Correspondence
1 107
subject of a previous report [I]. However, on that occasion, the fault was a t the proximal end of the tube rather than the connector. Although occasional faults will occur in mass produced disposable equipment [2],I was particularly concerned that this appears to have affected a whole batch of tracheal tubes. Royal United Hospital. Bath BAI 3NG
A. LIM
References [ I ] SMITHMB, WATTSJD. Splitting tubes. Anaesrhesia 1992; 47: 363.
Fig. 1.
[2] HANNINGTON-KIFF JG. Faulty Superset plastic catheter mounts. Anaesthesia 1991; 46: 671-2.
The Humphrey ADE breathing system and paediatric anaesthesia
We noted with interest the suggestion by Dr Humphrey (Anaesthe.7ia 1992; 47: 640-1) concerning the use of the Humphrey ADE breathing system to reduce pollution in the operating room during dental anaesthesia. We recently evaluated [I] the use of this system in children and would agree with the above proposal in that scavenging is easy with this system. Although we concluded that this system is suitable for use in children, we did not recommend its use, as claimed. We still feel that the Jackson-Rees modification of the Ayre’s T-piece is the ‘gold standard’ for use in paediatric anaesthesia. We were also interested that Dr Humphrey found that hand ventilation in the A mode in adults worked particularly well (Anac~sthesia1992; 47: 625). We found that in children hand ventilation in the A mode was less predictably efficient [I]. While the mean end-tidal partial pressure of carbon dioxide was 5.3 kPa, the range
was 4.1 to 7.7 kPa. Bearing in mind that switching to hand ventilation often occurs at more critical moments, higher fresh gas flows should be used in this mode during paediatric anaesthesia. Guy’s Hospital, London SEI 9RT Hospitals for Sick Children, Greot Ormond Street, London W C l N 3JH
C.E.P. ORLIKOWSKI R.M. BINGHAM
Reference [ I ] OKLIKOWSKI CEP. EWARTMC, BINGHAM RM. The Humphrey ADE system: evaluation in paediatric use. Britkh Journal qf Anursthesiu 1991; 66: 253-7.
Salbutamol via the laryngeal mask airway for relief of bronchospasm
We would like to report a method for administration of salbutamol via the laryngeal mask airway (LMA) for relief of intra-operative bronchospasm. A 63-year-old man scheduled for cystoscopy and with a history of chronic obstructive airways disease underwent general anaesthesia. Following premedication with temazepam, anaesthesia was induced with propofol and fentanyl and a size 4 LMA was introduced easily using the standard technique. Anaesthcsia was maintained with nitrous oxide, oxygen and isoflurane. ventilation being spontaneous. Towards the end of the procedure it was noted that the patient had a markedly prolonged expiratory phase with straining. Auscultation revealed widespread wheeze despite an endtidal isoflurane concentration of I .2%. A salbutamol aerosol (Ventolin inhaler: Allen and Hanbury) was connected to an 8 inch disposable Xylocaine spray nozzle (Astra B0643). the LMA was disconnected from the breathing system and the apparatus inserted down the LMA. Three metered doses (300 p g ) were administered synchronously with inspiration and rapid improvement of the patient’s condition resulted. Within 3 min there was no audible wheeze and the patient awoke breathing comfortably. Before insertion down the LMA. a slight curve may be
moulded at the end off the spray nozzle, the length of which is sufficient to protrude beyond the mask aperture bars. Brimacombe [ I ] reported up to 70% of patients with the LMA in situ had some part of the epiglottis visible from the end of the LMA. Therefore it is probably best to keep the end of the nozzle 1-2 cm proximal to the mask aperture bars to allow maximal amount of bronchodilator aerosol to enter the distal bronchial tree. This manoeuvre would also minimize the theoretical risk of precipitating laryngospasm following deposition of aerosol on the vocal cords. If using a closed circuit breathing system or during intermittent positive pressure ventilation via the LMA, a connector with bronchoscopy cap may be used to achieve drug delivery. Royal Perth Hospital, Prrth , WiJstern Australia 6001
B.T. SPAIN R . H . RILEY
R
1 107
subject of a previous report [I]. However, on that occasion, the fault was a t the proximal end of the tube rather than the connector. Although occasional faults will occur in mass produced disposable equipment [2],I was particularly concerned that this appears to have affected a whole batch of tracheal tubes. Royal United Hospital. Bath BAI 3NG
A. LIM
References [ I ] SMITHMB, WATTSJD. Splitting tubes. Anaesrhesia 1992; 47: 363.
