C-MACâ, Karl Storz GmBH & Co. KG, Tuttlingen, Germany). This becomes particularly problematic
when placing narrow-calibre microlaryngeal tubes or ‘laser tubes’ for airway surgery, as the smaller bougies required lack the rigidity to maintain a curved shape during intubation. We have found that a 22-Fr Yankauer suction tube (Covidien, Mansfield, MA, USA) can function as a useful rigid conduit through which a paediatric 10-Fr bougie (P3 Medical, Bristol, UK) can be passed in such cases, as the curvature of the Yankauer tube is similar to that of the C-MAC blade (Fig. 2). The Yankauer tube can then be removed and the tracheal tube railroaded over the bougie. J. Masters T. Rope Northwick Park Hospital, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
Figure 2 Yankauer sucker over a paediatric bougie to assist videolayngoscopic intubation. © 2015 The Association of Anaesthetists of Great Britain and Ireland
Reference 1. Kelly FE, Seller C. Snail trail. Anaesthesia 2015; 70: 501. doi:10.1111/anae.13170
Fractured laryngeal mask During magnetic resonance imaging (MRI), the reservoir bag attached to T-piece breathing system connected to a size-2 Flexicareâ LarysealTM (Flexicare Medical Ltd, Mountain Ash, UK) MRI laryngeal mask was noted not to be moving, with a flat capnography trace. Insertion of the laryngeal mask had been uneventful. The patient’s breathing appeared unobstructed, SpO2 was normal and there was no immediately apparent disconnection. Ventilating the patient’s lungs via the T-piece was not possible and a large leak was heard from the mouth. Suspecting dislodgement of the laryngeal mask, removal and reinsertion were reattempted, but during removal, the airway tube separated from the cuff (Fig. 3). The cuff remained in the oropharynx, but was easy to retrieve by hand. A new laryngeal mask was inspected and inserted, and anaesthesia continued uneventfully. The Medicines and Healthcare products Regulatory Agency (MHRA) was notified and devices with the same batch number were withdrawn from circulation. To our knowledge, this is only the second reported case of such a failure in a single-use laryngeal mask [1], although there have been several case reports of breakages of re-usable devices [2–5]. Although 1003
Anaesthesia 2015, 70, 997–1010
Correspondence
Figure 3 Fractured laryngeal mask.
our case resulted in no harm to the patient, there was potential for disaster. The remote location meant that additional airway equipment was not as readily available as it is in theatre. Ferromagnetic Magill’s forceps would not have been able to be used in such close proximity to the MRI machine, and it was fortunate that the cuff was easily grasped by hand and removed. Loss of continuity with the breathing system could have resulted in hypoxia, laryngospasm and awareness. Flexicare Medical Ltd was unable to determine a specific root cause for the failure but have strengthened its manufacturing inspection and included additional controls as a result. We suggest that in addition to the usual visual inspection, devices are gently checked for integrity by applying traction across every junction of the individual components. M. Steynor M. Babb Royal Stoke University Hospital, Stoke-on-Trent, UK Email: [email protected] 1004
No external funding and no competing interests declared.
References 1. Spielman FJ. Complete separation of the tube from the mask during removal of a disposable laryngeal mask airway. Canadian Journal of Anesthesia 2002; 49: 990–2. 2. Simon BP. A case of breakage of LMA Supreme on its first use. Indian Journal of Anaesthesia 2011; 50: 635–6. 3. Zavaratto M. LMA failure. Anaesthesia and Intensive Care 1996; 24: 119. 4. Vickers R. Problem with the laryngeal mask airway. Anaesthesia 1992; 47: 639. 5. Wong DR. Fractured laryngeal mask airway. Canadian Journal of Anesthesia 2000; 47: 716. doi:10.1111/anae.13147
New forceps for videolaryngoscopic intubation In their editorial, Fitzgerald et al. describe the potential of, and challenges during, videolaryngoscopic intubation [1]. Use of a bougie, however, does not always facilitate
videolaryngoscopic intubation as the authors describe. Furthermore, the use of new techniques may present further challenges, requiring the development of newer adjuncts to assist intubation [2]. Magill’s forceps were not designed for videolaryngoscopy, and modified Magill’s forceps [2] (with blade deviation towards one side) may harm the patient. I have developed forceps, therefore, specifically designed for videolaryngoscopy using an optic system with a screen view. So far, these have been tested on manikins and patented at the Swedish Patent Office [3] (SE 1200730-8; published under SE1200730 A1), but not tested in humans. Figure 4a provides a sketch of the new forceps positioned in the mouth. When the forceps are introduced in the midline, parallel to the videolaryngoscope blade, their tip is readily seen on a video screen. The forceps can also be used during direct laryngoscopy, but if the tip of the epiglottis is not visible, my experience is that conversion to videolaryngoscopy is advisable. The forceps are 23 cm long (adult), and curved twice in the sagittal plane (Fig. 4b). Unlike the Magill’s, these forceps have a locking mechanism to avoid finger fatigue during prolonged manipulation. The grip of the forceps is smooth and the jaw has a large surface area to avoid damaging the tube cuff and bronchoscope surface. The forceps can be used to grip and manipulate bougies, tracheal tubes, transoesophageal echocardiography probes, gastric tubes and bronchoscopes, with the tip of the
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2015, 70, 997–1010
References 1. Sinner B, Becke K, Engelhard K. General anaesthetics and the developing brain: an overview. Anaesthesia 2014; 69: 1009–22. 2. Rappaport BA, Suresh S, Hertz S, Evers AS, Orser BA. Anesthetic neurotoxicity – clinical implications of animal models. New England Journal of Medicine 2015; 372: 796–7. doi:10.1111/anae.13152
