THE AINTREE
Michael Lim
INTUBATION CATHETER
For Fibreoptic Assisted Endotracheal Intubation via the Laryngeal Mask Airway
Introduction
In the event of an unexpected difficult
laryngoscopy the Laryngeal Mask
Airway (LMA) has been advocated by
many prominent authorities as a conduit
for the fibreoptic laryngoscope1. In an
anaesthetised patient, this approach offers
advantages over attempting either a blind
intubation via a LMA or a fibreoptic-
assisted endotracheal intubation.
However, even this approach has
drawbacks, which are eliminated through
the use of the Aintree Intubation Catheter.
Problems with Blind
Intubation Through the
Laryngeal Mask Airway
The ease of correctly positioning a LMA
is independent of the difficulty of
laryngoscopy. This confers a significant
advantage in the difficult airway
situation. The logical next step would
then seem to be to insert a gum-elastic
bougie through the LMA, as its aperture
should be directly over the glottis if the
LMA is positioned correctly. However,
even if the LMA is providing a clinically
acceptable airway, it may not be in an
anatomically correct position. Hence the
blind passage of a bougie through the
LMA may be unsuccessful. Furthermore,
it is as likely that the bougie may pass
through one of the lateral slits as it would
pass between the two central slits. Clearly,
if it passes through one of the lateral slits,
it will deviate away from the laryngeal
outlet. In one study, the success rate with
this technique was only 28%2. First-time
insertion rates via the Intubating LMA
3 removable Rapi-Fit connectors, which
have been found to be 80% .
In addition, the blind passage of a bougie
has the potential for trauma to the upper
airway in a similar way to the injuries
caused by repeated attempts at
laryngoscopy.
Problems with Fibre-
optic Endotracheal
Intubation in an
Anaesthetised Patient
Whilst awake fibreoptic laryngoscopy is
generally considered to be the gold
standard for difficult intubations, by
providing a high success rate with a low
level of complications, once the patient
is anaesthetised and so loses tone in the
upper airway, it becomes considerably
more difficult. This loss of upper airway
tone will result in the walls of the upper
airway opposing each other, preventing
a clear passage for the fibreoptic
laryngoscope and obscuring its view.
Problems with Fibre-
optic Endotracheal
Intubation through the
Laryngeal Mask Airway
Fibreoptic assisted endotracheal
intubation through the LMA overcomes
the problems mentioned above by
providing an airway for the fibreoptic
laryngoscope, whilst the fibreoptic
laryngoscope can act as a “directable
bougie” once it exits the LMA. Indeed,
this technique has a success rate as high
as for awake fibre-optic intubation.
However, this technique also has its
pitfalls4:
These recommendations are intended to serve as a general guideline only. Please refer to the manufacturer’s instructions prior to use
Dr.
Dr. Julian Hunt-Smith
Intensive Care Centre
St. Vincent’s Hospital
Melbourne
Victoria 3065
Australia
INSERTION TECHNIQUE
• The cuff of the endotracheal tube
might be above or over the vocal
cords.
A standard endotracheal tube will
only protrude for 8cm beyond the
grille of the LMA. If the distance
1. Insert the Laryngeal Mask
from the grille to the vocal cords is Airway
then more than 3cm, the
endotracheal tube cuff will be Meanwhile load the Aintree Intubation
situated over the vocal cords. This
could result in an incomplete seal
Catheter over the fibreoptic intubating
and damage to the vocal cords bronchoscope
• The smaller endotracheal tube may
not allow adequate ventilation.
A Size 4 LMA will accept a 6.5mm
internal diameter endotracheal tube,
whilst a Size 5 LMA will accept a
2. Pass the bronchoscope
7mm endotracheal tube. When with the Aintree Intubation
considering the appropriate body
Catheter through the
weights for which these LMAs, then
it may be difficult to achieve an
adequate minute volume without Laryngeal Mask Airway
unacceptably high airway pressures. into the trachea
• Risk of extubation if removing the
LMA
The Aintree Intubation
Catheter
This is an adaptation of the Cook Airway
Exchange Catheter® with a larger 3. Remove the fibreoptic
internal diameter (4.8mm) to allow it to
be pre-loaded onto a 4.0mm fibreoptic
intubating bronchoscope
laryngoscope 5. Its external diameter leaving the Aintree
(6.5mm) allows its use with endotracheal
tubes whose inner diameter is 7mm or Intubation Catheter in the
larger. It is 56cm long so that once loaded
onto the fibre-optic laryngoscope, the trachea
directable distal 3cm of the laryngoscope
is left free. The catheter also has
allows the use of a ventilatory device if
necessary during the exchange procedure.
As can be seen from the figures on the
right, it allows full control of the airway
throughout the intubation procedure.
Clearly, a larger endotracheal tube can be
inserted without being impeded by the
LMA. The risk of accidental extubation
4. Remove the Laryngeal
if the LMA is removed is also eliminated Mask Airway then load the
as the LMA is removed before the
endotracheal tube onto
endotracheal tube is actually inserted.
In summary, the Aintree Intubation the Aintree Intubation
Catheter offers an elegant solution to the
problems associated with fibreoptic- Catheter
guided endotracheal intubation using a
laryngeal mask airway as a conduit.
References
1. Benumof JL. Laryngeal mask airway and the
ASA difficult airway algorithm.
Anesthesiology 1996; 84(3): 686-99.
5. Railroad the endotracheal
2. Gabbott DA, Sasada MP. Tracheal tube over the Aintree
intubation through the laryngeal mask using
a gum elastic bougie in the presence of
cricoid pressure and manual in line
Intubation Catheter and
stabilisation of the neck. Anaesthesia 1996;
51(4): 389-90.
pass into the trachea
3. Baskett PJF, Parr MJA and Nolan JP. The
intubating laryngeal mask. Results of a
multicentre trial with experience of 500
cases. Anaesthesia 1998; 53(12): 1174-1179
4. Asai T, Latto IP, Vaughan RS. The distance
between the grille of the laryngeal mask
airway and the vocal cords. Is conventional 6. Remove the Aintree
intubation through the laryngeal mask safe?
Anaesthesia 1993; 48(8): 667-9. Intubation Catheter,
5. Atherton DPL, O’Sullivan E, Lowe D,
Charters P. A ventilation-exchange bougie leaving the endotracheal
for fibreoptic intubations with the laryngeal
mask airway. Anaesthesia 1996; 51: 1123- tube in the trachea
1126.
The fibreoptic bronchoscope can then be
Acknowledgements used to confirm correct endotracheal tube
placement in the trachea
Dr DY Williams and the ICU nursing staff, St.
Vincent’s Private Hospital, Melbourne.