CASE REPORTS Aspiration and the laryngeal mask airway ... - BJA

British Journal of Anaesthesia 93 (4): 579–82 (2004)
doi:10.1093/bja/aeh228 Advance Access publication July 9, 2004
CASE REPORTS
Aspiration and the laryngeal mask airway: three cases and
a review of the literature {
C. Keller 1 , J. Brimacombe 2 *, J. Bittersohl 3 , P. Lirk 1 and A. von Goedecke 1
1 Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria.
2 James Cook University, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Australia.
3 Department of Anaesthesiology and Intensive Care Medicine, Philipps-University, Marburg, Germany
*Corresponding author. E-mail: jbrimaco@bigpond.net.au
The primary limitation of the laryngeal mask airway (LMAÒ ) z
is that it does not reliably protect the
lungs from regurgitated stomach content. We describe three cases of aspiration associated with the
LMA, including the first brain injury, the first death, and the first associated with the intubating LMA,
and review the 20 specific case reports of aspiration associated with the LMA that we were able to
find described in the literature.
Br J Anaesth 2004; 93: 579–82
Keywords: complications, aspiration pneumonitis; complications, mortality; equipment, masks,
laryngeal mask airway
Accepted for publication: May 25, 2004
Pulmonary aspiration of gastric contents accounts for 5% of
respiratory claims against the anaesthesiologist. 1 The primary
limitation of the laryngeal mask airway (LMA) is that it
does not reliably protect the lungs from regurgitated stomach
contents, although it may act as a barrier at the level of the
upper oesophageal sphincter if it is correctly positioned. 2 The
incidence of aspiration with the LMA has been estimated at
0.02%, 3 which is similar to tracheal intubation in elective
patients. 4 We describe three cases of aspiration associated
with the LMA, including the first brain injury, the first death,
and the first associated with the intubating LMA, and review
the literature.
Case report 1
A 49-yr-old female (ASA Physical Status III, BMI 16 kg m 2 )
with low-grade sepsis presented for incision and drainage of a
vaginal abscess. She had a past medical history of gastric
surgery for carcinoma and multiple intra-abdominal procedures,
but had no symptoms of reflux. On examination she
was Mallampati grade 1. The airway management plan was to
use a classic LMA; tracheal intubation was not considered
necessary as the patient was fasted and had no reflux; and the
ProSeal LMA was unavailable. Induction was with fentanyl
100 mg and propofol 120 mg. Maintenance was with propofol
6mgkg 1 h 1 in oxygen 30% and air. No neuromuscular
blocking agent was given. A size 4 classic LMA was easily
inserted by a second year resident at the first attempt using the
standard recommended technique and the cuff inflated with
20-ml air. Pressure controlled ventilation was commenced
and tidal volumes of 450 ml were easily achieved with peak
airway pressures of 15 cm H2O. The LMA and bite block was
fixed according to the manufacturer’s instructions 5 and the
patient placed in the lithotomy position. At the start of the
procedure, the patient suddenly started vomiting, which was
attributed to inadequate anaesthetic depth, and bile-stained
fluid was seen in the airway tube. The surgeon was asked to
stop, the patient was given oxygen 100%, anaesthesia was
deepened, head down tilt applied, and a neuromuscular blocking
agent administered. A suction catheter was passed to the
end of the airway tube and around 40 ml of bile-stained fluid
removed. Ventilation and gas exchange was unaffected.
Fibre-optic inspection down the airway tube revealed bilestained
fluid within the trachea. The LMA was removed and
the patient easily intubated. The procedure was completed
uneventfully. There were no postoperative complications.
Case report 2
A 73-yr-old female (ASA Physical Status III, BMI 35 kg m 2 )
presented for bilateral varicose vein surgery, to be done in the
{ This article is accompanied by Editoral II.
z LMA Ò is the property of Intavent Ltd.
