Laryngeal mask anaesthesia for repair of cleft palate

[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.

RESULTS

The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

AMBU® LMA® in Children With Cleft Palate for Ophthalmic Surgery: A Case Report

Airway management remains a challenge in children, and the presence of a cleft palate further complicates the scenario. Endotracheal intubation, although definitive and most preferred, may be avoided for certain short-duration procedures wherein the use of laryngeal mask airway can allow quicker emergence. We present the successful airway management of 2 pediatric patients with cleft palate undergoing ophthalmological surgery, using AMBU® LMA® as the airway device of choice, which was further used as a rescue airway device in an emergent situation of "difficult to ventilate."

Advantages, Disadvantages, Indications, Contraindications and Surgical Technique of Laryngeal Airway Mask

The beauty of the laryngeal mask is that it forms an air tight seal enclosing the larynx rather than plugging the pharynx, and avoid airway obstruction in the oropharynx. The goal of its development was to create an intermediate form of airway management face mask and endotracheal tube. Indication for its use includes any procedure that would normally involve the use of a face mask. The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anesthetic practice. Despite wide spread use the definitive role of the laryngeal mask airway is yet to be established. In some situations, such as after failed tracheal intubation or in oral surgery its use is controversial. There are several unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoids pressure prevents placement of mask. We review the techniques of insertion, details of misplacement, and complications associated with use of the laryngeal mask. We then attempt to clarify the role of laryngeal mask in air way management during anesthesia, discussing the advantages and disadvantages as well as indications and contraindications of its use in oral and maxillofacial surgery.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence.

RESULTS

The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway

Supplemental Digital Content is available in the text.

Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children

BACKGROUND

Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process.

MATERIALS AND METHODS

30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place.

RESULTS

Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15).

CONCLUSION

In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.

Flexible laryngeal mask airway for cleft palate surgery in children: a randomized clinical trial on efficacy and safety

OBJECTIVE

To evaluate the efficacy of a flexible laryngeal mask airway in children undergoing palatoplasty.

DESIGN

Prospective, randomized, single-center study.

SETTING

Jawaharlal Institute of Postgraduate Medical Education and Research.

PATIENTS

Sixty-six children (American Society of Anesthesiologists physical status 1 and 2) scheduled to undergo palatoplasty were assigned randomly to an endotracheal intubation group (RAE group, n = 33) and a flexible laryngeal mask airway group (FLMA group, n = 33).

MAIN OUTCOME MEASURES

Peak airway pressure, inspired and expired tidal volume, end-tidal carbon dioxide, lung compliance, and airway resistance were continuously measured after placement of the assigned airway. The percentage leak around the airway was quantified as the leak fraction. Parametric data between groups were analyzed using an unpaired Student's t test and within groups using a one-way analysis of variance. Nonparametric variables were analyzed using the Fisher exact test.

RESULTS

In two children, the flexible laryngeal mask airway was displaced from its original position; whereas, one endotrachial tube advanced endobronchially. The leak fraction was significantly higher in the RAE group when compared with that in FLMA group (13.34% +/- 13.74% versus 5.96% +/- 3.78%, p < .05) until the throat pack was applied. Peak airway pressure and resistance were significantly higher in the RAE group compared with the FLMA group at all time intervals, p < .05. During emergence, frequency of coughing, desaturation, and laryngospasm were increased in the RAE group.

CONCLUSION

A flexible laryngeal airway mask is suitable for maintaining the airway and helps in smooth emergence in children undergoing palatoplasty.

[Anesthetic management of pediatric cleft lip and cleft palate repair]

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.

Successful management of a neonate with Pierre–Robin syndrome and severe upper airway obstruction by long term placement of a laryngeal mask airway

The severity of airway obstruction varies in infants with Pierre-Robin syndrome (PRS). Some have severe upper airway obstruction that results in respiratory failure and even death. We report a case of neonate with isolated PRS who had a severe airway obstruction and respiratory failure after birth. She had complications of bilateral pneumothorax, subcutaneous emphysema, and hypoxaemia due to difficult tracheal intubation. Respiratory failure recurred immediately after extubation; she was resuscitated by inserting a laryngeal mask airway. The laryngeal mask airway was left inserted for 6 days. It was successful in this patient and eliminated the need for invasive surgical procedures. In conclusion, the relatively long term use of a laryngeal mask airway, which has not been reported before, could be an alternative therapy for patients with PRS with airway obstruction.

