Definitive Airway Management in the Presence of a Laryngeal Tube Supraglottic Airway: "There's More Than One Way to Skin a Cat".

Abstract

xxx 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1 The recent case report by Koumpan et al 1 outlines the difficulties when one finds themselves “between the devil and the deep blue sea” when dealing with the need for establishing a definitive airway in a complex polytraumatized patient with closed head and C-spine injuries and a difficult airway. Indeed, they eloquently outline a successful technique to establish a definitive airway by exchanging the King Laryngeal Tube (LT) reusable supraglottic airway (King Systems, Noblesville, IN) for an endotracheal tube (ETT) with the use of a previously described flexible bronchoscopic (FB) guided intubation technique.2 Although it is hard to argue with success, there is clearly more than one way to address this problem. Even though these authors mention that a surgical airway can be considered3 (although perhaps not optimal in this particular patient), other techniques have been used for endotracheal intubation in the presence of an LT. Hollingsworth et al4 reported the use of an FB inserted through an Aintree intubation catheter (Cook Medical Inc, Bloomington, IN) in a similar situation of an in situ LT airway. Indeed, one of the problems of using the Seldinger-like technique that they describe in advancing an ETT over an FB is that the “step off” between the FB and the ETT (due to difference in diameter) can make ETT advancement difficult. The use of the Aintree catheter with an FB decreases this step off and allows the ETT to slide more smoothly through the larynx. So although they successfully report the use of their own FB and video laryngoscope technique, one needs to be cognizant of the multiple other airway adjuncts that are available “to skin the cat” represented by the in situ LT that needs replacing in the setting of a difficult airway.