# The Board of Management and Trustees of the British Journal of Anaesthesia 2004
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supine position. She had a past medical history of adult onset 100%. Fibre-optic inspection revealed bile-stained fluid
diabetes mellitus, chronic obstructive pulmonary disease, within the trachea. The procedure was completed and the
and gastric surgery for cancer. On examination she was patient transferred to ICU. The patient developed adult
Mallampati grade 3. The airway management plan was to respiratory distress syndrome, renal failure, disseminated
use a classic LMA; tracheal intubation was not considered intravascular coagulation and septicaemia, and died 85 days
necessary. The anaesthetist was not aware of the past medical
history, nor of her symptoms of daily reflux, and a ProSeal
LMA was unavailable. Induction was with fentanyl 150 mg
later from multi-organ failure.
and propofol 180 mg. Maintenance was with oxygen 30% in
nitrous oxide and sevoflurane 1.5%. Muscle relaxation was
with atracurium 20 mg. A size 4 classic LMA was inserted
easily by a highly experienced consultant at the first attempt
using the standard recommended technique and the cuff
inflated to and held constant at 60 cm H2O using a digital
manometer. Volume controlled ventilation was commenced
with tidal volumes of 600 ml and peak airway pressures of 18
cm H2O. The LMA and bite block was fixed according to the
manufacturer’s instructions. In the middle of the procedure,
bile-stained fluid was seen pouring out of the airway tube into
the bacterial filter. The surgeon was asked to stop; the patient
was given oxygen 100% and head down tilt applied. Ventilation
was possible with the LMA, but gas exchange was poor
with Spo2 less than 90% when the Fio2 was 1. The LMA was
removed and the patient easily intubated, but there was no
improvement in gas exchange. Fibre-optic inspection showed
bile-stained fluid in the trachea. The procedure was stopped
and the patient transferred to ICU. On day 3, the patient
developed severe adult respiratory distress syndrome
(Fio2 1.0: Paa2 58 mm Hg). She was discharged from the
ICU after 56 days with a complete left-sided hemiplegia
from a cerebral infarct.
Literature review
We conducted a Medline search for ‘Laryngeal mask’, read
all the resultant publications and analysed all the reports
where case-specific details were given. We found a total of
20 specifically described case reports of aspiration of gastric
content associated with the LMA (Table 1). Of the 20 cases of
aspiration associated with the LMA, 14 were in adults 6–18 and
six in children, 19–24 6–17 19–24
19 were with the classic LMA
and one was with the ProSeal LMA. 18 In 14 cases, there were
factors that could increase the risk of aspiration, including, in
orderoffrequency,inadequatedepthofanaesthesia, 913192123
intra-abdominal surgery, 7 10 18 upper gastrointestinal disease,
9 11 lithotomy position, 11 20 7 20
patient movement,
exchanging the LMA for a tracheal tube, 12 16 full stomach, 22
multiple trauma, 6 multiple insertion attempts, 14 opioids, 6
obesity, 10 and cuff deflation. 7 There is only one report
where aspiration occurred where the patient had no risk factors.
24 In addition, Kluger and Short, 25 in a review of 133
cases of aspiration reported to the Australian Anaesthetic
Incident Monitoring Study, documented 27 cases of aspiration
associated with the LMA. However, the data from
these patients were not separated from aspiration associated
with a tracheal tube (n=8), Hudson mask (n=5), and
facemask (n=91).
Case report 3
A 78-yr-old female (ASA Physical Status II, BMI 32 kg m 2 )
presented for a total hip replacement. She had a past medical
history of labile hypertension and a hiatus hernia, but had no
symptoms of reflux. On examination she was Mallampati
grade 2. The airway management plan was to intubate the
patient via the intubating LMA rather than using direct
laryngoscopy to attenuate the haemodynamic stress response.
Tracheal intubation was considered necessary as the procedure
was prolonged and the ProSeal LMA was unavailable.
Induction was with methohexitone 80 mg. Maintenance was
with isoflurane 0.7% and nitrous oxide in oxygen 30%. Muscle
relaxation was with rocuronium 50 mg. A size 4 intubating
LMA was inserted easily by a second year resident at the first
attempt and the cuff inflated with 30-ml air. Manual ventilation
was commenced with tidal volumes of 500 ml and peak
airway pressures of 17 cm H2O. Before intubation through the
intubating LMA was started, bile-stained fluid was seen in the
mouth. The patient was given oxygen 100%, but head down
tilt was not applied. Ventilation was possible with the LMA.