Fiberoptic Tracheal Intubation Through a Laryngeal Mask Airway in a Child with Treacher Collins Syndrome

Treacher Collins syndrome (TCS) is a rare inherited condition characterized by bilateral and symmetric abnormalities of structures within the first and second bronchial arches. The mechanism of inheritance is autosomal dominant with variable expressivity. Because of this variability in expression, some affected individuals exhibit virtually no overt clinical manifestations. However, most children with TCS present with the following classic facial features: down-sloping palpebral fissures, colobomata of the lower eyelid, scanty lower eyelashes, malar hypoplasia, and micro- or retrognathia. Cleft palate is present in up to 35% of patients and an additional 30-40% have congenital palatopharyngeal incompetence. Abnormalities of the ear are very common and vary from minor malformations to severe microtia and hearing loss. Hearing loss may be due to atresia of the auditory canals or ossicular malformation of the middle ear. Despite these many development abnormalities, TCS patients are usually of normal intelligence. We report the case of a 3 1/2-yr-old patient with TCS undergoing cleft palate repair and discuss fiberoptic intubation through a laryngeal mask airway using two endotracheal (ETT) tubes secured via an ETT connector.

Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1-day-old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo-esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre-Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.

Drawover anaesthesia for cleft palate and lip surgery in Pokhara, Nepal

We describe our experience and problems with 335 children who had general anaesthesia for cleft palate and lip surgery. Drawover anaesthesia using halothane and trichloroethylene was easy to use and safe. The main early postoperative problems were airway obstruction and bleeding. Later postoperative care in the ward was hampered by the lack of nursing care and monitoring.

Anesthesia for Freeman-Sheldon syndrome using a laryngeal mask airway

PURPOSE

To present a case of Freeman-Sheldon syndrome (FSS) with a previously unreported technique of anesthetic management, consisting of a malignant hyperthermia free anesthetic and laryngeal mask airway.

CLINICAL FEATURES

Freeman-Sheldon syndrome (also known as whistling face syndrome, Windmill-Vane-Hand syndrome, cranio-carpo-tarsal dysplasia and distal arthrogryposis type 2) is a rare congenital disorder defined by facial and skeletal abnormalities. The three basic abnormalities are microstomia with pouting lips, camptodactyly with ulnar deviation of the fingers and talipes equinovarus. Patients with FSS frequently present for surgical correction of musculoskeletal or facial abnormalities. There are several anesthetic challenges including difficult airway, intravenous cannulation and regional technique. They may be at increased risk for malignant hyperthermia and postoperative pulmonary complications. We present a case of a two-year-old child with FSS undergoing elective unilateral inguinal hernia repair. A non-triggering anesthetic technique was used, consisting of 2 mg x kg(-1) propofol followed by a continuous infusion, nitrous oxide 50%/oxygen, and 3 microg x kg(-1) fentanyl. Intraoperative and postoperative analgesia was provided by an ilioinguinal nerve block with 10 ml bupivacaine 0.25% with epinephrine 1:200,000. The airway was maintained with a #2 laryngeal mask airway. The anesthetic was uneventful and there were no signs or symptoms of malignant hyperthermia. The patient was discharged home later the same day in good health.

CONCLUSION

The use of a laryngeal mask airway and non-triggering anesthetic technique should be considered as options for anesthetic management in patients with FSS for short procedures that do not require neuromuscular blockade.

The reinforced laryngeal mask in paediatric outpatient dental surgery

One hundred and twenty ASA I and II grade children aged 2-9 years scheduled for outpatient dental extractions under general anaesthesia were studied. They were allocated randomly to one of three groups for airway management: group R had anaesthesia with a reinforced laryngeal mask airway, group L with a standard laryngeal mask airway and group N with a nasal mask. Anaesthesia was induced in all children using halothane in 50% nitrous oxide with oxygen and maintained on halothane in 67% nitrous oxide with oxygen. An Ayre's T-piece with Jackson-Rees modification was used. The incidence of airway obstruction was significantly lower and surgical access significantly better with the reinforced laryngeal mask airway when compared with the standard laryngeal mask airway. However, the reinforced laryngeal mask airway was significantly more difficult to insert when compared with the standard laryngeal mask airway. On comparing the reinforced laryngeal mask airway with the nasal mask, there were significantly fewer episodes of airway obstruction, better oxygen saturation, less increase in heart rate and fewer arrhythmias in the reinforced laryngeal mask airway group. Total time for the procedures was the same for all three groups. Thus, the reinforced laryngeal mask airway was found to be a favourable alternative to the standard laryngeal mask airway and nasal mask for paediatric outpatient dental extractions.

