Download GastroLaryngeal Tube for endoscopic retrograde

Anaesthesia, 2010, 65, pages 1114–1118
doi:10.1111/j.1365-2044.2010.06510.x
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ORIGINAL ARTICLE
Gastro-Laryngeal Tube for endoscopic retrograde
cholangiopancreatography: a preliminary report*
L. A. Gaitini,1 A. Lavi,2 E. Stermer,3 P. Charco Mora,4 L. M. Pott5 and S. J. Vaida5
1 Clinical Associate Professor, Department of Anaesthesia, 2 Clinical Associate Professor, Department of Gastroenterology,
3 Senior Lecturer, Consultant Gastroenterologist, Bnai-Zion Medical Center, Haifa, Israel
4 Consultant Anesthetist, Department of Anaesthesia, Hospital Son Dureta, Palma de Mallorca, Spain
5 Associate Professor, Department of Anaesthesia, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
Summary
The Gastro-Laryngeal Tube is a modification of the Laryngeal Tube that provides a dedicated
channel for the insertion of a gastroscope. In this study of 30 patients undergoing general
anaesthesia for endoscopic retrograde cholangiopancreatography, we evaluated both the
effectiveness of airway management with a Gastro Laryngeal Tube and the feasibility of performing
it using the endoscopic channel. The Gastro Laryngeal Tube was inserted successfully in all
patients, in 27 patients at the first attempt. The mean (SD) time to achieve an effective airway was
26 (6) s. Mean (SD) inspiratory and expiratory tidal volumes were 336 (57) ml and 312 (72) ml,
respectively, and oropharyngeal leak pressure was 33.7 (2) cmH2O. These data suggest that
the Gastro Laryngeal Tube is an effective and secure device for airway management and for use
during performance of endoscopic retrograde cholangiopancreatography.
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Correspondence to: L. A. Gaitini
Email: [email protected]
*Presented in part at Euroanesthesia, Milan, Italy, June 2009.
Accepted: 18 August 2010
Endoscopic
retrograde
cholangiopancreatography
(ERCP) is usually performed in the prone position
under moderate or deep sedation, or under general
anaesthesia [1]. Conscious sedation for ERCP has been
associated with cardio respiratory complications, particularly drug-induced respiratory depression and airway
obstruction [2–5]. General anaesthesia has the advantage
of airway protection, a lower ERCP failure rate [6] and
lower complication rates associated with therapeutic
ERCP interventions [2, 7]. When general anaesthesia is
used, airway protection can be achieved with a tracheal
tube or a laryngeal mask airway [8]. However, tracheal
intubation usually requires the use of neuromuscular
blocking drugs and has been associated with a longer
extubation time compared with the laryngeal mask
airway [8].
The Gastro Laryngeal Tube (VBM Medizintechnik
GmbH, Sulz, Germany; Fig. 1) is a modification of the
Laryngeal Tube which provides a dedicated channel for
the insertion of a gastroscope, while acting as a supra1114
glottic airway for ventilation. It has two high-volume,
low-pressure interconnected cuffs: a proximal pharyngeal
cuff that seals the oropharynx and nasopharynx and helps
to stabilise the tube; and a distal oesophageal cuff that
is designed to seal the oesophagus and reduce the risk
of pulmonary aspiration. Both cuffs are inflated to an
intracuff pressure of approximately 60 cmH2O through
a single inflation valve attached to the pilot balloon. The
Gastro Laryngeal Tube is constructed of latex-free
medical grade silicone and has a built-in bite block to
protect the endoscope. The endoscopic channel has an
internal diameter of 16 mm and enables the insertion and
use of a gastrointestinal endoscope with a maximum
external diameter of 13.8 mm. It is coated with a special
polymer to minimise friction caused by the insertion and
movement of the endoscope. The Gastro Laryngeal Tube
is manufactured only in one size and can be used for
patients with a body length > 155 cm.
The purpose of our prospective observational study
was to make a preliminary assessment the safety and
2010 The Authors
Anaesthesia 2010 The Association of Anaesthetists of Great Britain and Ireland
Æ
Anaesthesia, 2010, 65, pages 1114–1118
L. A. Gaitini et al.
Gastro-Laryngeal tube and endoscopic retrograde cholangiopancreatography
. ....................................................................................................................................................................................................................
Figure 1 A Gastro-Laryngeal Tube.
effectiveness of this device for airway management in
patients undergoing general anaesthesia for ERCP, and
assess the feasibility of using its endoscopic channel for the
performance of the ERCP.
Method
The study was approved by the Bnai-Zion Medical
Center Human Ethics Committee and written informed
consent was obtained from all patients. Thirty patients,
aged between 18–75 years and with an ASA physical
status 1 to 3, scheduled for ERCP, were enrolled. Only
patients with normal airways were included into the
study. Patients were excluded if their modified Mallampati classification was 3 or 4, the thyromental distance was
< 3 fingers, the intercisor distance was < 2 fingers, the
head and neck mobility was limited, or if gross morphological abnormalities of the head and neck were present.
