Gastric Tube-Guided Reinsertion of the ProSeal™ Laryngeal Mask Airway

To the Editor: We report the use of a gastric tube as a guide to reinsertion of the ProSeal™ laryngeal mask airway (PLMA™) (1,2). A 53-yr-old, 102-kg, anesthetized, paralyzed man was undergoing surgery to the upper face using the PLMA™ and pressure controlled ventilation. Insertion of the PLMA™ had been difficult because of resistance at the back of the mouth and was eventually accomplished by using laryngoscope-guided passage of a gum elastic bougie into the esophagus, then guiding the size 5 PLMA™ along the drainage tube into its correct position. The oropharyngeal leak pressure was >40 cm H2O with 15 mL air in the cuff. Ventilation was adequate with tidal volumes of approximately 500 mL with peak airway pressures of 22 cm H2O. A 16F gastric tube was passed into the stomach at the first attempt and left in position. No fluid was aspirated from the stomach. During head/neck repositioning in the middle of the operation, a loud air leak suddenly developed and ventilation became inadequate. Removal of the drapes revealed that the PLMA™ cuff had been completely displaced into the mouth, probably because of traction from the anesthesia tubing and inadequate fixation. Rather than removing and reinserting the PLMA™ using the gum elastic bougie, it was simply and easily guided back into position using the gastric tube as a guide. Adequate ventilation was immediately restored and there were no further problems. Although the potential risks and benefits of gastric tube placement with the PLMA™ have not been quantified, we suggest leaving the gastric tube in situ during the operation if there is an increased risk of displacement, particularly if insertion was difficult. J. Brimacombe D. Vosoba Judd K. Tortely E. Barron H. Branagan