Effects of tracheal tube orientation on the success of intubation

through an intubating laryngeal mask airway: study

in Mallampati class 3 or 4 patients
L. Ye
1
, J. Liu
1
, D. T. Wong
2
and T. Zhu
1
*
1
Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu Sichuan Province
610041, Peoples Republic of China.
2
Department of Anaesthesiology, Toronto Western Hospital, University
Health Network, University of Toronto, Ontario, Canada M5T 2S8
*Corresponding author. E-mail: xwtao.zhu@gmail.com
Background. We evaluated the effects of conventional tracheal tube orientation on success of
intubation through an intubating laryngeal mask airway (ILMA) in Mallampati class 3 or 4 patients.
Methods. Two hundred adults, ASA I II, Mallampati class 3 or 4, undergoing elective surgery
under general anaesthesia were enrolled. All the patients were randomly allocated to either
normal or reverse group based on the orientation of the tracheal tube as it was initially inserted
into the ILMA. Tracheal intubation was considered successful, if proper tracheal positioning was
attained within three insertion attempts. x
2
analysis was used to compare categorical variables.
Results. Tracheal intubation through the ILMA was successful in 183 of 200 patients (91.5%): 157
(78.5%) on the rst attempt. Seventeen (8.5%) were intubated using direct laryngoscopy. The rst-
attempt success rate was higher in the reverse than in the normal group (85.0% vs 72.0%,
P0.025), although the overall success rate was similar between the reverse and the normal
groups (93.0% vs 90.0%). The incidence of sore throat was comparable in the normal group and
the reverse group (22.0% vs 12.0%, NS).
Conclusions. Overall, tracheal intubation was successful in 91.5% of patients through an ILMA
with a conventional tracheal tube in Mallampati class 3 or 4 patients. The rst-attempt success rate
was higher in the reverse group compared with the normal group, but the overall success rate was
similar between the reverse and the normal groups.
Br J Anaesth 2009; 102: 26972
Keywords: anatomy, airway; complications, intubation tracheal; equipment, laryngeal mask;
equipment, tubes tracheal
Accepted for publication: November 4, 2008
The intubating laryngeal mask airway (ILMA, LMA-
Fastrach
TM
, LMA North America, Inc., San Diego, CA,
USA) has been introduced into clinical practice for more
than 10 yr. The reusable, relatively expensive Fastrach
TM
silicone wire-reinforced tube was designed for tracheal
intubation through the ILMA.
1
A polyvinyl chloride con-
ventional tracheal tube is disposable, less expensive, and
readily available. However, Brain, the inventor of the
ILMA, did not recommend its usage for intubation
through an ILMA because of its stiffness and potential
difculties in passage through the glottis.
2
Studies have
shown that conventional tracheal tubes can be successfully
used for tracheal intubation through the ILMA.
24
It was
demonstrated that intubation success is higher, if the tra-
cheal tubes are inserted in a reverse orientation compared
with the normal orientation.
2 3
One limitation of these
previous studies is that all patients exhibited normal
airways with Mallampati class 1 or 2.
24
The purpose of
this study was to evaluate the effects of conventional tra-
cheal tube orientation on success of intubation through an
ILMA in Mallampati class 3 or 4 patients.
Methods
The study was approved by the Institutional Research Ethics
Board and written consent was obtained from all the patients.
Adult patients, ASA I or II, undergoing general anaesthesia
and tracheal intubation were examined and a Mallampati
class ascertained. Exclusion criteria included morbid
obesity, respiratory tract (oropharynx and larynx) pathology,
limited mouth opening (inter-incisor gap ,2 cm), and risk
#The Board of Management and Trustees of the British Journal of Anaesthesia 2009. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
British Journal of Anaesthesia 102 (2): 26972 (2009)
doi:10.1093/bja/aen365

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of aspiration (previous upper gastrointestinal tract surgery,
known or symptomatic hiatus hernia, oesophageal reux,
peptic ulceration, or not fasted). Two hundred consecutive
patients with Mallampati class 3 or 4 were enrolled. Patients
were randomly assigned by closed envelopes containing
computer-generated randomization codes, to one of the two
equal-sized groups (n100 each): normal group or reverse
group depending on the orientation of the tracheal tube at the
point of insertion into the ILMA. In the normal group, the
tracheal tube was inserted with its natural curve following
the 908 curvature of ILMA, but in the reverse group, the
natural curve of the tracheal tube was directed opposite to
the curvature of the ILMA (Fig. 1).