Further exclusion criteria were: oesophageal disease;
active gastro-oesophageal reflux disease; pregnancy;
restrictive lung disease; or > 20% deviation from the
ideal body weight. Two consultant anaesthetists experienced in the use of the Laryngeal Tube inserted the
Gastro Laryngeal Tube and two consultant gastroenterologists performed the ERCP.
General anaesthesia was induced with fentanyl up to
3 lg.kg)1 and propofol 2–3 mg.kg)1, and maintained with
a continuous infusion of propofol 100 lg.kg)1.min)1,
without neuromuscular blocking drugs. The patients
were allowed to breathe spontaneously and manual
ventilation assistance was only provided if necessary, for
short periods after induction of general anaesthesia. The
Gastro Laryngeal Tube was inserted with the patient in the
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Anaesthesia 2010 The Association of Anaesthetists of Great Britain and Ireland
supine position and the head in the neutral or sniffing
position, keeping it in the midline of the mouth with the
distal part against the hard palate. Once the hypopharynx
was reached, the left index finger was used to direct the
distal part into the oesophagus. This Gastro Laryngeal Tube
insertion technique is based on that of the Laryngeal Tube
or Laryngeal Tube Suction insertion method recommended by the manufacturer [9]. Airway manoeuvres,
graded as minor (adjusting the head ⁄ neck position, lateral
movements of the device) and major (re-insertion of the
device), were applied if the Gastro Laryngeal Tube was not
successfully inserted.
Both balloons of the Gastro Laryngeal Tube were
sequentially inflated with air using a manometer (Cuff
Pressure Gauge; VBM Medizintechnik GmbH) until
intra-balloon pressure reached 80 cmH2O, and then the
deflate valve was pressed to adjust the pressure to
60 cmH2O. Proper positioning of the Gastro Laryngeal
Tube was confirmed by bilateral chest movement and
auscultation, absence of gastric insufflation and by the
presence of a normal capnogram. The airway was judged
to be effective and adequate if the operator could achieve
at least 8–10 ml.kg)1 of expired volume during gentle
manual ventilation, as well as a normal capnogram trace
and a normal flow-volume loop. Two insertion attempts
were allowed and the number of insertion attempts was
recorded. The insertion time was noted from the removal
of the facemask to attachment of the device to the
breathing system and the appearance of a normal
capnogram trace.
After the demonstration of successful placement, the
patients were positioned prone with the head in the right
lateral position, and proper position of the Gastro
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L. A. Gaitini et al.
Gastro-Laryngeal tube and endoscopic retrograde cholangiopancreatography
Anaesthesia, 2010, 65, pages 1114–1118
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Laryngeal Tube was reassessed. Arterial oxygen saturation, expired carbon dioxide, and inspired and expired
tidal volumes were recorded using an AS ⁄ 3 Anaesthesia
Delivery Unit (Datex-Ohmeda, Helsinki, Finland) at
5-min intervals. Oropharyngeal leak pressure was determined by closing the expiratory valve of the circle system
at a fixed gas flow of 3 l.min)1 and noting the airway
pressure (maximum allowed was 40 cmH2O) at which
the circuit pressure stabilised [10].
The ERCP was performed with a 11-mm duodenoscope (Pentax ED-3480 Tokyo, Japan). The Gastro
Laryngeal Tube was manually stabilised during insertion
of the endoscope in order to prevent displacement.
Upper airway trauma was assessed by checking for the
presence of blood on the Gastro Laryngeal Tube after
removal. Patients were questioned postoperatively about
symptoms of a sore throat, hoarseness, dysphonia or
dysphagia in the post-anaesthesia care unit and again 24 h
after surgery. The patients were asked non-leading
questions. Symptoms were graded by the patients as
mild, moderate or severe. Clinically unacceptable ventilation, a peak airway pressure exceeding 40 cmH2O, or
an oxygen saturation below 90% resulted in immediate
termination of the study. Further anaesthetic management
was at the discretion of the anaesthetist.
Table 1 Patients’ characteristics and indications for endoscopic
retrograde cholangiopancreatography. Values are mean (SD) or
number.
Characteristics
Age; years
Weight; kg
Height; cm
Body mass index; kg.m2
Sex; M:F
ASA grade; 1/2/3
69.4 (4)
72.53 (4)
168.4 (7)
25.6 (5)
17 ⁄ 13
0 ⁄ 21 ⁄ 9
Indications
Choledocholithiasis
Cholelithiasis
Obstructive jaundice
Stent replacement
Stent removal
Suspected common bile duct stones
Common bile duct stenosis
Abnormal liver function test
5
5
8
3
2
3
2
2
Symptoms disappeared in all patients within 24 h without
any intervention.
The ERCP was performed successfully in all patients
though the endoscopic channel of the Gastro Laryngeal
Tube, with a mean (SD) duration of 43 (11) min.
