Department of Anaesthesia, Frenchay Hospital, Bristol BS16 1LE, UK
LMA® is the property of Intavent Limited.
Accepted for publication: January 29, 2001
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Abstract |
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Br J Anaesth 2001; 86: 88691
Keywords: complications, cardiorespiratory arrest; equipment, combitube; complications, cervical spine immobilization
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Introduction |
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The Combitube (Fig. 1) is a twin lumen device that is inserted blindly into the oropharynx. Each lumen is named to correspond to the position it will be in when used for ventilation of the lungs. One lumen (the tracheal lumen) opens distally, the second (the oesophageal lumen) opens at more proximally placed side ports. A large inflatable cuff (85100 ml) is sited proximal to the side ports, whilst a small inflatable cuff (1215 ml) is sited distally. It is usually positioned with the smaller cuff in the oesophagus,2 3 such that ventilation of the lungs occurs through the proximal side ports, with the larger cuff sealing the hypopharynx.
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Case report |
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His medications were warfarin 5 mg daily, amiodarone 100 mg daily, bumetanide 2 mg daily, enalapril 20 mg daily, bendrofluazide 2.5 mg daily and temazepam 1020 mg at night. He was a non-smoker.
On examination at the referring hospital, he was dehydrated, with an arterial pressure of 100/60 mm Hg, and pulse of 80 beats min1 in atrial fibrillation. There was a mitral regurgitant murmur and the jugular venous pressure was 5 cm. Neurological examination was normal. INR was 4.4 (normal range 0.91.3), plasma urea 31.8 mmol litre1, and creatinine 380 mmol litre1.
At the neurosurgical centre the warfarin was stopped, and cautious i.v. rehydration commenced. An early decision was taken to adopt conservative, non-surgical, therapy for this man in view of his debilitating intercurrent morbidities.
On day 2, x-rays revealed the cervical alignment to be inadequate warranting further manipulation of the craniocervical junction into flexion of approximately 510 degrees in the halo frame, such that the odontoid peg and body of C1 would be moved anteriorly on C2. The patient was kept nil-by-mouth for 6 h. On the ward during the procedure, he became increasingly tachypnoeic with peripheral oxygen saturation decreasing to 60% despite administration of a high flow of oxygen by Hudson mask. This was followed by a deterioration in conscious level and obstruction of the airway.
Anaesthetic assistance was urgently requested and the ward emergency airway trolley immediately made available. Bag-valve-mask ventilation was found to be impossible. A good mask to face seal was possible, but the airway remained obstructed despite the use of oro- and naso-pharyngeal airways, and oral suctioning. The patient was noted to have unrestricted mouth opening and full dentition. I.v. propofol 20 mg followed by succinylcholine 100 mg was given. With a Macintosh 3 blade, the epiglottis was not visible (Cormack and Lehane grade 4) but nothing was seen that could have caused airway obstruction. As other laryngoscope blades were not contained in the emergency trolley, the procedure was abandoned. A size 4 LMA was then successfully placed at the first attempt. With restoration of the airway, and bag-valve ventilation of the lungs through the LMA with 100% oxygen, peripheral resaturation to 100% occurred. Cardiac output was not lost at any stage. I.v. vecuronium 10 mg was given, and manual ventilation continued. The patient was transferred to the intensive care unit for artificial ventilation of the lungs. Sedation was maintained with a 1% propofol i.v. infusion at 1020 ml h1. Fibreoptic visualization of the vocal cords and trachea was possible through the LMA, enabling a size 6-cuffed tracheal tube to be passed over the fibrescope to secure the airway. This tube was then removed over a gum elastic bougie and replaced by a size 9-cuffed tracheal tube. At this stage, the patient was seen to move all four limbs.
The morning of the following day (day 3), further fluoroscopic reduction of the cervical spine involving 510 degrees of craniocervical flexion in the halo frame, was undertaken in the operating theatre. Again, all limbs were seen to move after the procedure.