2 3
A size 3 ILMA and a
7.0 mm ID polyvinyl chloride conventional tracheal tube
(Mallinckrodt
w
tracheal tube, Comamaddy Athlone Co.,
Ireland) were used for patients weighing ,50 kg, and a size
4 ILMA and a 7.5 mm ID tracheal tube were used for
patients weighing .50 kg. All procedures were performed
by a single experienced attending anaesthesiologist.
Standard monitoring, including ECG, pulse oximetry,
capnography, and non-invasive blood pressure monitor,
was performed and the anaesthetic management was stan-
dardized. Patients were pre-oxygenated (FI
O
2
1.0) for 3
min and general anaesthesia was induced with propofol
23 mg kg
21
and fentanyl 23 mg kg
1
. After conr-
mation of face mask ventilation, rocuronium 0.6 mg kg
1
was administered. An ILMA was inserted with the head
neck in the neutral position, and the cuff was inated with
air until an effective seal was achieved or up to the
maximum recommended volume (20 ml in size 3 and
30 ml in size 4). Adequate ventilation was assessed by
chest wall movement, capnograph waveform, and no oro-
pharyngeal leak with peak airway pressures .20 cm H
2
O
during manual ventilation. Oropharyngeal leak pressure
was taken to be that pressure at which gas could rst be
heard escaping around the laryngeal mask airway during
manually assisted ventilation. If adequate ventilation was
not attained, the ILMA was manipulated (updown and
Chandys manoeuvres)
5
in situ, and a single change of
ILMA size was permitted. Anaesthesia was maintained
with volatile anaesthetics in oxygen 100% during the intu-
bation attempts.
After lubrication, the tracheal tube was initially inserted
into the ILMA with the orientation according to randomiz-
ation (Fig. 1). If no resistance was encountered with the
passage of the tracheal tube, it was advanced to the full dis-
tance (2829 cm). If resistance was encountered during
passage of the tracheal tube, Chandys manoeuvre was per-
formed and further advancement attempted. An intubation
attempt was considered a failure if (i) the tracheal tube tip
could not be advanced the full distance of the tracheal tube,
(ii) the tracheal tube was advanced the full distance, but no
capnographic tracing was seen, or (iii) the patients oxygen
saturation was ,90% and the intubation attempt was aban-
doned. An intubation attempt was considered successful, if
the tracheal tube advanced to the full distance and a posi-
tive capnographic tracing was obtained. After successful
tracheal intubation, the ILMA was removed using the stan-
dard technique and the stabilizing rod.
In each patient, intubation via the ILMA was limited to
three attempts. After each failed intubation attempt, the
ILMA was reinserted and ventilation compliance opti-
mized. After three attempts, if intubation was not success-
ful, tracheal intubation was performed under direct
laryngoscopy. Fibreoptic bronchoscopy was available for
intubation if needed.
The primary outcome measure was the rst-attempt
intubation success rate between the normal group and the
reverse group in Mallampati class 3 or 4 patients. Other
outcome measures include cumulative third-attempt intu-
bation success rate between the normal group and the
reverse group in Mallampati class 3 or 4 patients. Patients
were interviewed the next day after surgery to evaluate for
sore throat using a verbal analogue scale (010). A verbal
analogue scale .3 was considered positive.
3
On the basis of our pilot study data,
6
the rst intubation
attempt success of the normal and reverse orientation in
Mallampati class 3 or 4 patients was 60% and 80%, respect-
ively. A sample size of 81 allowed the detection of a 20%
difference in the proportion of successful intubation
A B
Fig 1 (A) With normal tube orientation, the emergence angle was 478. (B) With reverse tube orientation, the emergence angle was 208.
Ye et al.
270

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between normal and reverse orientation in Mallampati class
3 or 4 patients, with an a of 0.05 (two-tailed) and a b of
0.20, power of 0.8. To account for attrition, a sample size of
100 was selected for each of the normal and reverse groups.