Suction tube-facilitated videolaryngoscopic intubation We thank Kelly and Seller for sharing their gum-elastic bougie ‘snail’ technique for aiding successful placement of bougies during videolaryngoscopy [1]. Similarly, we frequently find the problem of a superior view but difficulty passing a tracheal tube or bougie when using a curved-blade videolaryngoscope without a conduit (e.g. C-MACâ, Karl Storz GmBH & Co. KG, Tuttlingen, Germany). This becomes particularly problematic
when placing narrow-calibre microlaryngeal tubes or ‘laser tubes’ for airway surgery, as the smaller bougies required lack the rigidity to maintain a curved shape during intubation. We have found that a 22-Fr Yankauer suction tube (Covidien, Mansfield, MA, USA) can function as a useful rigid conduit through which a paediatric 10-Fr bougie (P3 Medical, Bristol, UK) can be passed in such cases, as the curvature of the Yankauer tube is similar to that of the C-MAC blade (Fig. 2). The Yankauer tube can then be removed and the tracheal tube railroaded over the bougie. J. Masters T. Rope Northwick Park Hospital, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
Figure 2 Yankauer sucker over a paediatric bougie to assist videolayngoscopic intubation. © 2015 The Association of Anaesthetists of Great Britain and Ireland
Reference 1. Kelly FE, Seller C. Snail trail. Anaesthesia 2015; 70: 501. doi:10.1111/anae.13170
Fractured laryngeal mask During magnetic resonance imaging (MRI), the reservoir bag attached to T-piece breathing system connected to a size-2 Flexicareâ LarysealTM (Flexicare Medical Ltd, Mountain Ash, UK) MRI laryngeal mask was noted not to be moving, with a flat capnography trace. Insertion of the laryngeal mask had been uneventful. The patient’s breathing appeared unobstructed, SpO2 was normal and there was no immediately apparent disconnection. Ventilating the patient’s lungs via the T-piece was not possible and a large leak was heard from the mouth. Suspecting dislodgement of the laryngeal mask, removal and reinsertion were reattempted, but during removal, the airway tube separated from the cuff (Fig. 3). The cuff remained in the oropharynx, but was easy to retrieve by hand. A new laryngeal mask was inspected and inserted, and anaesthesia continued uneventfully. The Medicines and Healthcare products Regulatory Agency (MHRA) was notified and devices with the same batch number were withdrawn from circulation. To our knowledge, this is only the second reported case of such a failure in a single-use laryngeal mask [1], although there have been several case reports of breakages of re-usable devices [2–5]. Although 1003
Anaesthesia 2015, 70, 997–1010
Correspondence
Figure 3 Fractured laryngeal mask.
our case resulted in no harm to the patient, there was potential for disaster. The remote location meant that additional airway equipment was not as readily available as it is in theatre. Ferromagnetic Magill’s forceps would not have been able to be used in such close proximity to the MRI machine, and it was fortunate that the cuff was easily grasped by hand and removed. Loss of continuity with the breathing system could have resulted in hypoxia, laryngospasm and awareness. Flexicare Medical Ltd was unable to determine a specific root cause for the failure but have strengthened its manufacturing inspection and included additional controls as a result. We suggest that in addition to the usual visual inspection, devices are gently checked for integrity by applying traction across every junction of the individual components. M. Steynor M. Babb Royal Stoke University Hospital, Stoke-on-Trent, UK Email: [email protected] 1004
No external funding and no competing interests declared.
References 1. Spielman FJ. Complete separation of the tube from the mask during removal of a disposable laryngeal mask airway. Canadian Journal of Anesthesia 2002; 49: 990–2. 2. Simon BP. A case of breakage of LMA Supreme on its first use. Indian Journal of Anaesthesia 2011; 50: 635–6. 3. Zavaratto M. LMA failure. Anaesthesia and Intensive Care 1996; 24: 119. 4. Vickers R. Problem with the laryngeal mask airway. Anaesthesia 1992; 47: 639. 5. Wong DR. Fractured laryngeal mask airway. Canadian Journal of Anesthesia 2000; 47: 716. doi:10.1111/anae.13147
New forceps for videolaryngoscopic intubation In their editorial, Fitzgerald et al. describe the potential of, and challenges during, videolaryngoscopic intubation [1]. Use of a bougie, however, does not always facilitate
videolaryngoscopic intubation as the authors describe. Furthermore, the use of new techniques may present further challenges, requiring the development of newer adjuncts to assist intubation [2]. Magill’s forceps were not designed for videolaryngoscopy, and modified Magill’s forceps [2] (with blade deviation towards one side) may harm the patient. I have developed forceps, therefore, specifically designed for videolaryngoscopy using an optic system with a screen view. So far, these have been tested on manikins and patented at the Swedish Patent Office [3] (SE 1200730-8; published under SE1200730 A1), but not tested in humans. Figure 4a provides a sketch of the new forceps positioned in the mouth. When the forceps are introduced in the midline, parallel to the videolaryngoscope blade, their tip is readily seen on a video screen. The forceps can also be used during direct laryngoscopy, but if the tip of the epiglottis is not visible, my experience is that conversion to videolaryngoscopy is advisable. The forceps are 23 cm long (adult), and curved twice in the sagittal plane (Fig. 4b). Unlike the Magill’s, these forceps have a locking mechanism to avoid finger fatigue during prolonged manipulation. The grip of the forceps is smooth and the jaw has a large surface area to avoid damaging the tube cuff and bronchoscope surface. The forceps can be used to grip and manipulate bougies, tracheal tubes, transoesophageal echocardiography probes, gastric tubes and bronchoscopes, with the tip of the
© 2015 The Association of Anaesthetists of Great Britain and Ireland
![[ORL laryngeal mask].](/assets/img/hold.png)
