1. Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference Dowling Amphitheater February 12, 2007

2. Case A 60 year old man, (80 kg, 5’8”) suffered a hemorrhagic stroke shortly after a full meal. He was taken to a community hospital unconscious and with breathing difficulty. In the ER, endotracheal intubation with direct laryngoscopy was attempted several times unsuccessfully. A laryngeal mask airway (LMA) was inserted and somewhat adequate ventilation was achieved. The patient was transferred to Boston Medical Center with the LMA in place, unconscious.

3. Physical Exam Unresponsive (GCS < 6) but not paralyzed Hemodynamically stable Husky, short neck Mouth opening – difficult to evaluate LMA #4 in place Full dentition Distended tympanic epigastrium Distant breath sounds – ventilated with bag-valve Hgb O2 Sat: 98%

4. Challenge How should we manage the airway?

5. Considerations 1.Fiberoptic assessment of larynx through LMA? 2.How long can he remain apneic? 3.Do we sit the patient up? 4.Should neuromuscular blocking agents be used? 5.Should a nerve stimulator be used? 6.Insert NGT? 7.Remove LMA? 8.Attempt direct laryngoscopy again? 9.Intubate through LMA? 10.Cricoid pressure? 11.Surgical airway? 12.Control hemodynamics?

6. Conventional LMA

7. LMA is a conduit

8. Fiberoptic Exam Through LMA

9. Intubating LMA

11. ProSeal LMA

12. Combitube

13. CT of the cervical spine showing an over-inflated distal balloon of the combitube (solid arrow), placed in the esophagus, severely compressing and narrowing the adjacent trachea (dashed arrow). From: Portereiko: J Trauma, Volume 60(2).February 2006.426-427 Combitube

14. King L-T

15. Other Devices

16. Cutting the LMA Anesth Analg 2003;97:299-300

17. Considerations Fiberoptic assessment of larynx through LMA? How long can he remain apneic? Do we sit the patient up? Should neuromuscular blocking agents be used? Should a nerve stimulator be used? Insert NGT? Remove LMA? Attempt direct laryngoscopy again? Intubate through LMA? Cricoid pressure? Surgical airway? Control hemodynamics?