The laryngeal mask airway reduces blood flow in the common carotid artery bulb

PURPOSE

The introduction of the laryngeal mask airway (LMA) has had a major impact on anaesthetic practice in the last ten years. Previous authors have demonstrated pressures equivalent to mean arterial blood pressure within the cuff of the LMA. This study examined the effects of cuff inflation on the cross sectional area, flow and velocity of blood flow at the level of the carotid sinus.

METHODS

Seventeen patients scheduled to have LMAs inserted as part of routine anaesthetic management were recruited into the study. Measurements of the common carotid artery bulb area, peak velocity and blood flow were performed upon LMA cuff inflation and deflation using a 5 MHz pulse wave Doppler probe.

RESULTS

Deflation of the cuff resulted in an increase in the cross sectional area (from 0.58 +/- 0.05 to 0.64 +/- 0.04 cm2; P < 0.005), an increase in blood flow (from 65.6 +/- 5.6 to 73.9 +/- 5.6 cm3.sec-1; P < 0.05) and a slight but non significant increase in velocity of blood flow.

CONCLUSION

This study demonstrates that inflation of the cuff on the LMA results in a decrease in carotid bulb cross sectional area which results in a decrease in blood flow.

Use of the laryngeal mask airway in oral and maxillofacial surgery

PURPOSE

General anesthesia for the nonintubated oral and maxillofacial surgical patient presents unique anesthetic conditions. The primary concern is the maintenance of an unobstructed airway and protection against aspiration, while minimizing both interference and interruption of the surgical procedure. The laryngeal mask airway is an alternative to the nasal hood for such airway management. The purpose of this article is to inform the oral and maxillofacial surgeon of the clinical relevant information pertaining to the use of the laryngeal mask airway in oral and maxillofacial surgery. Experience with clinical use is discussed.

Positive pressure ventilation with the laryngeal mask airway in children

We studied the safety of positive pressure ventilation (PPV) when using the size 2 laryngeal mask airway (LMA) in 46 ASA physical status I or II children (aged 38 +/- 21 mo) undergoing elective surgery. The LMA cuff was inflated in incremental steps to achieve a cuff leak pressure > or = 15 cm H2O. Abdominal circumference was measured before and after PPV in study patients, as well as in a control group managed with tracheal intubation. Cuff leak pressure was 17 +/- 4 cm H2O (range 12-34 cm H2O). Forty-five patients successfully underwent PPV. Gas leak around the LMA cuff prevented PPV in one infant. The only respiratory variable that changed significantly was end-tidal CO2, which decreased from 40 +/- 6 to 34 +/- 5 mm Hg. Abdominal circumference increased in 28 patients but was not associated with any complications. Change in abdominal circumference in the study group was not significantly different from that observed in the control group. However, abdominal circumference increased 8 cm in one study patient, prompting insertion of an orogastric tube. The size 2 LMA provides an effective airway for PPV. Mild gastric distention often occurs. The risk of clinically significant gastric distention appears to be small, but it warrants close monitoring. We conclude that with certain precautions described in the text, the size 2 LMA provides a relatively safe airway for PPV in children.

EXPERIENCE WITH THE LARYNGEAL MASK AIRWAY IN ANAESTHESIA

Laryngeal mask airway was used in 100 adult patients of either sex (ASA I/II) undergoing various surgical procedures. The duration of surgery varied from 17 to 145 minutes. The course of anaesthesia was smooth and uneventful in all cases. The failure rate of insertion of LMA was 7%. The overall incidence of complications was 12%. LMA insertion was associated with statistically insignificant change in haemodynamic parameters.

Current concepts in airway management for cardiopulmonary resuscitation

OBJECTIVE

To describe the methods of maintaining airway patency for oxygenation during cardiopulmonary resuscitation (CPR) that do not require expertise in mask ventilation or endotracheal intubation by direct laryngoscopy.

DESIGN

A review of rescue breathing and newer methods of providing airway patency is provided.

