Laryngeal Mask Airway for Ventilation in Patients with Nasogastric Tube: A New Perspective

Dear Editor Since the invention of the laryngeal mask airway (LMA) by Dr. Archie Brain in 1981, it has been a boon to anaesthesiologists.[1] It serves as both a rescue device for unanticipated difficult airways and the preferred airway device for short procedures. An Aintree catheter and a fibre-optic bronchoscope are utilised in a hybrid approach with LMA to establish a predicted difficult airway. We propose an extension to this list of uses of LMA. For an anaesthesiologist, mask ventilation in patients who are using nasogastric tubes (NG tubes) is frequently a taxing task. Our goal was to list the numerous approaches that have tried to resolve this issue and suggest the usefulness of the familiar LMA in an unfamiliar context. An NG tube is used in patients with gastric outlet obstruction, intestinal obstruction, and perforation to decompress the stomach. It is also used to feed patients with head-and-neck cancers. Anaesthesiologists encounter many patients with NG tubes to be intubated. Usually, these patients are intubated after effective suction of the NG tube and adequate pre-oxygenation. After muscle paralysis, mask ventilation can be challenging due to the improper fit of the NG tube with the face mask. Several alternatives have been proposed in the literature to address this challenge. Some of these include an endoscopic mask with a port for the NG tube’s departure, extra gauze or denture glue to plug the air leak and a partially filled cuffed face mask to precisely fit the NG tube’s contour to the patient’s face.[2,3] In our technique, we propose to electively insert an LMA after the patient has been induced and relaxed. After placing an LMA, a simple chin lift manoeuvre can be used to hold the LMA in place without the need for adhesive tapes to secure it. Until the time for intubation, the patient is ventilated using a LMA. The LMA is then removed, and the trachea is intubated by an endotracheal tube. Thus, LMA serves as a bridge or an intermediate between pre-oxygenation and intubation in patients with NG tubes. As the LMA rests on the laryngeal inlet, the air leak with this method is considerably smaller than with a face mask. Compared to utilising a face mask, operation theatre pollution can be significantly reduced by employing an LMA if inhalational agents are used during induction. However, this technique would not be helpful in patients with difficult airways, where an LMA cannot be inserted (e.g. limited mouth opening or oral masses). Suctioning the NG tube before ventilation can help prevent aspiration. Moreover, the risk of aspiration is lower when ventilated with an LMA rather than a facemask. Another benefit of this approach is that we can intubate through the LMA, provided that the LMA can facilitate intubation. Takahashi et al. described a tube mask technique in which an endotracheal tube is inserted into the oral cavity, after which the mouth and nostrils are closed.[4] The method we described is a simpler method of ventilation than that mentioned by Takahashi et al., as it eliminates the need for extra hands to close the nostrils. Bailey’s manoeuvre is another manoeuvre where LMA is employed as a transition to extubation. This manoeuvre is used in patients who undergo micro-laryngeal surgeries to wash out carbon dioxide and in neurosurgeries where coughing or bucking is to be avoided. Thus, after complete awakening, the LMA is removed without airway stimulation.[5] In our technique, LMA is similarly used as an intermediate but before intubation. Therefore, we conclude that electively using an LMA in place of a face mask in patients with NG tubes is a feasible technique to prevent air leaks and facilitate ease of ventilation. However, further studies are required to evaluate and strengthen the effectiveness of this technique. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.