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Correspondence  |   June 2007
Airway Obstruction due to Cuff Herniation of a Classic Reusable Laryngeal Mask Airway
Author Affiliations & Notes
  • Marc Wrobel, M.D.
    *
  • *University of Saarland, Homburg/Saar, Germany.
Article Information
Correspondence
Correspondence   |   June 2007
Airway Obstruction due to Cuff Herniation of a Classic Reusable Laryngeal Mask Airway
Anesthesiology 6 2007, Vol.106, 1255-1256. doi:10.1097/01.anes.0000265434.43689.d5
Anesthesiology 6 2007, Vol.106, 1255-1256. doi:10.1097/01.anes.0000265434.43689.d5
To the Editor:—
We report a 59-yr-old woman (height, 160 cm; weight, 58 kg) scheduled to undergo knee arthroscopy during general anesthesia. We used a reusable size 4 Laryngeal Mask Airway Classic  ™ (LMA  ™; The Laryngeal Mask Company, Henley-on-Thames, United Kingdom) as an airway device. Before insertion of the LMA  ™, the cuff was inflated with 20 ml of air and totally deflated for confirmation of adequate function as recommended by the manufacturer. No problems were detected at this time. Anesthesia was induced with 0.1 mg fentanyl and 150 mg propofol. Insertion of the LMA  ™ was easy, and ventilation was sufficient after one attempt. Anesthesia was maintained with desflurane and remifentanil, and the lungs were ventilated with an oxygen–air mixture (fraction of inspired oxygen 0.5). A tidal volume of 420 ml was administered via  controlled mechanical ventilation with a peak airway pressure of 14 mbar. Twenty minutes after insertion of the LMA  ™, an airway leak occurred. The anesthesiologist inflated the cuff of the LMA  ™ with an additional 10 ml of air, postulating a leak due to insufficient inflation of the cuff. Directly thereafter, ventilation was impossible. Consequently, the LMA  ™ was totally deflated, removed from the pharynx, and reinserted. Once again, ventilation was impossible after reinflating the cuff of the LMA  ™ with 20 ml of air. Finally, the LMA  ™ was removed and tracheal intubation was performed. Inspection of the LMA  ™ revealed a cuff hernia (fig. 1with inflated and fig. 2with deflated cuff) that did not exist before the first insertion when the cuff was checked by the anesthesiologist.
Fig. 1. Laryngeal mask airway with inflated cuff. 
Fig. 1. Laryngeal mask airway with inflated cuff. 
Fig. 1. Laryngeal mask airway with inflated cuff. 
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Fig. 2. Laryngeal mask airway with deflated cuff. 
Fig. 2. Laryngeal mask airway with deflated cuff. 
Fig. 2. Laryngeal mask airway with deflated cuff. 
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Another case of herniation with the LMA  ™ airway was reported with a disposable LMA  ™,1 where plastic layers between the inflated cuffs had separated and resulted in a herniation. In this case, the airway obstruction developed over 1.5 h. In our case, the obstruction occurred suddenly after inflation of additional air into the cuff. Here, fatigue of material due to repeated sterilization is the most likely cause. The manufacturer advises in the instruction manual not to use silicon-based lubricants and to use an LMA  ™ cuff deflator before sterilization to prevent cuff hernia. However, we used solely water as a lubricant, and sterilization was performed as recommended by the manufacturer.
Therefore, if ventilation is not possible with a reusable LMA  ™ airway, particularly after repeated sterilization, a herniated cuff should be considered, even if initial testing was inconspicuous. Removal of the LMA  ™ and inspection of the cuff should be considered to rule out this potentially deleterious technical problem.
*University of Saarland, Homburg/Saar, Germany.
Reference
Reference
England AJ: Respiratory obstruction secondary to laryngeal mask failure. Anaesthesia 2004; 59:1030–1England, AJ
Fig. 1. Laryngeal mask airway with inflated cuff. 
Fig. 1. Laryngeal mask airway with inflated cuff. 
Fig. 1. Laryngeal mask airway with inflated cuff. 
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Fig. 2. Laryngeal mask airway with deflated cuff. 
Fig. 2. Laryngeal mask airway with deflated cuff. 
Fig. 2. Laryngeal mask airway with deflated cuff. 
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