SLIPA™ may be more useful than other LMADs for difficult airway management

Abstract

, has advantages over other laryngeal mask airway devices (LMADs) because it provides better protection from regurgitation and has a better perilaryngeal seal. 1 However, SLIPA TM has not been tested in difficult airways. We report successful management of a difficult airway with SLIPA TM after laryngeal mask airway failure. We obtained the patient's written consent to publish this report.A 50-yr-old man (169 cm, 90 kg) with gastroesophageal reflux disease (GERD) was scheduled for reconstruction of finger tendons under general anesthesia. Difficult intubation was anticipated because of the patient's large tongue, short neck, thyromental distance, and a Mallampati score of 4. Because he refused awake fibreoptic intubation, we decided to insert a LMAD. After administering fentanyl 100 lg, thiopental sodium 450 mg, and succinylcholine 90 mg, a LMAD (Solus TM ; Intersurgical Ltd. Wokingham, UK) size 5 was inserted. Immediately after insertion, no leak was heard, the end-tidal carbon dioxide concentration (ETCO 2 ) was 28-30 mmHg, and the peak inspiratory airway pressure (PIP) was 22-25 cm H 2 O. At one minute after insertion, however, the PIP suddenly increased to 35 cmH 2 O, and a leak was detected. The LMAD was removed, and another insertion attempt was made after administering succinylcholine 50 mg. This time, the PIP was 40-45 cm H 2 O, and leaks were audible immediately. A fibreoptic bronchoscope (FOB) was inserted through the airway port of the LMAD, and the anterior portion of the epiglottis was found to be blocking the view. The fibrescope was passed under the epiglottis to examine the glottis, and a glottic narrowing was found.After removing the LMAD, a size 55 SLIPA TM was inserted. The PIP decreased to 20-23 cm H 2 O, and the ETCO 2 was 32-33 mmHg. No leak was detected. The FOB was inserted, through which the vocal cords were well visualized, and the periglottic seal was seen to be improved. Afterward, ventilation was maintained well, and there were no complications, including airway obstruction or aspiration.Examination of the glottis via the FOB provided possible explanations for the different performances of the two devices. First, the position of the epiglottis was different, which might be due to the designs of the respective bowls. The laryngeal aperture of SLIPA TM consists of a wide portion and a narrow portion, preventing airway obstruction (Figure), whereas the absence of epiglottic bars on the Solus TM could cause epiglottis downfolding and subsequent airway obstruction. However, previous reports suggested that because disposable LMADs, including the Solus TM , have a deeper bowl, ventilation is well maintained despite the absence of epiglottic bars. 2,3 In this case, the FOB passed under the epiglottis with ease, which makes obstruction by the epiglottis improbable.Second, the presence of a cuff and the shape and location of the bowl should be considered. The space between the tongue and posterior pharyngeal wall was probably narrow in this patient, becoming narrower because of laryngopharynge...

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