Air-Q laryngeal airway for rescue and tracheal intubation.

We report the successful use of the Air-Q laryngeal airway (Air-Q LA) as a ventilatory device and a conduit for tracheal intubation to rescue the airway in a patient with difficult airway and tracheal stenosis. This is the first case report of the device to secure the airway after two episodes of hypoxemia in the operating room and intensive care unit. Consent for submission of this case report was obtained from our institution's human studies institutional review board given that the patient died a few months after his discharge from the hospital before his personal consent could be obtained and before preparation of this report. All personal identifiers that could lead to his identification have been removed from this report. A 59-year-old man was scheduled for a flexible and rigid bronchoscopy with possible laser excision of tracheal stenosis. He had a history of hypertension, atrial fibrillation, and diabetes. Assessment of airway revealed a thyromental distance of 6.5 cm, Mallampati class II, and body weight of 110 kg. He had hoarseness and audible inspiratory/expiratory stridor with Spo2 90% breathing room air. After induction and muscle relaxation, tracheal intubation and flexible bronchoscopy were achieved without incident. The patient was then extubated and a rigid bronchoscopy was attempted but failed with Spo2 dropping to 92%; rocuronium 60 mg was given, and reintubation was accomplished with a 7.5-mm endotracheal tube. A second rigid bronchoscopy attempt failed, with Spo2 dropping to 63%. Subsequent direct laryngoscopy revealed a bloody hypopharynx. A size 4.5 Air-Q LA was placed successfully and confirmed with capnography, and Spo2 returned to 100%. The airway was suctioned through the Air-Q LA device, and the airway was secured using a fiberoptic bronchoscope to place an endotracheal tube of 7.5-mm internal diameter. The case was canceled because of edema of the upper airway from multiple attempts with rigid bronchoscopy. The patient was transported to the surgical intensive care unit (SICU). During day 2 of his SICU stay, he accidentally self-extubated and Spo2 dropped to 20% prompting a code blue call. A size 4.5 Air-Q LA was successfully placed by the anesthesia resident on call and Spo2 rose to 100%. The airway was then secured after suction of bloody secretions and visualization of edematous vocal cords with a fiberoptic bronchoscope and proper placement of an endotracheal tube of 7.5-mm internal diameter, confirmed by capnography. During the short period of hypoxemia, the patient's blood pressure, heart rate, and electrocardiogram had remained stable. On the sixth day of SICU admission, he underwent surgical tracheostomy and laser excision of a stenotic tracheal lesion, returned to the SICU, was weaned off mechanical ventilation, and discharged 2 weeks later to a rehabilitation center with stable ventilatory capabilities. This case demonstrates successful use of the Air-Q LA in the emergency loss of airway scenario as a ventilatory device and as a conduit for endotracheal intubation when fiberoptic bronchoscopy alone may be difficult and hazardous. This case suggests the need for further evaluation of the impact of the Air-Q LA on outcomes when used as a rescue device and conduit for tracheal intubation in patient with disease activity.

Outcome of laparoscopic adrenalectomy for pheochromocytomas vs aldosteronomas.

HYPOTHESIS: Laparoscopic adrenalectomy (LA) is most commonly performed for pheochromocytomas (PHEs) and aldosteronomas (ALDs). We hypothesize that LA for these differing tumor types is associated with different operative courses and outcomes. DESIGN: Retrospective study of a 10-year experience with LA. SETTING: University teaching hospital. PATIENTS: Laparoscopic adrenalectomy was performed on 149 patients. During data analysis, the initial 35 LAs performed for various adrenal lesions were excluded to account for the learning curve. Twenty-six of 30 PHEs and 34 of 45 ALDs were included. MAIN OUTCOME MEASURES: Analysis of variance was used to compare operative time, tumor size, estimated blood loss, and postoperative length of hospital stay between the PHE and ALD groups and subsets of these groups. chi(2) Analysis was used to compare tumor location, transfusion requirements, conversion to open procedures, and incidence of major complications. RESULTS: Right-sided lesions occurred in 19 of 26 PHEs, and left-sided lesions occurred in 28 of 34 ALDs (P <.001). Mean +/- SD tumor size of PHEs (4.9 +/- 1.8 cm) was larger than that of ALDs (2.7 +/- 1.7 cm) (P <.001). Mean +/- SD operative time for PHEs vs ALDs was 191 +/- 49 vs 162 +/- 48 minutes (P =.02). Mean +/- SD estimated blood loss was greater for PHEs (276 +/- 298 mL) than for ALDs (196 +/- 324 mL) (P =.33). Subset analysis revealed that the mean +/- SD size of right-sided PHEs (5.3 +/- 1.8 cm) was significantly larger than that of right-sided ALDs (3.0 +/- 1.5 cm) (P=.001). Mean +/- SD operative time for right-sided PHEs (198 +/- 44 minutes) was longer than that for right-sided ALDs (145 +/- 37 minutes) (P=.005). Six PHE patients required blood transfusions vs 2 ALD patients (P =.05). Two LAs, 1 PHE and ALD, were converted to open procedures. Mean +/- SD length of hospital stay was longer for PHE patients vs ALD patients (4 +/- 4 vs 2 +/- 3 days; P =.08). Six PHE patients had complications vs 3 ALD patients (P =.13). CONCLUSIONS: For PHEs, LA was associated with the removal of more right-sided lesions, larger tumors, longer operative times, and more complications. Trends toward greater estimated blood losses and longer hospital stays were observed for PHEs vs ALDs. Despite the advanced skills of an experienced surgeon, LA for PHEs is associated with a more complex course than for ALDs. Surgeons should begin performing LA for ALD early in their experience to avoid the potential pitfalls associated with PHEs.