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Analysis of Predictive Factors for Difficult Proseal Laryngeal Mask Airway Insertion and Suboptimal Positioning

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Analysis of Predictive Factors for Difficult Proseal Laryngeal Mask Airway Insertion and Suboptimal Positioning Anesth Pain Med 2013; 8: 271-278 ￭Clinical Research￭ Analysis of predictive factors for difficult ProSeal laryngeal mask airway insertion and suboptimal positioning *Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Ewha Womans University School of Medicine, Seoul, Korea Joo Hyun Jun*, Jong Hak Kim, Hee Jung Baik, Youn Jin Kim, and Doo Gyun Yun Background: There has been controversy about predicting INTRODUCTION difficult LMA insertion and suboptimal position. Our aim was to evaluate bedside predictors for difficult LMA ProSealTM (PLMA) The laryngeal mask airway (LMA) is used as a supraglottic insertion and suboptimal position. Methods: As the potential predictive factors for difficult PLMA device providing a secure airway for patients undergoing insertion and suboptimal position, we considered male gender, elective surgical procedures requiring general anesthesia. In increased body mass index (BMI), seven individual items suggesting addition to conventional use as device maintaining airway, difficult airway [modified Mallampati classification ≥ III, inter-incisor LMA is widely used as an intubation conduit in case of failed distance ≤ 5 cm, thyromental distance ≤ 6.5 cm, head/neck movement ≤ 90o, history of difficult intubation, buck of teeth ≥ intubation or guide for diagnostic and therapeutic fiberoptic moderate, upper lip bite test (ULBT) ≥ II] and ≥ 3 of total airway bronchoscopy because the distal end of an optimally placed score which is the sum of scores assessed by a score of 0, 1, 2 LMA faced the laryngeal inlet [1-3]. Therefore, LMA should in seven individual items. The PLMA position was assessed by be inserted in anatomically optimal position to minimize fiberoptic bronchoscopy to determine whether these predictors predict suboptimal position of PLMA (fiberoptic score ＜ 3, as graded unwanted events and maximize their intended function in on a standard fiberopitc scale). We also investigated the effect of various anesthetic practices. predictive factors on the failure of the first insertion of PLMA and However, the success rate of LMA insertion varies from 77– time required for successful Proseal LMA insertion on the first – attempt. 90%, and suboptimal positioning of the LMA occurs in 30 66% Results: 154 patients were enrolled in the study. The total airway of cases [4-7]. Moreover, an emergency pathway is needed for score did have a significant relationship with the fiberoptic findings. the airway management algorithm if the LMA fails to secure The male gender and ULBT I of investigated predictors did the airway in the ‘cannot ventilate, cannot intubate’ situation significantly correlate with failure on the first insertion of PLMA. We did not find any significant relationship between the predictive [8]. Incomplete mask sealing due to LMA malposition increases factors and PLMA insertion time on the first attempt. the risk of orpharyngeal air leakage or gastric insufflations Conclusions: The male gender and ULBT I indicate difficult PLMA [9,10]. Epiglottic downfolding makes difficult to visualize insertion, and the total airway score ≥ 3 indicates suboptimal laryngeal opening for effective conduit for tracheal intubation or position of PLMA. (Anesth Pain Med 2013; 8: 271-278) bronchoscopy. Therefore, it is necessary to recognize when Key Words: Difficult airway, Fiberoptic score, Laryngeal mask LMA insertion will be difficult and prepare for an emergency airway. alternative pathway. There has been controversy about predicting difficulty with Received: April 2, 2013. LMA insertion and suboptimal position of LMA. Some authors Revised: 1st, April 18, 2013; 2nd, July 26, 2013. reported that the Mallampati classification predicts difficulty in Accepted: August 8, 2013. achieving an adequate airway with the LMA [11], whereas Corresponding author: Jong Hak Kim, M.D., Department of Anesthesiology and Pain Medicine, Ewha Womans University School of Medicine, 911-1, others reported that insertion and placement of LMA are Mok-dong, Yangcheon-gu, Seoul 158-710, Korea. Tel: 82-2-2650-5285, independent of the Mallampati classification [12,13]. This study Fax: 82-2-2655-2924, E-mail: [email protected] It was presented The 88th Annual Scientific Meeting of the Korean was undertaken to assess whether bedside predictive factors TM Society of Anesthesiologists, November 2011, Grand Hilton, Seoul, predict suboptimal position of ProSeal LMA (PLMA). We Korea. also investigated the effect of predictive factors on the 271 272 Anesth Pain Med Vol. 8, No. 4, 2013 difficulty in PLMA insertion. insertion as having no gas leak at an airway pressure of 20 cmH2O, bilaterally equal breath sounds on chest auscultation, the MATERIALS AND METHODS absence of air influx in the gastrointestinal tract, and a normal rectangular shaped capnogram. A failed