Repeated Use of the Cuffed Oropharyngeal Airway in an Infant for Radiation Therapy

To the Editor: We recently encountered a 6-mo-old girl diagnosed with rhabdomyosarcoma of the left mandible, requiring general anesthesia to receive twice-daily radiation therapy for 6 wk. This required an atraumatic airway management technique that provided an effective airway during a propofol general anesthetic. Because of anticipated irritation-if not mucosal friability-secondary to the radiation dose, we sought to avoid using endotracheal intubation of the laryngeal mask airway. To address our concerns, and with the parent's consent, a small cuffed oropharyngeal airway (COPA; 6 cm) custom-made with a larger bite block (Figure 1 inset) to provide a consistent open jaw angle for consistent, precise delivery of radiation dose, was provided (Mallinckrodt Medical, Inc., St. Louis, MO). The COPA also allowed administration of oxygen and monitoring of end-tidal CO2.Figure 1: A custom-made cuffed oropharyngeal airway used in an infant.Although we encountered no significant complications during the 49 anesthetics performed using this technique, it was necessary, at times, to reposition the device or to use a tongue depressor to ensure proper positioning of the COPA cuff. These manipulations were considered to be related, at least in part, to the additional bite block limiting the movement of the tongue on inflation of the cuff. During the course of therapy, there was increasing external cheek redness and some buccal mucosal inflammation most likely related to the radiation, not the use of the airway itself. Although the COPA has been used successfully in adults and in older children (5-12 yr old) [1,2], this is the first report of its use in an infant. The COPA performed well in this patient, who was anesthetized with a propofol bolus, followed by an infusion with spontaneous ventilation, and provided a stable airway for remote monitoring during the radiation dose. Based on our experience with the COPA and on previous experience with older children, the COPA is a practical and safe alternative for airway management in this setting. Robert S. Greenberg, MD Departments of Anesthesia and Critical Care Medicine & Pediatrics; Johns Hopkins Medical Institutions; Baltimore, MD 21287 Cheryl B. Prichard Keith J. Jacquin Research and Development; Anesthesia and Respiratory Devices; Mallinckrodt, Inc.; St.