Data were analysed with SPSS Version 13.0 (SPSS Inc.,
Chicago, IL, USA). t-Test was used for continuous vari-
ables and x
2
analysis with the Bonferroni correction was
used for categorical variables. P,0.05 was considered stat-
istically signicant.
Results
A total of 2011 patients were screened for study eligibility.
Of these, 1754 patients (87.2%) were excluded because they
had Mallampati class 1 or 2. Sixteen patients refused to par-
ticipate in the study and 41 met one or more of the exclusion
criteria. Thus, 200 patients were included in the study.
The patient characteristics were similar between the two
groups (Table 1). Placement of the ILMA was successful
in all patients. The success rates of tracheal intubation
through ILMA are illustrated in Table 2. Tracheal intuba-
tion was successful in 183 (91.5%) of 200 patients.
Successful intubation on the rst attempt was achieved in
157 (78.5%) patients. In 17 (8.5%) patients, intubation
was accomplished using direct laryngoscopy. The mean
(SD) number of intubation attempts was 1.4 (0.7).
The rst-attempt success rate was higher in the reverse
group than in the normal group (85.0% vs 72.0%, P0.025,
absolute difference 13%, 95% condence interval for the
difference: 1.824.2%). However, the third-attempt cumula-
tive success rate was comparable between the normal and the
reverse groups (90.0% vs 93.0%). The number of intubation
attempts was higher in the normal group than in the reverse
group [1.5 (0.8) vs 1.3 (0.6), P0.004].
Sore throat
The incidence of sore throat was not signicantly different
between the two groups (22.0% in the normal group and
12.0% in the reverse group). Sore throat was mostly mild
and lasted for 23 days without requiring medical
intervention.
Discussion
Overall, tracheal intubation was successful in 91.5% of
patients through an ILMA with a conventional tracheal
tube in Mallampati class 3 or 4 patients. The rst-attempt
success rate was higher in the reverse group compared
with the normal group, but the overall success rate was
similar between the groups.
Since Brain and colleagues
7
reported a 99.3% success
rate in their preliminary clinical trial in 1997, studies have
used primarily silicone wire-reinforced tube for tracheal
intubation through the ILMA. However, none of the sub-
sequent studies could achieve the same success rate as
Brain and colleagues (8998%).
810
Despite certain disadvantages, clinicians continue to use
the polyvinyl chloride conventional tracheal tubes because
they are less expensive, readily available, and disposable.
In 2005, Kundra and colleagues
4
demonstrated a 96%
success rate within two intubation attempts with both
Rusch polyvinyl chloride tubes in normal orientation and
with silicone wire-reinforced tubes. Two other studies
reported insertion of conventional tracheal tubes via the
ILMA.
2 3
In 1999, Joo and Rose
2
reported a 96.7% intuba-
tion success rate with reverse orientation using polyvinyl
chloride tracheal tubes. In 2000, Lu and colleagues
3
reported a 95.4% third-attempt cumulative success rate
with the Sheridan tracheal tube in two orientations. Our
study demonstrated a third-attempt cumulative intubation
success rate of 91.5%. The rst-attempt success rate is
another important performance indicator for tracheal intu-
bation. Our study demonstrates a success rate of 78.5% on
the rst attempt compared with 80.886.7% in other
studies.
24
Our third-attempt cumulative success and rst-
attempt success rates are comparable with those reported in
the literature.
24
Findings from our study and from the lit-
erature
24
demonstrate that polyvinyl chloride conventional
tracheal tubes may be used for insertion via the ILMA.
Tracheal intubation via an ILMA with the conventional
tracheal tube inserted in reverse orientation was rst
described by Joo and Rose.
2
The present study and the
study by Lu and colleagues
3
are the only two randomized
clinical trials evaluating the effect of tracheal tube orien-
tation on intubation success with an ILMA. Both studies
found that there was no difference in the overall success
rates of tracheal intubation between the normal and
reverse orientation groups; but, our rst-attempt success
rate in the reverse group was higher than that in the
normal orientation group.
An important factor that determines the success of tra-
cheal intubation is the angle at which the tracheal tube
emerges from the distal aperture of the ILMA.