The intubating LMA was removed and the patient intubated
using a laryngoscope. Ventilation was adequate and gas
exchange acceptable with a Pao2 of 206 mm Hg on oxygen
Keller et al.
580
Discussion
All three patients in our series were at increased risk of aspiration:
the first had gastric surgery and low-grade sepsis; the
second had gastric surgery and diabetes; and the third had a
hiatus hernia. Both patients with adverse outcomes were
elderly, ASA grade III, or both. Although this is the first report
of brain injury and death from aspiration associated with the
LMA, it is likely that there have been other such events. Given
that the LMA has been used in 150 million patients since its
release in 1988 (www.lmaco.com), a frequency of 0.02% for
aspiration 3 and a mortality rate for aspiration of 5% (based on
data from the pre-LMA era 4 ), there should have been around
1500 deaths. Perhaps patients with the LMA have a lower
mortality rate, as the LMA tends to be used in healthy patients
undergoing minor procedures. Perhaps the lack of reporting is
related to medico-legal considerations, or journals decline
such reports, as it is already established that aspiration can
occur with the LMA and that aspiration can cause death.
An assessment of aspiration risk is critical to determining
whether the LMA should be used and, to a lesser extent, which
type of LMA should be used, as the correctly placed ProSeal
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Table 1. Cases of pulmonary aspiration of gastric contents. *P=placement phase, M=maintenance phase, E=emergence phase. { GIT=gastrointestinal tract, TT=tracheal
tube. z ICU=Intensive Care Unit, PPV=positive pressure ventilation, SpO 2 =oxygen saturation. # Approximate time of aspiration after induction. **ProSeal LMA.
+ Intubating LMA
Age Gender ASA Phase* Predisposing conditions {
LMA can prevent aspiration. 26–28 The patient should be questioned
about upper gastrointestinal disease, focusing on current
symptoms and treatment. Unfortunately, there are no
data from which to make an evidence-based decision
about whether or not symptoms are severe enough to warrant
tracheal intubation. Most anaesthesiologists consider that the
LMA is contraindicated in patients with gastroesophageal
reflux, but a recent survey revealed that 57–73% of Australian
anaesthesiologists would use the LMA in patients with a
history of reflux esophagitis or hiatus hernia provided it
was asymptomatic. 29 Interestingly, one of our patients had
an asymptomatic hiatus hernia. Other factors affecting
aspiration risk are fasting status, the use of gastroparetic
drugs, the presence/severity of pain, the type/duration/
position of surgery being performed, the depth of anaesthesia,
and airway obstruction.
All three patients in our series were intubated once a diagnosis
of aspiration had been made, even though ventilation
was possible with the LMA. We recommend that if pharyngeal
regurgitation or pulmonary aspiration is suspected, the
patient should be placed in the head-down position, oxygen
100% administered, anaesthesia deepened, suctioning performed
and the severity of the regurgitation/aspiration event
assessed fibre-optically. The decision about whether to
Aspiration and the LMA
Outcome z
Adults
Wilkinson et al. 6
50 F M (1.5 h) #
Multitrauma. Opioids
Griffin and Hatcher 7
26 F I E Movement. Cholecystectomy.
Cuff deflation
ICU 24 h. No PPV. Good recovery
Koehli 8
51 M II P ICU. PPV 20 h. Good recovery
Nanji and Maltby 9
74 M III M Dementia. Upper GIT disease.
Inadequate anaesthetic depth
ICU. PPV 4 days. Good recovery
Brain 10
M No sequelae
Brain 10
F P Obesity. Cholecystectomy No sequelae
Brimacombe and Berry 11
75 M III M Lithotomy. Dementia.
Upper GIT disease
ICU. PPV 1 week. Good recovery
Langer et al. 12
55 M II M LMA/TT exchange for
bronchospasm
Good recovery
Hamada 13
29 M I M Inadequate anaesthetic depth No PPV. Good recovery
Miyasaka 14
66 M II P Multiple insertion attempts Good recovery
Verghese and Brimacombe 15
68 F M ICU not required
Vogelsang et al. 16
77 F II M (2 h) #
LMA/TT exchange for
prone position
Multi-organ failure. PPV 7 weeks
Gaitini et al. 17 ** No details
provided
Brimacombe and Keller 18 ** 64 M I M (1 h) #
Unidentified malposition.