Results
Patients’ characteristics and indications for endoscopy are
presented in Table 1. None of the 30 patients recruited
into the study were excluded. The Gastro Laryngeal Tube
was inserted successfully in all patients, in 27 at the first
attempt and in three at the second attempt. The mean
(SD) time to achieve an effective airway was 26 (6) s.
Oxygenation and ventilation were successful in all
patients with a mean (SD) arterial oxygen saturation of
98.6 (0.6) % and expired carbon dioxide of 5.7 (1) kPa.
The mean (SD) inspiratory and expiratory tidal volumes
were 336 (57) and 312 (72) ml, respectively and oropharyngeal leak pressure was 33.7 (2) cmH2O. Minor airway
interventions were necessary in nine patients (adjusting
head ⁄ neck position in four patients and lateral movements of the device in five patients). Major airway
interventions (re-insertion of the device) were necessary
in three patients. Bloodstains were present on the Gastro
Laryngeal Tube after its removal in three cases (insertion
having been successful on the first attempt in two cases
and on the second attempt in one case).
Four patients complained of sore throat, one patient
complained of dysphagia, and one complained of dysphonia in the post-anaesthesia care unit. These symptoms
were all classified as mild, with the exception of one
patient who complained of a moderate sore throat.
1116
Discussion
This study describes the successful use of the Gastro
Laryngeal Tube for ERCP. The Gastro Laryngeal Tube
was successfully inserted, and allowed oxygenation and
ventilation as well as successful performance of diagnostic
and therapeutic ERCP. Except for short periods of
apnoea immediately after induction of general anaesthesia,
all patients were spontaneously breathing throughout the
procedure.
The anaesthetic management for ERCP differs from
institution to institution, and ranges from conscious and
deep sedation to general anaesthesia with tracheal intubation [2, 6]. Propofol, midazolam and fentanyl are safely
used as the preferred sedative drugs at many institutions
[1]; however the risk of oversedation, and respiratory or
cardiopulmonary complications is always present. Qadeer
et al. [11], in a meta-analysis of the current literature,
showed that the use of propofol for sedation in ERCP
had a similar risk of complications when compared with
midazolam, pethidine, and ⁄ or fentanyl.
Recently, the ASA House of Delegates approved a
statement on endoscopic sedation that recommended
monitoring exhaled carbon dioxide during laparoscopic
endoscopy procedures in which sedation is provided with
propofol alone, or in combination with opioids and a
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Anaesthesia 2010 The Association of Anaesthetists of Great Britain and Ireland
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Anaesthesia, 2010, 65, pages 1114–1118
L. A. Gaitini et al.
Gastro-Laryngeal tube and endoscopic retrograde cholangiopancreatography
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benzodiazepine. In addition, special attention to airway
management was recommended, especially during ERCP
in the prone position [12]. Conscious or deep sedation
may be inadequate for successful completion of the
ERCP, with lack of airway control causing inadequate
oxygenation and ventilation. A high incidence of hypoxaemia has been reported during endoscopies performed
under sedation [13–15]. Supplemental administration of
oxygen is usually sufficient to reverse hypoxaemia;
however, patients requiring deeper levels of sedation
may lose airway patency [8]. In addition, a decrease in
arterial oxygen saturation below 90% has been associated
with an increased risk of post-ERCP pancreatitis [15]. A
further risk to patients having sedation or conscious
sedation is aspiration of gastric contents as a result of an
unprotected airway. This potential complication requires
close attention to the patients’ airways at all times during
the procedure. For these reasons, some anaesthetists prefer
general anaesthesia with a tracheal tube.
The potential benefit of using a supraglottic airway
device for airway protection during ERCP is the
maintenance of a patent airway whilst avoiding laryngoscopy and tracheal intubation with their consequent
undesirable haemodynamic responses [16]. We are aware
of only one article describing the successful use of the
laryngeal mask airway to secure the airway during ERCP
[8]. In this study, the laryngeal mask airway was placed
and removed in the prone position, and was associated
with a shorter recovery time compared to the tracheal
tube [8]. In our study, the Gastro Laryngeal Tube was
placed and removed with the patient in the supine
position and the patient was safely turned into the prone
position with the device in situ. Oxygenation and
ventilation were normal during all the procedures,
showing that the Gastro Laryngeal Tube is an effective
device during spontaneous ventilation in the prone
position.
The incidences of bloodstains, sore throat, dysphagia
and dysphonia were similar to those of previously
published data describing the use of the Laryngeal Tube
and Laryngeal Tube Suction [17, 18]. These side-effects
are probably caused by either the insertion technique used
or the pressure exerted by the cuffs on the surrounding
soft tissues. A limitation of this study is that the two
anaesthetists who inserted the Gastro Laryngeal Tube had
significant prior experience with the Laryngeal Tube and
Laryngeal Tube Suction, which make well not be the case
for other anaesthetists.
Acknowledgments
The authors thank VBM Medizintechnik GmbH, Sulz,
Germany for providing the Gastro Laryngeal Tubes to
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perform this study. Apart from this, no external funding
and no competing interests are declared.
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