RESULTS

Airway patency during CPR is often difficult to achieve. Mask ventilation predisposes to hypoventilation and aspiration pneumonitis. Endotracheal intubation by direct laryngoscopy is the preferred method of maintaining airway patency for CPR. Alternative techniques for airway management include endotracheal intubation by lighted stylet, esophageal tracheal Combitube, laryngeal mask airway, and transtracheal ventilation. These methods are recommended by the American Heart Association and the American Society of Anesthesiologists. They have been approved by the Food and Drug Administration for maintenance of airway patency; they are easy to learn, effective, and applicable to CPR. Advantages and disadvantages of each technique may indicate or contraindicate one method over another in specific circumstances.

CONCLUSION

When CPR is compromised by airway obstruction that remains unresponsive to traditional techniques, using alternative methods is appropriate. The techniques selected must be based on individual familiarity and expertise.

Review of uses of the laryngeal mask in ENT anaesthesia

A review of the various uses of the laryngeal mask in otorhinolaryngological surgery is presented. Its primary use is in airway management, especially during recovery from anaesthesia.

Orotracheal intubation through the laryngeal mask airway in paediatric patients with Treacher-Collins syndrome

The laryngeal mask airway (LMA) is useful as an airway intubator (conduit) for an intubating tracheal bougie or fibreoptic bronchoscope, over which a tracheal tube is passed. However, in our paediatric patients with Treacher-Collins syndrome, only the latter technique was successful. This was attributed to the fact that a posteriorly protruded tongue displaced the LMA, made the glottis move considerably anterior and interfered with the attempts to enter the trachea with a bougie. Downward displacement of the epiglottis, which can sometimes impair the intubation technique through the LMA, was not observed in our patients. Partial obstruction of a tracheal tube within the LMA occurred in one of the patients.

A new technique for fibreoptic intubation in children

We describe a technique involving the use of a laryngeal mask airway, fibreoptic bronchoscope and a guide wire to manage the intubation of a child who was known to be a difficult intubation. The technique is simple, atraumatic, permits the use of an adult bronchoscope for infants and children, and allows control of the airway and ventilation throughout the period of intubation.

The laryngeal mask airway: its features, effects and role

The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anaesthetic practice. Numerous articles and letters about the device have been published in the last decade, but few large controlled trials have been performed. Despite widespread use, the definitive role of the laryngeal mask has yet to be established. In some situations, such as after failed tracheal intubation or in anaesthesia for patients undergoing laparoscopic or oral surgery, its use is controversial. There are a number of unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoid pressure prevents placement of the mask. We review the techniques of insertion, details of misplacement, and complications associated with the use of the laryngeal mask. We discuss the features and physiological effects of the device, including the changes in intra-cuff pressure during anaesthesia and effects on blood pressure, heart rate and intra-ocular pressure. We then attempt to clarify the role of the laryngeal mask in airway management during anaesthesia, based on the current knowledge, by discussing the advantages and disadvantages as well as the indications and contraindications of its use. Lastly we describe the use of the laryngeal mask in circumstances other than airway maintenance during anaesthesia: fibreoptic bronchoscopy, tracheal intubation through the mask and its use in cardiopulmonary resuscitation.

The laryngeal mask airway

The laryngeal mask airway (LMA) is a new concept in airway management. A miniature inflatable mask is positioned in the hypopharynx, forming a low-pressure seal around the laryngeal inlet. The mask is attached via a tube to the breathing circuit. It is inserted after induction of anesthesia without the need for muscle relaxants or laryngoscopy. The LMA can be used to facilitate both spontaneous and controlled ventilation in adults and children. The LMA has been used for a wide variety of surgical procedures but is probably best suited to short procedures, especially if a light general anesthetic is used in combination with a regional technique. It may be particularly useful in outpatient anesthesia, as it avoids the need for intubation or muscle relaxants. It can be used as an alternative to mask anesthesia or when an endotracheal tube would have been inserted to allow surgical access. It has been used successfully in cases of difficult or failed intubation, although its role here needs further appraisal. It does not protect against aspiration of stomach contents and should not be used when aspiration is a risk. Controversy exists regarding its use to facilitate positive-pressure ventilation (PPV) due to concern that gases under pressure may be forced into the stomach and predispose the patient to regurgitation. It may be more difficult to use in children. It is now widely used in the United Kingdom; however, it is not yet available for sale in the U.S. It has already had a major effect on practice in Britain and has the potential to do the same in the United States.