Cholecystectomy
No PPV. Good recovery
Current 49 F III M Gastric surgery. Septic.
Lithotomy.
No sequelae
Current 73 F III M (0.5 h) Diabetes. Gastric surgery ICU 56 days. Stroke
Current +
Children
78 F II P Upper GIT disease Multi-organ failure. ICU 85 days. Died
Maroof et al. 19
15 I–II M (2 h) #
Inadequate anaesthetic depth ICU. No PPV. Rapid recovery
Alexander 20
8 F II M Movement. Lithotomy position No PPV. Good recovery
Braun and Fritz 21
II Inadequate anaesthetic depth Good recovery
Ismail-Zade and Vanner 22
Lussmann and Gerber
7 II M Not fully fasted Spo2 fell to 86%; briefly intubated
23
10 F I M Inadequate anaesthetic depth PPV for 4 days. Good recovery
Cassinello 24
0.8 M I M None Pneumonia. No PPV. Good recovery
581
intubate the trachea or continue with the LMA will depend
on how well the LMA is functioning, the severity of the
regurgitation/aspiration event and the anticipated risk of
further regurgitation/aspiration. Removal of the LMA may
result in further regurgitation and consideration should be
given to intubating the patient fibre-optically via the LMA.
Consideration should also be given to passing a gastric tube,
but this may also provoke further regurgitation.
In summary, we report the first cases of aspiration-related
brain injury and death associated with the LMA, and the first
case of aspiration associated with the intubating LMA. In
principle, meticulous selection of patients and surgical procedures,
optimal management of the placement, maintenance
and emergence phases, and use of the ProSeal LMA can
reduce the risk of aspiration.
References
1 Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory
events in anesthesia: a closed claims analysis. Anesthesiology 1990;
72: 828–33
2 Keller C, Brimacombe J, Raedler C, Puehringer F. Do laryngeal
mask airway devices attenuate liquid flow between the esophagus
and pharynx? A randomized, controlled cadaver study. Anesth Analg
1999; 88: 904–7
Downloaded from
http://bja.oxfordjournals.org/ by guest on March 28, 2013

3 Brimacombe J, Berry A. The incidence of aspiration associated with
the laryngeal mask airway—a meta-analysis of published literature.
J Clin Anesth 1995; 7: 297–305
4 Warner MA, Warner WE, Webber JG. Clinical significance of
pulmonary aspiration during the perioperative period. Anesthesiology
1993; 78: 56–62
5 Verghese C. LMA-Classic TM , LMA-Flexible TM , LMA-Unique TM .
Instruction Manual. Henley-on-Thames: The Laryngeal Mask Company
Ltd, 1999
6 Wilkinson PA, Cyna AM, MacLeod DM, et al. The laryngeal mask:
cautionary tales. Anaesthesia 1990; 45: 167–8
7 Griffin RM, Hatcher IS. Aspiration pneumonia and the laryngeal
mask airway. Anaesthesia 1990; 45: 1039–40
8 Koehli N. Aspiration and the laryngeal mask airway. Anaesthesia
1991; 46: 419
9 Nanji GM, Maltby JR. Vomiting and aspiration pneumonitis with the
laryngeal mask airway. Can J Anaesth 1992; 39: 69–70
10 Brain AIJ. The laryngeal mask and the oesophagus. Anaesthesia
1991; 46: 701–2
11 Brimacombe J, Berry A. Aspiration and the laryngeal mask
airway—a survey of Australian intensive care units. Anaesth
Intens Care 1992; 20: 534–5
12 Langer A, Hempel V, Ahlhelm T, Heipertz W. [Experience with use
of the laryngeal mask in over 1900 general anaesthetics]. Anaesthesiologie
Intensivmedizin Notfalmedizin Schmerztherapie 1993; 28:
156–60
13 Hamada I. [Vomiting and pulmonary aspiration during the use of the
LM]. J Clin Anesth 1991; 15: 1219–20
14 Miyasaka C. A case of pulmonary aspiration during insertion of LM.
J Clin Anesth 1991; 15: 1360
15 Verghese C, Brimacombe J. Survey of laryngeal mask airway usage
in 11910 patients: safety and efficacy for conventional and nonconventional
usage. Anesth Analg 1996; 82: 129–33
16 Vogelsang H, Uhlig T, Schmucker P. [Severe multiorgan
failure caused by aspiration with laryngeal mask airway].