The patient was now breathing spontaneously on the Siemens Servo 300 ventilator at a rate of 18 bpm with triggered pressure support/positive end-expiratory pressure assistance of 12/5 cm H2O, generating tidal volumes of 7 8 ml kg1. With an inspired oxygen concentration of 40%, peripheral oxygen saturation was 99% and arterial carbon dioxide partial pressures less than 6.6 kPa. He was obeying commands with open eyes, and was coughing on the tracheal tube. Arterial pressure was 140/80 mm Hg. Following pre-oxygenation for 3 min, and oral and tracheal suctioning, he was extubated and given high flow oxygen by reservoir bag mask. Tachypnoea immediately followed, with peripheral oxygen saturations decreasing to 70%. His conscious level deteriorated. As before, bag-valve-mask ventilation was unsuccessful as the airway was obstructed. This was unrelieved by oral or by nasal airways, and suctioning. Tracheal intubation was not attempted in view of the previous difficulties, and unlikelihood of rapid control of the airway. Despite the gag response now being absent, attempts to insert a size 4 and 3 LMA, with and without digital guidance, were on this occasion unsuccessful. The LMAs would not pass beyond the oropharynx. Further peripheral desaturation to 60% occurred accompanied by a decrease in invasive arterial systolic pressure to 60 mm Hg, and electrocardiography showing a broad complex tachycardia of 140 beats min1. Peripheral i.v. methoxamine 20 mg was quickly followed by epinephrine 1 mg as the systolic pressure decreased further. Respiratory effort was now diminishing. At this stage, a small adult size Combitube was inserted without difficulty into the oesophagus and the cuffs inflated to the manufacturers guidelines (small cuff 12 ml, large cuff 85 ml). Manual ventilation of the lungs was immediately possible using a high-flow oxygen, bag-valve system through the proximal side ported, oesophageal lumen of the Combitube. This was confirmed by bilateral chest expansion, auscultation of the lungs and an improvement in the peripheral saturation to 98%. After control of the airway and breathing, infusions of epinephrine 0.15 µg kg1 min1 and norepinephrine 0.05 µg kg1 min1 were commenced via a central vein to maintain arterial pressure at 95/50 mm Hg. After 1 h of i.v. 1% propofol sedation, mandatory pressure control ventilation with 100% oxygen, and no spontaneous respiratory efforts, arterial blood gas analysis showed pH 7.22, PCO2 6.9 kPa, PO2 64 kPa, and base excess 6.8 mmol litre1.
At this stage, detailed discussions regarding patient prognosis took place between all the relevant physicians and the patients family. In view of the patients age, premorbid state and presenting pathology, and the systemic insult of two episodes of hypoxia, the decision was taken not to escalate treatment further. Over the following 10 h, lung ventilation through the Combitube was continued, but the patient became progressively hypotensive and died.
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Discussion |
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Management of the airway of a patient with halo frame cervical spine immobilization in place is difficult. The halo frame immobilizes the head and neck, and prevents sniffing the morning air positioning for intubation, where the cervical spine is flexed and the craniocervical junction extended. Undue force used during laryngoscopy and tracheal intubation may move the cervical vertebrae and jeopardize the spinal cord. For these reasons, preference over direct laryngoscopy is usually given to awake fibre-optic tracheal intubation, or use of the intubating LMA. In this case, as discussed below, only the contents of the ward emergency airway trolley as described were immediately available. The author became involved during the second airway episode, at which point the Combitube was available from his personal supply.
The Combitube is designed for insertion in the neutral position, with the occiput on the flat surface on which the patient is positioned. Supine patients with Halo frame immobilization approach this position. Successful use of the Combitube in the elective anaesthetic airway management of a patient with Halo frame cervical spine fixation has been described.17 The natural curve and rigidity of the Combitube facilitates its passage around the angle between the axis of the oral cavity and larynx. It, therefore, proved ideal in this case.
The recommended position for insertion of the LMA is sniffing the morning air.18 This is clearly not possible with a halo frame in place.
The LMA was successful in the first instance of emergency airway control, but failed after further craniocervical flexion during the second episode.
This is the first case described using the Combitube in the emergency management of the airway of a patient with halo frame cervical spine immobilization in place. It is also the first case of emergency airway management described where other airway techniques, including the use of the LMA, have failed and the Combitube succeeded. Moreover, airway obstruction caused by placement of a halo frame has not been reported. Pathology associated with the initial trauma, such as retropharyngeal haematoma, can cause obstruction, although in this case, no such abnormality was seen at initial laryngoscopy, and the post-mortem reported the upper airways as normal.
The cause of both acute deteriorations was airway obstruction following craniocervical junction flexion, the flexion being greater in the second instance (Fig. 3). However, this only became apparent after extubation on the ICU. The differential diagnosis initially included acute pulmonary oedema (although this was not evident clinically), cervical cord damage (although the patient moved all limbs throughout and no external cord abnormalities were seen at post-mortem examination), and tracheal mucus plugging (which was also not seen at post-mortem).
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When resuscitating the unconscious patient, where the sniffing the morning air position is not achievable because the cervical spine is, or must be, immobilized in the neutral position, then the Combitube may be preferential to the LMA as an adjunct device, or for use by those not skilled in tracheal intubation. In this regard, inclusion of the Combitube in the emergency airway trolley would be beneficial, although this does assume the operator has prior experience of all of these airway techniques.
In conclusion, this case demonstrates the utility of the Combitube in the management of the emergency airway in a hitherto unreported setting. It has been demonstrated to be effective where other airway techniques have failed, and its inclusion in the European Resuscitation Council guidelines has been reiterated.
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References |
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