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Retiring reusable laryngeal mask airways after 40: an anaesthetist's dilemma

Sir, We report a case where a cuffed oropharyngeal airway was used as a conduit for Gum Elastic Bougie-guided blind orotracheal intubation in an emergency setting. A 22-year-old male patient was brought to the emergency department of our hospital after a road traffic accident. He was unconscious, responding to deep pain by withdrawal of limbs and bleeding from the nose and mouth profusely; grunting respiratory sounds were present along with intercostal recession and inspiratory stridor. He was hemodynamically stable. A jaw thrust was applied, but it failed to relieve the airway obstruction. COPA size 10 (Mallinckrodt Medical, Athlone, Ireland) was inserted using the rotation technique and its cuff was inflated with 30 ml air and connected to Bain’s circuit with oxygen. The airway obstruction became relieved. But the bleeding did not improve. To safeguard against the aspiration of blood, it was decide to perform tracheal intubation. Midazolam, 2 mg intravenous, was given and laryngoscopy was attempted. Size 4 McIntosh Blade (LR Instruments, Victoria, Australia) could not be inserted as the mouth opening was less despite adequate relaxation. Proseal LMA (LMA North America, Inc, San Diego, CA) could be inserted with difficulty but we could not ventilate through it. Intubating LMA size 4 could be inserted successfully and ventilation was possible, but neither an endotracheal tube nor a Bougie could be inserted through it successfully even after repositioning and maneuvering. Intubating LMA was therefore removed. Finally, the COPA was reinserted and oxygen was attached to it. An adult Gum Elastic Bougie was lubricated and inserted through the COPA. After the resistance at the level corresponding to the oropharyngeal curve of the COPA, the rest of the insertion through it was smooth. We observed the anterior neck carefully to judge the placement of Bougie in relation to the laryngeal structures and an assistant placed his hand over the trachea, taking care not to obscure the vision of the neck. Initially, a bulge was seen on the right pyriform fossa; at that point the Bougie was slightly withdrawn and rotated anticlockwise by 901 and inserted gently. As the Bougie entered the trachea, the assistant could feel a characteristic click on his hand placed over the trachea, the patient bucked and the operator felt the Bougie entering a hollow space. The COPA was removed carefully after deflation of the cuff and the assistant stabilized the Bougie. A cuffed endotracheal tube size 8.5 was railroaded easily over the Bougie after applying a gentle jaw thrust. Successful tracheal placement was confirmed using end-tidal CO2 tracings. COPA-guided fiberoptic intubation has been described in the literature, but a fiberoptic scope is not available at all places. COPA can be used in such situations for Bougie-guided intubation. Although a ventilating Bougie would have been ideal for this, we did not have a ventilating Bougie in our department. We compensated for this by inspection of neck structures and the feel of the assistant’s hand in addition to the feel of the operator. The characteristic bucking of the patient as the Bougie enters the trachea is helpful in these emergency settings, where difficult airway is anticipated and use of muscle relaxants is usually avoided.