Intubating Laryngeal Mask Airway in Patients with Suspected C-Spine Injury
Abstract & Commentary
Source: Waltl B, et al. Tracheal intubation and cervical spine excursion: Direct laryngoscopy vs. intubating laryngeal mask. Anaesthesia 2001;56:221-226.
The aim of this study was to compare the excursion of the upper cervical spine during tracheal intubation using direct laryngoscopy to intubation using the intubating laryngeal mask airway (ILMA, Fastrach), by examination of lateral cervical spine radiographs in healthy young adults. Forty patients without any pathology of the cervical spine or airway who were scheduled for elective orthopedic surgery were randomized to two groups. In group A, patients were intubated using conventional laryngoscopy with a size 3 or 4 Macintosh blade. In group B, patients were intubated using a size 3, 4, or 5 ILMA. Cricoid pressure and stabilization of the head and neck were not applied in either group. Airway insertion time was recorded. Three lateral cervical spine x-rays were taken. The first radiograph was taken before any manipulation. In each group a second radiograph was taken at the point of greatest cervical excursion. In group A this was when the best possible view of the larynx was obtained. In group B this was when the ILMA reached the posterior pharynx and the rigid curved tube was advanced into the airway. The third radiograph was obtained immediately after intubation. The radiographs were analyzed for movements at cervical segments C1/2 and C2/3. A reference line was drawn along the posterior longitudinal ligament. Lines along the base of C1 and C3 were drawn through the reference line and respective angles were measured. The angles of the second and third x-rays were compared to the angle of the first x-ray. Radiographs were blinded and read by a radiologist who was unaware of the purpose of the study.
Intubation with direct laryngoscopy was successful on the first attempt in all patients. The ILMA was inserted successfully on the first attempt in all patients, and the trachea was intubated successfully on the first attempt in 17 patients. Intubation required more than one attempt in two patients, and was not possible in one patient (tracheal intubation success rate 95%). The mean time to successful intubation was 21 seconds (SD = 5 seconds) in group A and 39 seconds (SD = 7 seconds) in group B. The degree of cervical spine excursion during intubation with the ILMA was significantly less compared to intubation by direct laryngoscopy (P < 0.008). There were no complications in either group.
Comment by Michael A. Gibbs, MD, FACEP
I have two comments. First, I believe that oral endotracheal intubation using rapid sequence intubation is the airway maneuver of choice in the blunt trauma patient with known or suspected cervical spine injury, provided laryngoscopy and intubation are performed in a gentle, atraumatic manner and precise cervical immobilization is maintained throughout the procedure. There are several large case series demonstrating the safety of oral intubation in this setting. Second, the intubating laryngeal mask airway is an excellent technique for airway rescue in the emergency department when rapid sequence intubation fails. The technique is easy to learn, atraumatic, can be rapidly performed, and has few complications. Most importantly, the ILMA is the only blind airway rescue device that provides a definitive airway with a cuffed endotracheal tube. Although this study will not change my initial approach to the trauma airway, it does provide further evidence that the ILMA is a very reasonable rescue technique to use in the injured patient at high risk for cervical injury.
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