1 4
Brain
and colleagues,
1
and Kundra and colleagues,
4
have
Table 1 Patient characteristics. Data presented as mean (range or SD) or actual
values. The two groups were similar
Variables Normal group (n5100) Reverse group (n5100)
Age (yr) 45.6 (1878) 45.8 (1877)
Weight (kg) 57.4 (9.7) 57.7 (8.0)
Sex (male:female) 46:54 49:51
Table 2 Success rates and incidence of sore throat of tracheal intubation via
ILMA in Mallampati class 3 or 4 patients. Data are given as number of
patients (cumulative percentage). *P,0.05
Normal group (n5100) Reverse group (n5100)
First attempt 72 (72.0%) 85 (85.0%)*
Second attempt 10 (82.0%) 3 (88.0%)
Third attempt 8 (90.0%) 5 (93.0%)
Sore throat 22 (22.0%) 12 (12.0%)
ETT orientation and success through LMA
271

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demonstrated that the angle of emergence of the conven-
tional tracheal tube was different with different tubes,
which may explain the difference in success rates of tra-
cheal intubation. In our in vitro demonstration, the angles
of emergence of the tracheal tube were 478 and 208 for
normal and reserve orientation, respectively (Fig. 1). The
478 angle of emergence with normal orientation may
direct the tracheal tube against the anterior portion of the
upper airway (larynx, cricothyroid membrane, or trachea),
resulting in failure of the tracheal tube advancement. Brain
and colleagues
1
also explained that the tracheal tube was
unable to reverse its curvature from the point of exit from
the ILMA into the trachea because of the additional curva-
ture imposed by the metal shaft of the ILMA, thereby
getting caught in the trachea. However, an emergence
angle of 208 with reverse orientation may allow the tube
to approach the larynx at a more optimal angle, resulting
in higher intubation success rates.
2 3
This study was designed to evaluate the effects of con-
ventional tracheal tube orientation on success of tracheal
intubation via an ILMA in patients with exclusively
Mallampati class 3 or 4. We found that success in intuba-
tion through the ILMA was high in Mallampati class 3 or
4 patients and are comparable with the success rate in
patients with normal airways in the literature. Mallampati
grading has been shown to be predictive of difculties in
direct laryngoscopy and tracheal intubation.
11 12
However,
studies have demonstrated that predictors of difcult laryn-
goscopic view do not bear any consistent relationship to
the degree of difculty in utilizing alternative intubating
techniques such as the ILMA or lighted stylet whereby
direct visualization of the larynx is not required.
5 7 13
Sore throat was slightly more frequent in our study com-
pared with Lu and colleagues
3
(17% vs 14.2%). The minor
difference in incidence of sore throat may be attributed in
part to the subjective nature of the visual analogue scale, the
type and curvature of tracheal tube used, and the number of
intubation attempts. The incidence of sore throat for
LMA-Classic
TM
has been reported as 070%.
14
There are several limitations to our study. First, the exact
reason for unsuccessful passage of tracheal tube passage
was not clear. Possible reasons include poor ILMA posi-
tioning, downfolded epiglottis, or the tip of the tracheal
tube impinging on larynx or trachea. This study was
designed to evaluate the success of intubation using a blind
technique with two tracheal tube orientations. Further
studies incorporating bronchoscopic visualization before
and between intubating attempts may better illustrate
the reasons for intubating failures. Secondly, patients in
the study were of Chinese origin with relatively lower
stature and weight, and anterior larynx.
15
The results may
not be generalizable to the other population categories.
In conclusion, the tracheal intubation was successful in
91.5% of patients through an ILMA with a conventional tra-
cheal tube in Mallampati class 3 or 4 patients. The rst-
attempt success rate was higher in the reverse group
compared with the normal group, but the overall success rate
was similar between the groups. Conventional tracheal tube,
instead of Fastrach
TM
silicone wire-reinforced tube, inserted
through the ILMA may be considered as an option for
airway management in patients with Mallampati 3 or 4
classication.
Funding
This work was supported in part by National Natural
Science Foundation of China (NSFC) 30400423 and in
part by 973 Program (2005CB522601).
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