Management of a suspected and unsuspected difficult laryngoscopy with the laryngeal mask airway

The laryngeal mask airway (LMA) is a new development in airway control. Presented here are two cases of difficult airway management--one anticipated, the other not anticipated--during which the LMA was used effectively.

[Difficult intubation managed by laryngeal mask and fibroscopy]

A case is reported of a patient due to undergo a combined kidney and pancreas transplant who proved to be difficult to intubate. This diabetic hypertensive 35-year-old male patient also had ankylosing spondylitis. Mouth opening was normal (more than fingers' breadth), the chin-sternum distance was 4 cm on full cervical flexion, and cervical extension was only slightly impaired. The Mallampati score was 1. Anaesthesia was induced with thiopentone, fentanyl and 6 mg of pancuronium. Mask ventilation was quite satisfactory. However, on laryngoscopy, the vocal cords could not be seen. Several attempts to carry out endotracheal intubation, including with a stylet, failed. A laryngeal mask (LM) was therefore applied to ventilate the patient correctly. It was not possible to pass a small endotracheal tube (6 mm diameter) through the LM tube, probably because of a small malposition of this latter. A paediatric fibroscope, passed through the LM tube, served as guide for the endotracheal tube. The mask was not removed, although its cushion was slightly deflated, so as not to extubate the patient. The benefits and usefulness of a laryngeal mask in predictable and unpredictable cases of difficult intubation are discussed.

Flexible endoscopic intubation of the neonate

The development of the ultrathin bronchoscope has provided a means of providing flexible endoscopic intubation for the neonate and small infant. We report our experience of 26 such endoscopic intubations in 23 neonates with birth weights from 1,200 to 4,600 g and post-conceptional ages varying from 31.5 to 60 weeks. The most common indications for the procedure were dysmorphic airways with variable degrees of micrognathia, acquired airway lesions, and severe degrees of hydrocephalus. With the use of the current 2.2 mm and 2.7 mm diameter instruments, it is now possible to utilize this technique with 2.5 mm endotracheal tubes. There were no failed procedures and no evidence of laryngospasm, the most frequent adverse effect being a transient fall in oxygen saturation. The procedure as practiced by experienced individuals is well tolerated and is an important adjunct for intubation of neonates with dysmorphic upper airways or other disorders that prevent adequate visualization of the larynx.

Anaesthesia for Treacher Collins syndrome using a laryngeal mask airway

Patients with Treacher Collins syndrome pose a serious problem to anaesthetists in maintaining their airway because of retrognathia. Two patients with Treacher Collins syndrome undergoing tympanoplasty are reported in whom a laryngeal mask was used in place of an endotracheal tube for airway maintenance.

The laryngeal mask airway. An unusual complication

The laryngeal mask airway is an important addition to the anaesthetist's armamentarium, but its use is not without the possibility for misfortune. We encountered an unusual and potentially serious complication. A patient's epiglottis became trapped between the pliable grates in the mask portion of the laryngeal mask and partially obstructed his airway. Should this problem occur and remain unnoticed, in addition to the problem of airway obstruction during the anaesthetic, the oedematous epiglottis could be severely injured upon removal of the laryngeal mask. This, in turn, could result in airway obstruction requiring emergency treatment.

The laryngeal mask airway in children. A fibreoptic assessment of positioning

Clinical and fibreoptic assessment of the positioning of the laryngeal mask airway was performed in 100 children. Clinical observation indicated a patent airway in 98% and severe airway obstruction in 2% of cases. Perfect positioning, as judged by fibreoptic laryngoscopy, was found in 49% and the epiglottis was within the mask in 49%. Fibreoptic evidence of partial airway obstruction in 17% was not detected clinically.

The Brain laryngeal mask. A comparative study with the nasal mask in paediatric dental outpatient anaesthesia

Fifty ASA grade 1 children, who presented for dental outpatient extraction were studied. They were randomly allocated to two groups after induction: group 1 had conventional nasal mask anaesthesia and group 2 anaesthesia with a laryngeal mask. Group 2 had fewer hypoxic episodes and significantly better arterial oxygen saturations (p less than 0.01). There was no difference between the groups as regards surgical access, difficulty of extraction or bleeding. The laryngeal mask appears to provide an alternative to conventional nasal mask anaesthesia, with better overall oxygenation and would seem particularly suitable for prolonged or difficult extractions.