Fig. 1.
[2] HANNINGTON-KIFF JG. Faulty Superset plastic catheter mounts. Anaesthesia 1991; 46: 671-2.
The Humphrey ADE breathing system and paediatric anaesthesia
We noted with interest the suggestion by Dr Humphrey (Anaesthe.7ia 1992; 47: 640-1) concerning the use of the Humphrey ADE breathing system to reduce pollution in the operating room during dental anaesthesia. We recently evaluated [I] the use of this system in children and would agree with the above proposal in that scavenging is easy with this system. Although we concluded that this system is suitable for use in children, we did not recommend its use, as claimed. We still feel that the Jackson-Rees modification of the Ayre’s T-piece is the ‘gold standard’ for use in paediatric anaesthesia. We were also interested that Dr Humphrey found that hand ventilation in the A mode in adults worked particularly well (Anac~sthesia1992; 47: 625). We found that in children hand ventilation in the A mode was less predictably efficient [I]. While the mean end-tidal partial pressure of carbon dioxide was 5.3 kPa, the range
was 4.1 to 7.7 kPa. Bearing in mind that switching to hand ventilation often occurs at more critical moments, higher fresh gas flows should be used in this mode during paediatric anaesthesia. Guy’s Hospital, London SEI 9RT Hospitals for Sick Children, Greot Ormond Street, London W C l N 3JH
C.E.P. ORLIKOWSKI R.M. BINGHAM
Reference [ I ] OKLIKOWSKI CEP. EWARTMC, BINGHAM RM. The Humphrey ADE system: evaluation in paediatric use. Britkh Journal qf Anursthesiu 1991; 66: 253-7.
Salbutamol via the laryngeal mask airway for relief of bronchospasm
We would like to report a method for administration of salbutamol via the laryngeal mask airway (LMA) for relief of intra-operative bronchospasm. A 63-year-old man scheduled for cystoscopy and with a history of chronic obstructive airways disease underwent general anaesthesia. Following premedication with temazepam, anaesthesia was induced with propofol and fentanyl and a size 4 LMA was introduced easily using the standard technique. Anaesthcsia was maintained with nitrous oxide, oxygen and isoflurane. ventilation being spontaneous. Towards the end of the procedure it was noted that the patient had a markedly prolonged expiratory phase with straining. Auscultation revealed widespread wheeze despite an endtidal isoflurane concentration of I .2%. A salbutamol aerosol (Ventolin inhaler: Allen and Hanbury) was connected to an 8 inch disposable Xylocaine spray nozzle (Astra B0643). the LMA was disconnected from the breathing system and the apparatus inserted down the LMA. Three metered doses (300 p g ) were administered synchronously with inspiration and rapid improvement of the patient’s condition resulted. Within 3 min there was no audible wheeze and the patient awoke breathing comfortably. Before insertion down the LMA. a slight curve may be
moulded at the end off the spray nozzle, the length of which is sufficient to protrude beyond the mask aperture bars. Brimacombe [ I ] reported up to 70% of patients with the LMA in situ had some part of the epiglottis visible from the end of the LMA. Therefore it is probably best to keep the end of the nozzle 1-2 cm proximal to the mask aperture bars to allow maximal amount of bronchodilator aerosol to enter the distal bronchial tree. This manoeuvre would also minimize the theoretical risk of precipitating laryngospasm following deposition of aerosol on the vocal cords. If using a closed circuit breathing system or during intermittent positive pressure ventilation via the LMA, a connector with bronchoscopy cap may be used to achieve drug delivery. Royal Perth Hospital, Prrth , WiJstern Australia 6001
B.T. SPAIN R . H . RILEY
R