PLMA insertion was Patients, ranging from 18 to 65 years old, of American characterized as not having advanced into the pharynx, a severe Society of Anesthesiologists physical status 1 or 2, and who gas leak through the airway or the drain tube, an absence of were undergoing elective surgery under general anesthesia were normal lung ventilation, or an abnormal end-tidal carbon dioxide included in our study. Our ethics committee approved this pressure (PETCO2). If insertion was failed, positive pressure study and we obtained written informed consent from all ventilation was administered via a face mask for 1 minute, and patients. Patients with cervical spine injury, severe cardio- then PLMA insertion was reattempted. Unsuccessful insertion vascular disease, gastroesophageal reflux, poor dentition, or air- after three attempts was regarded as failure. way anatomic abnormalities that required awake fiberoptic in- We recorded the success/failure, number of attempts, and the tubation were excluded from the study. Their demographic data time required for PLMA insertion for each patient. The PLMA are shown in Table 1. insertion time was measured from when the operator first Prior to anesthesia induction in the operating room, all pa- opened the patient’s mouth to when he removed his hand from tients underwent airway assessment according to seven pre- the patient after inserting the PLMA. We analyzed the data for dictive factors including the modified Mallampati classification, insertion time of the 132 patients in which PLMA insertion interincisor distance, thyromental distance, head/neck movement was successfully accomplished on the first attempt. [14,15], history of difficult intubation, the presence of buck The position of the PLMA was fiberoptically (LF-GP, teeth, and the upper lip bite test (ULBT) [16,17]. A score of 0, Olympus, Japan) observed from the mask aperture bar and a 1, or 2 was assigned for each criteria and the sum of all the fiberoptic score was assigned. The fiberoptic scoring system scores constituted the total airway score (Table 2). was as follows: 4: only vocal cords were visualized; 3: the Patients were then preoxygenated with 100% oxygen for two vocal cords and the posterior epiglottis were visualized; 2: the minutes. Anesthesia was induced with intravenous fentanyl 1 vocal cords and the anterior epiglottis were visualized; 1: μg/kg, midazolam 0.04 mg/kg, and followed by propofol 2 unable to visualize vocal cords but PLMA adequately mg/kg. Maintenance of anesthesia was achieved with a functioning; 0: unable to visualize vocal cords and PLMA continuous infusion of 1% propofol at 6 mg/kg/hr, and failing to function [18]. A fiberoptic score of 3 or more was neuromuscular relaxation was achieved with rocuronium 0.3 regarded as appropriate PLMA positioning, whereas a score mg/kg. After 3 minutes of controlled ventilation via a facemask less than 3 meant suboptimal PLMA positioning. We analyzed with 100% oxygen 6 L/min, a researcher experienced with the data for fiberoptic scores (FS ≥ 3 or FS ＜ 3) of the PLMA (ProSealTM LMA, LMA North America Inc., USA) and 148 patients who had successful insertion of PLMA within who had not participated in the airway assessment, placed the PLMA. The PLMA size was chosen according to the patient’s weight: ＜ 50 kg: size 3; 50–70 kg: size 4; and ＞ 70 kg: size Table 2. Preoperative Assessment of the Airway Score for Predicting 5. After inserting the PLMA, the cuff was inflated according to Difficult Airway the “just seal” method, with the minimum volume of air 0 1 2 required to prevent gas leak. We defined a successful PLMA Modified Mallampati class Class I/II Class III Class IV Inter-incisor distance ＞5 cm 5–4 cm ＜4 cm Thyro-mental distance ＞6.5 cm 6.5–6.0 cm ＜6 cm o o o Table 1. Demographic Data (n = 154) Head/Neck movement ＞90 90 ＜90 History of D/I No Questionable Definite Age (yr) 41.2 ± 14.5 Buck teeth No Mild Moderate Gender (M/F) 84/70 ULBT I II III Height (cm) 165.3 ± 9.8 Weight (kg) 65.0 ± 11.1 D/I: difficult intubation, ULBT: upper lip bite test, ULBT I: Lower BMI (kg/m2) 23.8 ± 3.3 incisors can hide mucosa of the upper lip, ULBT II: Lower incisors partially hide mucosa of the upper lip, ULBT III: Lower incisors Values are mean ± SD or number of patients. BMI: body mass index. unable to touch mucosa of the upper lip. Joo Hyun Jun, et al：Predictors for difficult PLMA insertion 273 three attempts. analysis for fiberoptic scores. In our study, we expected that PLMA placement would be difficult in the following situations: male gender, increased RESULTS body mass index, a modified Mallampati classification of III or more, interincisor distance of 5 cm or less, a thyromental One hundred fifty four patients were enrolled in our study. distance of 6.5 cm or less, head/neck movement of 90o or There was no one who had history of difficult intubation. less, history of difficult intubation, the presence of buck teeth, Thus, as predictor, history of difficult intubation was excluded an ULBT score of III or more, or a total airway score of 3 from analysis.
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