To the Editor:-Several letters have been written citing the use of a laryngeal mask airway (LMA) as a reserve tool in the management of a cannot-intubate or cannot-ventilate situation. [1,2] As such, the LMA is included in the ASA difficult airway algorithm in the instances wherein traditional laryngoscopy has failed and mask ventilation is difficult or impossible.  In one case,  there was a patient with a difficult airway (which was appreciated preoperatively) who refused regional anesthesia or awake intubation. Anesthesia was induced with propofol, and after succinylcholine, intubation and ventilation proved to be impossible; the LMA was used successfully to ventilate the lungs. In the other patient, anesthesia was induced with propofol, and after rocuronium, intubation and ventilation proved to be impossible. After unsuccessful transtracheal jet ventilation, the LMA was used successfully to ventilate the lungs.
Clearly, the LMA can help prevent potential catastrophes, but perhaps a different approach would have avoided the need for a “rescue” LMA. We reserve the administration of muscle relaxants (in the non-rapid sequence induction setting) until we have demonstrated the ability to ventilate the lungs. If ventilation proves to be impossible, we allow the patient to resume spontaneous ventilation and awaken. If muscle relaxants were administered, resumption of spontaneous ventilation certainly would be delayed. We believe that administration of a muscle relaxant simultaneously with an induction agent clearly poses a risk to patients. Further, the routine dependence on the LMA as a “rescue” device may predispose to a more cavalier approach, resulting in a potentially devastating event.
C. Mark Bazzell, M.D., Resident in Anesthesiology
Neil Roy Connelly, M.D., Assistant Professor of Anesthesiology
Tufts University School of Medicine, Baystate Medical Center
Springfield, Massachusetts 01199
(Accepted for publication January 3, 1997.)