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Abstract & Commentary
Source: Ferson AZ. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesi-ology 2001;95:175-181.
The authors of this retrospective case series reviewed the records of patients with difficult airways in whom the LMA-Fastrach was used electively or emergently at four institutions from October 1997 through October 2000. All patients had at least one of the following characteristics: 1) a failed intubation associated with a grade 4 laryngoscopic view; 2) an immobilized cervical spine; 3) a distorted airway secondary to tumor, surgery, or radiation therapy; or 4) the presence of a steriotactic head frame. Both blind insertion and fiberoptic-guided insertion were performed. In each case the number of insertion and intubation attempts were recorded.
The LMA-Fastrach was used in 257 procedures performed in 254 patients with difficult airways. Two hundred patients (78%) were under general anesthesia, 51 patients (20%) were pretreated with topical anesthesia, and six unconscious patients (2%) received no pretreatment. The overall success rates for blind (n = 200) and fiberoptic-guided (n = 57) intubation through the LMA-Fastrach were 96.5% and 100%, respectively. The number of attempts required for blind intubation were: one in 151 cases (76%), two in 28 cases (14%), three in seven cases (3%), four in five cases (3%) and five in two cases (1%). Fiberoptic guided intubation had a 100% success rate on the first attempt.
In the subset of patients with cervical immobilization (n = 70), blind insertion of the LMA-Fastrach was successful in 97% of cases; in two cases, fiberoptic insertion was successful on the first attempt. In the subset of patients with distorted upper airways (n = 50), fiberoptic insertion of the LMA-Fastrach was successful on the first attempt in 100% of cases.
Commentary by Michael A. Gibbs, MD, FACEP
The laryngeal mask airway (LMA) is one of several airway rescue options recommended by the American Society of Anesthesiology’s Difficult Airway Algorithm.1 The LMA-Fastrach offers a significant advantage over the standard LMA in that insertion of a cuffed tube into the trachea is possible. In this, the largest published case-series to date, the device was highly successful in patients with difficult airways. While retrospective and uncontrolled, the results are a strong endorsement for the device. Emergency physicians should invest the time required to become familiar and comfortable with the LMA-Fastrach, as well as other airway rescue devices. We don’t need them too often, but when we do there is absolutely no room for error.
1. Caplan R. Practice guidelines for management of the difficult airway: A report by the ASA Task Force. Anesthesiology 1993;78:597-602.
Dr. Gibbs, Residency Program Director, Medical Director, Medcenter Air, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, is on the Editorial Board of Emergency Medicine Alert.