Anasthesiol Intensivmed Notfallmed Schmerzther 2001; 36: 63–5
17 Gaitini LA, Vaida SJ, Somri M, Ben-David B, Hagberg CA. A randomized
controlled trial comparing the Proseal laryngeal mask
David and Heinrichs
British Journal of Anaesthesia 93 (4): 582–6 (2004)
doi:10.1093/bja/aeh231 Advance Access publication July 26, 2004
airway with the Sonda Laryngeal Tube in Mechanically Ventilated
Patients. Anesthesiology 2002; 96: A1319 (Abstract)
18 Brimacombe J, Keller C. Aspiration of gastric contents during use
of a ProSeal laryngeal mask airway secondary to unidentified
foldover malposition. Anesth Analg 2003; 97: 1192–4
19 Maroof M, Khan RM, Siddique MS. Intraoperative aspiration
pneumonitis and the laryngeal mask airway. Anesth Analg 1993;
77: 409–10
20 Alexander R, Arrowsmith JE, Frossard RJ. The laryngeal
mask airway: safe in the X ray department. Anaesthesia 1993;
48: 734
21 Braun U, Fritz U. [The laryngeal mask in pediatric anesthesia.]
Anaesthesiologie Intensivmedizin Notfalmedizin Schmerztherapie
1994; 29: 286–8
22 Ismail-Zade IA, Vanner RG. Regurgitation and aspiration of gastric
contents in a child during general anaesthesia using the laryngeal
mask airway. Paed Anaesth 1996; 6: 325–8
23 Lussmann RF, Gerber HR. [Severe aspiration pneumonia with the
laryngeal mask.] Anaesthesiologie Intensivmedizin Notfalmedizin
Schmerztherapie 1997; 32: 194–6
24 Cassinello F, Rodrigo FJ, Munoz-Alameda L, et al. Postoperative
pulmonary aspiration of gastric contents in an infant after general
anesthesia with laryngeal mask airway (LMA). Anesth Analg 2000;
90: 1457.
25 Kluger MT, Short TG. Aspiration during anaesthesia: a review of
133 cases from the Australian Anaesthetic Incident Monitoring
Study (AIMS). Anaesthesia 1999; 54: 19–26
26 Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the
ProSeal laryngeal mask airway prevent aspiration of regurgitated
fluid? Anesth Analg 2000; 91: 1017–20
27 Brimacombe J, Keller C. Airway Protection with the ProSeal
Laryngeal Mask Airway: a case report. Anaesth Intens Care 2001;
29: 288–91
28 De Silva KK, Young P. Protection against aspiration with the Proseal
laryngeal mask airway. Anaesth Intensive Care 2002; 30: 391
29 Crilly H, McLeod K. Use of the laryngeal mask airway—a survey of
Australian anaesthetic practice. Anaesth Intens Care 2000; 28; 224
(Abstract)
High-frequency oscillatory ventilation and an interventional
lung assist device to treat hypoxaemia and hypercapnia
M. David* and W. Heinrichs
Department of Anaesthesiology, Johannes Gutenberg-University, Mainz, Germany
*Corresponding author. E-mail: david@mail.uni-mainz.de
A male patient accidentally aspirated paraffin oil when performing as a fire-eater. Severe acute
respiratory distress syndrome (Pa O2 /FI O2 ratio 10.7 kPa) developed within 24 h. Conventional
pressure-controlled ventilation (PCV) with high airway pressures and low tidal volumes failed
to improve oxygenation. Hypercapnia (Pa CO2 12 kPa) with severe acidosis (pH