Removal of the connector on the laryngeal mask airway provides a useful alternative to the intubating laryngeal mask.
OBJECTIVE
We describe two cases in which fiberoptic intubation through the standard laryngeal mask airway (LMA) was successful with large-bore tracheal tubes (TTs) when an intubating LMA (ILMA) could not be used.


METHODS
Patient # 1, with obstructive sleep apnea, underwent elective surgical repair. His mouth opening was just under 25 mm, but difficult intubation was not anticipated. We induced general anesthesia, easily ventilated the patient by mask, and established neuromuscular blockade. Direct laryngoscopy and attempts to insert either a #5 or a #4 ILMA into the mouth failed. A standard #4 LMA, with the connector removed, was inserted, through which a 7.0 mm nasal RAE TT, fiberoptically guided, passed into the trachea at the first attempt. Patient #2, with a loosened implant after left hip arthroplasty, underwent revision prosthesis. Her neck movement was limited. We thus planned awake securing of the airway, but the patient refused. We induced anesthesia and established bag-mask-valve ventilation. The limited neck movement prevented direct laryngoscopy. Visualizing the laryngeal inlet with the fiberoptic bronchoscope (FOB) proved impossible as bloody secretions obscured the FOB's tip. Ventilation by mask was easy. As an ILMA was not available, we removed a #5 LMAs connector and passed an 8.0 mm nasal RAE TT through the LMA. Fiberoptic-guided intubation was easy. In both cases, the remainder of the intraoperative course was uneventful.


CONCLUSIONS
A standard LMA whose connector has been removed to allow passage of TTs of >6.0 mm internal diameter may be substituted for the ILMA when necessary.
Preis
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Department of Anesthesiology and Intermediate Care, Rudolfinerhaus, Vienna, Austria. c.preis@rudolfinerhaus.at
Preis
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D001049:Apnea / Q000601:surgery; D019644:Arthroplasty, Replacement, Hip; D001999:Bronchoscopy; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D017214:Laryngeal Masks; D008297:Male; D008875:Middle Aged; D011475:Prosthesis Failure