1998 OPEN FORUM Abstracts
USE OF THE LARYNGEAL MASK AIRWAY (LMA) DURING PERFORMANCE OF PERCUTANEOUS, BEDSIDE TRACHEOTOMY
Charles G. Durbin, Jr., MD, Wanda Seay, RRT, University of Virginia Health System, Charlottesville, Virginia
Bedside, fiberoptic bronchoscope-guided tracheotomy is a safe and cost-effective alternative to open tracheotomy performed in the operating room. Occasionally tracheotomy is indicated for prolonged airway protection in patients with depressed gag and poor cough who are not already intubated. It has been suggested that topical anesthesia of the upper airway and placement of an LMA could be used to avoid the need for endotracheal intubation during the procedure. Using an LMA in these patients facilitates bronchoscopy and protects the scope from damage from the seeking needle. We report a series of 6 patients in whom percutaneous tracheostomy was performed under bronchoscopic control through an LMA placed with topical anesthesia and light sedation.
Results: Patients ranged from 19 to 79 years of age, 4 were female and 2 were male. One patient had a severe closed-head injury with an intraventricular bleed, 5 had intracranial hemorrhage due to ruptured cerebral aneurysms (3), hypertension (1), or as a consequence of a cerebral embolization attempt (1). All were at least 5 days out from their neurologic injury. All were able to maintain adequate gas exchange with spontaneous ventilation on low inspired FiO2 (2-5 I O2/min nasal prongs). Patients all had depressed airway reflexes and were not expected to have significant recovery of these for at least several weeks. Upper airway anesthesia was provided by topical instillation of 1% lidocaine, trancheal and laryngeal anesthesia by bronchoscopic application of .5% etidicaine. Light sedation with propofol was used in all patients, one patient required neuromuscular blockade with rocuronium due to inability to suppress a vigorous cough. One patient developed mild laryngospasm during airway manipulation. All patients were successfully and easy visualized with the bronchoscope inserted through the LMA, and correct placement of the tracheotomy wire and dilators were confirmed. Manual ventilation was successful in all cases and no patient experienced a significant fall in oxygen saturation during the procedure. No bleeding or other acute complications occurred in this group of patients. The entire procedure took an average of 20 to 30 minutes to complete.
Conclusions: The LMA facilitates percutaneous tracheotomy in the unintubated patient ensuring adequate gas exchange during the procedure as well as protecting the bronchoscope.
The 44th International Respiratory Congress Abstracts-On-Disk®, November 7 - 10, 1998, Atlanta, Georgia.